#38 – HARD CASES – INTRO AND TWO VIGNETTES

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

The Clients

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

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

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

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

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

Brief Family Histories

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

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

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

The Mothers

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

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

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

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

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

The Fathers 

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

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

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

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

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

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

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

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

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

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

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

Processes

Nathan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patrick

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

           

          

#37 – Holding At Bay – Analysis and Comments

The therapies for these three cases had a few basic similarities. They were all relatively long, each being more than thirty sessions and lasting more than eighteen months. The anxiety and depression symptoms were largely resolved. The clinical processes all began with conjoint formats that included their siblings, and moved into split-session formats where the mothers were seen first and the client second. The older boy also finished his work by being seen individually following his bout with suicidal ideation. From a statistical perspective, his therapy was one of the most successful within the whole study group, gaining thirty CGAS points and being one of only four relatedness cases to resolve his problematic pre-Axis II traits. 

The mothers all had strong relationships with their children. They also had more than adequate resources and skills to negotiate the vicissitudes of post-divorce struggles. Each of them took advantage of their individual clinical time in the split-session format to sort out their own concerns, decisions, and communications with their children, and also in regards to the fathers along the way.

None of the fathers made an appointment, but appeared to track the processes. As per the mothers’ infrequent comments, none seemed enthusiastic. They ranged from expressed doubts to passive opposition. But again, the men tended to have relatedness difficulties themselves and likely entertained a more conservative view about therapy in general. At least with Hank’s case, the father lessened his antipathies. The other two fathers were difficult to discern at termination, but suffice to say, the clients resolved much of their anxiety about parental conflicts and their fears of changes in their parental relationships.

Clinical Considerations

Though not directly involved in the therapy processes, the divorced fathers remained to be central considerations. For the ‘other’ parent to be being at least neutral toward their child’s involvement is a positive. These particular cases, though, involved parents with likely Axis II involvement, leading to a greater likelihood of post-divorce troubles that could both exacerbate their child(rens) adjustments to the new family arrangements, and/or complicate the therapy. The intensity of the conflicts may rise with the severity of the parental disturbances themselves, complicated by the reality that the level of severity is almost impossible to ascertain from a distance. The fact that most non-participating parents are male and as a result tend to be less enthusiastic about therapy in general could further add to the challenge. Developing reliable clinical methods and tactics that aim at fostering and maintaining at least the neutrality of the non-participating parent may help to produce positive clinical outcomes, but at the least may offset torpedoing the processes involving their children.

The following concepts and guidelines proved helpful:

Support the basic triangle

First do no harm

Protect the process

Maintain boundaries

Use discretion re: judgements 

In a family-based therapy approach to child and adolescent mental health issues, all three sides to the parent-parent-child triangle are taken into account. In cases of divorce where co-parenting continues in one form or another, the professional relationship with the  ‘other’ parent not involved in the therapy can be still be seen as resembling something fiduciary in nature. The therapist wants the other parent to have trust and confidence in their professionalism. For the parent – parent – child triangle to solidify in some way or another as a result of the therapeutic interventions, the triangles involving the therapist and the family members are best being supportive and neutral. First do no harm toward the relationships of the child and the active ‘other’ parent uninvolved directly with the therapy. For example, focus on behavior change rather than speculating or deciphering the other parent’s motivation. These can lead to judgements, and family feedback loops will persist beyond divorce. This can also be seen as protecting the process.

Using the different available formats within the family therapy structure proved to be particularly helpful in these post-divorce child therapy cases. The family work focuses in part on the relationship between the participating parent and the child. Particularly in the split-session format, where the clinician meets with the parent and child separately during the hour, the involved parent can work on the relationship with the ex. The third side of the triangle – that of the child and the non-participating parent – can get addressed with the child at any point in the therapy regardless of the format.

After the six years of community NPO mental health work that began my career, another six years was spent as an in-patient medical social worker at Seattle’s venerated Children’s Hospital, a far cry from outpatient mental health. Two invaluable psycho-social nurse colleagues mentored me about how the floors and bays operated, e.g.’the doctors diagnose and prescribe treatments; the nurses run the place.’ One eternally helpful advice was to “write chart entries as if the patient and parents are looking over your shoulder.’  Likewise, assume that what the therapist says in the office can and will be quoted to others. 

Words matter. Clinical statements the therapist may make regarding the non-participating parent and subsequently conveyed by the participating parent, child, or possibly even someone else can pose problems. Particularly In helping adult clients understand the nature of their experiences vis-a-vis difficult relationships, some therapists will suggest diagnostic terms to describe the other parent such as “narcissistic” or “paranoid”, suggest characteristics like “self-absorbed” or “manipulative”, or define patterns as being  “demeaning” or “contemptuous”.

The problems in employing this tactic are threefold. Perhaps they are accurate – only perhaps  – but at worst they can be interpreted as insults, gibes, or sarcasms when conveyed to the other parent.The more insecure that parent may feel about themselves and their relationship with the child, the greater may be their opposition and even direct interference. Such characterizations do not provide a feasible plan of what to do about the concrete problems the terms are intended to encompass, so they can easily become an idle, even snide critique that may somehow build the client’s confidence in the therapist’s knowledge, but in effect do little else except to denigrate a bit. The more serious consequence is when the terms are later quoted in the midst of, say, a hard or heated argument between the divorced or separated parents. However uncommonly that may occur, that does happen and runs the risk of further destabilizing that parent – other parent – therapist triangle. Protect the process.

The Karpman Drama Triangle concept was developed in the early late 60’s and incorporated into Eric Berne’s Transactional Analysis therapy in the early 70’s (ref: Wikipedia entries on Karpman and Berne). To me, anyway, TA seemed to be an attempt to create a relational diagnostic taxonomy as a parallel to the DSM system of individually-based diagnoses. Popular at least in the western states during the 70’s as an alternative therapeutic narrative, TA faded as a treatment about the same time as mental health treatment began to industrialize in the 80’s. The one remaining operative vestige, to my knowledge, is Karpman’s victim – rescuer – persecutor triangle. Karpman’s hypothesized that a dysfunctional threesome would necessarily fall into these three roles. The dynamic is that a victim would be oppressed by the persecutor, and then the rescuer would enter to save the victim. T/A postulated a very specific shift within the triangle where, after being ‘rescued’, the vengeful victim becomes the persecutor, the rescuer becomes the victim, and the former persecutor now rescues the rescuer-turned-victim. The roles continually shift in that pattern. And around and around again and again as the threesome live out their pathologies.  Berne had data to support the hypotheses. The main point is that while helpers help others get better and stronger, if the ‘helping’ verges into ‘rescuing’, the well intended ‘helper’ who misguidedly rescues can end up being the victim, e.eg lose the case. And the original perceived persecutor  – the other parent – certainly won’t rescue the therapist. When this phenomena occurs in child therapy, the ultimate victim is the child him themselves. The process is injured or finished. The client stops getting help. This does happen.

Every once in a while, a therapist is asked to write letters of support or provide testimony of some sort in support of a parent’s legal or administrative defenses or pursuits, or even offer to do so. In the context of child and adolescent cases involving two divorced parents, a prudent approach is to defer, particularly so in those cases in which the contentiousness persists long after the dissolution. Letting the participating parent know at the outset of the therapy process that, as the child’s therapist, the clinician will work to avoid direct involvement in a legal process will serve to diminish the possibility of being approach by that parent to help. Rather, the parent will seek counsel about where to go, or the therapist can recommend to whom to turn.

Whatever the request may be, someone in the system is likely to be more suited to provide the service than the therapist, e.g. guardian ad litems, community advocates, forensic clinicians. They will usually contact the therapist for confidential input. To get involved runs the risk of being in the rescuers role by leaving the course of neutrality and broaching into the maelstrom. Becoming one more item on a list of complaints from the ‘other’ side can jeopardize the therapy itself. Be judicious and maintain boundaries.

The three children in this group were each subjected to frightening scenarios by the fathers: one had passive-aggressive tendencies that undercut the mother’s attempts to meet her responsibilities; one subjected his children to an onerous home environment; and one created an environment of terror early in his child’s life, one likely permeated the child’s being.

As Isabel’s academic and social improvements progressed, the pressures within the father’s home were not abating, and possibly worsening. The mother’s dilemma about whether to move Isabel and her brother into a different school system was pronounced. Her portions of the split-sessions were becoming more focused on the father’s environment and less so on parenting, per se. Communications she was having with him were discussed, shaped, honed, and re-shaped to little avail. Her own distress was becoming more central as her daughter was gaining a nice sense of herself and not requiring as much support and attention. 

The mother did not overtly ask for an opinion about whether to move the kids, working more on the details of helping them negotiate the disquieted atmosphere. In essence, her parent time during the session was verging into a separate therapy for herself. Although this turned out to probably be not the case, the question of whether she might be having commitment issues with her husband also entered the clinical thinking. In deference at the moment to the maxim ‘unsolicited advice is worse than no advice at all’, a unilateral suggestion she seek therapy for herself was not forthcoming, but eventually a referral would be necessary. Just about this time, the mother openly wondered about going into counseling herself. With concurrence, I gave her a colleague’s name with whom she did begin her own work.

When employing this split-session format, the distinguishing line between counseling an adult in their role as a parent and conducting individual therapy for the adult’s own problems is admittedly fuzzy. Unless the therapy being provided is a systems-oriented process based on circular causation, one in which the family is the “identified client”, the youth is the therapist’s client, and the participating parent is a collateral. In taking the parent as a client working on problems separate and different from those of the child, two basic problems can emerge.

The first is the possible impact on a child of feeling displaced, which is not out of the question. Secondly, for children in the 10 – 16 year old bracket, and particularly if separate appointment times are set, the client can develop mistrust about the maintenance of confidentiality. This possibility would just about be a given if mistrust is a issue spread through the family. While these developments can be managed clinically, creating et another presenting problem to be resolved is also an issue.

Even if the therapist has gotten to know the parent through the periods of conjoint and split-session formats, and trust has been established, and the segue into personal therapy seems natural, you still don’t know exactly what you’re taking on. The problems may simply be extrapolations of what you have already learned and experienced, no problem. They also may be far more complicated and reflective of a side about which you were unaware. The process may go well, but by the same token, the course of events could go decidedly off-kilter with unanticipated consequences. Again, this would be particularly of concern if the parent involved possibly has Axis II issue. The negative impact on the child’s work could include a premature termination of both the child and parent processes by the parent.

Using the guidelines outlined, accepting the involved parent as a simultaneous client for their own personal problems runs the risk of unbalancing that  client – parent – therapist triangle. The possibility then exists of rippling tensions within any one or combinations of the three sides, not the position in which the therapist wants to find themselves. While this kind of outcome would seldom happen, the possibility of an inhibitor introduced into the child’s therapy needs to be taken into account. Hence the referral to a colleague for Isabel’s mother. Maintain boundaries.

The Child – ‘Other’ Parent Side

Hank, Isabel, and Jackson all spent some time during their therapies on their complicated and sometimes distressing relationships with their fathers. Of the three, only Isabel was both in a position and had an interest in talking directly with the father about her concerns and complaints. Hank was too young to take this on directly, and Jackson was in a different place in his life, both in terms of his emancipating developmental stage and by virtue of his father living in a different part of the country.

Being six-to-eight years old during his time in therapy, Hank was simply too young to take on the task of talking with his father individually. Understanding his own feelings in regards to his father, what he could say to him, and how to manage himself were issues addressed in the conjoint work with his mother. She would make suggestions about what he could say or do differently, sometimes with my input to her. During his individual time, I would help him process his own feelings, and, generally, suggest that he talk with his mother about what to do. 

Jackson had abandoned thoughts of moving in with his father as his own attentions were drawn toward the social life and relationships of latter adolescence. Father’s antipathy toward mother seemed not far from the surface when the two interacted, either during the summer or on the phone. That veiled attitude of the father’s may have served to reinforce Jackson’s irritability toward his half-sibs, resentment toward step-father, and a sense of being the victim. Jackson’s difficulties seeing himself in his father was not particularly approachable until he returned to treatment following the suicide plan.The sheer fright of that episode helped soften the edge against painful insights. The relationship surely continued, probably around fishing, but other than issues stemming from the modeling, no direct work involving his paternal relationship was necessary at that time he terminated. All appeared settled, without underlying resolutions, but also without calumnies. 

As per Alan Leider, “Working with a family is like walking through a minefield. They know where the mines are, and you don’t. If you try and lead them through, you’re likely to get blown up.”

On the other hand, Isabel wanted to talk to her father. Offered here is, very roughly, one side of an interchange. She gave a session-opening description of a spiky Sunday afternoon at her father’s home a few days earlier. The previous session involved somewhat similar content, mostly descriptive and disburdening. As she got up to leave this session, she mused about talking to him. As I shook her hand going by, I just said “good enough, maybe next time”. To begin the next appointment, Isabel reports almost disconsolately on the last time at her father’s home. What follows is the clinical portion of the therapeutic interaction. She was then close to 13.

Note: The style of the following vignette is anode to Shelley Berman

“Well, listening to this, those were a couple of hard days. Kind of painful, really. So, is this the kind of stuff you want to talk with your dad about?”

“So, how can I help?”

“Well, what sort of thoughts have you had so far about what you’d like to say to him?”

“You want me to call him in here? I’m glad you’re smiling. I can’t call him in. It’s a sort of rule. Maybe I can help you figure out what you’d like to do with him and how to go about doing it?”

“So, again, what have you already thought about saying”?

“OK.You want to talk with him about your relationship, how he sees you, that sort of stuff?”

“So, let’s start off with the problems being in his house, how you feel, the ones you’d like him to think about. What might they be?”

“OK. So far, that seems to be right on target. What else?”

“OK, what else?”

“Anything else?”

“Well that covers quite a bit…it’’s a good start. Now, your step-mom is involved here, so, whenever this happens, would you like to talk with the two of them together, or your father alone?”

“Alone? Right. I totally agree with that. Doing this for the first time with both of them sitting there sounds like it could be hard. What exactly do you want to see better with your dad?”

“List, say, five things.”

“What comes to mind when you list those things is that you really want to be seen differently by your dad, like you want his approval?”

“And the same with your step-mother?”

“I don’t know, maybe she could surprise you.”

“Well OK. One way or the other, we’ve got some work to do. So, let’s start off with what you’d like to see different over there.”

“What else?”

“There you go. Good. What else?”

“Anything else?”

“That’s even better. It’s certainly enough to start with. Most of those were things you’ve mentioned are things you’d like to see stopped. So, let’s re-define it into what it is you’d like to see get better? You remember us doing this in the first family meeting with you, your mom, and your brother? Right, so, go ahead.” 

“OK, what else?”

“And what else?”

“Does that cover it?”

“OK, I’m writing all this down. Now, that does cover a lot of what you’ve been talking about. I’ve got another question, though. In what ways does your dad do what you like, and more importantly, in what ways does your dad see you that you like?”

“What else?”

“Anything else?  No? OK. In what way does your step-mother see you positively.”

“Nothing at all?”

“Not a single thing? Well, what’s the closest thing to positive she’s said, even if it’ like, ‘I’m glad you like my spaghetti.’

“OK, that’s better. Every one has at least some bit of light. Last question along these lines. What do you think you can improve upon when you’re at your father’s?. What else?”

“Anything else?

“Alright, good, that’s really is very helpful. At some point you may want to acknowledge that to him, you know what I mean?

“Right, and maybe say, if you mean it, you want to work on that?” 

“Good. Very last question about this stuff – what can your brother do better around that house that you could remind him about? How can you help him?”

“That’s good, too. What you could do better are just things to keep in mind whenever it is that you decide to talk with your dad. So, you have this list of things that aren’t going well, and then a list of things you’d like to see get better, and some things you could do better. By the way, that last one is called ‘taking the high road’.”  

“So, can you list a few of each group in your head?” 

“And you’d like to have time with him, a couple of things you’d like to do with him – like maybe he could go and help you pick out a coat?”

“No way? I’d think about it, anyway?” 

“OK. So, pick out maybe two or three things in each group – things that aren’t going well, things you’d like to see better, what you could do better, and maybe what you’d like to do with him alone. I’ve got them written down here, so we have a record you could use if you want, I just have to copy it, give it to you when you leave.”

“Good. Put them together in a way that you’re comfortable, and then talk to me like you’re talking to your dad. Just to test it out.”

“Good start. And how did you feel saying that stuff?”

“Alright, try it again, maybe with a bit more detail about what you’d like to see better. ”

“Yes, yes. You know, these things you’re pointing out may help him sort things out, too. The remaining thing is that what you’re saying does not include much of how you feel when things are gong badly, and like when things get better, and when you’re getting along with your dad. And remember what we’ve talked about before, that beneath being angry is being worried about something.Your feelings are the most important thing to you, what you worry about maybe the most important and hopefully to him, too. So, try to put in something else about your feelings. Do one more time?””

“Oh, really good. You’re a trooper. How do you feel when he’s  angry with you?”

“Good – no, not good, but you know what I mean.  And remember that beneath the anger is worry. You have a pretty good idea?’I think it’s really getting there.” 

“OK, you may want to check out what you want to say to your dad with your mother, because she knows him best. She may help you change something here or there. I think it’s good on its own,  and you’re certainly old enough to do it on your own. That’d be up to you. Your mom may be a good double-check.””

“Good. So, it’s possible that you’ll decide not to do it right now. That’s OK, too. If you do talk to him, though, I’d be interested to hear how it went. I’m learning about what works here, too. At some point either now or in the future, though, I’m pretty sure you’re going to be doing something like this. Any questions?”

“Yes, you’ll be nervous. What I’ll tell you is that most of the things that are really important you’ll

remember at the time, as you talk. Those you forgot can always be said later. It’s always OK to take deep breaths. You know, you don’t have to solve the problems right then, you just want to get a conversation going. The point is making the effort…to help your family. And it may not work, at least the way you want, but this is a first try, and you’ll have lots of opportunities as life goes on. Right?”

“OK. So, I think you’ve done really nice work today, and I hope it helps.There’s one more thing I want to bring up, and that’s this…what really impresses me is your sense of loyalty to your dad, and to your family,  and I think to your good friends, too. I know they mean a lot to you as well. That firm sense of loyalty is a great value to have, and It will help you out in the future, so, you know, stay with it.”

An exercise like this would probably take most, if not all of a split-hour session. The alternative is that at almost any point early in the recitation of problems, the clinician could unilaterally interject, ‘what I’d recommend for you to say (or do) is _________”. The quick dispatch would allow for a more efficient use of the 25 – 30 minutes, could be just as good, maybe even more to the point. 

Two advantages of taking the longer route are worth considering. First, the client would be using her own thoughts. Going on 13 and having the relationship with her mother that she does, she’d likely talk with her about this as well. The therapist has been helping her figure out her own words and manners rather than providing the direction. Less likely to get blown up.

Secondly, this kind of exercise can become a ripe opportunity to provide some random, unanticipated positive reinforcement, which can never hurt as long as the observation is demonstrably true.

Once in a while, a twist of fate pushes toward a resolution. In this case, while dropping Isabel and her brother off at the mother’s home one Thursday summer night, Isabel’s step-mother entered the house to search for missing items.  Doing so was not allowed. The mother notified the father. A repeat occurred two weeks later. Isabel in particular was upset with the allegations toward her and breach into her room, more so with the accusations. Her room was apparently always presentable. Enough was enough, and the mother decided to move the children to her husband’s home. They would stay with the father every other weekend. 

The therapy process ended a month later. Although the move itself made continuing less feasible, the client was ready anyway. She had not yet talked with the father, but she did have had a kind of template when the moment called. The door was open to return.  Her mother was continuing her own therapy.

Thanks to Connie Dunn, Transcriptionist, for years of faithful work

#36 – HOLDING AT BAY – THREE VIGNETTES

Continuing the examination of cases involving divorced parents where at least one within the couple appeared to have Axis II issues, in these three situations the contentiousness over child care continued well beyond the divorce itself. The inter-parent struggles involved custody, child support, living arrangements, educational decisions, and/or healthcare authorizations that included those for mental health treatments. The client mental health problems were not solely caused by the wrangling, but all three clients experienced anxiety symptoms and expressed distress over the family splits, parental conflicts, and fright about what could be perceived as unpredictability in their the overall care and basic connectedness with both parents. Given that the relationships between the parents could appear unstable, the relations that the child has with both could be seen as threatened and subject to changes that were out of the child’s control or influence. The on-going situation becomes traumatic in and if itself.

Addressing The Non-participating Parent

Non-participating parents in therapy cases involving divorce were notified about the counseling using a method honed during the first years of the practice. During the treatment planning that occurred at the end of the assessment summary session, the participating parent was asked to notify the non-participating ( ‘other’) parent that they could call and make a one-time appointment to meet with me. The purpose could be for them to share their perspective and concerns about the child, or to find out what the clinical thinking and planning may be, or simply to assess me for their own knowledge. The notification included that they would be responsible to pay the session fee or co-pay at the time of the service. The session could only occur in the office, e.g. not by phone (Zoom, et. al., could change that, and covid-19 would change that, but nothing really replaces the effectiveness of face-to-face for interviews that can easily be tricky to effectively manage). If the other parent did not call, the participating parent would keep the other parent informed about the therapy, as per whatever was required. I would check with the participating parent that the other had been notified.

The participating parent along with the other parent, if they came in, were also told that I would avoid being involved in any legal process to the best of my abilities. If an opinion concerning the client was necessary for legal or administrative purposes, my input could be gathered by a guardian ad litem or other formally involved professional. Most parents accepted that statement at face value. For any parent who asked why, the explanation was that direct involvement with a legal process could be detrimental to the child’s therapy itself. The assertion could be anecdotally buttressed.  For the ‘other’ parent, this notification was a certain comfort, and helped with gaining their tacit support

The purpose of this protocol was to create as much trust as possible with the other parent short of reaching out. Soliciting a session is problematic, even more so under these circumstances. About 10% of the non-participating parents did make this one-time appointment. Over the years, perhaps three or four of these parents over the years asked to be involved in some way. They were accommodated. Aside from the important symbolism of devotion, their involvements were brief and not particularly consequential in terms of clinical gain.  

As an other aside, one result of this notification method was never getting that puzzled call of ‘I hear you’re seeing my kid and I’d like to know what’s going on’, or that angry call that included,  ‘…and I want a copy of the record!” These inquiries or demands are complicating, presumbly unpleasant, and potentially jeopardize the important perception of a clinician’s neutrality, particularly in instances of marital separation or divorce. Also to be mentioned is that while this particular protocol of addressing the other parent was never vetted and perhaps has flaws, the system always worked as intended. The clinical neutrality necessary for a child or adolescent’s trust in the therapeutic relationship was left out of the fray, and that “call” never materialized.

None of the fathers in this group called to make an appointment.  Again though, not doing so was the norm for the ‘other’ parent throughout this practice and need not be seen as a negative critique.

Clinical Summaries

The clients of the group included an early-elementary boy, a junior high girl, and a high school boy. Depressive and behavioral issues were present for all three, but anxiety was their major problem. The younger boy was anxious that something bad would happen, the girl about how she was being seen, and the older boy weighed down by persistent difficulties in his environment and a lack of resolution between his mother and father over the many years after a traumatic divorce.

The two boys had bouts with suicidal ideation. The older of those two was also one of the nineteen youth in the study that presented with a relatedness, or pre-Axis II problem, defined in this study as having three or more of the identified 31 relatedness traits (Post 25). He demonstrated four, thus on the lower end of the study’s spectrum.

Hank

In addition to anxiety symptoms, Hank had bouts of frank sadness and on a few occasions uttered that he “might as well be dead”. He was often irritably defiant at home and occasionally non-compliant at school. Starting therapy in first grade, Hank was a basically affable and usually gentle boy who also had the size and capacity for an offensive lineman’s intensity. He was liked by his peers at school, though he was convinced thought he was disliked. He had two older brothers, one in high school and the other in junior high. The younger of the those two was moderately compromised by a spectrum problem. The older had been similarly diagnosed at one point, but his controlling rigidity in certain circumstances seemed to be more personality than spectrum. Otherwise, he had fair social competence. All three boys posed parenting challenges.

The acidic dissolution of the marriage was a given under the circumstance of oath breaches by the father. The settlement phase was contested to the point that the judgement itself was likely impacted in the mother’s favor. Thereafter, providing sustenance, guidance, and solace for her three boys and defusing random eruptions from and among all four males in her life became an almost ubiquitous juggle. “Tiring”, she would describe.

The mother was a home-based communications consultant. The father was in product development for a small firm. Neither had re-married nor were they in standing relationships. Since the separation when Hank was two, the three boys had been living primarily with the mother. The father was allowed three nights out of fourteen. The older two were now of sufficient age that they often independently chose to stay at their mother’s, particularly so with the older boy whose choices just as often were expressed with characteristic adamance. Hank’s anxieties were clearly exacerbated by the sum of all tensions, tending toward a clinginess around the mother that could pose its own dilemmas. 

The two year therapy began as conjoint with the mother, both sibs, and Hank for eight months, a similar period with the mother and Hank together, and then finished with split sessions for the mother and Hank. They both liked the last arrangement in particular, but the conjoint work helped to resolve broader family relational and behavioral issues that could not have been adequately addressed by using only the last two formats.

Hank’s overall progress was gradual. Once the therapy process began, the suicidal talk did not recur.  Feeling identification followed by the inferred problem solving was the primary modality, the positive results of which were liberally reinforced. Even at age 7, Hank was something of a natural processor once comfortable. That was a major factor in his progress. Reinforcement-of-the-opposite behavior was used extensively, decreasing clinginess and defiance with observances of self-regulation and cooperativeness. Coordinated through the school counselor, Hank’s teacher randomly reinforced changes noticed in school that paralleled those seen during therapy. Hank himself reported about better grades on tests and assignments. His initiative improved, and his self-esteem in regards to peer status also seemed to rise.

The mother’s time during both the family session and split-session phases afforded her an opportunity to gather thoughts and develop actions and responses in regards to the three boys, their relationships, compliance, and cooperativeness.  Some of the work involved separating what she thought she needed to do vis-vis her ex from how she felt about having to do so, because the two would conflate and that dynamic occasionally turned into an escalation between the two. The sessions were a more a sounding board than a source for suggestions. 

The Rub

At least insofar as could be discerned from the mother’s reporting, the father had always been miffed about the decreed custody arrangement. While his negativity toward her could spill into his parenting, his actual pursuit of more time with them had apparently not been withering.  When the episode of  suicidal ideation came out, though, the father began to lobby for a week on – week off parenting arrangement with Hank, citing the overall environment at the mother’s home. She was steadfast about the 11 – 3 day split in child care.

About the time when the parental conflict level rose, Hank became yet more clingy with mother. Part of the work was helping him to speculate and identify what others thought and felt about issues in which he was involved. This particular work almost always begins between client and mother, and that was the case here. Through this tool, the mother was able to clarify questions he had about the stability of custody as a result of the father’s comments. He did seem to be more independent and less guilty. The clinginess subsided over time.

Two years of therapy is a long time, allowing for adequate room for growth and change. What with the mother’s increased clarity in communicating with the father, Hank’s increased comfort with disparate viewpoints between the parents, and his overall change and growth, the father’s  settlement complaints and the entreaties voiced toward Hank, as reported by the mother, subsided. She also kept the older boys in the loop of information, although those two did not appear to be as impacted as their younger brother. To what degree the change was a function of the mother’s efforts, or of a relegation to the facts of reality on his part is difficult to discern. 

Isabel

From the intake with the mother and the assessment wih Isabel herself, the picture was of a pre-adolescent girl who was anxious, insecure, prone to telling tall tales, a bit hypochondriacal, and underperforming at school. She did not talk until age three, impeding early social experiences. She was also the youngest child in her class. The combination of the transient developmental delay and age drawback likely contributed to her insecurities. By the time of her first interview at the age of eleven, though, all that needed to be said was “What can I do for you”, and she immediately talked freely and on topic for an unusually long time. Being the center of attention had some appeal for Isabel, and may have provoked issues like the story-telling, but just based on the flowing and reasonably organized content of her unhesitating participation, her problems clearly seemed workable.

The client and her autistic younger brother were in the mother’s custody. The parents were divorced for incompatibility five years earlier. The mother was a high-end commercial realtor. The father lost a business in the Great Recession and now worked in retail. Both had remarried within two years. The mother’s husband lived in a suburban area of the county while she maintained the original family home in a rural area. The two children were week on – week off between the two parents’ homes, both at the father’s request and to fulfill the mother’s desire for keeping the children in their original school district. The mother essentially lived in two homes as well as the children. Functionally, the primary parent in the father’s home was his second wife, whose apparently unrelenting and verbally aggressive parenting style was becoming increasingly difficult for both children, as per congruent reports and observations by both kids and the mother.

The father, who was portrayed by the imaginative daughter as one who “treats me like a ghost”, was likely anxious about the mother moving the children to her husband’s home. The relationship between the daughter and the step-mother had been fraught since her father married. In the mother’s judgement, the girl had made good faith efforts to please the step-mother and clearly wanted a positive relationship with her father. However, the step-mother’s exasperation and anger increased over time, as did the father’s subsequent criticisms of his daughter. Isabel made a good case for being in double-binds from time to time. The father’s approach to the girl may have been paradoxically aggravating his own marriage as well, as his wife wanted less talk and more punishments. All three sides to that particular parent – step-parent – child triangle were lacking in strength, creating an unstable environment. The father’s frequent irritation toward her was Isabel’s most distressing issue entering treatment. 

The twenty month clinical process followed the same basic format as that of Hank’s, beginning with family work that sometimes included the younger brother, and moving into the split session format about halfway through.The father had indicated to his daughter an intent to contact me, but never did. The tall tales that occurred with some regularity at the beginning of the process ceased after a couple of months without any specific clinical attention. The odd physical complaints similarly disappeared, although taking a longer period of time to do so, again without clinical focus. The interesting experience with her during the individual work that spanned her transition from older childhood to early adolescence was a change in manner of relating to me. She gradually became less disclosive with her personal thoughts and feelings, clearly deciding to share some things and not others. The clinical choice was to let that change be, particularly since she was getting better and they were probably nearing termination. Watching young clients change as they move from one to the next developmental stage was, to me anyway, one of the real treats in this work.

Since one of the mother’s concerns was whether to move the children to her husband’s home, I referred her to a colleague for individual counseling. There she could get advice independent of her daughter’s therapy. Months later and close to the end of therapy, a new problem emerged when the step-mother began making disallowed entries into the mother’s home while dropping the children off, searching for allegedly missing items. The mother decided to move the children to her husband’s house, and their time with the father became limited to every other weekend.

Isabel’s overall improvement was well above average, about CGAS 20 points. Part of the advances were probably a result of continued developmental growth to the point where she had essentially caught up with her average peer, and as a result of the collective therapeutic efforts.

The Rub

Through the intricacies of her own life and the switchovers of her family, Isabel was resolute in keeping the relationship with her father at least viable. The relationship with the father was the first issue she identified during her assessment session. An interesting, speculative question is the degree to which her early developmental deficits contributed to an over-reliance on her father’s presence for approval and anxiety reduction.

 According to the mother, she was distraught for a couple of months after he moved out, but she settled into the two-home routine. Given the age of six or seven at the time, her sex, her personality, and her dependence, Isabel likely tried to care for him in his new home. Given that the father lost his business, the attention had probably had a solace importance. However, the evolution of the father’s living circumstances with his new wife would seem to have significantly increased rather than modulate her anxiety. He seemed to have distanced himself by either being assigned or assuming a role verging on that of an enforcer.

The imbalance of that father – step-mother – child triangle was troublesome. The client is making progress at her mother’s, in school, and socially. One possibility was that both father and step-mother had some Axis II issues themselves, which would make predictability difficult. The common problem with an Axis II parent, particularly fathers and more particularly in cases of divorce, is (untoward) pressure being brought to bear on custody or some other aspect of a child’s life. That was not the case here. The lesser form is to (unintentionally) create havoc in  child’s life by pursuing some alien purpose or goal that negatively impacts mental health statuses. This would be the concern here.

While the question did not arise, the possibility hung in the air. Could he get yet more harsh? Without saying so, in essence she wanted to know that he would not abandon her and would love her at least in his own way. At the same time, she is learning to take care of her own emotions, i.e. not wither away. Her task was equanimity, specifically keeping an anger that could easily erupt within his home at bay, focus more on what was worrying her, and, perhaps most importantly, what she could do. That would include both what she needed to improve upon in that home, and how to address what sounded like harshness.

Jackson

During his assessment interview, high school sophomore Jackson reported restlessness, fatigue, tension, irritability, and inability to concentrate. The accumulated experience of the anxiety symptoms led to mood and other depressive symptoms, eventually to include suicidal ideation. He was occasionally defiant at home, and argumentative to the point of verbal aggression with younger half-siblings. His academic average had declined more than 1.5 points, and later in the long, complicated process, his social life began to fray during his senior year.

The parents divorced when he was three. The marital problems included physical assaults by the father upon the mother. They were twice witnessed by the client before he was 2 1/2. He had no recollection, but was basically aware something physical occurred. The mother had full custody. The father moved to an eastern state where his son would spend a portion of each summer. The mother remarried and had three children while starting a floral business. The youngest of the three children by her second husband was diagnosed with a spectrum disorder. The boy’s irritability often frightened his two step-brothers, generating considerable resentment on the part of his step-father. On the other hand, he was gentle, attentive, and playful with the youngest, an affable girl. Jackson also demonstrated four relatedness traits, making him one of the nineteen study group youth with a relatedness problem in addition to the concerns with anxiety, depression, and behavior.

The father was an independent small plane pilot, mostly crop dusting. He never remarried, but had a couple of cohabiting relationships over the years. Connections between the father’s partners and the son never really materialized. For several years, the father had been imploring his son to leave what he knew to be a difficult situation in his ex-wife’s home and live with him, occasionally complaining about an “unfair” and “stupid” divorce settlement when doing so. He could be vehement, if not fierce, about his wishes. The father’s pursuit did become more of a feasible alternative as problems increased in the mother’s home. He and the father spent summer time river raft fishing, which he enjoyed. As such, the father’s place may have posed an enticing alternative, at least as a flotation, but the only strong relational confidence he had was with his mother. These external and internal conflicts both contributed to the boy’s distressed emotional states.

Jackson’s process was the most complicated. The conjoint phase managed to bring the client and the two older half-sibs closer, reducing in-home clamor to a mild degree. Shaping his “oldest sib” role, done initially thru a play therapy with Jenga, but in large part again by using the consistent reinforcement of helping behavior evidenced during sessions and reported by the mother and step-father toward the two younger sibs. When not irritated, he enjoyed helping.This helped to develop his ability to accommodate others.The relationship with his step-father became somewhat less intense, but the kind of psychological bond one could anticipate after a step-father has been in that role for more than half of the step-child’s life was by no means manifesting. 

The clinical gains through these first few months were modest, but basic trust in people other than his mother, to a degree of indeterminate meaning with his young step-sister, and a couple of school friends was not forthcoming. After a review session with the mother and client, the process switched from the whole family into seeing just mother and son. The anxiety symptoms of fatigue and muscular tension had dissipated, suggesting that the agitated anxiety was at least no longer chronic. His reactivity to negative events and circumstances was a focus, and his reported improvements as corroborated by the mother were systematically reinforced. Those improvements helped to provide an impetus to continue. School performance remained low relative to his high capacity, acceptable, and his social relationships remained intact. However, the progress had essentially plateaued. 

Upon returning from his summer stay with the father, the client arranged to live with his maternal grandparents on the Oregon coast for his junior year. The intent was presumably to seek respite, but quite unusual for a high school  junior who did have decent peer relations where he was. The mother came in a half dozen times during his leave for help in her supportive role.

Jackson returned to live at home the next fall, having had a less stressed but more socially isolated experience. Back home, his social life became conflictual as well. After a particularly bitter fallout with an old female companion, he decided death would be better. Suicidal ideation had not theretofore been a presenting problem or issue. He hastily formed a plan and initiated the preparation, and drove to a selected spot. He had a sobbing breakdown after opening the car door, and returned home to his mother. As they talked through the episode, among other things he asked to resume counseling, this time individually. I hadn’t seen him for almost eighteen months.

The Rub

That work lasted the rest of the school year. As Jackson neared his suicidal act, he appeared to have a corrective emotional experience, altering his point of view. Part of the therapy was a continuation of socio-cognitive work, specifically his perception of how a group of others might see him differently from how he saw himself. Being highly defended in the context of family matters, including those involving his father past and present, accuracy in his perception of others had been something of a struggle in and of itself. 

On her own initiative in the aftermath of the suicidal scare, Jackson’s mother shared with him more details about the father’s temper problems when they were married. He brought the information into session. Slowly, the notion that he might be modeling his father with some of his behaviors toward his step-father and two step-sibs, albeit with much lesser intensity, emerged. No “Come to Jesus” moment occurred, but his insights increased. While he did have the capacity for remorse and empathy, in practice they had not appeared very often except toward his mother and spectrum-disordered half-sib. In its stead, a defensive distrust, defiance, intimidation, and verbal aggression arose. His ability to experience and use empathy and forgiveness noticeably improved. 

In the meantime, the mother was keeping the father updated on Jackson’s progress following his crisis. Just based on following the reported conversations, discussions, and events between the original triangle of mother – father – son, a reasonable inference was that the father was backing off on his harbored anger toward the mother. Verifying that would be difficult, perhaps that conclusion is too rosy, but something had clearly changed for the better.

The sum total of the work on himself led Jackson to become one of only four (of nineteen) relatedness cases in the overall study group to resolve their issues. He actively terminated, and moved on to community college. The question that never directly entered the therapy per se was the connection between having watched his distraught mother being physically manhandled and emotionally mistreated at a preconscious age, and his overall anxiety issues. While the problem itself was largely bettered, that did take quite a while during which a dangerous moment occurred. Some of the new research on PTSD might shed light on the question. 

Analysis and comments in the next post

#35 – WORKING THRU ADULT AXIS II INVOLVEMENTS

Note:   As a reminder, systematically analyzing the impacts and case management considerations of parental Axis II defense mechanisms occurred recently and not during the practice itself. An awareness of the general problem in each case was certainly there at the time of treatment, and decisions were made during case management in their regard. Nevertheless, the analyses here are made in hindsight, so please take that into account.

As per previous vignettes, ensuing short case summaries are likenesses with altered identifying detail.

Eight cases experienced successful therapy processes while having one adult family member with a potentially disruptive defense mechanism.

Seven of the eight youth had anxiety issues among their presenting problems. Three presented with suicidal ideation, all resolved by treatment’s end. Two had relatedness problems that were also resolved during treatment. They were among the only four out of nineteen relatedness cases to do so.

Five families were intact. The participating parent in the cases of divorced parents were mothers, including one remarried with three more children, one re-partnered for several years, and one single mother. Among the intact families, three of the fathers were the primary caretakers and the primary participating parent. They represented an unusual cluster. In another unusual cluster, all three of the divorced mothers had more resources than the fathers to deal with legal problems involving custody, visitation, and other matters as they arose.

All eight cases had one parent with a likely Axis II involvement. Six were fathers, and two were mothers. The manifested defenses of the fathers included: one with suspiciousness and distrust of positivity; one tending to ignore boundaries; one divorced father in denial, a conclusion presumed via reported patterns that occurred throughout a moderately long therapy in which he did not participate; and three splitters, two with an accompanying aggressiveness, and the other with lying and manipulating. 

Of the two mothers, both of intact families, one had difficulties with boundary recognition and had demanding tendencies. Through the first moderately long process of 34 sessions, she evidenced  vulnerabilities hidden by strengths widely noted in her community.

These eight cases are split into three groups. The first is where the defense itself was accommodated. The second is where the defense was modulated. The last is where the defense was essentially held off.

Accommodated

Piaget postulated that the key to healthy adaption is the ability to both accommodate and assimilate. Roughly translated, accommodation is an adaption to another’s manners or needs, and assimilation is the ability to have others adapt to one’s own. The two opposites are also intrinsic components of therapy, a process whose essential purpose is to enhance the adaptability of individuals and families. In simple terms, the therapist assimilates the client/family into new ways or methods of understanding, changing, and managing their realities, and then accommodate their growth and eventual departure. The exception is that the therapist works to accommodate the client’s particular scheduling and other logistical needs. The clients accommodate the therapist’s process at the outset, and assimilate what’s helpful in order to finish. 

Uncommonly, a parent(s) makes an unconventional stipulation or has an exceptional expectation arcing outside the normal therapy process. Occasionally, the dictum of ‘protecting the process’  enters into the internal deliberation of the clinician and the decision is made to meet the client’s insistence. In hindsight, the decision was often a clinical accommodation to an operative adult Axis II defense.

Two cases involved primary caretaker fathers from intact families who evinced inherent reservations about therapy from the outset. One was retired and the other ran a small consulting business out of the house. The mothers were both involved with time-consuming professional work and could only attend sessions sporadically. The parents were caring for troubled sons, one in latter elementary and the other in junior high. 

The younger of the two boys was described as depressed, anxious, underperforming in school, occasionally contemptuous, often defiant and non-compliant at home, and “in a funk a lot.” The older one was similarly having difficulties with anxiety and depressive symptoms, and internalized the stress through odd and unusual eating habits and physical complaints. 

In hindsight, distrust and suspicion about positivity describes one of the fathers, and boundary recognition was something of a problem for the other. Both of the fathers involved here were well read. During the first meeting, the father of the younger boy matter of factly professed doubts about therapy in general, explaining his reservations in terms of a long-standing conservative perspective. The other father was less explicit, but a similar reservation was palpable. 

Shankar Vedantam’s podcast Hidden Brain is occasionally programmed into NPR’s Weekend Edition. In October, 2018, the presentation was Red Brain Blue Brain, a discussion about certain differences in thinking between conservatives and a liberals based on interesting neurological findings. Briefly, when a human is faced with an ambiguous image, neurological scanning identifies disparate responses in two different parts of the brain. One kind of reaction triggers an alert to possible danger. A distinctly different response in another area of the brain activates a search for more information. Neurologically, self-identified conservatives react with anxiety and prepare to defend, and liberals look for understanding toward compassionate responses. The scanning had very high rates of correct identifications, liberal or conservative.

Understanding that going into therapy for the first time is a novel situation, a conservative ls more inclined to take a stance of self-protection. Convincing them otherwise will more likely be the result of an on-going experience rather than words in the first moments and sessions.

To investigate further and gain something of anthropological-sociological perspective, google Red Brain Blue Brain and listen to Hannah Holmes’ piece from 2014 in addition to Vedantam’s.

An open-ended conjoint process would have been the normal recommendation for both cases. Based on several factors, the prognoses for change and resolution would normally have been good. Not surprisingly in their cases, the initial recommendation for conjoint work was declined by both fathers, something of a rare occurrence among the practice’s general clientele. The self-declared conservative wanted individual work for his son, and inferred an expectation of a short process, i.e. fix the child and finish up. The other father also wanted individual treatment for his boy, but said he may want to occasionally sit in at his own discretion, primarily to observe and “perhaps” to participate. The mothers would occasionally come in fo a session. Those sessions would likely be conjoint, but to be determined. I concurred with both.

For his individual assessment, the younger boy was reluctant just to walk through the door from the waiting room, again somewhat uncharacteristic among the overall clientele. In all of my initial child and adolescent interviews, I used a five-tiered sequence of questions designed to generate discussion about the problems that brought them into the office. Despite his initial hesitations, he began talking freely after the third opening question, which was the most common point where the work began in a case.The notes of the third individual session began by describing the boy talking before the office door was shut and then continued from there through the session. He was easily engaged and wanted to be there. 

The problem set was multiple and serious, but he started making progress fairly quickly. The attitude around home improved via father’s comment, he seemed more cheerful at school by the school counselor’s report, he stopped being sent out of class, and had no repeat of the isolated suicidal thought that led to the therapy. All this occurred over eight weeks of individual work. Several problems, though, including school performance, sleeping, and continued sibling conflict at home remained to be notable concerns. The father, who had been quite pleasant throughout, was satisfied that the changes so far were sufficient and gave two weeks notice. He knew the door was open, and given the experience they both had, would probably be more amenable if the suicidal thoughts or some new manifestation of the boy’s discontent arose.

The junior high student made surprising gains over a twenty session process, the CGAS score eventually moving two deciles from 53 to 73. His progress was verified by teachers via the school counselor. Class-based friendships primarily with female desk mates at school, one of whom was a class leader, developed. The male peer mockery and intimidation subsequently dissipated. For the most part, the clinical work was individual. The sick days and in-school visits to the nurse’s office decreased and eventually stopped, and his appetite eccentricities seemed to abate. The father stayed in the waiting room through the first half dozen sessions. The mother came twice, once for an interim review and once for a conjoint session. 

The father began to sit in every other session or so, adding to the narrative on occasion. As per his stated intent, though, he mostly sat further away and observed. When he first did so, the son looked nervous. Rather that woking to involve the father, I asked the boy somewhat light-heartedly if he was concerned his father was judging him. He glanced at his dad and nodded toward me. Without looking at the father, I came back that the father wasn’t there to judge him, but rather he was judging me, and that was fine. Then I looked at the father and he smiled a nod and the boy audibly breathed relief.  Come the twentieth session, the father inaugurated a discussion about stopping. After a good discussion, we agreed to do so in three weeks. I contacted the school counselor, who checked with the teacher, and his progress was confirmed. 

The father sat out the next session, but on the 22d session came in, pulled out a book, and read throughout most of the session. His uncomfortable presence suggested that something of importance had been missed – that was clear – but this being the next-to-last session, the clinical choice was to ignore the behavior and continue consolidating the gains. Keep the door open. The final session unfolded as per usual by reviewing the process, gains, continuing growth, and what to monitor, then more informally fielding remaining questions and exchanging thanks. The boy had always readily talked and continued to the end. The father was more reserved, as always, but mutedly appreciative. Something didn’t feel quite right.

Now in the hindsight of several years and given the odd reaction to the pending termination, attempting to do some family-of-origin narrative work at some point in the process with the father, to explore the possibility of unresolved loss, might have been fruitful. The problem was the accommodated boundary issue that led him to be essentially unavailable, but I did not do enough to assimilate him over the course of treatment. But then, the progress had been really good all along.

Both cases involved accommodating the wishes of defensive fathers. Neither ended like mutually agreed-upon terminations usually do, but at least their progress got as far as it did. Thus the door was feasibly left open for both, and the father of the ten-session case did call three years later to have his younger son seen. That therapy was conjoint with sufficient time to achieve much more in the way of significant gains than the boy’s older brother. In an interesting aside, the process of nineteen sessions incorporated a time-limited therapy approach due to my planned retirement. The father becoming energetically involved and helpful to the point where he was the key to processing a reenactment of the presenting problem, a predictable phenomena of the time-limited approach, a few weeks before the last session. His change was really appreciable.

Modulated

Therapy can help modulate a parent’s own patterns of relatedness that the child may be modeling, or enable the child to be less influenced by patterns that are likely to persist. These three cases involved processes that helped reduce the parent’s defense mechanism itself or mitigated its impact. With the two cases where the Axis II problem itself lessened, one was  through direct work with parent and the other was done through the participating parent. In the third case, the latter adolescent’s age-appropriate individuation and enhanced coping skills reduced the impacts of a defense that was not likely to change in and of itself. 

The work is fairly straight forward. Nevertheless, a bit of caution is advised. The psychotherapy business tends to be mistake-intolerant, but this quality can be more acute when Axis II issues are involved. 

The cases involved boys aged 9, 14, and 20 at termination. Coincidently, each boy was experiencing more depression than anxiety, but both emotional problems were clinically significant. One client returned to therapy after becoming seriously suicidal some four years following his first process, one that terminated with modest gains.  the other two were defiant at home and socially isolated, and one of those was non-compliant at school as well. He would have been seen as oppositional-defiant disordered, but lacked the vindictive and spiteful qualities. He was basically disruptive.

All three were intact families, and importantly, all three involved stable marriages, jobs, and resources. Two of the cases were split processes where the case returned to therapy for continued work, including the client who became suicidal. All three cases were relatively long term, each using more than 35 sessions. Patience is at a premium with this kind of work. These cases represent different methods by which the relevant clinical goal of the child’s mental health betterment can be achieved. 

The problems being experienced by the clients could be at least partially attributed to parental Axis II patterns. Two cases had a parent displaying aggressiveness, one of them contemptuousness as well. Both of those children were modeling their respective parents, one a non-participating father and the other a participating mother. The third case involved a parent with difficulties focusing on the ‘other’ in the context of the self-and-other paradigm.

Directly helping the parent change some of their patterns generated by Axis II traits can be done through conjoint family work, which is certainly preferable, or during individual counseling as part of a split session process. The split-session format is where the child and parent are seen individually during the hour. The mother who was modeling the aggressive and demanding traits  both at home and toward the child’s school could be a typical situation of this group. The elementary-aged boy had become defiant in both settings and and socially isolated. That particular therapy was conjoint throughout. With supportive discussions that included observations from both husband and son during the family sessions. The mother developed alternate ways to have her concerns addressed. In doing so, that the mother changed enough to provide a sufficiently different model that the boy began to assume with both parents’ support and guidance.

 In another type of case, the parent of concern is not participating in the therapy. In this particular instance a father presumed to be ego-syntonic (‘that’s just who I am’) by description.     He was modeling aggressiveness and contemptuousness. The boy had experienced multiple disciplinary actions from teachers and social rejection in multiple settings for similar behaviors. 

As usual in the situation where one parent is participating in therapy and the other is not, the participating parent customarily relays the content of sessions to the spouse. 

Over time, information arising from the therapy includes possible connections between the client’s behaviors and those of the non-participating parent. The impact could be either modeling or conditioning. The participating parent is acting as a kind of clinical surrogate. The therapist helps shape the information being conveyed. The client made his changes quite deliberately, although a significant part of a motivation was to get out of therapy that did not abate much. But he did make changes, as did th father o some degree, as per the mother’s report.

The third is where the client – usually a latter adolescent – works toward individuating and coming to acceptable terms with the parent of concern. This particular case involved a latter adolescent struggling to pursue independence from an somewhat unrequited maternal relationship.

Clinical Considerations

The adult trait/defense problem itself may be best left off the problem list, both in practice and in notes. 

Approach the issues in behavioral terms, both in definition and outcome, both in practice and  also in clinical notes. The guiding dictum is to always make records assuming your client(s) is looking over your shoulder.

In doing child, adolescent, and family work, the first consideration is, obviously, the clinical needs of the youth, your client. The second consideration is the mother – father – child triangle. The basic guiding principle of healthcare being ‘first do no harm’, clinical actions best take into account each side of the triangle.The actions taken are either neutral or supportive to each of the three relationships. Weakening of any side to the triangle as a result of therapeutic input is a problem to the therapy itself, and so ultimately to the child. Do not harm.

Marital stability is requisite for the participating parent to be an informal surrogate. A solid relationship can be enhanced, but a fractured one can be riven.

With latter adolescence, encourage autonomy and independent problem solving

Stress with fathers the importance of expressing approval to their children.

Socio-cognitive work that is focused on the child or adolescent can be equally impactful on the parent(s). The exercise of the child imagining or guessing what the particular parent thought and felt about a problem of one sort or another is a learning experience for the parents as well. They can be asked to reciprocate. The therapist guides as passively as possible.  For most parents, the socio-cognitive work on their part is more or less routine. For parents who struggle in their own relationships, the process can be educative in and of itself. A significant side benefit to this tool is a language shaping process that focuses on the differentiation of thoughts and feelings, again assisted by the therapist. This bit of work in particular facilitates clear communication throughout the therapy.

Reinforce the parents’ coming recognitions of their own patterns and their impacts. The question is whether to do that in front of the child or separately. That decision is mostly one of clinical intuition, so trust your instinct. When in doubt, save the reinforcement for a private moment.

Avoid reinforcing a youth’s anger toward their parents or redefining their feelings as being anger 

toward one or the other or both, particularly so toward mothers. One approach could be a language shaping technique of converting the discussion from anger to worry, guilt, or sadness, and follow that particular path to some kind of inner peace or relational resolution.

Hyacinth

About fifteen years, a high school counselor referred a senior girl for problems with considerable anxiety that included school absences as a result. She had approached the counselor for advice about depressive symptoms that included sleep difficulties and an inability to concentrate. The combination of the two issues led to the referral.

The student was the first of four children spaced over nine years. The younger siblings were all boys. The father was an associate dean at a Seattle university, and the mother was a nursing home finance director who wanted to create a business out of her passion for horticulture. Their daughter’s name was Hyacinth, after the hardy, fragrant Eastern Mediterranean flower of many brightly colored varieties. In mythology, the plant represents rebirth and spring, apparently to be handled with care lest the bulb irritate the skin. The young woman was known as Cintha.

The family lived a traditional arrangement. The mother tended more to the domestic side of life, the father on the durable support of house, home, lifestyle, and future, but sharing back and forth was part and parcel of their pact. The mother and daughter tangled quite a bit, particularly as she reached adolescence. The father provided a balancing impact within that triangle. The boys tended to be more self-directed. By all accounts, the marriage was stable, communicative, and meaningful. The family was cerebral. Cintha could be stubborn.That quality may have added to family tensions, but carried her through truly difficult times over her college years in Seattle. If hyacinths are stubborn plants, as they apparently are, she and her mother differed by shades of a same color.

Beginning in mid-elementary school, my client began to have symptoms like small phobias and terrors. Socially adept with girlfriends throughout her life and boyfriends beginning in ninth grade, she nevertheless began to avoid social activities and parties in addition to family activities, restaurants outings, and extra-curricular activities in order to cope with anxiety attacks. Beginning in tenth grade, her school performance began to suffer. When the problems escalated to include school refusal, physical complaints, a couple of trips to the ER, and frequent visits to the nurses office, the parents sought psychiatric help. A year later she was referred to me.

Cintha’s diagnosis was and remained to be Panic Disorder. She began psychotropic treatments which increased over time in the variety and quantity of medications prescribed, a trajectory that continued well into the five + years that she came to the office. Whatever the exact anxiety problem was, her multi-pronged malady was  complicated and seemed to be beyond one particular diagnosis.

Because the primary intervention was psychiatric, the focus of the outpatient therapy was not the anxiety per se, but rather for support and guidance as she moved through an important year in her education, and as she emancipated through her college years. She indicated a preference for individual work from the outset, but was amenable to being seen with her parents. All three were not interested in having the brothers join the family work. My preference would be to see all five, but their wishes governed. In hindsight, they were right. For the first sixteen months, the work was primarily with the triangle.

Over the first two to three months, a mild to moderate decrease in overall anxiety occurred. Two instances which would have normally resulted in a trip to the ER were managed at home. A two to three week period passed with no panic attacks. School absences decreased. Grades started to rise again, particularly important for college applications in the process of being considered. She ended the relationship with her boyfriend and withstood the loss. 

At the same time, anxiety remained the dominant problem for both her and the family. The pharmacological treatment was still searching for an optimal combination of meds. Her relational problem was with the mother, and like the psychiatric portion of her treatment, the family therapy was essentially searching as well. The three never wavered in support of the processes. 

Now after several months and almost twenty sessions, mother and daughter had been doing somewhat better together. High school was nearing an end, Cintha’s grades were up, a new boyfriend was in her life, and she’d been accepted to a quality university in New York City, the one place outside of Seattle she had yearned to be. NYC never did pan out. Family concerns about finances and distance overrode the dream, as those kinds of concerns have a way of doing, but that was to come later. She accepted the disappointment. The mother was slowing the tempo of her parenting while under duress.

As usual, we’re sitting in a sort of square arrangement, Cintha and mother on the couch, the father in a chair to my left, and me in a stuffed rocker circa 1920. The sheer amount of time together did bring a measure of comfort among us. The clinical benefit of all that work is that comfort buys latitude. The week had been testy, including a number of disputes over time with new boyfriend, uncompleted chores and other household help, completing schoolwork, and handling bursts of anxiety. The metaphorical picture left was that of mother laying down the law, leaving the room shaking her head, and Cintha left smoldering. 

What to do? Now only a month before graduation and by design finishing up the family portion of therapy, we’d done this before. now only a month to graduation. Mentally scanning for an interventional path for a few seconds, probably scratching my forehead, nothing but a blank slate. The benefit of latitude emerged. 

I looked at Cintha and said “So, what’s the problem with someone being angry with their mother…a lot?”

I had completely no idea what I was doing, but this being a family that dwelt well in the abstract, maybe they could figure this out. None of them skipped a beat – for all they knew, this was just normal therapy. Unfortunately, I can’t remember Cintha’s exact response and didn’t make a note later, but her answer was too concrete. So I explained why the response really didn’t deal with the question, and repeated the question again. Again the answer was not going to work, and I explained and repeated the question again. I noticed out of the corner of my eye that the father squirmed a bit. That was actually notable because he was a still sitter. 

Another answer which still didn’t do. Cintha and mother were still focused and interested, so I plowed ahead and repeated the question a fourth time.The father squirmed around even more. Cintha tried another answer which still fell short of some completely unknown point, and I knew this was going to be pushing things, but, you know, comfort is comfort although comfort miscalculated could be a bomb but, well… just this one more time. Repeated.

In his soft academic manner, the father just exploded “Because if you stay angry with your mother, she will abandon you and you’ll die!”.

I was in awe, and “Where did you get that from?”

The father shrugged with raised palms and the accompanying pursed smile of modesty, and said “From the Discovery Channel.” 

So, the question had some substance after all. However metaphorical for human beings the Discovery Channel’s piece may have been, the answer provided an indelible image – don’t take family relationships for granted. Some additional importance may exist for the mother – daughter dyad in particular. Their ability to resolve problems in equitable terms and remain emotionally connected may be the most important model for a species that struggles in its organization. 

Unfortunately, I can’t remember the segue from there that night, that moment had to have had an intrinsic value within this circumstance. The process continued as per usual thereafter. I

think the line was used as a reference a couple of times during the remaining few conjoint sessions. On its face, the clinical event that night did not seem to be a corrective emotional experience or provide a tectonic movement of the psyches, but to be fair, a lot was going on with graduation nearing and a shift in the therapy format on the horizon. I do think the father’s answer caused both mother and daughter to step back a bit and look at what each themselves were doing. If that occurred, the episode may have been as important as anything else. 

Some years after she graduated from college and finished with me, I crossed paths with Cintha in Seattle and spent a couple of minutes. She had gone into mental health work for a community mental health organization. Being smart, industrious, compassionate, and un deterrable, a template of millennial women, she could do well there. She still had problems with anxiety, still taking medications, but managing much better.

Her relationship with her mother? With the tiniest hint of a sigh, “Well, there’s still stuff there, but things really are better”, said without any hint of the frustration and even bitterness that would have characterized a response to the question years earlier.

“Counseling helped.”

Note: The last three cases in this group of eight will constitute the next post.

#35  – Working Through Axis II  – Cases With Significant Gains

Note:   As a reminder, systematically analyzing the impacts and case management considerations of parental Axis II defense mechanisms occurred recently and not during the practice itself. An awareness of the general problem in each case was certainly there at the time of treatment, and decisions were made during case management in their regard. Nevertheless, the analyses here are made in hindsight, so please take that into account.

As per previous vignettes, ensuing short case summaries are likenesses with altered identifying detail.

Eight cases experienced successful therapy processes while having one adult family member with a potentially disruptive defense mechanism.

Seven of the eight youth had anxiety issues among their presenting problems. Three presented with suicidal ideation, all resolved by treatment’s end. Two had relatedness problems that were also resolved during treatment. They were among the only four out of nineteen relatedness cases to do so.

Five families were intact. The participating parent in the cases of divorced parents were mothers, including one remarried with three more children, one re-partnered for several years, and one single mother. Among the intact families, three of the fathers were the primary caretakers and the primary participating parent. They represented an unusual cluster. In another unusual cluster, all three of the divorced mothers had more resources than the fathers to deal with legal problems involving custody, visitation, and other matters as they arose.

All eight cases had one parent with a likely Axis II involvement. Six were fathers, and two were mothers. The manifested defenses of the fathers included: one with suspiciousness and distrust of positivity; one tending to ignore boundaries; one divorced father in denial, a conclusion presumed via reported patterns that occurred throughout a moderately long therapy in which he did not participate; and three splitters, two with an accompanying aggressiveness, and the other with lying and manipulating. 

Of the two mothers, both of intact families, one had difficulties with boundary recognition and had demanding tendencies. Through the first moderately long process of 34 sessions, she evidenced  vulnerabilities hidden by strengths widely noted in her community.

These eight cases are split into three groups. The first is where the defense itself was accommodated. The second is where the defense was modulated. The last is where the defense was essentially held off.

Accommodated

Piaget postulated that the key to healthy adaption is the ability to both accommodate and assimilate. Roughly translated, accommodation is an adaption to another’s manners or needs, and assimilation is the ability to have others adapt to one’s own. The two opposites are also intrinsic components of therapy, a process whose essential purpose is to enhance the adaptability of individuals and families. In simple terms, the therapist assimilates the client/family into new ways or methods of understanding, changing, and managing their realities, and then accommodate their growth and eventual departure. The exception is that the therapist works to accommodate the client’s particular scheduling and other logistical needs. The clients accommodate the therapist’s process at the outset, and assimilate what’s helpful in order to finish. 

Uncommonly, a parent(s) makes an unconventional stipulation or has an exceptional expectation arcing outside the normal therapy process. Occasionally, the dictum of ‘protecting the process’  enters into the internal deliberation of the clinician and the decision is made to meet the client’s insistence. In hindsight, the decision was often a clinical accommodation to an operative adult Axis II defense.

Two cases involved primary caretaker fathers from intact families who evinced inherent reservations about therapy from the outset. One was retired and the other ran a small consulting business out of the house. The mothers were both involved with time-consuming professional work and could only attend sessions sporadically. The parents were caring for troubled sons, one in latter elementary and the other in junior high. 

The younger of the two boys was described as depressed, anxious, underperforming in school, occasionally contemptuous, often defiant and non-compliant at home, and “in a funk a lot.” The older one was similarly having difficulties with anxiety and depressive symptoms, and internalized the stress through odd and unusual eating habits and physical complaints. 

In hindsight, distrust and suspicion about positivity describes one of the fathers, and boundary recognition was something of a problem for the other. Both of the fathers involved here were well read. During the first meeting, the father of the younger boy matter of factly professed doubts about therapy in general, explaining his reservations in terms of a long-standing conservative perspective. The other father was less explicit, but a similar reservation was palpable. 

Shankar Vedantam’s podcast Hidden Brain is occasionally programmed into NPR’s Weekend Edition. In October, 2018, the presentation was Red Brain Blue Brain, a discussion about certain differences in thinking between conservatives and a liberals based on interesting neurological findings. Briefly, when a human is faced with an ambiguous image, neurological scanning identifies disparate responses in two different parts of the brain. One kind of reaction triggers an alert to possible danger. A distinctly different response in another area of the brain activates a search for more information. Neurologically, self-identified conservatives react with anxiety and prepare to defend, and liberals look for understanding toward compassionate responses. The scanning had very high rates of correct identifications, liberal or conservative.

Understanding that going into therapy for the first time is a novel situation, a conservative ls more inclined to take a stance of self-protection. Convincing them otherwise will more likely be the result of an on-going experience rather than words in the first moments and sessions.

To investigate further and gain something of anthropological-sociological perspective, google Red Brain Blue Brain and listen to Hannah Holmes’ piece from 2014 in addition to Vedantam’s.

An open-ended conjoint process would have been the normal recommendation for both cases. Based on several factors, the prognoses for change and resolution would normally have been good. Not surprisingly in their cases, the initial recommendation for conjoint work was declined by both fathers, something of a rare occurrence among the practice’s general clientele. The self-declared conservative wanted individual work for his son, and inferred an expectation of a short process, i.e. fix the child and finish up. The other father also wanted individual treatment for his boy, but said he may want to occasionally sit in at his own discretion, primarily to observe and “perhaps” to participate. The mothers would occasionally come in fo a session. Those sessions would likely be conjoint, but to be determined. I concurred with both.

For his individual assessment, the younger boy was reluctant just to walk through the door from the waiting room, again somewhat uncharacteristic among the overall clientele. In all of my initial child and adolescent interviews, I used a five-tiered sequence of questions designed to generate discussion about the problems that brought them into the office. Despite his initial hesitations, he began talking freely after the third opening question, which was the most common point where the work began in a case.The notes of the third individual session began by describing the boy talking before the office door was shut and then continued from there through the session. He was easily engaged and wanted to be there. 

The problem set was multiple and serious, but he started making progress fairly quickly. The attitude around home improved via father’s comment, he seemed more cheerful at school by the school counselor’s report, he stopped being sent out of class, and had no repeat of the isolated suicidal thought that led to the therapy. All this occurred over eight weeks of individual work. Several problems, though, including school performance, sleeping, and continued sibling conflict at home remained to be notable concerns. The father, who had been quite pleasant throughout, was satisfied that the changes so far were sufficient and gave two weeks notice. He knew the door was open, and given the experience they both had, would probably be more amenable if the suicidal thoughts or some new manifestation of the boy’s discontent arose.

The junior high student made surprising gains over a twenty session process, the CGAS score eventually moving two deciles from 53 to 73. His progress was verified by teachers via the school counselor. Class-based friendships primarily with female desk mates at school, one of whom was a class leader, developed. The male peer mockery and intimidation subsequently dissipated. For the most part, the clinical work was individual. The sick days and in-school visits to the nurse’s office decreased and eventually stopped, and his appetite eccentricities seemed to abate. The father stayed in the waiting room through the first half dozen sessions. The mother came twice, once for an interim review and once for a conjoint session. 

The father began to sit in every other session or so, adding to the narrative on occasion. As per his stated intent, though, he mostly sat further away and observed. When he first did so, the son looked nervous. Rather that woking to involve the father, I asked the boy somewhat light-heartedly if he was concerned his father was judging him. He glanced at his dad and nodded toward me. Without looking at the father, I came back that the father wasn’t there to judge him, but rather he was judging me, and that was fine. Then I looked at the father and he smiled a nod and the boy audibly breathed relief.  Come the twentieth session, the father inaugurated a discussion about stopping. After a good discussion, we agreed to do so in three weeks. I contacted the school counselor, who checked with the teacher, and his progress was confirmed. 

The father sat out the next session, but on the 22d session came in, pulled out a book, and read throughout most of the session. His uncomfortable presence suggested that something of importance had been missed – that was clear – but this being the next-to-last session, the clinical choice was to ignore the behavior and continue consolidating the gains. Keep the door open. The final session unfolded as per usual by reviewing the process, gains, continuing growth, and what to monitor, then more informally fielding remaining questions and exchanging thanks. The boy had always readily talked and continued to the end. The father was more reserved, as always, but mutedly appreciative. Something didn’t feel quite right.

Now in the hindsight of several years and given the odd reaction to the pending termination, attempting to do some family-of-origin narrative work at some point in the process with the father, to explore the possibility of unresolved loss, might have been fruitful. The problem was the accommodated boundary issue that led him to be essentially unavailable, but I did not do enough to assimilate him over the course of treatment. But then, the progress had been really good all along.

Both cases involved accommodating the wishes of defensive fathers. Neither ended like mutually agreed-upon terminations usually do, but at least their progress got as far as it did. Thus the door was feasibly left open for both, and the father of the ten-session case did call three years later to have his younger son seen. That therapy was conjoint with sufficient time to achieve much more in the way of significant gains than the boy’s older brother. In an interesting aside, the process of nineteen sessions incorporated a time-limited therapy approach due to my planned retirement. The father becoming energetically involved and helpful to the point where he was the key to processing a reenactment of the presenting problem, a predictable phenomena of the time-limited approach, a few weeks before the last session. His change was really appreciable.

Modulated

Therapy can help modulate a parent’s own patterns of relatedness that the child may be modeling, or enable the child to be less influenced by patterns that are likely to persist. These three cases involved processes that helped reduce the parent’s defense mechanism itself or mitigated its impact. With the two cases where the Axis II problem itself lessened, one was  through direct work with parent and the other was done through the participating parent. In the third case, the latter adolescent’s age-appropriate individuation and enhanced coping skills reduced the impacts of a defense that was not likely to change in and of itself. 

The work is fairly straight forward. Nevertheless, a bit of caution is advised. The psychotherapy business tends to be mistake-intolerant, but this quality can be more acute when Axis II issues are involved. 

The cases involved boys aged 9, 14, and 20 at termination. Coincidently, each boy was experiencing more depression than anxiety, but both emotional problems were clinically significant. One client returned to therapy after becoming seriously suicidal some four years following his first process, one that terminated with modest gains.  the other two were defiant at home and socially isolated, and one of those was non-compliant at school as well. He would have been seen as oppositional-defiant disordered, but lacked the vindictive and spiteful qualities. He was basically disruptive.

All three were intact families, and importantly, all three involved stable marriages, jobs, and resources. Two of the cases were split processes where the case returned to therapy for continued work, including the client who became suicidal. All three cases were relatively long term, each using more than 35 sessions. Patience is at a premium with this kind of work. These cases represent different methods by which the relevant clinical goal of the child’s mental health betterment can be achieved. 

The problems being experienced by the clients could be at least partially attributed to parental Axis II patterns. Two cases had a parent displaying aggressiveness, one of them contemptuousness as well. Both of those children were modeling their respective parents, one a non-participating father and the other a participating mother. The third case involved a parent with difficulties focusing on the ‘other’ in the context of the self-and-other paradigm.

Directly helping the parent change some of their patterns generated by Axis II traits can be done through conjoint family work, which is certainly preferable, or during individual counseling as part of a split session process. The split-session format is where the child and parent are seen individually during the hour. The mother who was modeling the aggressive and demanding traits  both at home and toward the child’s school could be a typical situation of this group. The elementary-aged boy had become defiant in both settings and and socially isolated. That particular therapy was conjoint throughout. With supportive discussions that included observations from both husband and son during the family sessions. The mother developed alternate ways to have her concerns addressed. In doing so, that the mother changed enough to provide a sufficiently different model that the boy began to assume with both parents’ support and guidance.

 In another type of case, the parent of concern is not participating in the therapy. In this particular instance a father presumed to be ego-syntonic (‘that’s just who I am’) by description.     He was modeling aggressiveness and contemptuousness. The boy had experienced multiple disciplinary actions from teachers and social rejection in multiple settings for similar behaviors. 

As usual in the situation where one parent is participating in therapy and the other is not, the participating parent customarily relays the content of sessions to the spouse. 

Over time, information arising from the therapy includes possible connections between the client’s behaviors and those of the non-participating parent. The impact could be either modeling or conditioning. The participating parent is acting as a kind of clinical surrogate. The therapist helps shape the information being conveyed. The client made his changes quite deliberately, although a significant part of a motivation was to get out of therapy that did not abate much. But he did make changes, as did th father o some degree, as per the mother’s report.

The third is where the client – usually a latter adolescent – works toward individuating and coming to acceptable terms with the parent of concern. This particular case involved a latter adolescent struggling to pursue independence from an somewhat unrequited maternal relationship.

Clinical Considerations

The adult trait/defense problem itself may be best left off the problem list, both in practice and in notes. 

Approach the issues in behavioral terms, both in definition and outcome, both in practice and  also in clinical notes. The guiding dictum is to always make records assuming your client(s) is looking over your shoulder.

In doing child, adolescent, and family work, the first consideration is, obviously, the clinical needs of the youth, your client. The second consideration is the mother – father – child triangle. The basic guiding principle of healthcare being ‘first do no harm’, clinical actions best take into account each side of the triangle.The actions taken are either neutral or supportive to each of the three relationships. Weakening of any side to the triangle as a result of therapeutic input is a problem to the therapy itself, and so ultimately to the child. Do not harm.

Marital stability is requisite for the participating parent to be an informal surrogate. A solid relationship can be enhanced, but a fractured one can be riven.

With latter adolescence, encourage autonomy and independent problem solving

Stress with fathers the importance of expressing approval to their children.

Socio-cognitive work that is focused on the child or adolescent can be equally impactful on the parent(s). The exercise of the child imagining or guessing what the particular parent thought and felt about a problem of one sort or another is a learning experience for the parents as well. They can be asked to reciprocate. The therapist guides as passively as possible.  For most parents, the socio-cognitive work on their part is more or less routine. For parents who struggle in their own relationships, the process can be educative in and of itself. A significant side benefit to this tool is a language shaping process that focuses on the differentiation of thoughts and feelings, again assisted by the therapist. This bit of work in particular facilitates clear communication throughout the therapy.

Reinforce the parents’ coming recognitions of their own patterns and their impacts. The question is whether to do that in front of the child or separately. That decision is mostly one of clinical intuition, so trust your instinct. When in doubt, save the reinforcement for a private moment.

Avoid reinforcing a youth’s anger toward their parents or redefining their feelings as being anger 

toward one or the other or both, particularly so toward mothers. One approach could be a language shaping technique of converting the discussion from anger to worry, guilt, or sadness, and follow that particular path to some kind of inner peace or relational resolution.

Hyacinth

About fifteen years, a high school counselor referred a senior girl for problems with considerable anxiety that included school absences as a result. She had approached the counselor for advice about depressive symptoms that included sleep difficulties and an inability to concentrate. The combination of the two issues led to the referral.

The student was the first of four children spaced over nine years. The younger siblings were all boys. The father was an associate dean at a Seattle university, and the mother was a nursing home finance director who wanted to create a business out of her passion for horticulture. Their daughter’s name was Hyacinth, after the hardy, fragrant Eastern Mediterranean flower of many brightly colored varieties. In mythology, the plant represents rebirth and spring, apparently to be handled with care lest the bulb irritate the skin. The young woman was known as Cintha.

The family lived a traditional arrangement. The mother tended more to the domestic side of life, the father on the durable support of house, home, lifestyle, and future, but sharing back and forth was part and parcel of their pact. The mother and daughter tangled quite a bit, particularly as she reached adolescence. The father provided a balancing impact within that triangle. The boys tended to be more self-directed. By all accounts, the marriage was stable, communicative, and meaningful. The family was cerebral. Cintha could be stubborn.That quality may have added to family tensions, but carried her through truly difficult times over her college years in Seattle. If hyacinths are stubborn plants, as they apparently are, she and her mother differed by shades of a same color.

Beginning in mid-elementary school, my client began to have symptoms like small phobias and terrors. Socially adept with girlfriends throughout her life and boyfriends beginning in ninth grade, she nevertheless began to avoid social activities and parties in addition to family activities, restaurants outings, and extra-curricular activities in order to cope with anxiety attacks. Beginning in tenth grade, her school performance began to suffer. When the problems escalated to include school refusal, physical complaints, a couple of trips to the ER, and frequent visits to the nurses office, the parents sought psychiatric help. A year later she was referred to me.

Cintha’s diagnosis was and remained to be Panic Disorder. She began psychotropic treatments which increased over time in the variety and quantity of medications prescribed, a trajectory that continued well into the five + years that she came to the office. Whatever the exact anxiety problem was, her multi-pronged malady was  complicated and seemed to be beyond one particular diagnosis.

Because the primary intervention was psychiatric, the focus of the outpatient therapy was not the anxiety per se, but rather for support and guidance as she moved through an important year in her education, and as she emancipated through her college years. She indicated a preference for individual work from the outset, but was amenable to being seen with her parents. All three were not interested in having the brothers join the family work. My preference would be to see all five, but their wishes governed. In hindsight, they were right. For the first sixteen months, the work was primarily with the triangle.

Over the first two to three months, a mild to moderate decrease in overall anxiety occurred. Two instances which would have normally resulted in a trip to the ER were managed at home. A two to three week period passed with no panic attacks. School absences decreased. Grades started to rise again, particularly important for college applications in the process of being considered. She ended the relationship with her boyfriend and withstood the loss. 

At the same time, anxiety remained the dominant problem for both her and the family. The pharmacological treatment was still searching for an optimal combination of meds. Her relational problem was with the mother, and like the psychiatric portion of her treatment, the family therapy was essentially searching as well. The three never wavered in support of the processes. 

Now after several months and almost twenty sessions, mother and daughter had been doing somewhat better together. High school was nearing an end, Cintha’s grades were up, a new boyfriend was in her life, and she’d been accepted to a quality university in New York City, the one place outside of Seattle she had yearned to be. NYC never did pan out. Family concerns about finances and distance overrode the dream, as those kinds of concerns have a way of doing, but that was to come later. She accepted the disappointment. The mother was slowing the tempo of her parenting while under duress.

As usual, we’re sitting in a sort of square arrangement, Cintha and mother on the couch, the father in a chair to my left, and me in a stuffed rocker circa 1920. The sheer amount of time together did bring a measure of comfort among us. The clinical benefit of all that work is that comfort buys latitude. The week had been testy, including a number of disputes over time with new boyfriend, uncompleted chores and other household help, completing schoolwork, and handling bursts of anxiety. The metaphorical picture left was that of mother laying down the law, leaving the room shaking her head, and Cintha left smoldering. 

What to do? Now only a month before graduation and by design finishing up the family portion of therapy, we’d done this before. now only a month to graduation. Mentally scanning for an interventional path for a few seconds, probably scratching my forehead, nothing but a blank slate. The benefit of latitude emerged. 

I looked at Cintha and said “So, what’s the problem with someone being angry with their mother…a lot?”

I had completely no idea what I was doing, but this being a family that dwelt well in the abstract, maybe they could figure this out. None of them skipped a beat – for all they knew, this was just normal therapy. Unfortunately, I can’t remember Cintha’s exact response and didn’t make a note later, but her answer was too concrete. So I explained why the response really didn’t deal with the question, and repeated the question again. Again the answer was not going to work, and I explained and repeated the question again. I noticed out of the corner of my eye that the father squirmed a bit. That was actually notable because he was a still sitter. 

Another answer which still didn’t do. Cintha and mother were still focused and interested, so I plowed ahead and repeated the question a fourth time.The father squirmed around even more. Cintha tried another answer which still fell short of some completely unknown point, and I knew this was going to be pushing things, but, you know, comfort is comfort although comfort miscalculated could be a bomb but, well… just this one more time. Repeated.

In his soft academic manner, the father just exploded “Because if you stay angry with your mother, she will abandon you and you’ll die!”.

I was in awe, and “Where did you get that from?”

The father shrugged with raised palms and the accompanying pursed smile of modesty, and said “From the Discovery Channel.” 

So, the question had some substance after all. However metaphorical for human beings the Discovery Channel’s piece may have been, the answer provided an indelible image – don’t take family relationships for granted. Some additional importance may exist for the mother – daughter dyad in particular. Their ability to resolve problems in equitable terms and remain emotionally connected may be the most important model for a species that struggles in its organization. 

Unfortunately, I can’t remember the segue from there that night, that moment had to have had an intrinsic value within this circumstance. The process continued as per usual thereafter. I

think the line was used as a reference a couple of times during the remaining few conjoint sessions. On its face, the clinical event that night did not seem to be a corrective emotional experience or provide a tectonic movement of the psyches, but to be fair, a lot was going on with graduation nearing and a shift in the therapy format on the horizon. I do think the father’s answer caused both mother and daughter to step back a bit and look at what each themselves were doing. If that occurred, the episode may have been as important as anything else. 

Some years after she graduated from college and finished with me, I crossed paths with Cintha in Seattle and spent a couple of minutes. She had gone into mental health work for a community mental health organization. Being smart, industrious, compassionate, and un deterrable, a template of millennial women, she could do well there. She still had problems with anxiety, still taking medications, but managing much better.

Her relationship with her mother? With the tiniest hint of a sigh, “Well, there’s still stuff there, but things really are better”, said without any hint of the frustration and even bitterness that would have characterized a response to the question years earlier.

“Counseling helped.”

Note: The last three cases in this group of eight will constitute the next post.

#34 – Working Through Adult Defenses – Introduction

Introduction

A major thrust of family therapy processes that treat youth mental health problem(s) is the use of the parents as therapeutic surrogates. In essence, the therapist enables the parents to effect and maintain changes for the child via three basic influencers. They include psycho-educational information, conditioning, and modeling.

The educational component includes any information and instruction, presumably evidence or experientially based, that the therapist offers the parents in their role to guide the child’s behavioral improvement, emotional growth, relational skills, and values clarifications. This process can occur either in the child’s presence or separately. My own inclination was to do as much of this work in the child’s presence as possible, but on occasion I’d ask for a few minutes with the parents.

The conditioning is done mostly through reinforcement. The feedback could occur as a result of a suggestion or direction, taking the form of anything from overt praise to a simple nod. The approval could be immediately after something they did differently, or periodically in an effort to maintain an important change. The most powerful reinforcement can be random, unanticipated approval. When parents or children are reporting about events and interactions in between sessions, for example, the therapist can remain alert to opportunities that point out positive differences. The conditioning can also occur via rehearsal, i.e.suggesting they use some tool that has been imparted successfully in the past. The idea to to keep the progress in motion. Giving the feedback in front of the child or privately is a matter of clinical judgement.

Modeling is mostly the result of the observations and absorption by the clients as they experience the therapy process and the therapist themselves. What the therapist does and who they appear to be becomes a subject of scrutiny and conversation within the family, more so in the beginning of a therapy process. What gets said and done in session, what they think the therapist is thinking, how the process seems to work, and what the therapist’s intentions may be are probably typical. Perhaps most importantly, the parents watch how the therapist communicates with the child, how the child responds, and what seems to have been the effect. Most parents look for ways to relate more effectively, and one of the main sources of their own education in therapy is what the therapist does in session that has desired impacts.

Being comfortable with your skills, your purposes, and your self is helpful. An innate enjoyment of kids shows.

In a sense, working through the parents is akin to a research project. The researcher (therapist) guides the behavior of the independent variable (parents) to see what kind of impact the manipulations have on the dependent variable (child or adolescent). An independent variable is assumed to have a certain degree of stability, and the dependent variable has a certain degree of malleability, which is the basis of the therapy. 

In fact, most sets of the parents fit the definition. They may be coming for help, but they tend to be consistent, operate in what they believe to be in the child’s best interests, answer questions to the best of their ability with the needed level of honestly and forthrightness, make good faith efforts to apply the suggestions and recommendations they think can be of help, and provide open feedback about what’s working. Maybe 85% of them.

What happens, though, when one or both of the “independent variables” are actually dependent variables themselves? They have difficulty functioning interactively, cannot differentiate between the needs of their child(ren) and their own, and their own methods do not necessarily work to the advantage of themselves and others at the same time. The problem is prominent when one has some kind of Axis II involvement, exponentially so if both parents are so involved.

Loss or the perceived threat of loss generate a myriad of personal reactions. The perceived threat could be toward: one’s sense of self or identity; the marriage, filiation, or some other aspect of family; one’s personal safety and well-being; possessions and property; or one’s perceived prospects. Part of one’s personality is the array of self-protective defenses that tend to remain constant over time in service to one’s coping. Most of them are within the wide range of norm, generally recognizable and  understandable by others, and usually effective for oneself and those around them. Axis II defense mechanisms that are activated in a therapy process, however, can be difficult to comprehend, difficult to accommodate, and very difficult to either countenance or confront without threatening the family therapy process itself. 

Variables

Defense Mechanisms

The following common Axis II defense mechanisms are compiled by combining two such lists. As with other Axis II traits, employed defenses appear in multiple settings, circumstances, and relationships, are persistent over time, and are generally impervious to self-awareness. Successful Axis II treatment that includes recognizing and overcoming dysfunctional defenses can take years.

Of the overall fifty-six study group cases, eighteen cases (32%) involved parents, step-parents or other parent figures who demonstrated Axis II defense mechanisms that influenced therapy process and case management. Eleven of these thirteen defenses above could be identified among the twenty-four adults involved (twelve cases with one parent and six with both). Because the case selection for this particular evaluation was entirely based on my own judgement in hindsight, previous cautions re: validity and reliability apply.

The two defenses not demonstrated here were suicidal and self destructive behaviors, and extremes of behavior beyond an ability to clinically manage. Over the course of the practice, very few of those particular situations arose. How common or unusual these types of problem defenses appear in outpatient child and adolescent is hard to say. Based on the combined experience of this practice and several hundred consult group case presentations, the these situations are at most uncommon. One case comes to mind as an example of extreme behavior beyond the ability to manage will presented in a brief vignette to follow.

The most common defenses were six cases of a parent being demanding, aggressive, and/or rejecting, and six engaged in splitting. Four appeared to have vulnerabilities hidden by apparent strengths. Clear patterns of manipulating and lying occurred in three. 

Three of the cases involved divorced fathers who evoked splitting, manipulating, and demanding/aggressiveness during the treatment processes. These particular cases were among the most difficult type to simply experience. A case vignette in a following post will elaborate.

Psychological Impacts

Another defining factor in these case analyses is the impact that the family dynamics have on the young clients themselves. In doing so, the following typology of psychological mistreatment is offered as definitional system. 

The source of this definition is “The Psychologically Battered Child”; Garbarino, Guttmann, and Seeley; Jossey-Bass: 1986. James Garbarino was among the first and foremost researchers in the field of of child abuse and neglect. Beginning in the late 60’s, most research in the field focused on physical child abuse and neglect. While a significant social concern, the definition of psychological abuse and neglect was somewhat amorphous, and the acts were generally not reportable to state children’s protective services. This book helped make that intervention more feasible. 

Outlining these five types remains to be a most helpful delineation of the problem. “Battered” is a strong word, and, as applied to the eighteen kids in this study sub-group, could be seen as a little hyperbolic. Particularly, though, in the context of persistent and sometimes volatile struggles between parents over marriage and parenting, custody disputes, or post-divorce child management conflicts that includes heated disagreements about counseling, the child can feel battered, i.e. feel rejected, isolated, ignored, or terrorized as a result of a parent or a couple’s behaviors. From a clinical perspective, the issue is not so much the specific commissions or omissions of the parent, which may not rise to the level of these definitions, as much as how the child’s feelings about themselves and their world evolve, which can rise to those levels. The younger the child, the more difficult the psychological task of sorting through these experiences and feelings.

Case Outcomes  

The same basic therapy approach, a recursive kind of process developed over the years, was the same for all eighteen cases. The parents were seen first appointment, and the child or adolescent of concern for the second. Perhaps 5% of the youth assessments took two sessions to complete. The third was with the parents again for a summary, recommendations, and planning session. The fourth was generally conjoint, including as many siblings as feasible and designed to create a universal baseline for the case by identifying what people wanted to see get better. The fifth and sixth were usually conjoint as well, designed to begin reinforcing change and inculcate the therapy process itself. Cases began to differentiate in terms of format (described in Post 13), thereafter. The few exceptions were usually older adolescents who initiated counseling themselves and were intent on being seen individually. Under those circumstances, that assessment process was abbreviated into two sessions before the therapy, per se, begin.

For the purposes of the analysis, the eighteen cases are divided into four groups. Eight completed successful therapy processes. The other three groups had outcomes less favorable. They included: four cases that unilaterally terminated with moderate to poor clinical results, all embroiled in contention and conflict in which Axis II issues were central and proved difficult to resolve; two cases that ended due largely to chaotic and clinically unmanageable circumstance and severity of the youth’s relatedness problems; and four cases that ended prematurely by client and family decisions that may have involved clinical errors or miscalculations on my part.

Comparative Statistics

The eight successful case outcomes had an average initial CGAS score of 47, almost a full decile lower than that of the remaining forty-eight cases (that include the other ten in this group of eighteen. The average CGAS gain was 21 over an average of 34 sessions. The average per-session gain was .68, well above the study average of .44, and among the highest for any of the study’s sub-groups.

Of the other ten cases, the initial CGAS average was 54.9, exactly that of the study group as a whole. The average gain was 7.7 over an average of 16.9 sessions, both numbers particularly low. The average gain per session is .23, which would be among the lowest of any sub-group. These figures underscore the complicated nature of these ten cases, average in overall presentation but difficult to develop a momentum of change.  Again, the one constant was the presence of a parent or parent figure with Axis II complications, particularly with activated defenses while under what is to them the stress and even duress of the therapy.

Note: Additional results and discussion concerning the gain-per-session metric will be presented in the study summary posts to follow these sub-section analyses. One of the interesting findings of the study is the correlations between average initial CGAS scores and the gains per session data, the overall results implying that lower initial CGAS scores take relatively more sessions to achieve significant improvements, hence lower average gains-per-session. This kind of data has as much in the way of social policy relevance as for clinical considerations.

In the spirit of keeping posts shorter, the analyses of case outcomes are to follow in the next two posts. The first will focus on cases that had successful outcomes, and the second on those that were less so.

Extremes Beyond Management

In the late 80’s, a16 year old high school junior was referred by her high school counselor who had been seeing her on an as needed basis for support. She had been having difficulties  concentrating on schoolwork and was socially isolated after a best and only friend moved out-of state. More recently, she had been complaining about depression.

As per usual, the intake session was with the mother. Friendly and emanating a self-assurance, she uncommonly began the interview herself expressing thanks for the help.

Bess was an itinerant administrative assistant with a specialty in small corporate office management, working in a dozen settings over her career. Her daughter Lacey was an only child whose biological father had never been involved. She had been cohabiting with a house painter for the past nine months of whom she was fond. Briefly, her relational history suggested that of a serial monogamist. She was quick to add in perhaps her most serious moment that she was scrupulously careful about her daughter’s well-being with her boyfriends and never had any trouble. The persona definitely had a protective instinct, and wanted the help for her daughter. Inferentially, life was not at stake so the urgency was modest and she’d be available but expecting individual work as per Lacey’s intent. The mother would come in either if she had a concern to discuss or for a check-in or review.

Lacey asked that her appointment be the next day, which in and of itself was unusual. She was friendly, composed, organized in her thinking, careful at the session’s outset, but became teary and somewhat dysphoric as she recounted her concerns. Problems included the loss of her friend, dropping school performance, feeling lonely, and feeling distanced from her mother.

Falling asleep, poor mood, inability to focus and concentrate, and feelings of hopelessness indicated a moderate adjustment disorder level of depression, and occasional stomach aches indicated some anxiety. She reported having no suicidal thoughts. Using the Piers-Harris Self-Esteem Questionnaire at the time, she scored high in both behavior and physical appearance and attributes, average for intellect and school performance (presumably a combined result of high intellect and low grades, and low in anxiety, peer skills and social status, and overall happiness and satisfaction. Her socio-moral development evaluation, based on Kohlberg’s Scale, was at a solid stage 4, very good for a high schooler, and, for all that matter, for a large proportion of the population.

As a matter of note, anxiety problems were quite a bit less frequent in the late 80’s than today, so the evaluation of that problem area was typically less comprehensive. I used headaches and stomach aches as the primary indicators unless the presentation suggested one of the several types of anxiety disorders or seemed particularly pervasive. In this instance, her mother was unaware of the stomach problems. Lacey said the aches were not that bad, and she would let her mother know if they became a problem. Attention to that issue could be deferred, but her quietly firm stance was somewhat puzzling. 

We confirmed a weekly individual format with the understanding that her mother would come in separately from time to time about which Lacey would be informed and briefed.

My client proved to be a quick leaner, not surprising given the evaluative results and overall impression she left. That kind of pattern is commonly mentioned at some point as feedback and positive regard. 

Having already used the school counselor and now being familiar with the basic process, Lacey came into the office with specific issues, events, or problems to discuss. Over the course of the first few sessions, the focus curved toward the loss of her friend and the impacts, and a certain lack of social confidence. The conclusion of the meeting would always include a recommendation of some sort in regards to the particular issue she presented at the session’s beginning. By the fourth or fifth individual session, she was reporting on improvements at the beginning of a session, which was presumably in anticipation of the question she knew would be asked.

The sleep had improved, though not resolved, and the stomach aches had lessened, though not resolved. Not on the problem list at all, Lacey’s levels of energy had improved. My sense was that school work would start getting better as well. She initiated a change in lunch tables, and found that group more inclusive. The mood seemed to be getting lighter, but the gap between her capacity and her confidence was still evident. That would likely take time. Having now gotten beyond the first few sessions with some movement and the insurance coverage being comprehensive, time would likely be available. 

The main focus began to shift toward her biological father, in some part spurred by critical comments she had made about a previous boyfriend of her mother’s who had inserted himself as a father-figure. That led to conflicts and, quite probably the man’s departure. She did yearn from time to time, and thinks about trying to find her father at some point in the distant future. Taking a bit of a risk, I wondered if that might have something to do with her occasional stomach aches. She considered and thought not. In hindsight, her hopelessness was likely the symptomatic connection. 

The clinical relationship was developing. In addition to noting and often examining reported positive change, the random reinforcement and feedback components of the therapy process were well received. They tended to be about her cognitive abilities and evidences of a gradually increasing initiative.

Bess came in about ten weeks into the process at my request for a check-in. She had seen some improvements, citing more attention Lacey took to her appearance, less withdrawn, and  initiating kitchen clean-up. With a kind of guilty-girl smile, the mother also related an episode of open door intimacy while Lacey was presumed to be out of the house sand about which she reacted with irritation, all related to me with assurances they were all fine afterward. She did not have any particular questions for me.I did not press beyond asking questions about Lacey’s development and their relationship over time, believing that doing so would sensitize her further to the nuances of the girl and the pair of them.

A month or so later, almost as an aside and with no particular affect, Lacey reported that her mother was sick “with something”. Her own session content had started to shift toward a boy in whom she had an interest. That in turn led to her expressing frustration with what she described as a shambled and unpredictable household that was too embarrassing to bring her interest home. The complaint turned toward what action she could pursue. That discussion led to one  about adaption being the ability to both accommodate and assimilate, and recognizing that both were important to settling such a conflict. She worked well with that kind of abstraction. And then   recognize to her that ability. 

Lacey’s improvement had been steady over the four-plus months into the therapy. She seemed to be entering a plateauing phase. In a couple of the following sessions, she updated her mother’s continued and still undiagnosed medical issue. The therapy was now working more in the area of school motivation issues, per Lacey’s initiation, as springtime brought the end of the school year into sight. 

The plan for the next session had been to follow up on the last session’s discussion and recommendations re: schoolwork. At the beginning of the session, though, Lacey let me know her mother was now in the hospital. Still unperturbed but noting my puzzled look, she went on to explain that her mother often had medical problems. I finally began asking questions, and gathered that the problems over time had been often, varied, and as as pattern somewhat inexplicable. 

At least from my vantage and given the mother’s presentation, the notion that she could be hypochondriacal seemed very plausible. However, Lacey’s improvements coupled with her apparent comfort with this status quo led to a conservative approach. Rather than pursuing a course of more carefully evaluating her mother with her daughter for her sake, we moved on.

Two weeks later, Lacey reports her mother had been transferred to the ICU and was on a ventilator. 

I blurted an alarmed “What?” 

An unfazed Lacey said the hospital still didn’t know exactly what was wrong. 

My alarm continued “This is really serious!”

With a hint of shortness, Lacey waved me off “Oh, she’ll be fine, this happens all the time”.

“She’s been on a ventilator before?”

“I think so, but you know, she’s been in the hospital a lot and she always gets better.”

A flood of thought raced through. Munchausen’s. She had no idea. I overreacted. Couldn’t tell her why, not a good idea, not my ole. What she’d been through,  She’d have to get the understand some other way. Protect the gains. So, just stay with it.

“OK, but if something comes up between now and next week and you feel like coming in, give me a call.”

Bess was discharged a few days later. Barring a relapse, she was returning to work the week following. In debriefing her mother’s hospitalization, the counseling helped define and validate Lacey’s own long standing worry and perplexity, and suggesting her mother know more about her worries. 

School ended three weeks later. Lacey was going to be working the summer at a local horse farm and had planned to finish with me. Her progress had continued and from a clinical standpoint she was ready to stop. Since the last few sessions provide the opportunity for culminating work, which some believe the most important of the entire therapy, her mother’s hospitalization provided a fertile field. 

The most important clinical step under the circumstances, in my view, was having the client compare how she handled this episode of her mother’s illness to previous ones. Improvements had occurred in all of the diagnostic and problem areas identified during the assessment, from modest changes in overall happiness-and-satisfaction and sleep to resolutions in focus, concentration, school performance, and solving her social isolation. In reviewing the hospitalization experience, Lacey realized that her stomach aches, which we hadn’t touched upon for a while, hadn’t occurred. Being able to talk about her mother during that time provided an outlet for her anxiety. The value of a supportive outlet presumably reinforced the importance of having girlfriends. The summary input stressed a demonstrable improvement in confidence, and her ability to care for herself. One bit of specific advice, taken with aplomb, was to review with her mother at some point the plan for Lacey if her mother became impaired or passed.

A temptation is to link the Munchausen episode with Lacey’s growth toward age-appropriate self-care, thus separating further from her mother’s care during the period of therapy.  That could infer a conjoint process.The central conundrum is the assumption that Munchausen’s can be acknowledged. The far greater likelihood is that a psychological problem so highly defended is much more likely to torpedo the therapy, most anything associated with the therapy could have been the trigger. The mother had given signs of having something concerning from the beginning, and a latter adolescent specifically requesting individual therapy is likely to get what they wish. So, the chosen format was a foregone conclusion and in hindsight, I think correct. Having choices in format available in any given child and adolescent therapy is important to the rule of protecting the process. 

The defense of extremes of behavior beyond the ability to clinically manage in this instance may also have created an environment where the child’s needs were ignored, not maliciously but negligently. The therapy focused on what the client can do for themselves and how they may better engage the parent, and the parent was not directly involved.

Lastly and to reiterate, you never know exactly what problem is first walking through the office door, and understanding what that problem is can take months and longer. 

# 33 – CONDUCT DISORDER(S)

Note:  Just as a forewarning, this is a particularly long post with a considerable amount of practical practice content concerning a complicated topic, so please take your time.

In a paper summarizing research psychologist Stanton Samenow’s work on conduct disorder, my colleague and a psychologist himself, Dr. Steven Taylor, wrote that the diagnostic term ‘Conduct Disorder’ was dimensional rather than categorical. The term encompasses an area of human functioning that spreads beyond the historical field view that a conduct disorder was the youth equivalent of the adult Antisocial Personality. ‘Conduct disorder” is more a syndrome than a distinct diagnosis, which, among other things, makes appropriate treatment choice a multiplicity rather than something singular. The one consistency is that conduct problems in all their various forms can be among the most difficult problems that outpatient mental health addresses.

As per the DSM V, the diagnosis of a conduct disorder for a child or adolescent requires three or more of  the following symptoms

Relatedness traits that often appear in conduct disorder presentations include:

Prevalence Data

The DSMs III – V all cite the range of conduct disorder prevalence studies  to be 2% to 10%. They establish the rate at 4%. Another study source (Understanding The Demographic Predictors… of Conduct Disorder; Patel, et.al; Behavioral Sciences; 9/12/18) indicates that 9.5% of youth in this country have a period of conduct disorder before adulthood, including 12% for boys. At any given time, they state that 4% – 9% of youth are in the midst of a conduct disorder, averaging out to 6% (presumably 7+% for boys). In essence, that study is saying roughly one out of eight boys have a conduct disorder at some time from childhood through eighteen years of age, and one out of fourteen boys do at any given time. 

One article that was researched also stated that conduct disorder occurs at 3% across “many countries”. At the same time, 6% of American black youth black youth have a CD diagnosis at any given time, almost double that of other races. Assuming that African countries were included in the cited international rates, is the higher rate among African American youth in this country a function of diagnostic bias or from the overall experience of racism, or to what degree both. Unfortunately, the notation of the article was not transcribed, and the article now could not be re-located, so take that summary with a grain of salt…or two.

If the rate of mental health disorders among youth in this year 2020 is between 20% and 24% and assuming this 4% prevalence of CD, close to one out of five youth who are experiencing mental health disorders have a conduct disorder. Understanding the DSM and Behavioral Sciences deserve and have  all due respect as the major source of reliable professional information in regards to diagnosis, these figures do seem inordinately high and difficult to believe. 

Only one case (2%)in this study fitting the Conduct Disorder diagnostic criteria seems statistically low. Translated in an epidemiologically loose sense to my practice and based on the DSM the prevalence rate of 4% conduct disorder, the number of Conduct Disorder cases within this group of 56 would be somewhere around10 – 12,  or certainly something much higher than one. 

4% just doesn’t correlate to my experience working with youth and families, and makes me wonder exactly what criteria is being used in the field on an ongoing basis. Look again at the diagnostic criteria, keeping in mind that one has to have three or more of those symptoms at the same time to warrant the diagnosis. In hindsight, I recognize now that my seeing a client as having a ‘conduct disorder’ was based more globally on the severity of misbehavior rather than an exact application of the diagnostic criteria. Do difficult youth get tagged with a conduct disorder when the actual problem may well be something else, including problems less intransigent and socially toxic?

When first doing the statistical breakdowns of these sub-groups, and this was before looking at the diagnostic criteria myself, I labeled four as being conduct disordered sub-group. Subjectively at the time, an average of two severe or serious conduct problems in any given year subjectively sounded about right.  I now doubt that I saw as many as 20 true conduct disorders, that being out of 1000. Perhaps this is standard for an outpatient, masters-level mental health practice. Likely no data exists against which these numbers could be compared. Still, something just seems to be off with the formally estimated prevalence numbers cited in the DSM.

One other odd set of study results is worth considering. One international study quoted found that nations around the world had 3% of their youth having conduct disorders. Another found that 6% of African American youth had conduct disorders. One assumes that the international study included sub-Saharan African nations. Concerning this result that doubles the incidence rates of black children in the U.S.A., is that a result of the experience of racism, or do black children get more easily tagged with the diagnosis, or some combination of the two.

As our consult group was gathering one evening in the early 90’s for a monthly session at Steven’s place, he was sharing an anecdote from a Seattle workshop given by a national figure on child and adolescent behavior disorders. As with all seven members of this particular group, Steven is committed, discerning, and responsible. And from that perspective, he was grinning incredulity at an over-the-top proclamation by the expert. 

“Being empathetic with and antisocial is like pouring delectable sauce over bad meat.”

Our 70 year old, gold standard child psychiatrist Alan Leider, who sat in on these meetings as a peer, was not amused. He could be intolerant of blanket disregard, so he wasn’t letting the matter just drop. Alan was notoriously stubborn. In a socratic-like style, he pushed the six of us to examine our own experiences, conceptions, and conclusions about conduct disorder. I’m certain his intent was for us to appreciate the variations within our group’s thoughts, and the inchoate nature of the diagnosis itself. Conduct disorder was more a range of issues than a distinct behavioral system. The ’delectable sauce’ could still be of some substantive help with some of the kids involved, but some were also clearly beyond that kind of help. Identifiability was hard.

Study Group “Conduct Disorder” Cases 

Data Summary

The identification of sub-groups within the study occurred about a year after the initial data collection. Conduct disorder was one of several specific sub-group of interest. I simply went through the list of cases and selected those that seemed to fit. The judgement was based on having established a client’s patterns of posing a threat to others, over a period of time, and in multiple settings. Identifying conduct disorders within the 56 case study group was based on experience rather than using the DSM V’s symptom list – that came as the post itself was being organized a couple of months ago. The data collection process certainly presents validity issues, let alone reliability. Once again, though, certain statistical results of the relatedness sub-group as whole do correlate with other findings, lending a soft support to validity. Please do take these cautions into account as you read on.  

Four boys, aged 9, 11, 15, and 18, presented with problems that included multiple elements of the seven relatedness traits listed above. They represent 7% of the study group. None were among the four (of seventeen) relatedness cases that had their presenting problems resolved by treatment’s end. 

Only one of the 56 study cases qualified for a diagnosis of Conduct Disorder using the DSM symptom list. Not coincidently, that was the only case with eight overall relatedness traits. in order of their age, youngest to oldest, the four clients had 4, 1, 1, and 0 DSM CD traits. The older client was involved in an illegal activity – dealing – that could be seen as a threat to the community but which did not fit the DSM CD criteria. Not all illegal behaviors are conduct disorder symptoms. Both of the younger two conduct problem clients posed a threat to fellow students, one in the form of verbal and physical aggression, disruptiveness, and theft of personal items, and the other in the form of “conning”. None of the four engaged in any of the last three symptoms of the DSM conduct disorder list, which do seem categorically different than the first twelve.

Using the above list of relatedness traits found in conduct problems, the four cases had 5, 3, 3, and 2, youngest to oldest. The total relatedness traits for each were 8, 5, 6, and 6. Roughly half their traits contributed to the conduct problems. All four were involved in lying, etc., and three had remorse/empathy problems. Additionally, two of the biological parents among the four cases were APD and four others appeared to have had immature-group personality problems. 

The DSM symptom list was insufficiently elastic to include some of the presenting patterns of behavior that were illegal. By the same token, a list of relatedness traits can lack specificity. If one were to use the level of threat that the client posed toward family, school, social relationships, and the broader community as the baseline of concern, the number of relatedness traits deemed relative to conduct problem may well be a more definitive assessment tool than the DSM CD criteria.

Their average initial CGAS score was 40.5, and their termination average was 48. Their average number of sessions was 25, and the average length of treatment 1.1 years. Compared to the overall data results, The 7.5 point average gain is low for the number of services used. 

None of the four cases left treatment wholly resolved, although two did show some to modest  improvement.  The youngest was referred to an individual therapist following a short psychiatric hospitalization I had recommended. The next went through phases of family and individual therapies and terminated, ostensibly due to financial problems but a certain degree of chaotic parental circumstance was a determining factor. The next was also in family therapy followed by individual therapy; ceased the risky behavior and had some other noticeable improvements; elevated his functioning from a low serious level to a low moderate level disturbance; the parents were comfortable with stopping, albeit at his request, and would have been comfortable returning upon need. The fourth went to inpatient drug and alcohol treatment without much in the way of clinical gain; six months after leaving inpatient he remained abstinent, a follow-up indicated his continuing outpatient CCDC counseling and doing better in other areas; the initial therapy improved his compliance and self-awareness, and contributed to his cooperation in being sent to inpatient treatment, according to his custodial grandmother.

Categorizing conduct problems

Premeditative Behavior

Journalist Jennifer Kahn published an article (New Yorker Magazine, 5/11/12) that discussed the nature of    conduct disorders, particularly in children. She followed the family of a life-long troubled youngster. In doing so, she also sought information and explanations from the psychologist working with the boy. Dan Waschbusch is a researcher at Florida International University who specializes in child and adolescent conduct problems, including conduct disorders, ADHD, oppositional defiance, and pediatric bipolar disorder.

Waschbusch splits the conduct disordered youth into two sub-types, the callous-unemotional (CU), and the “hot-blooded”. Citing several research findings and quotes from other researchers, the typical CU youth is manipulative, deceitful, and untruthful. Rather than being reactively assaultive or otherwise physically threatening, the CU is manipulative, observant, scheming, impulsive, often charming, emotionally flat, lacking in the capacity for remorse and empathy, aggressive, and defiant. States Waschbusch, “you have a person who may be hostile when provoked, but who also has this ability to be very cold. The attitude is ‘so let’s see how I can use this situation to my advantage, regardless of who gets hurt.” The anger that “goes way beyond” refers a style of the smoldering, plotting, and carrying out  revenge. Manipulativeness is often the most defining element of the callous-disordered . The CU afflicted child can be seen as a “fledgling psychopath”.

Waschbusch estimates that the CU-sub-type constitutes 1% of the population. A substantial plurality of prison populations are Antisocial Personality Disordered, the frequent adult outcome of childhood Conduct Disorder. Assuming the DSM estimate that 3% of the youth population are conduct disorders is accurate, the CU would represent around 1/3 of them. One study concluded that heritability brings about 80% of callous-unemotional personalities.

At the time of Kahn’s article, an emerging belief was that psychopathy was like autism in the sense of being a distinct neurological condition that can be identified. Low levels of cortisol and amygdala activity have been noted. Another neurological scanning finding indicates the brain portion that processes negative feedback is less active. Child psychopathy scales appear to identify psychological markers of CU as early as the age of three. 

In terms of the fifteen Conduct Disorder symptoms in the DSM, the CU youth could be engaged in any one of these. The last three can either be manifestations of Conduct disorder or ODD. The difference is that ODD youth generally do not engage in any of the first twelve DSM CD symptoms, at least in my experience. Of the seven relatedness traits listed above, the CU can be identified with six out of seven, reactive rages being the one exception. 

Reactive Rage

Rage can be seen as categorically different from the CU type, posing threats to physical and emotional safety, and to damage or theft of property.  Rage and ODD are similar in the sense that both are reactive to frustration, as opposed to the CU’s heedless plotting, manipulativeness, and scheming. One major distinction is that ODD youth experience anxiety, and though they may be loath to admit it during their rages, they feel empathy and remorse. 

 According to Waschbusch, one theory is that the ‘hot-blooded’ conduct disorder has a hyper-active threat detection system. Functional impairments have been identified in neurological research of rage. Pre-frontal cortex functioning and brain lesions similar to those of PTSD have been identified as precipitants. Low levels of cortisol and amygdala activity have also been noted. Another neurological scanning finding indicates the brain portion that processes negative feedback is less active. However, identifying rage propensities at young ages like the psychopathy scales that can help detect CU at early ages. Perhaps hot-blooded, as per Waschbusch’s description, could be akin to autism as well.

With the possible exceptions of cruelty to animals and conning, the youth with rage-type conduct disorder would seem capable to do any of the fifteen DSM Conduct Disorder Symptoms. Rage-troubled youth could fit any of the relatedness traits common to conduct disorder listed above, with the exception of premeditated exploitation.

Other Conduct Problems

Waschbusch pointed out the difficult problem of differentiating the natures of the callous-unemotional type  conduct disorder from the hot-blooded conduct disorder type from ODD from Pediatric Bi-polar Disorder from ADHD. Is the defiance, vengeance, spite, and disruptiveness that a client presents ODD or CD? Are the up-and-down behavioral patterns and the aggressive nature of irritability – particularly with boys – Pediatric Bipolar or CD? Is the impulsivity ADHD or CD? With increasing frequency, the diagnoses become dual and the client gets treatment for both. My own experience is that two concurring treatments for the same problem can create as many problems as it solves, if not more. Dual conduct diagnoses run the risk of over-diagnosis, the issue of ‘two diagnoses for one problem’ issue,  possibly complicating an already complicated situation.

ODD in particular had been seen as a co-diagnosis with conduct disorder, hence another precursor to adult Antisocial Personality Disorder. After the pediatric bi-polar diagnosis was popularized in the early 90’s and quickly became over-diagnosed (read Your Child Does Not Have Bipolar Disorder, Stuart Kaplan, MD, Penn State Univ. 2011), clinicians and other counselors increasingly grouped bi-polar, oppositional defiant, and conduct disorders as contiguous in some way. Understandably wanting to cover the bases and meet what were becoming informal community standards of treatment, particularly using dual diagnoses, assessments generated treatment plans for two and occasionally three diagnoses, i.e. ODD, Bi-polar, and ADHD. The treatment plan often became a complicated combination of psychotherapy and some admixture psychotropics, sometimes numbering up to five different medications. (For an interesting perspective on this, read a front-page investigative article on pediatric bipolar appearing in the New York Times on May 12, 2007).

Multiple mental health diagnoses for youth, particularly adolescents in the midst of identity formation, can create the sense of not only having a problem, but being defective, and that self-perception be carried into adulthood. Determining the “best” management approach can be difficult with difficult kids amidst pressures both internal and external to the case itself. But, best embrace the challenge given the opportunity…for them and for you. 

Treatment Considerations

Please be reminded that all writing here is from the perspective of the line practitioner, often in private practice, often solo. The treatment suggestions are the result of experience and a continued education that consists of trainings, consulting, collegial talk, reading, listening, and otherwise absorbing over time. Pick through here and take what seems helpful. This can also serve as a picture of child, adolescent, and family practice out there, challenged by new problems to be understood, never having quite enough information, having to rely on your developing process (they are always developing), your ingenuity and commitment, and priding yourself when things work out, and they usually do, and you don’t even think about that very much in the aftermath because some new case has already come along.

Depression

The improvement rate for depression within the seventeen relatedness cases group was lower than that of the other three diagnostic categories, including anxiety, behavior, and relatedness itself, and was substantially lower than that of the thirty-nine non-relatedness cases. Depression appears to be an issue for these conduct disorders.

Based on that finding, the depression part of the evaluation for a client who appears to have relatedness difficulties, including conduct disorders, may warrant greater scrutiny. For example, in going through the ten depression symptoms during the initial evaluation, spending more time fleshing out the picture of the endorsed or postulated symptoms could sensitize others in the client’s orbit to his or hers dilemmas. That may reduce negative feedback that had little chance of external impact on the client’s behavior. The same approach might be used if the evaluation entails some depression inventory rather than question-and-answer, i.e. go through each endorsed area more closely.  

Empathy and Remorse 

76% of the relatedness group had empathy and remorse problems. Usually, all of the conduct disordered have this problem, although one of the four who were deemed to be conduct disorders by this study’s criteria did demonstrate that problem. 

The experience here is that the format of choice is conjoint family, best including siblings, unless the problem set mandates some other clinical process. Regardless of what particular problem the family brings into the session for discussion, socio-cognitive work can be inserted into the hour. In part, this entails the client and another family member, usually the mother when the technique is first being used, and having the client identify what the mother or other was thinking and feeling in regards to something that happened involving the client. The process then progresses to an informative back and forth, with guidance as needed by the therapist.This is an exercise which is usually approached with an intent interest and often a certain enthusiasm by youth. Part of the clinical work is helping the conduct disordered client identify and differentiate their feelings of anxiety, anger, and particularly guilt.

The work can also be done in individual therapy with the clinician using hypotheticals. On a limited basis, the therapist can be the ‘other’ in the dyadic exchange.. The work is less rich compared to the family format, and probably not effective until a firm trust of the clinician is developed. 

Improvements and resolutions can occur during therapy. If they don’t, they can still occur later as the client matures, and I have heard that in follow-ups. The family process lends new communication techniques, a way for the parents to more impartially judge the growth of their child, and a way to be easier on themselves. Sometimes the delectable sauce works, less so than with other kinds of clients, but sometimes. In those cases, members of the family can at least be better prepared to deal with problems in the future that the conduct disordered youth may present.

Callous – Unemotional Conduct Disorder Type

If the callous-unemotional conduct disorder type is a distinct neurological disorder and in that regard a cousin to autism, the future of C.U. treatment may be vastly different than what we have at present. Life now for autistic youth is incomparable to that of years before, to wit:

What’s Up With Lukie 

Following undergrad studies at UW, I was hired by Russ Roepcke to be a counselor guiding a group of eight Everett adolescents as part of a city summer youth work project. This would become my first venture into something resembling social work. I liked the experience, began to understand the intentions and nuances of job, and probably could have found something similar to do up there and explore the field further. For a host of reasons, though, among them being done with college and just needing to get out again, I took off with a backpack for East Coast roots.

After being dropped off at an I – 90 eastbound entrance in Bellevue one late August dawn, I stuck out my  right thumb. Six days and nine rides later I walked into Hyannis, Massachusetts, noted for the Kennedy estate, but more germane for me, near the area of the Truro beach summer vacations as a kid. It being the early seventies, I had a place to crash for a few days within an hour. Two days later I applied for a job posted on a bulletin board as a child care worker at a residential school for autistic children in nearby Chatham. By the end of the week, I had the job, rented a cheap, month-by-month motel room in South Dennis, bought a used bike, and started cycling the fifteen miles back and forth to work. The salt air was good.

In a traditional New England-style clapboard house, the May School housed about 20 autistic kids ranging from five to eighteen years old, mostly boys. Included were the May’s twin sons, who were both autistic. They were about 25 and had grown up there, occupying a large bedroom on the third floor. Their father, who was a United Nations official working out of NYC, and mother built the school for them. The school blended in to the surrounding residential area amidst the small town. I was responsible for shepherding a half dozen of the school’s younger boys through the week-days, from 8AM to 5PM with time out for lunch, an afternoon break, and an after-work dinner. I was invigorated, as I guess was the intent behind the move.

Chatham is at the point of Cape Cod’s elbow. The school was off a two lane road and up a shady residential street, somewhat hidden by trees and shrubs. The only nearby commerce was a tiny, quaint tourist stop with a cluster of four or five small cabin-like shops down a tree-lined lane across the road. One was a candy store. Within a minute after one of the May boys escaped out the front door, the unhappy owner was letting the school know the boy was raiding her jars. He couldn’t be stopped.  All staffers were implored to make sure the front door was always locked. Other than that, the School was welcomed by what seemed to be an iconic sort of quiet, old-style New England.

The only contact I’d ever had before with autistic kids was during sixth grade. Because the wave of baby boomers were overwhelming the capacity of public schools in Ridgewood, NJ, the sixth grade classes were moved out of George Washington Elementary into the annex building of the Westside First Presbyterian Church across Monroe Avenue, traditional places labeled by traditional names. For good weather morning recess, our class was usually marched in two lines back to the recreation area behind the school proper. On the way out, off to the right and more or less out of public sight, was a fenced-in area maybe fifteen feet wide in front. Often times, a group of maybe ten kids, our age and younger, would stand on the other side, faces pressing the fence, fingers grasping the mesh, expressionlessly watching us except those of us in line knew they were at least curious and must have wanted to be out? I’d look at them, then look down, feeling uneasy. 

Most of them had features that we now readily recognize as Down’s. One couldn’t help but feel sorry. The others standing there, as I came to realize at the May School, must have been autistic. The memory of those kids behind the fence stays with me, still haunting.

After a couple of weeks at the School, I spent several afternoon breaks going through the charts of each resident. I wanted to understand things like early history, what was done, did anything really work. The stories were interesting, but didn’t really help.  

For some now forgotten reason, one 11 year old seemed somehow reachable to me, at least less remote than the other five with whom I usually worked. During an afternoon break and with permission, I took Thomas on a walk over to the nearby Atlantic beach. He seemed comfortable, if expressionless, looking over little interesting things I picked up off the sand, or looking at sightings of mine as I chattered. He didn’t really engage. He was calm during the hour-long the trip, but I didn’t notice anything different about him for the rest of the afternoon.

I took him on the same walk a twice more, these times asking him a small few questions about his own experience. That did not get. Sometimes I walked along side him then moved away as we went, moved closer, moved away, sometimes quietly, sometimes talking. He moved slowly but steadfastly ahead. I worked on him holding stuff I picked up, talk about it, ask about it, and he’d quietly look and hand it back. The third time I gave him a long, perfect gull feather to take back to the school. He dropped that, too, but I took it back and showed a couple of staffers with him by my side. I’m just experimenting. Nothing yet.

Toward the end of that fourth walk, we came across a horseshoe crab shell that had washed up overnight. My brother and I would find an occasional shell on the beach in Truro, carry them back to our cabin only to have Mom declare “not in here!”. Picking up the piece, I explained its details, mentioning finding them years ago as a kid myself. Tom silently looked, as was his bent, but he did seem interested. I handed the shell over to him, and he turned it over a couple of times to look himself. I suggested he carry it back and show the others. He seemed to understand. We walked another few yards, and just as wordlessly he dropped the find back on to the beach and kept walking. Nothing had really happened. I didn’t take him the next week, or the next, and nothing in the way of recognition or reaction to not going, maybe no memory at all. I didn’t know. The experience changed neither how I related to him nor how he did with me. A bit of a let down. Who were these kids?

As seen by a novice, they didn’t really relate, could use a few words, some with a kind of intent, some difficult to decipher, some quite silent; they could get preoccupied with minutia or routine from which they could be difficult to detach, but once in line, easy to lead from one class to meal to an activity to the playground, but nothing interactive along the way like we always did as kids ourselves; learning was problematic but once a routine was set, they went along; infrequently, they could individually get riled up, sometimes understandably from circumstance and sometimes bewildering, thankfully more infrequently; as a group they could act distressed, albeit in twenty  different ways.

They also could enjoy and smile, some could laugh. Working with them did involve joy,  both theirs and ours. They could come out occasionally with adept comment or observation. They could be touching. Having no real idea about their fundamental capacities, we relied on articles of faith and keeping them safe. They were comfortable with us, but attached? Impossible to tell. For sure, we’d get attached to them.

The fall on Cape Cod that year was warm, with those wild arboreal yellows, oranges, and reds lasting through October. People were out and traveling. During one Friday though, more than the common citizenry got out.

The May twins, young men at this point, were active. They were about 5’ 7”, maybe 5’ 8” because both tended toward sloped shoulders, and surprisingly muscular. As I recall, they were groomed every couple of days, making me think they may not have been so cooperative. So they’d be unshaven for a day or two, monosyllabic, hair occasionally unkempt. Particularly with one of the two’s quickness and intent when wanting something, for all the world he could look a bit pongidae-ous. The both of them could create mayhem, and when they did, not surprisingly, tension could radiate through the building. They could be like loose fire alarms.

On this particular Friday morning, the more aggressive one – I can’t recall their names – escaped out the front door and loped a beeline to the candy store, went right to to the salt water taffy container and began grabbing, all in front of three terrorized elderly shoppers who had dropped by the shops on their casual way to a day in Provincetown. As the irate shop owner was calling the school, having long memorized the number, a staffer had raced through the front door and pulled the spiky, resistant resident out. No one had a heart attack. 

The day got worse. One of the other older boys – maybe the one of the twins but I never asked and no one wanted to know about it let alone ask about it because of its vile implications – did a smear job on an upper bedroom wall. This was truly the worst of the job. The boy’s staffer had to clean it off, and he was probably gagging fury. The rest of us were pale…there but for the grace of God… an unsettled state crept through the house. Early in the afternoon, a younger girl somehow hurt herself during a game of log-rolling down the back yard slope. It’s hard to get injured that way, but she was led crying into the small nursing room. Then later in the afternoon one of my boys twisted an ankle jumping off the small jungle gym, and he was upset, and the mood permeated yet more. This was not a happy-camp day. 

Normally the work is constant, without being an overload. The administrator was adept at staffing and scheduling, getting the reasonable most out of his workers. Put the events of this day into the mix, and the work becomes truly taxing. I was heads down walking after work into the staff dining area for dinner, having briefed the night staffer on the day’s events. The older woman muttered something about Jesus but I wasn’t paying attention. I was done and done in.

I ate alone at the small four-person table in a nook by the kitchen. When finished, Lukie appeared at my side. His job was to clean off dishes and take them into the kitchen to be washed.

Within the school population, Lukie stood out. About fifteen years old, he’d been at the School for ten years, I think from Roxbury. His family seemed to be around a bit more than others during weekends, at least as I understood. He was a bit more verbal than the others, but not conversant nor curious. I was told he could recognize and remember the names of his school caretakers going back to his first years. He was probably the only resident who could reliably manage the task of clearing a table. He was also the only African-American kid in the facility, which made him being the busboy a little weird, but he was the only one who could consistently manage the task and he wouldn’t begin to understand the irony. Lukie was usually happy.

I found out from another staffer that Lukie had been taught this trick. If he is asked “Lukie, how’re things lookin’?”, he’d look straight up at the sky and reply “Things’re lookin’ up!” and then look at you with a smile, and then clear the table. He clearly liked the interchange, and when Lukie looked right into your eyes, he had a  smile that could melt clear down to absolute zero. For us day workers who ate dinner there, that the last person with whom we’d interact each day being Lukie made the trip home all that much better.

So, on this day of days, Lukie comes up to clear off the table. I was so tired, so with simply a glance and return to gaze at the plate, wearily I do my part of then skit. “Lukie, how’re things lookin’?”

“Things’re lookin’ sideways!”, followed by that same grin.

I whipped my head to the right with brows creased poised doubt ”What??? “, but Lukie’s just standing there smiling like nothing new and waiting for me to laugh. I forced a chuckle and he seemed pleased as always, cleared the table as always, and turned around to disappear into the kitchen, as always. I don’t know how long I just sat there, but eventually left peddled hard toward the west because the sun had just set and riding in the dark could be a problem, Lukie on my mind.

Somebody must have taught him that line, recently, maybe that day, or the previous night. On Monday, I checked around. No one had heard it before, no one gave a hint of holding back about being the source. I checked with the night staff when they came in. Same thing. Somebody taught him. But why did he know to use it that day? And I never heard him say it again – thereafter, always ‘things’re are lookin’ up’ , just as before.  And I did the routine with him every day, and every day he smiled the same way.

I puzzled more about autism. There was more to these kids.

I never got much further with the thinking. A few weeks later, I got a call from Russ. He’d been hired as the director of a community crisis and youth counseling center, and he wanted me as the assistant director.

There was something in that kid that went beyond what we imagined.

Arguably, the greatest advancement in psychology over the past few decades has been the development of intensive early intervention techniques for the autistic. With autistic kids being mainstreamed into regular classrooms increasingly over the past twenty years, referrals to private practitioners by school counselors for help with family and social difficulties started arriving. My first one was a sixth grader running the risk of being transferred out of his regular elementary classroom and into a behavior class.  A combination of problem relationships within the family coupled with urges toward inappropriate touching that were difficult for him to control led the parents to choose the option of family therapy.  

Given my experience in the early 70’s and a lack of contact with the autistic population since then, the difference between Lukie and my new client was shocking. Using conjoint family therapy that included the boy’s younger sister as an important source of information, feedback, and reinforcement, the boy’s social problems resolved nicely over many months. He related, he participated, he worked like a normal client would, developed social relationships in school, controlled the urges. The process did take 2 1/2 years. Stepping back, though, the change in autistic functioning seemed almost other-worldly. 

After doing all the pre and post CGAS scoring for the 56 cases in this study, reminiscing back to this case raised the question about whether an autistic youngster could score above 80, The answer seems to be ‘yes’ . At the end of the last appointment, he made certain that a small construction-paper story booklet he wrote and illustrated, intended for other kids coming into  waiting-room play area to read, was securely fastened to the wall. 

If half the youngsters currently scoring high on psychopathy scales are predicted to resolve their issues by adulthood, do those that do not resolve lack the capacity to love another person?  Just a question….

That the callous-unemotional profile may be identifiable in the toddler stage may add credence to the theory that CU is more closely related to autism than to other forms of conduct problems. Some core element(s) of relatedness is missing. The theoretical hope would be that targeted, intensive early interventions could be developed to work on re-programming an afflicted child’s cognitive impairments and social deficits. Again theoretically, the treatment could aid in the development of trust, attachment, empathy, remorse, and operating with a functional set of values. The person gains a life of acceptance. Society could eventually be spared a good portion of the estimated half-billion dollars annual cost that antisocial personality behaviors generate, the figure quoted in the Kahn article. The incentives are there to fill the vacuum.

In the meantime, though, the psychotherapeutic world deals with the dilemma of the “delectable sauce”. Kahn quoted John Dadds, a psychology professor at the University of New South Wales, who said that “the nuns used to say ‘Get them young enough, and they can change.”  Kahn reported also one early study indicating that warm and loving parenting can reduce callousness, even for those kids that resist the close warmth.Yet another expert was quoted  “to take the attitude that psychopathy is not treatable because it’s genetic, that is not accurate”. The resolution rate may be small, but an effort can also be life-saving.

Via Taylor’s summary, Samenow suggested that mental health work is “typically amoralistic”. Normally, the function of psychotherapy is to facilitate change through any through any number of techniques in the context of a clinical relationship, relying upon the client’s trust toward the therapist to inculcate feedback and suggestions that the client thought to be meaningful, given who they were. The existence of a client’s functional value system is presumed. 

On the other hand, when dealing with anti-socials, including conduct disorders, who do not trust, are blind to their drives, and and bereft of considered choices, taking the approach that emphasizes values and self-respect rather than self-esteem and social regard may prove more effective. The National Association of Social Workers issues a frequent on-line ‘SmartBrief’ shares information on various clinical and social concerns. A recent SmartBrief discussed a number of values that have applicability in the clinical setting. Those plus a couple more form the following list:

With this particular list, the first five involve the socio-cognitive awareness of how the client perceives others perceiving them. The second five underscore giving where nothing is expected in return. In turn, discussions about manipulativeness, first in the abstract, and then moving into an examination of self can occur when the client becomes more comfortable talking about issues from a values perspective. 

Clinical patience is a necessity here. The last message that the clinician wants to convey is disappointment or any other negative judgement that the client can detect by the merest of grimaces or movement of the eyes upward. The CU probably has a geiger counter for rejection as much as they have one for an opportunity to manipulate.

Working one at a time from a list of chosen values that might number eight to ten, the clinician can shape whatever situation the clients brings to discuss toward examining one of values. Exploration of the client’s thoughts and feelings about the value itself, its application to the particular situation, how the client might employ the value itself to someone else’s benefit, and how that might ultimately be of help to the client themselves would be the general clinical process. Perhaps assume they may not “feel it”, but they can ‘think’ in lieu of ‘feel’ as they try to apply. 

Values work can also shapes the language used in future sessions.They become points of reference that both client and clinician understand in similar terms. That opens an avenue for spontaneous and random positive reinforcements the clinician can offer the client as the clients changes are carefully observed. Hence, the reinforcement is deserved. The reinforcements may need to be almost understated, lest the client’s inherent suspiciousness interprets the praise as a euphemism, something that disguises less flattering the therapist is thought to think. 

Other ideas based on Samenow’s advice for callous-unemotional conduct disorder work can be implemented in either family or individual work, and include:

Elicit disclosure, follow the path 

Randomly reinforce insight improvements 

Focus on self-respect rather than self-esteem – the values work outlined above is a good example

Use open-ended questions about lessons from experience, 

Don’t try to “build” rapport – be yourself

Teach rather than confront

Use praise judiciously

Work on the ability to recognize worry

Detach from power struggles that begin to emerge in treatment*

Help build an acceptance that “Life can be unfair” 

Develop humility, reinforce its evidences appearing in treatment

*My Wyoming-bred practicum supervisor and future department head at Children’s Hospital Dept. of Social Work once advised in regard to power struggles  “Don’t get into a pissing match with a skunk – you’ll lose.”

“Hot-blooded”-type Conduct Disorder

The prototype would be the older child or adolescent who flies into rages and retaliates by acting upon several DSM conduct disorder symptoms, including physical aggression, bullying, intimidating, use of a weapon, stealing, damaging property, and/or setting fires. The episodes would occur randomly in multiple settings with virtually no sincere remorse in the aftermath. As such, they pose a threat to the welfare of individuals and safety within the community.

Two clients who resorted to fits, aggressions, and destruction come to mind, one in this study and one from the calendar year before. The clinical formulation at the time of service for case in the study assumed a genetic load for conduct disorder based on his biological parents’ profiles, but he was also manifesting PTSD. His parents were deprived of parenting rights dues primarily to serious neglect. The aggressions decreased some, but most concerns persisted.The case before the study could have been seen as conduct disordered at treatment’s outset, but turned out also to be PTSD. Once the trauma was revealed during a session, the conduct problem quickly dissipated. The boy returned to high 80’s – low 90’s CGAS functioning.

Based entirely on recollective impression, maybe 20 – 25 of these ‘hot-blooded” rage cases appeared in the practice over time, or roughly 2% of the practice’s population. Most these cases are probably funneled into psychiatry, community mental health programs, state custody, or other mandated treatment programs .

Anger management programs are becoming the community standard of treatment. If the clinician wants to remain involved but has concern about the client being a continued danger to the community, a referral to an anger management program or to a child psychiatrist would seem requisite. Still, the clinician can remain clinically involved and be of a difference-making service. The problem is segregating the anger management treatment that is occurring elsewhere from the work being done in the psychotherapy office. The family or individual treatment would focus on other problems and symptom areas that would do not include anger management, per se, unless necessary and coordinated with the specialist.

Other Conduct Problems

Both ODD and Pediatric Bi-polar Disorder are distinct from Conduct Disorder, and will be discussed in what is planned to be a Diagnostics Section within the overall Therapy Process segment of this blog project.

Process Management Considerations for C.U. disorders

High risk traits like major breaches of laws, norms, etc, lying, intimidating, physical and verbal aggression, and rages probably need to be on the explicit problem list. Included in major breaches would be most all of the fifteen DSM conduct disorder symptoms. Other traits may be best left on the clinician’s baseline list. 

As stated earlier, avoid trying to “build” a clinical relationship. In the same vein, avoid enthusiastic praise, at least until a certainty about clinical trust is present. The praise may be reinforcing the perceived personal change, or reinforcing the client’s manipulativeness. With these clients, a full basic trust is hard to achieve, and hyperbole may not help. 

The basic footing of clinical trust is always honesty, acting in the best interests of the client(s), maintaining the boundaries of confidentiality and other ethical considerations, and the ability to answer whatever

questions that may arise from the client regarding process and communications.

Supporting the basic mother – father – child triangle (substitute other gender arrangements as needed),  inasmuch as possible in keeping all three sides viable. Avoid “taking sides”.

Maintaining an awareness of parental Axis II ramifications, and adjust as seems required to protect the process. The next post addresses some of those concerns.

Lastly, avoid leaving a floridly CU child alone in the waiting room while meeting with the parent(s) unless demonstrable progress is being made. Waiting rooms have been known to get vandalized under those specific circumstances – not likely to enhance the therapy process.

Administrative Considerations

Particularly if the setting is private practice and the work involves behaviorally high-risk clients, the clinician may want to have certain resources available upon need, however uncommon that need might arise. They include:

Consultant or consult group – the most important resource for difficult cases.

Child psychiatrist – available for second opinions and medication evaluations. Most of the cases referred for psychiatric evaluations involved more serious instances of suicidal thinking rather than antisocial behaviors, but having that psychiatric expertise and sets of skills and tools available will prove helpful.

Neuropsychologist – if available within a reasonable distance, for evaluations of questionable cognitive- behavioral processes and educational recommendations. Not commonly used by mental health practitioners, but as neurology becomes more involved in mental health, neuropsychologists are likely to take a more prominent role.

Certified Chemical Dependency Counselor (CCDC) – for evaluations and recommendations on need.

PTSD expert or clinic – Certified PTSD specialists are becoming a community standard of treatment beyond some level of severity, as per CCDCs for alcohol and drug problem,  so having one as a referral and consulting source will become of increasing benefit.

Lawyer – For advice. This may seem like overreach, but I used one with a mental health special throughout my practice, contacting him for advice four times, all phone calls, a couple of which he charged and the other two he didn’t, all worthwhile. Like child psychiatry, having that expertise identified and available upon need is a comfort.

Therapy tends to the person, about whom the diagnosis is but a fraction, and occasionally incorrect. 



#32 – TRAITS – Part 2

More Intractable Traits

Note: 

The following ten traits seemed more inured to change as a function of common therapy, at least in my experience. Coincidently, they are equally divided between the three DSM groupings of the ten personality disorders. Colloquially and in order, they have been known as the Immature, Anxious, and Odd personality disorders.

These ten traits were seen less frequently than the others. As moods rose during therapy, anxieties diminished, behaviors normalized, and relationships improved, instances of frankly unanticipated resolutions did occur for a small few of the traits listed above. Contemptuousness, perfectionism, and distrust were examples. In those particular cases, the resolved traits were likely more etiologically experiential than genetic.

The least treatable in family-type therapy were the last three from the Odd group. Perhaps four or five among them appeared over the years. Difficulties with reality testing, as per these traits, would typically appear as parents explored treatment possibilities for their child, anything that might work. Not seeking help for themselves, the parents were referred to more appropriate providers, usually either psychologists with expertise in the relevant clinical diagnosis, or child psychiatrists.

Treatment Considerations – Immature Group

The immature group has self-perceptual, socio-cognitive, and affect regulation difficulties. On occasion, they do show capacities to mature into more normal patterns. Typically, though, change has occurred with a considerable amount of therapy provided by a dedicated individual or group therapist.

In isolated instances, significant diminishment or resolution of immature group traits – grandiosity, arrogance, entitlement, and contemptuousness – did occur. The longest case among the 56 (168 sessions covering a half-decade) did see resolutions in contemptuousness, particularly as his social skills improved emerging into mid-adolescence, but other traits did not resolve. One shorter-term family therapy of a relatedness case saw diminishment in grandiosity, particularly as the mother and father began to act more in concert with each other and improved their behavior management. In a remarkable case of what appeared to be an adolescent-onset of arrogance and contemptuousness coupled with defiant and retributive behaviors that got nowhere in family therapy, an individual process was requested by the parents with the boy’s somewhat reluctant concurrence. In a narrative-type discussion about dating relationships some ten sessions into the individual work, the client suddenly became tearful and disclosed a break-up in which the girl repeatedly slashed herself. She was subsequently hospitalized medically and then psychiatrically. His feelings of guilt became manifest, and thereafter the “immature” patterns quickly abated. Note that in none of these cases were the specific trait behaviors explicitly addressed.

Particularly if negative modeling exists within the home, a depressed and irritated adolescent can exhibit a generic contemptuousness but can be later led to see their own behavior with some degree of remorse. At best, the client could even correct the impression left with the target. The kind of contemptuousness that rises to a trait level is more pervasively expressed. Like defiance, verbal aggression, and disruptiveness, trait-level contemptuousness can nevertheless improve. Those gains take processes of moderate to long length. Family relational skill development and socio-cognitive work during family sessions can be effective. Contemptuousness coupled with grandiosity and arrogance probably do not improve, but progresses in other areas of life areas and relationships still remain possible.The overall progress in that instance is just likely to be less than average.

The DSM includes Antisocial Personality Disorder along with borderline, narcissistic, and histrionic in the immature group. However, the lack of conscience and manifest anxiety coupled with aggressive and predatory instincts would seem to make APD categorically separate. Whereas the other nine traits can be tragic, resistant to change, and difficult to socially accommodate and support, APD is menacing and dangerous to others. Bear in mind that Conduct Disorder is seen as an antecedent of APD.

Anxious and Odd Groups

These two groups of traits are more likely to be endogenous, not the result of experience, and therefore less likely to change. Psychotherapeutic clinicians are not commonly involved in direct treatment of the afflicted child or adolescent, if at all in this day and age. In rare circumstance, though, the line clinician can find themselves working with a client demonstrating one of these traits

Perfectionism is a cousin of some degree to OCD, and difficult to change in standard outpatient psychotherapies. However, one relatedness case involving an elementary-aged, single child who was rigidly perfectionistic at home and school, and who would steadfastly avoid social settings and extra-curricular activities, did loosen rigidities and begin to join. As the therapy unfolded, the narrative history became clearer. The mother in particular gained more confidence as issues and events emanating from maternal postpartum depression and a period of alcohol abuse were processed. They provided an explanatory model of the child’s difficulties that aggravated an intrinsic tendency toward anxiety and compulsiveness. Without specific recommendations or instructions, the parent-child relationship became more effective, and the perfectionism did lessen to the point that the child was no longer viewed as odd in school, and joined the school’s math and chess clubs. Narrative and psycho-educational were used often during this relatively long-term process.

As an aside, working with OCD youth and families could be a very worthwhile sub-specialty for a child and adolescent family practitioner. Any number of family problems can arise simply as a function the stresses that the rituals, obsessions, and compulsions can generate. This work can be very effective with anxious or depressed parents, stressed marriages, and conflictual sibling relationships. The same could probably be said for families of youth with any of the other seven traits from the last two groups.

Solitariness and avoidance are other problems that could be either traits or manifestations of anxiety, depression, loss, or trauma, but are usually more a function of character rather than experience, modeling, and conditioning.

The range of a psychotherapist’s clinical territory is never quite finite. A family with means may very well want to try psychotherapist to treat some aspect of their child’s ‘anxious’ or ‘odd’ dilemmas.The clinician can never know for a fact what’s coming through the office door for the first time. The youth may like being there. The parents are trusting. You have the time and an interest. Do consider doing it.

Suggestions:

  1. Apply your standard assessment process; research the problem area and contemporary clinical approaches to whatever the trait problem may be; use consultation
  2. Carefully assess for depression and anxiety symptoms via separate inputs from both client and parent(s) 
  3. Stay with the agreed upon format – individual, conjoint, or split sessions; change formats only after sufficient discussion(s) with both client and parents
  4. To the degree possible, let the client and parents determine session content and weave into that your therapeutic work – let them lead you through their experience and work from there
  5. Be patient, comfortable, flexible, creative, interested, and learn from the experience
  6. Seek feedback from the client and parents, separately or conjointly, whichever seems most comfortable to the client and parent and profitable for you
  7. Reinforce positive change as noted
  8. Appreciate growth, theirs primarily, yours secondarily – these are the cases from which you can learn and expand

General  Clinical Focus

With any of these relatedness cases, depression and anxiety problems can be the most effective baselines from an evaluative standpoint. Via the dictum “use the most conservative therapy feasible”, effective work with life problems and relationships usually leads to resolutions, or at least a lessening, of emotional and behavioral issues. The depressions among the seventeen relatedness cases in this study were particularly aided. Given their isolation and negative social interactions, depression would be a natural consequence. If the therapy helps lessen the isolation, depression tends to alleviate. If the therapy enables the youth to change and be seen in a more positive light by family, peers, and others, then both anxiety and depression can be lessened. The most important factor here, though, is that the relatedness traits themselves could result in alleviation. 

Perhaps in hindsight the result seems obvious, the most surprising finding in the relatedness data was the preponderance of remorse and empathy problems. That trait doubled in frequency compared to any of the other thirty traits. If the youth is demonstrating several traits, one clinical task is to specifically address empathy and remorse, almost regardless of whether that seems to be one of the client’s or not. 

The socio-cognitive work that could be used in conjunction with remorse/empathy difficulties is beneficial in and of itself. Selman’s scale of five socio-cognitive developmental stages, discussed in Hugh Rosen’s work “Piagetian Dimensions Of Clinical Relevance (Columbia Press, 1985) is the basic frame of reference for determining where the client stands and for what specific improvements may be needed. The simple guided interaction of the client with a parent or other family member concerning awarenesses of the other’s thoughts and feelings in regards to some behavior or event is the staple technique. The tool nicely segues into the use of other clinical tools, primarily language shaping, family relationship skills, and psycho-education. These areas of work will be discussed at greater length in the Middle Work Section of the Therapy Process description phase of this blog, presumably this coming spring or summer.

Re: Paranoia

Watching cable coverage of the Virginia Tech shooting, 33 dead including the shooter, was shocking, sad, and ultimately a kind of foreboding experience. Looking back, that tragedy wasn’t the worst. Despite VT’s  enormity just in terms of the numbers dead, Sandy Hook was in yet another dimension of wicked. The image of a six year old racing down the school’s hallway only to be shot dead in the back three or four steps from escaping through an outside door stays imprinted. It just doesn’t go away. Of all the traumatic events between 1985 and 2015, only two directly led to clinically significant reactions within my caseload at the time of occurrence, those being the crashing buildings of theTrade Center, thousands dying in a moment before the world, and Newtown, with closeted, motionless teachers draped over the equally motionless first graders they had tried to protect, something that seemed more like Nazi than anything that could happen in America, at any time. But it happened here, and nothing in recent America quite rises to Sandy Hook’s level of horror, and we’ve had plenty of horror with which to compare.

But now in ’07, the Virginia Tech massacre was massive and cold. After Columbine in ’99 and the two subsequent mass school shootings, one at Minnesota’s Red Lake Reservation Senior High in 05’ and the Amish one-room West Nickel Mines School in ’06,  the awareness that something dark and culturally dangerous was really taking hold grew. Virginia Tech somehow confirmed that this new reality was not just random weirdness. This was now beyond a pattern. This was a cultural problem. What and who is next would be a question answered by measures separated only by weeks and months, and no remedy about.

Watching several hours of coverage over the next three days didn’t provide social confidence or political direction. The shooter’s self-videoed death rant was ramblingly and psychotically bizarre. I don’t specifically remember any of the media commentary save one. At some point maybe during the third afternoon of reporting and analyses, a news program had a guest psychologist to offer another point of view, another attempt at understanding.The white, middle aged, average looking man seemed nervous and a little out of his element standing alone before a camera and as I recall in front of a blank white wall, seeming to sort through his thoughts as he spoke, unlike the polished predecessors who had already appeared and left their studios. I was feeling a bit sorry for the guy. He was clearly earnest in his attempt to help make sense for all of us, near the end of a long string of experts and talking heads. And then he gathered for his last offering, a declaration bursting just as the hosts readied their ‘Well-thank-you-for-your -thoughts’ part of the script.

“It’s time we as a country take seriously the problem of paranoia.”

I was a bit stunned by the psychologist’s probity, him addressing a problem that has the public appearance of being almost scrupulously avoided as unsolvable. He was right. And he’s still right.



#31 – Working With Traits, Part 1

Introduction

This post presents an example of integrating a new tool or paradigm into an existing process or structure. As indicated in the previous post, the development of the relatedness trait list occurred over the last few months of the practice, during the inception period of the outcome study. The compilation of adult Axis II clinical resistances and defense mechanisms was created long after the practice closed. These newer tools are applied to the basics of this therapy process. The emerging caution is that the resulting summaries, judgements, and recommendations coming out of this analysis, while augmented by considerable experience, have obviously not been field tested. Most conclusions are basically suggestive.

Unlike the information about symptoms, problem areas, history, family relationships, etc., gathered during the assessment process, relatedness traits become evident more through observation of client and process over time. The clinician may accurately speculate about the presence of pre-Axis II dynamics based on initial contact and history, but confirmation can take time. One major question is whether a client’s identified traits are to be explicitly included on the problem list and therapeutic goals, or remain internal considerations within the clinician.

Note: As a reminder, the following comments and suggestions emanate from the vantage and perspective of the private practitioner, particularly toward child and adolescent work. 

Trait Management

Approaches to clients with relatedness trait problems will vary depending on the severity of their particular trait system and the nature of their specific traits. Those cases with four traits or less have demonstrated a capacity to more easily resolve relatedness traits with standard family and CBT-type therapy. These particular clinical gains occurred as a byproduct of work on the other diagnostic and problem areas.

While isolated traits did demonstrate an ability to be resolved for those cases involving five or more traits, these complex systems of multiple traits were more intransigent toward treatment. Gains in the other diagnostic and problem areas of these cases nevertheless did occur, albeit at rates that averaged less than half of those made by the four-and-under group. Trait resolution itself occurred with even less frequency. The work was yet more complicated by client resistances, adult defenses, and relatively more administrative and logistical impediments.

In order to change, the five-plus trait cases likely require prolonged family and/or individual treatment focused on personality change itself. Family work that identifies problems and inaugurates a process of positive change seems to be a reasonable prelude to more extended individual work, or perhaps could be the treatment of choice in and of itself throughout. A strong clinical relationship with the youth is a necessity. The clinical ability to help guide the youth through developmental stages is also requisite. Applicable technique is a mainstay.

A second treatment consideration is the determination of content.The therapist does need to take into account client and parent sensitivities that, if activated, could result in resistances and premature terminations. Putting traits on the overt problem lists and treatment goal lists can be a risky tactic. An adolescent being led to directly address, say, their contemptuousness, or lack of remorse, or solitariness could quite well bring about terminal umbrage. Sometimes the clinician has to bide time until an inviting opportunity appears to overtly introduce the problem into the treatment plan, or find other, less explicit means.

Contemporarily, decisions to make any or all traits part of the treatment plan and goals can be influenced by forces outside of mental health itself.  Since the late 80’s, the mental health industry has increasingly moved toward symptomatic treatment programs, and away from the traditional processes focusing on life problems, family, and social relationships. Symptomatic treatment is seen as more efficient. Efficiency has been the driving force in American economic policy since the late 70’s. (read The Economist’s Hour by Binyamin Applebaum, 2019, for subtext re: efficiency). The problem is that symptomatic approaches to relatedness trait problems may well be counter-productive.

Their sometimes intransigent natures and accompanying resistances and defenses mitigate against change. Without change, cases usually terminate with some degree of displeasure. Understanding typical adolescent ambivalence about therapy, anything that reinforces a negative view needs to be avoided. The traditional focus on general diagnostic and life problem areas may still be the treatment of choice from an effectiveness standpoint.

At one time or another, all of these traits listed above demonstrated a capacity to change with family-based treatment. With the exceptions of suicidal ideation, cutting, and aggression, the traits were generally not explicitly on the listed case problems or part of the treatment goals. As stated earlier, change occurred as a function of broader improvements with depressive, anxiety, and/or behavioral issues, and resolutions of family, school, and/or social problems.

Some traits are clearly more receptive to outpatient therapies than others. Suicidal ideation, non-compliance, and aggressive behaviors generally were resolved. Indifference to praise or criticism, detachment, and entitlement, for example, are among the types of traits that generally did not change much, although even those three can show a capacity to improve in uncommon circumstances. Still, putting these traits on the explicit problem list runs the risk of being illusory, leading to disheartening results from the client’s perspective.

In hindsight and from the perspective of a line practitioner, the more resolvable traits seemed to be more a function of pre-disposition, circumstance, experience, modeling, and conditioning. Those that were less inclined to change were presumably more the result of the genetics that drive these wider networks of traits, five traits and above. Another way of viewing the dichotomy is that the more difficult traits are driven by compulsions essentially beyond the ability to be consciously re-directed, where the milder versions are receptive to the reasoning and instructions of standard cognitive and experiential psychotherapies. The difficulty lies in understanding which may be which.

The traits more inured to changed include: manipulation as part of a conduct disorder; avoidant; anxious of rejection; indifference to praise or criticism; entitlement; need to be center of attention; solitary, detached; perfectionistic; odd beliefs; magical thinking; and paranoid ideation.

Several of the traits appear in Oppositional Defiant Disorder cases, to include: defiance; non-compliance; deceit; vengeful; spiteful; both verbal and physical aggressiveness; problems with remorse and empathy; and, oddly enough given the penchant for chaos that ODD kids can create, some perfectionism. Over the time of adolescent growth and development, all these can be resolved, again in the context of ODD and not its more serious behavior disorder cousin, Conduct Disorder.  

Anecdotally, having had a successful sub-specialty in oppositional-defiant disordered youth and having tried early in the practice both individual and family approaches, family work was clearly the most viable path. Specifics on the treatment approach to ODD will appear in the Middle Work Section of the Therapy Process, which in itself will follow the outcome study’s conclusion.

Safety First

Five traits can present immediate concerns about safety. They include: cutting; risky behaviors; addiction; physical aggression; and suicidal ideation. Each present their own management dilemmas.

Cutting: 

Four cases in the study involved cutting. The few cutting cases seen through the years were in the milder ranges of the disorder, the cutting being skin-deep and generally sporadic. The treatment for more serious patterns of deep flesh and slashing wounds are usually handled by psychiatry and psychology practitioners with diagnostic and treatment skills in the area. Supportive family therapy can be a helpful therapeutic adjunct. The formats used for the cases in this study were both conjoint and individual. 

In particular, two of the cases were among the 17 relatedness cases, and the other two from the 39 others. Three stopped the cutting during the course of therapy. One non-relatedness case began having suicidal ideation and started cutting after beginning a course of SSRI’s for depression prescribed by a consulting psychiatrist. The symptoms stopped shortly after discontinuing the medication. The other non-relatedness case stopped cutting during the individual counseling, but the case terminated prematurely for administrative reasons. In my opinion, the cutting was still prognostically vulnerable to resumption. Both relatedness cases stopped cutting, but other trait problems persisted. One terminated normally with a modest clinical gain, and the other was referred out for individual work separate from the family process that itself stopped shortly thereafter.

The treatment approach for this level of cutting was to view the behavior as stemming from depression and/or anxiety issues. The cutting was not necessarily the clinical center of attention, and in fact was sometimes served more as a point of reference than being a clinical focus. The assumption that the behavior for these milder cases were within the ability of the client to resolve appeared to be substantiated.

One clinical dilemma that occasionally appeared over the years was the client’s expressed need for confidentiality that conflicts with the parental need-to-know for reasons of client safety and therapeutic support. The clinician is in the middle, so the  client – parent – clinician relational triangle becomes a concern. One basic tenet of child and adolescent work is to keep all three sides as strong as possible. Again, these were relatively mild versions of the behavior that allow for some latitude in parental notification. My inclination was toward parental involvement  and most clients concurred. On uncommon occasion, though, the process deferred to the client’s wish for individual counseling. The work was toward resolving the problem and simultaneously help resolve the client’s anxiety in regards to the parents. These types generally resolved. 

Epidemiologically, the incidence of cutting has clearly increased.. Cutting is closely associated with suicidal ideation, which itself has increased 30% over the past 30 years. According to one study, cutters are seventeen times more likely to take their lives than the overall population (Hawton, Harris; PubMed.gov; National Institute of Health; 2008; original research at Oxford, UK). Washington State now has mandatory suicide trainings every six years for licensing accreditation. Sooner or later, more specific community standards of treatment will likely be developed for cutting as well, particularly if the incidence rate keeps rising and also given the omnipresent trend within health care in general toward specialization. Hopefully, these standards will be sensitive to the severity of the cutting, and not lump all cutters under the same clinical expectations of treatment. The dynamics at either end of the spectrum seem based different etiologies, courses of development, and effective resolution processes.

Risky Behaviors: 

Patterns of risky behaviors were not common. Isolated tempts of fate do occur, like a youngster spraining an ankle jumping off a staircase from too many steps up. When the youngster does not learn from the behavior and continues to challenge reasonable limits, they are demonstrating a pattern that needs to be overtly addressed. That also would be a low level of risky behavior.

Two cases in this study included risky behavior as a presenting problem. One six-trait mid-adolescent   swatted the home of an antagonist. The inevitable swatting retaliation some months later landed the client and father facedown on their front lawn, watched over by armed sheriff deputies while their house was searched. Once the son admitted his involvement, the parents initiated counseling. What emerged from the assessment and early phase of the family therapy was a moderate conduct disorder that had developed over the previous two years. Adolescent-onset conduct disorders are usually less severe than childhood onset (DSM V), and more treatable. The risky behavior did stop in the aftermath of the incident. Eventually the case terminated on the basis of partial gains and the boy’s request. The parents were agreeable.They could always return, and were given another name if an issue arose after my office was closed. 

The second case involved drug dealing, some of the product on credit followed by debt repayment scrapes. That case was referred to an inpatient alcohol and drug treatment center covered by adoptive grandparents. The PTSD-type losses within the family history paradoxically raised the prognosis prospects. Some promising responses to the conjoint therapy suggested some substance within the young man.

Addiction: 

The above case referred to an inpatient treatment facility received follow-up treatment provided by a Washington State Certified Chemical Dependency Counselor (CCDC) to whom I referred. Having a CCDC referral source for casework and consultation is a necessity for a private practitioner, in my opinion. At the very least, the collegial relationship helps reduce the client’s anxiety of moving to another professional. A call to grandmother six months later indicated that the young man was still in treatment, and she was optimistic. The case was also an adolescent-onset conduct disorder.

A non-relatedness case presented with excessive gaming. Other problems included a moderate depression following a family trauma. Once the depression resolved and the family dealt with certain family aspects of the fallout, the parents took the client to an MD process addiction therapist. Via mother’s later report, the results by her account were somewhat disappointing, although the parents eventually reached an accommodation with the boy on their own after termination there. Two years later, the now-16 year old was described by his mother during a phone call on an unrelated matter as doing well in all areas, but still gaming too much. I think she was probably right. To what degree the process addiction work helped is unclear. What’s clear is that one did follow the other. Excessive gaming being an addiction, per se, rather than an obsession is debatable, but that viewpoint admittedly runs counter to conventional thinking about the topic.

Physical and Verbal Aggression:

Problems with aggressiveness are always part of the treatment plan. Physical safety of the client becomes an issue with both types of aggressiveness. All four cases had verbal aggression, and two had physical aggression as well. All four verbal aggression problems were resolved. Physical aggression was resolved in one of the two. The one with both verbal and physical aggression reming had four other traits. A therapy process with some promise over the first fourteen sessions was abruptly terminated by the parents, who redirected the treatment to a different kind of health care.

The clinical techniques that were typically employed with aggression issues include: language shaping; socio-cognitive work; narrative; behavior management; family communication skill building. 

Language shaping helps channel discussions toward clarity, objectivity, and inclusiveness in a family process. The early sessions that involve aggressions are almost always conjoint, and in general those early sessions almost universally use brief language shaping interventions to facilitate discussion.

Socio-cognitive work used with aggressions aids with the development and improvement of empathy and remorse. The clinical technique is akin to mindfulness, but rather than focusing on self-management, this exercise works on client understanding of others’  thoughts and feelings, particularly in regards to the client’s own actions. The guiding reference is a five-stage model of socio-cognitive development devised by Robert Selman (best presented in Piagetian Dimensions of Clinical Relevance, Chapter 4, Hugh Rosen, Columbia Press, 1985). 

Narrative work helps with insight about motivations and leads to solutions of alternative, healthy behaviors. Among other benefits, going through the relevant histories helps re-define issues of anger into those of anxiety or worry (also an element of language shaping) that leads resolutions toward thoujght and understanding in lieu of angered action and reaction.

Perhaps the main behavior management objective is to keep the consequences involved with aggressions instructive rather than punitive, and inculcate the use of reinforcement of the opposite behavior, in this case appropriately managing oneself in the face of provocation.

Clear family relational processes aim toward meaningful reconciliation, among a myriad of other functions and situations. 

All these CBT-type tools will be discussed more fully in the Middle Work Section of the Therapy Process portion of this blog. 

Suicidal Ideation: 

A separate section on Suicidal Ideation and Behavior follows this one on Relatedness. The trait is always an explicit part of the clinical problem list and goals of treatment. 

21 cases presented with suicidal ideation to one degree or another, from eleven with fleeting or occasional thoughts to two who approached an implementation of a plan. With the exception of one older adolescent client, parents were aware of the issue. 

The initial clinical assessment of the client during the second session of this therapy process always included going through a list of ten symptoms of depression (derived from the DSM III R and DSM 4), the last one of which addressed suicidal thoughts. Over time, the percentage of clients endorsing the symptom rose from an estimated 15% – 25% to this group that represented 37% of the study group.

One older adolescent did acknowledge some periods of rumination, although in other important ways did not manifest immediate concerns. The parents were unaware. Strategic thinking is that casework is enhanced by parental knowledge and adroit inclusion in the clinical process. Whatever wrestling occurred in my own clinical thinking during the first ten sessions of what was looking like a prognostically promising, long term process was another case cut short with a sudden termination by the mother for administrative reasons. That never sat well, particularly because the treatment withdrawal was triggered by an administrative oversight of my own. But stuff does happen, less so with experience, but realistically possible at any time.Two and possibly three cases in all left treatment without a clear and recognized resolution of the suicidal thinking. 

No guarantee could be made that the problem would not return at some point after treatment, at the end of treatment, but that’s generally true for most any mental health issues. The chances, though, are much reduced, and that’s the purpose of therapy. Among the 10% of cases that were the split process cases – those in which the client and family finishes a process only to return at some point in the future – none returned with a repeat suicidal ideation. One case that did not have suicidal ideation during the first therapy process did return five years later with a serious suicidal concern. That problem did get resolved, and tied up some loose ends left when the first process terminated.

The emergence of suicidal thinking usually galvanized the family of the troubled youngster or adolescent. The upcoming data suggests that parents had a greater tendency to see the process through to a mutually agreed upon conclusion. Anecdotally, they seemed to function during the time of therapy with less dispute and rancor that may have been the case leading up to the phone call for help. An old psychotherapy tenet from the 70’s is that children functionally sacrifice themselves for the benefit of the family, i.e. get depressed, anxious, or act out to prevent the family from breaking apart. To assert that axiom as a truth would be too much, but when the casework is seen from that vantage, the saying does make sense. To the degree this is true, family therapy is again the treatment of choice. And why wouldn’t  family therapy be the treatment of choice anyway?

The one clinically technical problem that could arise on uncommon occasion is when the 13 + year old client divulges mild suicidal thinking, not rising to concerns about immediate safety, and refuses to either inform the parents or authorize the therapist to do so. This leaves the clinician in the unenviable position of trying to convince the client. Helping is part of the job, not so much convincing. 

Several clinical considerations arise in regards to this particular confidentiality problem, where the task is to help both the youth and the family through a serious clinical problem. The first is having available a dependable treatment approach that incorporates the parents into the process, best from the beginning and onwards. Another is educating the youth about how the process works, particularly in regards to the countervailing realities of confidentiality and parental responsibilities. Others are developing, repairing, or reinforcing the young client’s ability to trust (using the clinical relationship as an example if necessary). and integrating the client’s demonstrated strengths into both the individual and family therapy discussions as a matter of validation, in essence reinforcing the opposite behavior. Lastly, having consultation available when in need, either in a consult session or in an informal collegial format, is useful to everyone concerned.

 



#30 – RELATEDNESS CASE OUTCOMES

Foundation Review

Operative elements of CB types of therapy may include: develop trust; create a viable relationship; be observant; teach skills; recognize improvement; reinforce positive change; facilitate autonomy; enhance community; and promote kindness and cooperation. 

The therapy begins with the initial contact, usually by phone, and concludes with the termination. Everything done from beginning to end has clinical meaning. The therapy contract is an understanding between the clinician, the parent(s), and the child or adolescent client, to the degree a child is competent to do so. Included are the problems to be addressed and the methods to be employed. Any external limitations in service coverage or external expectations of clinical methodology are reviewed and discussed. Administrative concerns such as scheduling and payment are covered in these agreements, as are potential interactions with other involved parties such as a separated or divorced parent, referents, other involved clinicians, lawyers, etc.

The process continues until the client(s) are ready to conclude or the external limitations have run their course. Other administrative developments, such as moving, change in financial status, change in job or work hours, or change of insurance do occur from time to time. The decision to termination is preferably with the  mutual concurrence of the therapist. Unilateral decisions by the client to stop are respected by the clinician with overt support or neutral acceptance. The door is usually left open to return. 

Regardless of the school of therapy or treatment program employed, the process used by an individual therapist is their own. The development of that process begins with the first educations and experiences in the field. Deliberate and spontaneous experiments in methods as small as phraseology to as large as an entirely new treatment constructs occur throughout a career. Elements that have proven helpful in the short run get incorporated into the clinician’s process. Weeding along the way occasionally occurs as well. Speaking from personal experience, that developmental process of method continues until the office door is closed following that last session.

 And in spite of all the above, stuff still happens. 

Common Axis II Defense Mechanisms 

The following is a melding of three Axis II resistances or defense mechanisms lists found and filed a few years ago. Citations were not noted at the time. The particular intent here is to share a more methodical way of understanding an array of parental behaviors that can have significant impacts on processes involving their children. 

The question pertaining to client child and adolescent clients is how to treat their problems. With parents who have ‘personality’ issues, though, the concern is more how to work with and sometimes around autonomically triggered reactions to clinical and other life events that would be difficult to help change, manage, or modulate. The therapeutic objective is to sustain as much time and opportunity as possible to aid the client, work the process, and allay disruptions and premature terminations. That may sound utilitarian, but one steadfast rule is to ‘protect the process’.

About The Four Resolved Cases

Understanding that any numerical finding with this group of four is suggestive only, the resolved group is similar to the unresolved group in a few ways, including: the average age is 12 (9 – 14); the parent configurations included a roughly equivalent three mother-father families and one mother-stepfather; the initial CGAS averages were in the middle of the serious disturbance decile for the unresolved, and in the high serious for the resolved; and the DA/PA averages at intake were 5 and 6 for the resolved and unresolved, resp. There the similarities end.

The resolved cases all had three or four traits initially where the unresolved had two of the four trait cases and everything else from five to eight. The resolved average number of sessions was 41 compared to half as much for the unresolved, excluding the 168 session case. The average CGAS gain was 27.0 compared to 8.4. One of the eight biological parents of the resolved may have had an Axis II disorder where around nine seemed likely so for the thirteen unresolved.

In addition to the relatively low number of traits at the treatment’s outset and the overall mental health of the parents, all four resolved youth had the benefit of determined mothers and stable households. The families all had sufficient resources to see their children through to completion almost regardless of how long the process might take. This is not to diminish the equally willful majority of mothers for the unresolved. Financial self-sufficiency was likewise true for at least six of the unresolved. The resolved simply had higher percentages in these crucial areas. 

Unresolved Relatedness Cases – Recaps

Junior HS student; six traits; mother was a corporate executive, father was retired with day-time child care responsibility, and three older adolescent brothers at home with several DA/PA issues among them. Father required a brief process, an unusual approach with which I concurred. The father was quietly demanding, though neither aggressive nor rejecting. A conjoint time-limited conjoint therapy was used. Over ten sessions, school performance improved and the precipitating suicidal ideation ceased; four traits remained, although this is said in hindsight since I was generally not thinking in Axis II until this study began a couple of years later. Conservative and dubious about therapy, the father became a surprisingly active, contributing clinical ally. Child went from 45 – 55 CGAS..

JHS student; five traits; single mother, father with visitation; demonstrated splitting and possibly a rejecting defense; opposed to therapy; the boy stopped raging and suicidal thoughts dissipated, but he became resistant. Worked with mother briefly in the aftermath. 

Latter elementary student at beginning of five year process; vignette case at the end of Post 27. Rages stopped, verbal aggression toward family members subsided toward family members, and school performance went up a full point, although still 1.5 to 2 below capacity. Other issues remained essentially unresolved.

Latter elementary student; seven traits;. began at CGAS 40 (severe), had a 13 CGAS point gain over fifteen sessions, verified by school counselor; involved parent appeared to be either in denial of problem severity or anxious about social stigma; clinical error may have been questioning the severity perspective just enough to cause a fleeing; parents switched treatment to a neurologist.

JHS student; six traits, single mother, primary parent via settlement; re-married father with visitation and  now contesting custody custody battle; father splitting, demanding, manipulative; client had improvement with rages, suicidal ideation, other problems remained; refused to continue after a few months. 

HS student; six traits, two of which were anti-social in nature, home safety a concern due to provocations with peers, lying and manipulative; neither parents nor younger brother Axis II involved; dangerous behaviors subsided, remorse improved; parents were amenable to discontinue therapy under subscribed conditions; process resumed in a few months to address school issues, which did improve; other problems remained; client eventually became resistant, parents amenable to terminate. 

HS student; four traits; combination of behavioral and odd physical symptoms; lying, avoidant, anxious of rejection, and quietly defiant; working single mother, father in seldom contact, financial support undependable; client comfortable and engaged in office, but little change in ten sessions; long-term process indicated; went to neurologist re: physical symptoms, who re-directed case to a psychologist.

Late elementary student; four traits, some progress over twenty four sessions, prognosis basically good; job change, had to move to Bellevue, but too far via commuter -laden highway

JHS student; complex of six traits from all three of the personality disorder groupings; distrusting, grandiose, anxious of rejection; single mother, head of six person family including grandchild, father completely out of picture; school refusing among other diagnostic and problem areas, district inferring legal action; fourteen sessions over six months, matriculated into alternative public school, CGAS gain from 40 to 50 CGAS;  unwieldy work hour change plus resulting increased daycare expenses led to a premature termination.

HS student; five traits; father deceased, mother in prison; alcohol and drug abuse problems among others; referred to inpatient D&A treatment, subsequently referred to local CCDC for follow-up treatment. Treatment here helped facilitate the transition to inpatient, according to custodial grandmother.

Latter elementary student; 7 traits, including lying, manipulative, and exploitive; parent vulnerabilities hidden by apparent strengths, chaotic lifestyle; 45 sessions over 2+ years; improvement in compliance a home and home work completion, but social relationships deteriorated during seventh grade and other problems persisted; unilateral termination attributed to financial problems.

Latter elementary student; 8 traits; abused and neglected, parental rights terminated; adoptive parents sought family therapy that would include the client, his older, also adopted sister, and a younger adoptive child with a mild developmental delay; overall chaotic life management. The client was admitted for evaluation and treatment to a two-week child psychiatry inpatient program with little result. Eventually I recommended the adoptive parents find an individual therapist fitting their insurance to do individual work with the client, and remain in reserve to be available upon need as the family therapist. 

JHS student; 6 traits, mid-50’s CGAS functioning; dominant father, demanding and manipulative, working mother engaged in process; stayed with the family therapy format too long, father terminating abruptly. A split process would probably have been better. However, with two Axis II problems within the family, the prognosis may have been poor from the outset regardless of method or format. 

Summary

Three of these thirteen cases essentially ran their course with relatively small gains. The youth were wanting to stop, and the parents were comfortable enough to continue on their own, the door remaining open. One of the six parents did manifest a constricting defense mechanism, but members of that family as a whole were very close, if a bit chaotic.

Two families had to stop due to job changes.

Two clients were referred out, one to inpatient drug and alcohol treatment, and the other to another therapist by another health care provider.

The other six cases (10% of the study group) all involved premature, unilateral terminations brought about in at least in some part by Axis II parents operating under a number of defense mechanisms.

In two of these six, the non-custodial divorced fathers exerted pressure on the clients and mothers both to abandon the therapy processes. Seen now in hindsight, the resistances of splitting, demanding, and manipulativeness on the part of the fathers seems evident. Rejecting appeared to be another, more directed at the ex-spouses than the child, but the boys were at least aware their fathers were capable of rejecting and that has a personal impact of creating anxiety. The clinical management dilemmas here will be discussed later. Suffice to say, no easy solution was evident.

Two families were enmeshed in chaotic lifestyles. One situation was brought about more by lifestyle decisions than personality driven. In their admirable desire to contribute, the kind-hearted adoptive parents assumed what ultimately became too many pressing, and occasionally urgent individual issues. Combined with their own life problems, the sheer number of calls for attention in the context of limited time available and resources tended made a CBT-family therapy untenable. The other case was the only family in the study, from my viewpoint, that evidenced Axis II issues for both parents and child, all three.

One case involved the parent struggling with either denial or anxiety about social stigma and switching to a different kind of therapy. The prompt to do so was possibly a viewpoint of mine concerning the basic problem, laid out as a possibility but perhaps taken as conclusion.

The other case was that of a defiant child and a father whose determination to manipulate the therapy was under-appreciated by me. In hindsight, switching formats to split sessions and focus more on the father’s agenda pertaining to the therapy process itself just may have saved the case.

Comments   

At least given the current levels of clinical knowledge and neuropsych/biology technology, a certain inevitability exists that a few child and adolescent cases will not end well. Even with our levels of clinical and biological knowledge rising, as they are, stuff will still happen. These personality/relatedness issues play a significant role here. 

In hindsight, incorporating this list of clinical resistances and defense mechanisms as a clinical process tool years ago would have been unquestionably helpful.  Among the 1000 or so child and adolescent cases that were seen in the practice over thirty years, all of these defenses appeared, some with regularity within this group, others less commonly. Only having an intuitive belief of what may be going awry in a given case has a limited utility at best. In reviewing these thirteen unresolved relatedness cases, being able to specify more exactly what the dynamics were in a particular case could have provided a more focused and planned direction. Again in hindsight, I could see adjustments that may have spared a small few of these cases from inadequate improvements and premature terminations.

The next posts in this relatedness sub-group section will be focused on matters of treatment. The last overall post will be one more vignette of a case from this group. 


#29 – James James

A soon-to-be thirteen year old boy was referred shortly after his seventh grade year ended. The mother explained during the initial parent interview that an abnormally difficult school year had begun to improve during the spring, but grades and mood tumbled toward the end. In the last week of school, the boy had approached a teacher saying he had placed a knife over his heart, thinking about taking his life. The school counselor took over and interviewed him. The mother was beckoned to the school, and ultimately the situation was referred here. The first appointment occurred a couple of days later. 

The family included: the father, a co-owner of a fifteen person tech services consulting company; the mother, a part-time administrator for a modest-sized philanthropic organization; and an eight year old sister going into fourth grade. They immigrated from New Zealand a few months after James was born, as the father started his company with an American colleague. Both children attended schools from an outlying school district.  

The mother described her son as very smart altho never a great student. He usually maintained B’s with occasional  A’s. Over the previous couple of months, he had slackened and the grades had dropped to D’s. Threatened with summer school, he brought the grades to C’s and a B. He also complained of boredom, was less inclined to prepare for tests, and randomly did not turn in homework that had been completed. He was often slow to respond to requests or directives at home. The non-compliance that occurred in school occasionally required faculty attention or the occasional call home. Withdrawal and avoiding the rest of the family was an increasing issue. Still, that he was so upset as to have suicidal thoughts was a shock.

The mother first described her son as “12 going on 17”. Later, she noted he became pubescent at a young age and was ‘dating’ a girl two years his senior and a class above. She inferred the relationship to be precociously intimate. I didn’t ask further.

He had been complaining of depression off and on during the school year, but the mother could not discern any particular symptom other than sleep and difficulty waking him in the morning. She herself had problems with depression earlier in her life, and her own mother “suffers from everything”. He complained of stage fright when presenting or called upon in class. He was described as socially being a loner, perhaps with one male friend. He was also finicky about matters of appearance, tended to be stubborn, and worried “obsessively” about his on-line game status.

Neither the daughter nor mother were experiencing mental health issues. The father was almost chronically stressed about the viability of his company during the now two-year-old Great Recession, particularly after having to lay off three long time employees several months earlier. She described the family as being very busy, “rushed every morning”, leaving James to skip breakfasts and sometimes lunch as well. 

The next appointment was with James individually to do an assessment, as per usual. He seemed basically comfortable from the outset, actively talking about his difficulties after the second question of a five-tiered opening system, one designed to facilitate the youth’s descriptions of the problems leading them to be there. Most boys his age start with the third or fourth question.

James was almost immediately teary. He talked about suicidal thoughts, which included a variety of methods considered. Prompted by my question, he said that the impact his death would have on family and friends would stop him from attempting. During the evaluation, he complained of both falling and staying asleep, stage fright, impatience, boredom, inability to focus and concentrate, evidently teary, and irritated with his father for reasons hard for him to define. He did not endorse problems with feelings of hopelessness. The notable feature of his appearance was a shaggy haircut that could completely cover his eyes, depending on his mood and circumstance.

During the office-administered evaluative tests, the results of a self-esteem test using the Piers-Harris model ranged from 5 – 9 on a scale of 10 in six different life areas. The 5 was for physical appearance and attributes, puzzling because he was a tall and handsome youth who assuredly knew so. His socio-moral score was age appropriate, but the ego-development result came out as immature for his age. In answering the questions involved with these three evaluative tools, he showed a clear intelligence. 

At the end of the assessment interview, he had no questions he wanted to ask me, and also none about the upcoming meeting I was to have with his mother and father. By then, he was at ease. His initiative, candor, and responsiveness were appreciable, his sadness concerning but not alarming.

In the third, summary session, the mother came in alone again. The father would likely not be participating in the treatment process directly, which was unusual but neutrally accepted. James’ reaction to being here was more positive than she had anticipated. Later that day, they had a talk about suicide that culminated with his unsolicited oath that he’d never do something like that to his family. The recommendation was to see mother and son together, with the younger sister invited when available. As sometimes does happen with cases surfacing in the last week or two of school, I wouldn’t see them for another couple of months. I reviewed with her the available back-up resources available while I was on vacation.

Through a dozen sessions from the end of August into November, the results were improvements in compliance and relationships at home, and a relatively smooth entry into his eighth grade year. The school performance was still a half to a full grade point below his B+ ability, but above the D average he carried into the last few weeks of seventh grade. Two teacher complaints about non-compliance had been conveyed to the mother. The modest overall progress nevertheless belied the tears shed by both mother and James with some frequency during these sessions, individually and occasionally both at the same time.

The Issues presented during the fall sessions included classroom work, presentation performance anxiety, failing to turn in completed homework, excessive gaming, difficult to arouse on school days, girlfriend anxiety, conflicts mostly pertaining to James on all three sides of the mother-father-son triangle, occasional non-compliance, an instance of outright defiance at school, and a return of suicidal thoughts that he was quick to clarify had no intent behind them. He was learning to be more careful with his words, and that helped to reduce the intensity at home. The problems heading into winter were significantly more internal than external. Negative self perceptions persisted in spite of overt evidence and feedback to the contrary from both family and faculty.

The mother kept the father updated on the sessions, guiding him in his interactions, and reinforcing instances of a more moderate, effective approach on his part. The father’s overall stress levels continued to be high. Mother noted his appreciation for the efforts to help his son. The sister helped by offering unsolicited observations about what seemed to be better, clearly riffing on a line I customarily use in the first two or three family sessions of a case. I was in contact with the school counselor, with whom I had worked before, to check in and coordinate.

I was mistakenly identifying the tears and other assorted problems as evidences of a depression. Self-critical perceptions remained persistent. The problem with the hypothesis was no evident history of major loss. Something was missing here, but that’s not rare at this point in a complicated case. James and his mother were clearly engaged, progress was happening, but the overall picture suggested a potentially longer process than average. A certain luxury exists for private practice cases with a family of means that includes insurance coverage with no service limits or other constrictions. The process could take a natural course.

I was also becoming aware that James could turn away from therapy on a dime, so to speak. If the problem was not depression, an Axis II problem became the first possibility. 

Working conjointly with the problems as presented weekly was indicated. The younger sister came a few times at the beginning, but later chose to stay in the play area of the waiting room instead, drawing pictures for the wall, and later still would stay at home. 

    Use the most conservative, least invasive treatment feasible.

The CBT elements employed thus far included: language shaping; psychoeducation; parent training; socio-cognitive work; and behavior management. The mother was essentially a surrogate who transmitted the parent training and behavior management skills to the father, including the use of reinforcement for appropriate behaviors and other improvements.

The downturn that had occurred during the winter of James’ seventh grade year began anew in eighth. The only difference in his circumstance was a more vigorous social life. Via his new girlfriend, a friend of his old girlfriend and also two years older, he became involved with a clique that tended toward a goth sub-culture and a fascination for the paranormal. This did mesh with a developing thread of nihilism in his worldview, and also could have influenced his self-reports during individual sessions. His face could disappear as yet more as his hair grew.

Mostly at James’ request, the therapy shifted into a split session format, meeting with the mother alone followed by individual work with him. With the mother, the sessions involved reviews of the previous week, working with her presenting problem of the week, and in other ways being of support. With James, the work began with whatever issue he wanted to discuss, and do individual therapy with the goals of problem resolution, personal growth, and building the clinical relationship. If he tended toward Axis II troubles, the clinical relationship becomes that much more important to facilitate change and protect the process.

What unfolded over the next 25 – 30 sessions was an unusual string of presenting problems. Roughly two out of three appointments focused on these presenting problems, and the other third characterized by a countervailing passivity. As had been the case from the beginning, he was comfortable in the office and wanted to be there, but he was also testing.

The presented problems sequentially included: breaking up with his girlfriend; hallucinations; less hallucinations but now fainting spells; claustrophobia in school; hopeless; nightmares of being physically abused, mostly by family members but sometimes by strangers; x-box struggles; uselessness of school; chronic headaches; renewed suicidal thoughts; dysphoria and irritability; abnormally low appetite; more air going out than in while breathing; inability to focus and concentrate at school; anger that his parents tracked the number of texts he sent during one 30 day period  (15,000, verified by mother, who is anything but hyperbolic, (but still….)

Simultaneously, the objective reports by mother included: a B-C average in school; helping more around the house; occasionally cleaning the dishes on his own initiative; an episode of lying to a teacher; negativistic but compliant; fewer x-box struggles; more accepting  of consequences; recovering more quickly from the girlfriend break-up; and more congruent parenting.

As James’ professed problems began to unfold in December, the term ‘Axis II problem’ finally appeared in the case notes. Depression may have been a symptom, but not the deeper problem.  The relatedness trait, “need to be center of attention”, seemed more definitive. 

Where depression can be seen as a problem of affect, the center-of-attention problem is one of relatedness. For clinical purposes, I’ve assumed that depression involves functional self-management and connectedness, where immature personality group (borderline, narcissistic, histrionic) type problems involve developmental issues with trust and autonomy. Understanding this is only a working hypothesis, augmenting the young man’s ability to trust seemed central. The problems themselves essentially came and went.

These half hour meetings with James were often poignant demonstrations of the autonomy problem, one of alternating excessiveness of dependence and that of independence both. The dependence was routed through these odd symptoms and complaints, some of which were unusual, and the sum total of which was rare. The independence took the form of an insistence to refrain from initiating and engaging in content other than the problems, certainly his right, but not normal. 

The emotional component appeared to be anxiety, either the cause or the result of this autonomy imbalance, i.e. never getting quite comfortable. The underlying issue was a partial problem with basic trust. I believed he trusted family, but not himself and not others outside his social peer group. That would include me. But he came and stayed and worked when necessary in the office.

The omnipresent factor in working with individual problems like trust and autonomy are the potent client defense mechanisms that can get activated in a heartbeat. My mentor, Dr. Alan Leider, had a metaphor aimed at family therapy, but equally applicable to these individual personality issues: Working with families is like walking through a minefield. They know where the mines are. You don’t. If you try to lead them through, you’re likely to get blown up.

James refrained from initiating anything in the way of discussion in sessions that did not begin with a problem. What I was not going to do was ask extraneous questions about personal interests, favorites, activities, etc. The topic had to be something in which we could both actively engage in a way that was beneficial to him.

The best entry was to ask what classes he was taking. I’d select one of them, mostly history, English, or science, and ask what the class was studying at that time. If I knew something about the topic, we’d get a conversation going. James had an a budding interest in wars, so history often came into play. I’d ask questions like what he would have done if he were, say, the general or the president. He had interesting, commendable ideas to reinforce. The history and english classes also occasionally led to discussions about contemporary events and social problems that were focused on he own perceptions and thoughts, a sort of Socratic process. He participated well. 

The class content gambit some times wouldn’t work, like he Intuitively understood the question was a gambit. The usual way to approach a pattern of resistance is to simply point it out and explore the thoughts and feelings that were occurring. With these trait problems, though, the exploration can be interpreted as a disavowal. In turn, unforeseen Axis II defense mechanisms can be triggered that might cause the client to flee. The therapist has to feel comfortable that will not be the result and I wasn’t quite there.

I avoided asking about his social group or girlfriend, particularly the latter, because I couldn’t be certain the response would be true, and/or I’d get a response I didn’t want to hear. 

At some point a couple of months into this pattern, I’m wondering if this approach would wear thin. I asked him if his mother ever read Christopher Robin to him when he was younger. His parents are New Zealanders, hence part of the Commonwealth, so I thought their reading Milne was possible. My mother was Australian, loved Now We Are Six, wore out the green cover reading to us. I thought possibly his mother had done so as well. James shook his head ‘no’. 

“So, you never heard of James Morrison?”

He shakes his head again. 

“Oh, you’ll love it. It goes like this”. 

James was looking very dubious. 

This was delivered in a kind of metered, pattered rhythm that could entertain a six year old.

James eyes widened and then he scrunched up his nose and lips in a frown to display his deep displeasure, but he absolutely could not stifle this grin that kept creeping into this attempt at prohibition. The face was an instantaneous classic, one of those moments that we as therapists treasure. 

The thought that came to me during the moment was that we were OK, that what we were doing would likely work. The tiny episode also reflected the instantaneous vacillations between childhood and adolescence that can make the transitional 12 – 13 year old group so interesting.

Every once in a while during a silence thereafter, I look upward and quietly say “James, James….”  and he’d scrunch his face up again, not grinning at this point, and say “Don’t!”, and I’d just quietly laugh, and he grinned and we went on to whatever was next. 

He broke up with his girlfriend, was despondent for two days but otherwise nonplussed.

In a repeat of the last school year, his school performance waned March and April, and in a repeat of the parental response, summer school was threatened and the x-box went. After a day or two of vehement objections, he relented. In a different reaction from that of the last year, his grades began to rise again and his mood stayed more stable.

A month or so before school was to end he started looking better, figuratively and literally. He had his hair cut, and his eyes could no longer be hidden. He started wearing glasses he had heretofore eschewed. He was more responsive to my queries. He came in one time and volunteered that he likes coming to the office to feel better. At some point, I reflected that it seemed like he was coming out of a “nihilistic funk”. After I read aloud the definition of nihilism off dictionary.com, he laughed and said that was right. That may have been his first outright expression of joy in session. 

His grades had gone back above 3.2. He was excited to report about a classroom experience, this for the first time in session. His history teacher gave an assignment to identify an historical figure he’d like to meet, list the questions to ask, and answer them as you think your character would. James chose God, and his questions were asking why the problems facing the world at the time were happening. 

The control that the parents had asserted and the breakup of a relationship that had become stressful would seem to be obvious precipitants to these changes. But the relatedness traits of needing to be the center of attention, the anxiety about being rejected, the frequent episodes non-compliance and occasional defiance, and the suicidal thinking were all largely gone. A more positive sense of self was clearly surfacing. Those changes went beyond the stress relief created by a structure to raise grades and a conflictual girlfriend gone. The propelling experience could not have been the ‘James, James….’ moment. The CBT work in its varied appearances certainly helped in demonstrable ways. Still, though, the en masse trait changes remain difficult to explain.  

By the end of 8th grade, the process had been going for a full year. Including the summer off, 46 sessions had taken place. Seeing a family at a 40 session-per-year clip was not common, let alone 46. Just getting family together in any place 40 times per year for anything in this 21st century, even dinner, is an achievement itself. Credit goes to the mother here, who, in her own quiet way, was determined to make this happen and see her son through.

The therapy continued another twenty months. 

During ninth grade, his grades dipped again in the fall and remained a source of conflict. What did not return were the odd symptoms, complaints, and compliance problems that so dominated the middle months of his eighth grade school year. The social group changed to something more moderate with the newest girlfriend, but he was now maintaining friendships with male peers outside of his relationship clique. By the spring, the grades were back close to 3.0. 

As of graduation from 9th grade, the family relationships were in the normal range. The issues that his under-achieving school performance provoked at home such as homework and x-box, were no longer rancorous.  He’d get off the screen when told, and would generally do so himself for homework. Also, the father was now believing he would not lose his business. The impact of that prevailing situation within in the family cannot be overstated. 

School motivation had varied over time, and mood likewise. Mood shifts unquestionably occurred in reaction to the emotionally demanding intimacy of his girlfriend relationships. As he was getting older and commensurately more mature, that factor was lessening in its negative impacts. 

Interestingly, in an interim re-test of his ego-development around Thanksgiving, using Hy and Loevinger’s ego development scale and test system, he had jumped from Level 3, the self-protective stage, to level 5, or self-aware. Level 3 was immature for his 12 year old age at the time of the initial assessment, while self aware is age appropriate  for a 14 – 15 year old. Many adults never get to stage 5.

The anger in having to be in school at all and the self-perception he was not very smart that seemed genuine, and remained as concerns. As had been the case all along, an encompassing effort to reinforce the opposite behavior, specifically those times when he demonstrated pride in achievements and positive self-perceptions was the primary behavioral intervention. Both the mother and the school counselor were essentially surrogates in the effort, getting family and faculty, resp., to participate.

By the end of 9th grade, his grades were close to 3.0, passing but still mildly underachieving. He was not quite done. Building self-perception is a slow construction.

At the beginning of 10th grade, James’ schoolwork was not getting good reviews, repeating the fall time pattern of the previous two years. This go around, though, the pattern reversed once the feedback became clear.The termination process was planned for four months away over an increasingly spaced four sessions.

Part of the termination process is to review improvements and remaining concerns. The improvement review is to reinforce, but perhaps more important, to create an impression. For posterity, part of the process is also to complete the work in a way that a summary accomplishment can be experienced. The question was how the therapy had impacted James’ sense of trust. 

For an adolescent, that task requires more concrete definition. Sometimes the clinician just has to make up a construct. We decided that trust involved honesty and dependability on the part of both James and the ‘other’. For family members, caring is important, too. He could see where his honesty and dependability had been wanting, at least from time to time. 

In hindsight, he knew his family members cared. He could see improvements within himself, but the concept of honesty and dependability had him thinking. The notion gave him a concrete way to think about the quality vis-a-vis others. His current girlfriend and close friends passed the test. He’d have to think about others. I didn’t ask about the therapy process itself, and he didn’t volunteer. He felt his own ability to trust was good now, and that really sufficed.

James needed more internal constancy from the beginning, and in large measure now had what was normal for his 15 year-old age. Admittedly, a lot of leeway exists in that version of ‘normal’ for adolescents, but for him he had really improved. 

Mother, on the other hard, was the essence of constancy from the beginning. The process used 83 sessions over 2 1/2 years, and determination was an imperative to carry it through to an encouraging end. All four of these resolved relatedness cases had mothers with this kind of determination. To be modulating here, all four had the necessary resources and family support to do so. 

James stayed the course, beginning to end without resistance, to his great credit. He trusted his mother first and foremost, and she was resolute in her persistence. James did the work,  Lee was the key.

Post Script

James is now 22. The ambivalence about school was never completely resolved. He graduated high school with an adequate GPA, but the overall performance was probably a full grade point below his abilities. Lee said that a degree was always important to him, but performance was not. He received an associate’s degree with a stronger B average. He has had two service jobs over the last six years, receiving rave performance reviews in both. Relationships with all three family relations are strong. In fact all four are doing well individually and as a unit. James strength is his likability, a steady quality through high school, college, work settings, and personal relationships. He’s always had a girlfriend, the latest relationship being of four years.