#42 – REVIEW – PREVIEW #3

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

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

Whither Goest Family Therapy?

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

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

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

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

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

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

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

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

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

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

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

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

A last point, allegorically about efficiency and its impacts:

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

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

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

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

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

Basic Advantages

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

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

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

Keeping Up

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

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

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

Review 

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

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

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

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

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

Preview

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

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

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

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

For Whom

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

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

Recursiveness and Mastery

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

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

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

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

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

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

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

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

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

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

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

On Personalized Process

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

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

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

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

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

#41 – WHO’S WATCHING

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

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

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

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

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

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

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

The Tracker’s Realities

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

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

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

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

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

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

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

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

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

Care for self-and child  

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

Track and nurture as possible the family relationships 

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

Relate More Effectively With  Axis II-like Exes?

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

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

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

Deny a problem exists  

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

Vulnerabilities hidden by apparent strength

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

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

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

Demanding 

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

Stigma of having a problem

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

Rejecting

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

Lying, manipulative, splitting

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

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

Addictive, substance abusing

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

Suicidal

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

Suspicious of warmth and positivity

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

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

Chaotic life management

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

Self Destructive Behavior

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

Expand Use of Other Formats?

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

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

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

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

Enhance the effectiveness of communication with the fathers?

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

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

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

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

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

Deny a problem exists  

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

Vulnerabilities hidden by apparent strength

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

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

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

Demanding 

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

Stigma of having a problem

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

Rejecting

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

Lying, manipulative, splitting

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

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

Addictive, substance abusing

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

Suicidal

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

Suspicious of warmth and positivity

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

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

Chaotic life management

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

Self Destructive Behavior

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

Conclusion(s)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Keep the door open.

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

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

Prelude

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

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

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

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

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

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

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

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

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

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

Anomalies 

#1 – Double the problem…

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

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

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

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

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

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

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

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

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

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

#2 – Steep falls following substantial gains…

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

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

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

#3 – If something happens once…

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

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

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

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

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

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

#4 – Single mothers with ODD children 

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

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

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

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

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

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

But, what to do?

The Dark Matter

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

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

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

Emphasize the terms ‘inflexible, impaired, persistent’

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

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

Clinical Considerations

1. Confront the father problem?

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

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

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

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

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

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

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

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

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

2. Interim Parental Reviews?

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

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

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

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

3. Stuck on Format?

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

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

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

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

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

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

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

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

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

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

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

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

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

4. For future reference….

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

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

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

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

HARD CASES – VIGNETTE #39

Owen

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If something happens three times, you have a problem.

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

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

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

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

Analyses and comments are in the next post.

#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.