#32 – TRAITS – Part 2

More Intractable Traits


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

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

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

Treatment Considerations – Immature Group

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

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

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

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

Anxious and Odd Groups

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

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

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

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

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


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

General  Clinical Focus

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

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

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

Re: Paranoia

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

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

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

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

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

#31 – Working With Traits, Part 1


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

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

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

Trait Management

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

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

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

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

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

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

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

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

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

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

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

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

Safety First

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


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

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

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

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

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

Risky Behaviors: 

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

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

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


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

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

Physical and Verbal Aggression:

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

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

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

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

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

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

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

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

Suicidal Ideation: 

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

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

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

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

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

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

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

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



Foundation Review

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

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

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

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

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

Common Axis II Defense Mechanisms 

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

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

About The Four Resolved Cases

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

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

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

Unresolved Relatedness Cases – Recaps

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

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

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

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

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

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

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

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

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

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

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

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

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


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

Two families had to stop due to job changes.

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

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

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

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

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

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


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

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

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

#29 – James James

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    Use the most conservative, least invasive treatment feasible.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“So, you never heard of James Morrison?”

He shakes his head again. 

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

James was looking very dubious. 

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

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

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

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

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

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

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

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

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

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

The therapy continued another twenty months. 

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

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

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

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

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

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

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

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

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

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

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

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

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

Post Script

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


The Diagnostic and Problem Area data offers a more detailed and concrete look into the specific impacts of therapy upon the relatedness group. The Diagnostic Areas include:  anxiety; depression; and behavior. The category of relatedness itself is not included. The Problem Areas include: family relationships; school performance; social relationships; and community activity.

The definitions and data collection process were discussed in Post 21. As a quick review, the presence of any of these seven problems was usually determined during the three session assessment process. Infrequently, an additional problem(s) could and did surface during the course of the therapy. An interconnectedness of Diagnostic and Problem areas usually existed in terms of any given symptom, e.g. depressive symptoms connected to declining school performance, or a flagging school performance leading to defiance at home. The existence and impacts of relatedness traits specifically were based more on clinical observations during intake and therapy, and were usually not included as explicit elements of the family’s problem and clinical goals list.

The determination that a diagnostic or problem areas was no longer an issue was based primarily on client and family reports. Collateral observations from community professionals, mostly school counselors, helped refine the overall clinical picture of a case. 

As a reminder when evaluating the above data, all the relatedness clients were males. How that fact skews the results is not clear, but some kind of skew can be assumed.

Consider dividing the seven DA/PA categories into three distinct sub-groups, including: anxiety and depression; behavior, school, and community; and family and social relationships. Anxiety and depression are internalizing symptoms.  Behavior, school, and community problems tend to be the result of externalizing processes. Family and social relationships involve both.

The comparative results indicate that the non-relatedness groups tended to have internalizing problems more frequently, 73% compared to 50% for the non-relatedness group. The relatedness group similarly tended to have externalizing problems (76% to 50%). While relational issues are presumably driven by both internalizing and externalizing factors, the respective rates of their relational issues are almost identical to the externalizing data, perhaps suggesting, that the two relational status categories are more driven by externalizing processes.  If so, this result may be more driven by the all-male cohort.

The relatedness group’s strongest area of improvement was anxiety. Their rate of resolution was above that of the non-relatedness group, as were the results in family relationships. The lessening of anxiety would appear to be related to the improvement of family relationships.

In contrast, the lowest improvement areas for the relatedness group were depression, school, and social relationships. This data is amplified further by the fact that all of the unresolved area problems within the relatedness group were those of the unresolved relatedness cases. The relationship between depression on the one hand, and school performance and social relationships on the other is probably one of mutual reinforcement. Again, these were the lingering problems of the unresolved relatedness group of thirteen at their terminations.

DA/PA Average Gain X 17/39, 13/43, 4/13

Note: In this chart, ‘Pre” refers to average number of the eight DA/PA categories each group has intake.  ‘Post’ is the number remaining at termination, and ‘Gain’ is the difference. In Post 22, one resolved category was calculated to be the approximate equivalent of a 5 point CGAS gain.


The average unresolved relatedness case improved 2.0 DA/PA during therapy, evidence that youth having the misfortune of relatively intractable relatedness traits can nevertheless benefit from effective therapy. Being in the CGAS 50’s or 60’s is eminently more tolerable than being in the 40’s and 30’s, and offers a better opportunity for continued change and growth.

The vignette ending the previous post, #27, suggests that at least a few of the clients with relatedness problems that were unresolved at termination can continue to improve after termination. Two factors are almost certainly involved in determining which cases continue improvement and those that substantially do not. 

First, as the number of traits in an individual rises, the possibility of full recovery appears to diminish. In the aftermath of asserting this, though, while the outpatient client may never resolve their relatedness tangles, they are still to be considered competent and capable of making improvements in at least some of the diagnostic and problem areas. The work could take a long while without much in the way of guaranteed gains. This clinical reality does pose a social policy conundrum.

Second, family support, particularly that of the parents individually and relationally, is of crucial importance. Part of the clinical task is to support and facilitate their roles. Capacity, tenacity, resilience, and reservoirs of energy are helpful attributes.

The statistical comparison above of the resolved group of four with the thirteen unresolved group highlights both the suppressive nature of a problematic trait system, and the almost kinetic recuperation when the traits fortunately dissipate.

The initial CGAS and DA/PA average scores of the resolved and unresolved relatedness cases are fairly close to each other: 49.8 CGAS for the resolved, and 44.8 for the unresolved; and 5.3 initial DA/PA for the resolved, and 5.8 for the unresolved. Both the clients who ultimately resolved their relatedness traits and those who did not began therapy functioning a decile or more lower than the non-relatedness group of thirty-nine. 

The post scoring was dramatically different: 76.8 CGAS for the resolved, and 53.2 for the unresolved, and 5.3 DA/PA improvement for the resolved cases compared to 2.0 for the unresolved. The unresolved relatedness termination average was the lowest of any sub-group, and that of the resolved relatedness group was the highest.

The inference of the low Pre score for the entire relatedness group, from those with three traits to those with eight, may be having traits of any number is enough to disrupt one’s ability to relate, adapt, be accepted, and be trusted. How many traits may be a less significant factor than their mere presence. 

The resolution of a relatedness problem, though, is definitely related to the number of traits existing at the outset of treatment. The resolved four cases had three and four traits while the unresolved cases had all the other scores, including the remaining four-trait cases and all else from fiver to eight.

The inferences of this data are that the presence of relatedness traits inhibit the development of normal relationships and mire the young person in situations of being distanced if not outright rejected as peers and others in their lives; and that once the traits begin to dissipate and disappear, the young person can climb into the normal strata of family, school, and social relationships.

The presence of traits are suppressive. Families, classes, and peer groups can be forgiving when the client starts to make changes. Speculatively, the combination of the conjoint identification of family problems early in the therapy, family relationship work using a socio-cognitive perspective exercise, and behavior management information for the parents helped lessen client anxiety. A good process and therapeutic relationship can provide modeling. Reinforcement both planned and spontaneous, anticipated and random can provide conditioning. The ability of children and adolescents to adjust and welcome the functionally improved into the social fold becomes an important feature of the client’s growth.

At least anecdotally, the experience with these four resolved cases suggests that trait resolution tended to follow improvements in other symptoms and problem areas. Notably, these traits were small in number. Perhaps, as suggested earlier, these low number trait systems are more the result of modeling and conditioning. Another viewpoint is that higher numbers of traits quickly develop a life of their own, mutually reinforcing each others’ existences and become much more difficult to resolve. Research on identical twins raised in separate environments suggests the genetics alone cannot explain why lower levels of traits tend to be more easily resolved, but genetics may account for the higher levels of traits that one have.

 As the number of traits rose, the number of DA/PA at treatment’s outset rose as well. While some improvements, such as a lessening of anxiety and an improvement in family relationships, could be achieved, the higher numbers of the traits tended to make other gains difficult. Another factor with increased traits is a tendency to have other family dysfunctions that complicate the case and limit the capacity of the change process. Personality disorder-type defense mechanisms are potent treatment inhibitors as well.

The sad part of this schema is that many child and adolescent relatedness problems do not resolve. Positive changes can be made, and functionality can be improved, but existence at CGAS levels less than CGAS 71 continues. We do keep working our best until the case terminates. 

The last point is a reiteration. These listed relatedness traits used here are culled from the eighty total traits listed in the personality disorder section of the DSM. Many of the cases had traits from more than one of the personality disorders. The same can be said for the DA/PA section in general. Most had two diagnostic area problems, a few had three. a couple had four. Most had more than one problem area, a few had three, and a couple had four. No one had all eight, but in a larger cohort, a small few could be reasonably anticipated.

A proposed dictum: the functional issue for therapy is not the diagnosis per se, but rather the number of extant DA/PA problem areas and relatedness traits.

Lastly, a system that identifies diagnostic and problem areas is graphically more indicative of change realities than a system based on diagnoses. This is said in some part because symptoms and problem areas are the prism through which line therapists have historically seen clients. A problem list is developed and a therapy proceeds from that point. An active mutual termination generally includes a review of what changed and what did not, for everyone’s reference. 

Parenthetically, that style of treatment may be in the process of changing.


Comparative CGAS Data

The following chart lists CGAS averages to compare, including:  the seventeen relatedness cases with the other thirty nine in the study; the thirteen unresolved relatedness cases with the other forty three; and the thirteen unresolved cases with the four resolved.


The average relatedness-troubled youth begins treatment with a CGAS score more than a full decile lower than the non-relatedness cases. The average unresolved relatedness client begins almost fifteen points below those non-relatedness cases, who generally appear in the 50’s and 60’. These are the moderate – mild disturbance deciles. At that level, the client’s problems are usually noticed only in limited areas of functioning where the traits and associated problems are manifest. In other areas of their lives, the client does not stand out as troubled.

For the serious or severe deciles, the 40’s and 30’s, the problems are noticed in most or all areas of functioning, meaning the young people who have relatedness issues receive more negative critique. Consciously aware or not, the client is experiencing greater degrees of stress in their day-to-day lives. To add to their dilemmas, the traits themselves are clinically more difficult to treat than common anxieties, depressions, and behavior disorders. 

On average, the CGAS gains of the relatedness group were within a point of the average non-relatedness gain. In spite of the relatedness deficits, the clients nevertheless made progresses. On its face, the result was surprisingly positive. The overall statistic, though, disguises a significant disparity between the results of the thirteen unresolved relatedness cases and the four resolved cases.

The thirteen unresolved relatedness cases collectively had among the lowest average gains of any sub-group in the study. Paradoxically, the four resolved relatedness cases had the highest average gain of any specific group. In a statistical sense, the major distinction between the two group is the numbers of traits for individuals in each group. The four resolved relatedness cases included the one with three traits and three of the five cases with four traits. The thirteen unresolved cases included the other two with four traits, and the remaining eleven constituted all the cases with five, six, seven, and eight traits.

While the small N of seventeen precludes any suppositions about why this particular division in the relatedness group might be the case, speculatively, an overarching concept does come to mind. 

The DSM lists a number of diagnostic traits for each personality disorder, usually eight to nine. As with virtually all mental health diagnoses, to qualify for a formal diagnosis the patient needs to display a minimum number of the listed traits for the personality disorder in mind, usually five or six. Four or lower would be viewed as sub-clinical.

A second consideration of any given trait is whether the genesis is genetic or experiential/environmental. Would it be possible that a greater proportion of traits in a sub-clinical case be more experientially based, and for those that meet the clinical criteria of, say, five traits or more, a greater proportion would be genetically based? 

The reason this makes sense is that the four “resolved” cases all gained 24 CGAS  points or more, which was quite a long way to go from the beginning to end a therapy. Because they had been demonstrating these traits in their various life arenas, they all had experienced negative and sometimes punitive responses from those effected, complicating their lives further. The resolution of the traits themselves within this group was clearly easier.

The four resolved cases were able to overcome the emotional, behavioral, and social issues including the traits themselves and rise into the functional areas of the 70’s and 80’s, or transient problem and normal deciles. In contrast, resolution of traits with the unresolved relatedness cases were far less noticeable, and in several cases, none at all. Problems that result from modeling and conditioning are, almost by definition, easier to resolve than the more genetically based, thus the speculation that the resolved cases particular traits may have been more the result of conditioning and modeling than those of the unresolved.

The overall point when looking at the levels of improvement for both groups is that CGAS gains can be made whether the trait problems get resolved as not.  At lower numbers of traits, for whatever reason, gains can be truly impressive. But gains can still be made by those youth whose trait problems do not change much. 

Improvement can and does occur without necessarily changing the traits themselves. The modest changes as a result of the clinical work can and sometimes do evolve into greater changes over time. Once the positive feedback loop is injected into their living systems, an ability to potentiate change can persist. As in other kinds of problems, family involvement can be crucial to creating a change process, reinforcing the changes that occur, maintaining the changes over time, and promoting further growth.

Comparative Results Using Other Variables

This chart compares the unresolved relatedness cases (13) to the remaining study (43) using six variables, including: age; number of sessions; length of treatment; parent configuration; primary treatment format; and termination type. Values of each as follows:as follows:


For all variables except format, the relatedness and non-relatedness case were closely correlated. In that sense, they are similar. The format distribution leaning toward some kind of individual work with the clients is an indicator of both severity and complexity both. Remember that most of the relatedness cases began in the CGAS 30’s and 40’s where, for the most part, the non-relatedness clients began in the 50’s and 60’s. 

A picture of how a relatedness case presents does begin to emerge. If the client seems to be in a serious or severe state of functional impairment at the beginning of counseling, and the history does not include serious trauma, spectrum disorder, significant learning disability,  developmental disorders specified and unspecified, or other adequate explanation, a strong likelihood of a relatedness problem exists. 

Cases of this complexity and severity generate excitement – not necessarily the positive kind. For the less experienced clinician, the in-session self-management task may be to slow down, certainly in the first parent meeting. Likely, they are not looking for productivity or new ideas at this initial session. Likely, they are more wanting to be heard, understood, and appreciated for the position in which they find themselves, that being sitting in your office for their child’s problems that appear in both private and public dimensions. 

The receptions they’ve experienced elsewhere in the aftermath of concerning, annoying, and even angering behaviors on the part of their child have often been often pressured or unpleasant. All you may need to do is to neutrally and empathetically understand as you gather the intake information and get a feel for your clients. 

If problems with empathy and remorse begin to surface during the intake, given its high correlation with more intractable relatedness issues, the clinician buckles up. This could be a long and bumpy ride. But you want that journey. Relatedness problems have universality. Their occurrences cross lines within areas such as socio-cultural, racial, ethnic, economic, sexual or gender, and/or spiritual issues. Genetic factors are minimally half the influence, and they are challenging to any clinician. Fomenting change takes skill, time, and good fortune, all three.

The format findings, weighted toward split and consecutive therapy processes, reflects the complexities and lengths of therapies involving children and adolescents. A family therapist would like to do conjoint work as much as possible for a variety of reasons, but having optional formats available that can be tailored to the specific needs and demands of the client does lessen premature terminations. One primary responsibility is to protect the process.


The gain-per-session may seem trivial, but the results using the statistic for the overall study group do make an interesting point that will be covered in the study summary that follows the sub-group section. Here, a social policy point can be made.

Being in an era of efficiency, economy, and bottom lines both private and public, mental health care is as impacted as any other industrial institution. Outpatient practitioners are part of this industry, and our work itself is affected. One of the manifestations has been a broad managed care pursuit that has developed several methods designed to produce less expensive results. This includes treatments designed to produce quicker results, and others that limit services per problem, per individual, or per family per annum. Ethical problems abound. Line therapists know this, and work thru and around the constrictions in a variety of ways, learning to live with them and learning from them.

In putting this Gain Per Session chart together, the initial intent was to simply evaluate the statistic’s utility. What emerged, though, was a concrete example of the ethical dilemmas that the designers of managed care systems face, cognizant of these ethical dilemmas or not.

The list above is organized in terms of gain per session, from highest to lowest. The additional information is the levels of difficulty the clients had at the outset, the gain made, and the number of services utilized. In particular, note where the resolved cases stood in this hierarchy.

As a diligent managed care program designer, where, how, and on what basis would you make the cutoff or shape the therapy?

Please also note, I contacted the last, .06 case after organizing this chart. The client wanted to stop counseling. Understandably, the time had come and I concurred.  After five years of clinical work with a minimal gain for the efforts, the parents were disappointed, determined, and gracefully appreciative. Now five years after leaving counseling, the young man gradually did get better. He made his way through high school, then went to a Colorado community college to prepare for a career in the skiing industry, a sport at which he had always been adept. He is employed doing what he enjoys most, traveling internationally, now getting along well with family members, great job reviews, and no other particular problems. I did not go into a detailed update on relatedness issues, except that the mother said she and father still have their worries. But things right now are fine, very good, thank you. They think about the counseling experience “often”. Their dedication had been everything.


On Validity and Reliability

To quickly review, the development and collection of this relatedness data occurred within a few weeks of the original CGAS data collection, now four years ago. The cases demonstrating pre-Axis II interactional styles were chosen first, numbering seventeen. The trait list was then developed by reviewing all eighty symptoms of the ten personality disorders in the DSM V. Thirty-one traits were selected. Then each of the identified cases were scored using the list. One result is indicated above.

The validity and reliability problems with this methodology are readily apparent. Nothing can be seen as conclusive in these forthcoming comments. Conclusions are suggestive, as said before on occasion in prior posts.

The DSM’s III – V used the same estimate that 15% of the American adult population has a personality disorder, single or mixed type. The percentage of children and adolescents was not mentioned.  Whatever that national figure may be, 30% (17/56) of a general outpatient treatment population does seem realistic. 

The 15% figure is striking. That one in seven adults has a personality disorder seems high. One in ten, maybe; one in twenty too little; but somewhere in between one and two standard deviations. Just thinking in terms of what is and what is not one standard deviation (that 15% comprising the first level of abnormality), the psychological depth of a personality disorder seems deeper than problems of anxiety, mood, and behavior (the old Axis I groups). Hypothetically, the personality disorder would then be at a rarer level of abnormality, e.g. a 1.5 standard deviation off the norm.

The reasoning is that the breakdown of self-management and coping mechanisms seems different from the basic synergy of physical, mental, emotional, and social drives that governs how one creates congruence between a sense of self and sense of world about. The latter seems biologically more fundamental. A parallel could be the statistical difference between the incidence of sexual identity and that of gender identity. The first is generally seen as a 2% phenomena while the second is .2%, or thereabouts for both. One would think gender identity to be a more deeply embedded genetic factor. In the same sense, an Axis II disorder seems deeper and a statistically more rare phenomena.

Given this perspective taken into the scoring of these seventeen cases, the point here is that my own intuition may underestimate the frequency of personality disorder. The selection of these cases be an underestimate. The assignment of observed traits could be underestimated as well, FYI.

Comments on Results

The Age Distribution of the relatedness sub-group replicates that of the study group as a whole, with a non-significant tilt toward the younger client. The 12 – 14 modal area is also the case with the study group. The relative lack of 16 – 18 year old clients may represent the difficulty that these potential clients pose to parents who would like to see them in some kind of therapy but encounter steadfast refusals. Resistance can be stiff. Note the list of defense mechanisms in the next post, and think of adolescent vehemence. 

The results of Cases Per Number of Symptoms form a normal curve. The one case with three symptoms would be at the left end of the graph, and the one with eight symptoms at the right. The resolution rate within the relatedness sub-group was 4/17 (24%). The suggestion is that the typically more difficult case, one that would warrant an equivalent adult the personality diagnosis diagnosis, begins at the point of four or five traits for a youth. On the right side of the curve, uncommonly occurring cases may present with nine or ten traits; rare situations yet higher.

A few months before retiring, a mother and father came in with household safety and welfare concerns over their eldest,18 year old son. They were seeking either therapeutic help or other recommendations about what to do. At stake was having the young man leave their home, an ultimately sad resort. The problems were serious, multiple, of long duration, and rather than tempering as he neared graduation the issues were accumulating, including graduating itself. The parents themselves had reached a stage of resignation, or so they appeared, as they went through their list with an application of togetherness. Their other two kids, at least, were OK.

Taking down the presenting problems in that friendly, nodding, indecipherable professionalism, my pen stopped dead during their last example of challenging behaviors. 

A few weeks earlier, Grady was leaving school through the gym. The girl’s volleyball team was doing dig drills in the middle of the court as the coach stood and observed from the bench. The young man was heading past her toward the rear exit of the gym. That was the first sign. One veers away from a coaching coach while traveling though a gym or anywhere, not toward her, unless a good reason exists. His was not a good reason.

Stopping right next to the rapidly alarmed young woman, he casually propositioned her with a raunchy, vilest innuendo. She paled, and then reddened, and then yelled at him like only a coach can yell a “get out” that echoes off the walls, all happening within a few of short seconds. The team immediately knew what occurred without having heard anything distinctly. Her girls all started moving quickly toward her. The client hasted  out the door. All women were mad.

Instead of continuing my note-taking, I found myself just locking gazes with the two mortified folks, likely agape.. Something about this was almost predatory and not merely stupid, but I couldn’t know.

Grady and I actually did OK together during the individual evaluation session. He took the questions seriously, worked to provide answers, if not the insights the quality of thinking was there. Other directedness or self-awareness one would anticipate from a high school senior was amiss. Malice, though, was not a forethought.The outlook, still, was dubious. 

I met with the three of them next, skipping the summary review with the parents. The work was laying out the problems, eliciting what each of the three wanted, and clarified the minimal   Expectations of living at home. Grady was alternately argumentative and accepting, affectively almost disconnected from the situation’s severity.

Later that day, I took out the list of relatedness traits, completed only a month or so earlier, to use for the first time at work. He had nine, possibly ten. I was nevertheless willing to do the work. He didn’t leave, though, and was respectful even in his complaints and disregards. He never displayed that reptilian look of someone gauging prey.

Before the fifth session he left home at his own initiative. 

I met with the parents two more times, working with grief reactions and planning, and referring them to was a local Tough Love group that had a very good reputation. I was  willing to do the work, offered to see anyone, at any time, for anything. I wouldn’t have been surprised if he returned, wouldn’t if he didn’t, and he didn’t. So be it.

Beyond-eight traits are out there, uncommon if not rare, but they are present. And they’re tough to treat, some probably thoroughly untreatable given contemporary clinical mental health technology, but one does not know. Over the years, I saw two boys who wouldn’t surprise me if either or both made the A or B Section front pages of the local Times. That wasn’t Grady. Whether his tangle of traits is in reality a Gordian Knot or not remains to be seen. The pain of the parents suggested substance within the family, and that’s where healing begins.

To continue with the commentary, when the relatively high total of empathy-remorse problems became evident, the non-relatedness portion of the study group, N = 39, was also scored for comparison’s sake. The result was 9/39  (22%) for the non-relatedness group,  compared to 13/17  (76%). The overall frequency of 22/56 (40%), though, would demand a specific response.

The findings also note that those thirteen unresolved empathy and remorse problems of the  entire study group were all assigned to the thirteen unresolved relatedness cases.

 To the degree this finding can be generalized, empathy and remorse difficulty is a key marker for potentially more difficult clinical problems. As an aside, the benefits of doing some kind of on-going data collection than can aid and abet intervention developments are evident. But even having a specific attention in mind does not necessarily mean treatment success within the realm of pre-Axis II issues. Client defense mechanisms have enormous impact. More on that in the Relatedness Summary, planned for Post 29, including one list of those defense mechanisms.

Last comment:  52/56 of the study group were males. All relatedness cases were males. Take a second look at the top five scoring traits above. Not much in the way of occurrence or pattern differentiations between the genders is made in the Personality Disorder Sections of the DSM’s III – V, but those top five certainly seem more male than female. An interesting comparison would be for some similar work done with 50 or 60 females. Personality is part genetic and part experience (50 – 50 according to one study, get into that later) and comparing this kind of data results between similar groups of females and males would be interesting in that light.

Note: Refer to Post 7: Gender Distribution for explanations of this disparity between males and females in my practice if not read already.

Discussions about clinical approaches to these cases will occur in the summary post of the relatedness sub-group section. 




Origin of ‘Relatedness’. 

For anyone not familiar with the term, please note that “Axis II” is a holdover from earlier DSMs. The 5-Axis categorization system of the DSM III and IV was deleted by the DSM V. The term had become professional shorthand for personality disorder. 

Interactional traits that have the appearance and effect of adult personality disorders begin to appear as early as mid-childhood, but predominantly in adolescence. As a group, these youth are among the most difficult with whom to do effective therapy. The traits can be debilitating to the patient and disruptive to the environments in which these young people live and function.  Little research or other work has been done to systematically identify them, e.g. the depth and breadth of the problem, how clinical work is impacted, and just how to go about doing the work. This section introduces data concerning pre-Axis II clients, including identification, frequency, severity, and outcomes.

The DSM’s III – V have had the same formal guidelines for diagnosing a child or adolescent personality disorder. If the cluster of traits in question has a childhood version of an adult personality disorder diagnosis, the clinician uses that version. For example, would be a conduct disorder diagnosis for a youth who, as an adult, would be diagnosed with an anti-social personality disorder. For those disorders that do not have a childhood antecedent, the diagnosis can be made for both adults and children. Currently, using the same diagnosis for both populations  would apply to seven of the ten recognized personality disorders. An example would be a schizotypal personality disorder.

For practical purposes in fieldwork, though, a different set of guidelines and conventions has been used. The personality disorder diagnosis itself was rare. For most of us, the diagnosis was never used. Just the term ‘personality disorder’ in the context of outpatient child and adolescent therapeutic work was rarely heard, even in settings like staffings, consults, community trainings, or continuing education workshops. Other explanatory diagnoses and concepts can be used in its stead. This included elite treatment settings. While working on the inpatient medical units at Seattle Children’s Hospital from ’78 – ’84, I frequently spotted for the inpatient psychiatry unit’s social worker in her absence. In those highly comprehensive, multi-disciplinary  staffings, I cannot recall ‘personality disorder’ being used, even informally. 

Clinicians are cautious about this label for a couple of reasons. One, a personality diagnosis could well be premature. A clause in the basic DSM definition of personality disorders states that the traits have to be enduring and appear in multiple settings. Since a youth’s development is incomplete, young clients could theoretically “grow out of it”, and often do. 

Two, a caution that borders on prohibition concerns the lack of a fully developed sense of identity. A young person would likely have difficulty incorporating the negative connotation of something so fundamental as their personality and continue to see themselves as they had.  Rather than understanding the problem as some aspect of themselves needing help, the child or adolescent could see themselves as defective, damaged, aberrant, etc. That self-perception can become part of their identity set. The colloquial dictum has been that a clinician can’t give a child or adolescent a personality disorder diagnosis.

A concern about the term ‘personality disorder’ being shared with adults raises the same concern about doing so with an adolescent or child, even though the clinician had been thinking so. The question then arises, why use a mental health term that is largely not shared with the client when other terms more viable are available to the clinician for sharing their formulations with the client? Is the use of ‘personality’ as the global reference point for this class of disorder really necessary? 

Hence the term ‘relatedness’. However, “relatedness” is not being offered as an alternative, but only as an example of the possibilities. Do keep in mind that the thoughts in the last paragraph are personal opinions.

Lack of remorse and lack of empathy were initially listed separately. The first half dozen lack-of-remorse cases were also scored as having lack of empathy. The two were listed in different personality disorders. Stopping to reassess, the qualities of each seemed sufficiently similar. Continuing to see them as separate seemed to be a scoring misrepresentation that made these particular clients a step more troubled or dysfunctional than was really the case, in my opinion. So, the two traits were combined into one. 

“Listen to the nurses. They know what’s going on’

Thanks to Cathy Baker, RN

Hospital Mentor and Guide



The DA/PA posts conclude the global study data, posts 6 – 23. Comprehensive review will be in Study Summary Section, following Sub-Groups.


Sub-Group Section  – 

Relatedness, or pre-Axis II symptoms

Suicidal Ideation

Parent Configuration #4 – Single mothers

Sexual Identity



Unresolved depression, suicidal ideation

Clients with CGAS gains under 5

Clients with CGAS gains over 24

Clients Length of Treatment over over 2 years

Clients Length of Treatment under 7 weeks

Termination Type 3 – 5 – unilateral and administrative terminations

Format 3 – Conjoint Family followed by Individual Therapy

Clinical errors

Axis II summary

Study Summary Section

Review of Findings


Therapy Process Section

Setting Up A Practice

Initial Contact

Assessment: parent interview, child evaluation, summary session

Initial family sessions

Middle Work


Context Section

Publishing Estimates

Sub-Group Section – 15 – 20 posts, planned completed in Jan/Feb

Study Summary – 3 – 4 posts, planned completed in March

Therapy Process – 30 – 40 posts, planned completed late summer 2020

Context Section – Planned completed – Spring, 2021

I believe that changes made in this compassionate treatment, as described in earlier posts, are more effectively sustained because of the family’s intimate awareness of how the growth occurred, and how to keep everyone involved and on track. This contention would be an interesting part of research that examines what works and how among therapy types.

For the reader interested in doing child, adolescent, and family therapy, one thought to entertain as this work proceeds is where this discipline will fit in the future. Prescriptive therapies and other programs designed for children and adolescents will proliferate as the patient population grows larger. Competition can get noisy, advertising seductive. Compassionate-type therapies will continue to be quiet, patient, few quick fixes, no bells, no whistles. Private practice will remain viable and less impacted by efficiency strictures within mental health industry policies. The solo office may become the only viable setting in which long-term therapy can occur.

A market for family therapy will always be there, but may be limited. Income may be a challenge. Creativity, determination, and health help. If you’re still tempted to go in this noble direction, take heart and keep the faith. To paraphrase a Joni Mitchel lyric, ‘sacrifice and satisfaction, you know they’re the same release’ (from People’s Parties).

“Listen to the nurses. They know what’s going on.”

Thanks to Kittee Berfelz, RN,

Guide and Mentor at Seattle Children’s Hospital


In addition to being an alternative measurement of effectiveness, diagnostic and problem area data can be used to assess specific areas of both process strength and need for particular attention within specific clinical groups. The following data charts compare the outcomes of three age groupings: 5 – 11; 12 – 13; and 14 – 18.  While this division created an arithmetic balance, the three could also be seen as representing three distinct stages of growth: childhood; transitional; and adolescence. 

Six Diagnostic and Problem Areas are used, including: anxiety, depression, behavior;  and family, school, and social. For the purposes of this particular analysis, relatedness and the problem area of community are not included. Relatedness does not constitute an Axis I diagnostic category for children and adolescents. As indicated in an earlier post, the community problem area was insufficiently designed, and only involves relatedness cases.

Generalizability of these results to other practices is limited due to the validity issues already described. The section is meant as a demonstration of how the data system can be used by the individual practitioner, and how the results could have been translated into clinical work.


The relatively low number of children with depressive symptoms was surprising. The total of DA/PA issues seen in Group 1 were a third lower than the other two groups, but the depression score of 3 was well below any other line. The assessment for depression symptoms was uniform and applied to all new children and adolescents, and if questions arose about the child’s capacity to answer, the parent(s) would be consulted during the assessment. The scoring seems valid. 

All three of the clients included in the depression category, whose ages were 7, 8, and 10, reported suicidal thoughts. The eight year old had random, repeated thoughts over a period of months. The others were more blurts during emotional interchanges.The children’s schools had not experienced suicidal thoughts or behaviors with these children. A couple of teachers did report other depressive concerns like irritability and teary reactions to normal happenstance. These symptoms, including the irritability and excessive sensitivity resolved by the end of treatment. Many dissipated shortly after the assessment and therapy processes began.

Given that the numbers of DA/PA areas of concerns for the youngest group were roughly two/thirds of the older two groups, even this low number of depression issues may have been within the range of norm. Another possibility is that younger children may be more prone to manifest depression in anxious and/or behavioral terms. 

As a very general observation, the general receptivity of youth to family therapy increases as the child is younger. 

The 46% resolution rate of anxiety problems within the 14 – 18 year-old group was likely due to two prevailing issues. A few of the group may have had sexual identity worries which, if so, can be profound. Another few had processes that terminated due to administrative issues. 

Sexual identity was seen as a possible explanation of anxiety problems that either arose or worsened as adolescence progressed. Most within the study group were in this age bracket. They just a portion of  the only clients with anxiety. Probability ranged from degrees of possibility to probable, so they were an inferred and unconfirmed group.

These particular clients tended to do well in other areas of concern. In the exquisitely difficult work with a portion of these boys who seemed more probable and were suffering, this one possible underlying cause of the anxiety problem was not a focus of exploration due to presumed reluctance and potential negative consequences. In other ways, though, the therapy was commonly experienced as a validation of their abilities, self-perceptions, and self-worth, resulting at least in a diminishment of worry. Much of the anxiety, though, remained at termination. This particular group will also be covered in the following Sub-Group Section.

In the early 20-teen years, the Evidence Based Treatment movement was just beginning to gain traction in the mental health business, and was not utilized in my practice. If the initial clinical approach failed to generate improvement, an appropriate EBT would be sought and used now.

The low resolution rates for both anxiety and school were impacted by a high number of administrative terminations in the 14 – 18 year-old group. Not much can be done about processes driven out by circumstance except to learn what one can. This would be particularly true if some clinical issue became a prompt of one sort or another. Axis II parent or parent-figures do form a portion of the administratively terminated client and family. The problem is that the client is commonly still anxious. The Termination Type 5 group will also be reviewed in the Sub-Group Section. 

The high resolution rate for depression is also notable. A common aphorism used in the past is ‘activity alleviates anxiety’. By the same token, one can conceive that  ‘connectedness alleviates depression. Although possible, connectedness may not necessarily resolve depression but can lessen depression’s drag on one’s being. Simply experience of effective family therapy enhances connectedness. 

The DA/PA data conveys the point that a multiplicity of issues accompanies most any new case. The chart above indicates that 80% of clients come in with more than kind of emotional or behavioral problem. Similarly, 80% come in with more than one problems area of concern. Therapies have a field of responsibility that tends to everything within its power for that given case, in that given situation, in some way or another.

 Focused therapies can carve out specific symptoms and problems areas to treat, but a broader approach is quite likely necessary for tending to the range of issues that are outpatient material in nature. Tending can be simply watching, or making a referral, or added to the treatment problem list. Cover as much as possible, feasible, and ethical. ‘Some way or another’ is the art of what we do.