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.