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.
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.