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.