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.
- Apply your standard assessment process; research the problem area and contemporary clinical approaches to whatever the trait problem may be; use consultation
- Carefully assess for depression and anxiety symptoms via separate inputs from both client and parent(s)
- Stay with the agreed upon format – individual, conjoint, or split sessions; change formats only after sufficient discussion(s) with both client and parents
- 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
- Be patient, comfortable, flexible, creative, interested, and learn from the experience
- Seek feedback from the client and parents, separately or conjointly, whichever seems most comfortable to the client and parent and profitable for you
- Reinforce positive change as noted
- 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.
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.