A major thrust of family therapy processes that treat youth mental health problem(s) is the use of the parents as therapeutic surrogates. In essence, the therapist enables the parents to effect and maintain changes for the child via three basic influencers. They include psycho-educational information, conditioning, and modeling.
The educational component includes any information and instruction, presumably evidence or experientially based, that the therapist offers the parents in their role to guide the child’s behavioral improvement, emotional growth, relational skills, and values clarifications. This process can occur either in the child’s presence or separately. My own inclination was to do as much of this work in the child’s presence as possible, but on occasion I’d ask for a few minutes with the parents.
The conditioning is done mostly through reinforcement. The feedback could occur as a result of a suggestion or direction, taking the form of anything from overt praise to a simple nod. The approval could be immediately after something they did differently, or periodically in an effort to maintain an important change. The most powerful reinforcement can be random, unanticipated approval. When parents or children are reporting about events and interactions in between sessions, for example, the therapist can remain alert to opportunities that point out positive differences. The conditioning can also occur via rehearsal, i.e.suggesting they use some tool that has been imparted successfully in the past. The idea to to keep the progress in motion. Giving the feedback in front of the child or privately is a matter of clinical judgement.
Modeling is mostly the result of the observations and absorption by the clients as they experience the therapy process and the therapist themselves. What the therapist does and who they appear to be becomes a subject of scrutiny and conversation within the family, more so in the beginning of a therapy process. What gets said and done in session, what they think the therapist is thinking, how the process seems to work, and what the therapist’s intentions may be are probably typical. Perhaps most importantly, the parents watch how the therapist communicates with the child, how the child responds, and what seems to have been the effect. Most parents look for ways to relate more effectively, and one of the main sources of their own education in therapy is what the therapist does in session that has desired impacts.
Being comfortable with your skills, your purposes, and your self is helpful. An innate enjoyment of kids shows.
In a sense, working through the parents is akin to a research project. The researcher (therapist) guides the behavior of the independent variable (parents) to see what kind of impact the manipulations have on the dependent variable (child or adolescent). An independent variable is assumed to have a certain degree of stability, and the dependent variable has a certain degree of malleability, which is the basis of the therapy.
In fact, most sets of the parents fit the definition. They may be coming for help, but they tend to be consistent, operate in what they believe to be in the child’s best interests, answer questions to the best of their ability with the needed level of honestly and forthrightness, make good faith efforts to apply the suggestions and recommendations they think can be of help, and provide open feedback about what’s working. Maybe 85% of them.
What happens, though, when one or both of the “independent variables” are actually dependent variables themselves? They have difficulty functioning interactively, cannot differentiate between the needs of their child(ren) and their own, and their own methods do not necessarily work to the advantage of themselves and others at the same time. The problem is prominent when one has some kind of Axis II involvement, exponentially so if both parents are so involved.
Loss or the perceived threat of loss generate a myriad of personal reactions. The perceived threat could be toward: one’s sense of self or identity; the marriage, filiation, or some other aspect of family; one’s personal safety and well-being; possessions and property; or one’s perceived prospects. Part of one’s personality is the array of self-protective defenses that tend to remain constant over time in service to one’s coping. Most of them are within the wide range of norm, generally recognizable and understandable by others, and usually effective for oneself and those around them. Axis II defense mechanisms that are activated in a therapy process, however, can be difficult to comprehend, difficult to accommodate, and very difficult to either countenance or confront without threatening the family therapy process itself.
The following common Axis II defense mechanisms are compiled by combining two such lists. As with other Axis II traits, employed defenses appear in multiple settings, circumstances, and relationships, are persistent over time, and are generally impervious to self-awareness. Successful Axis II treatment that includes recognizing and overcoming dysfunctional defenses can take years.
Of the overall fifty-six study group cases, eighteen cases (32%) involved parents, step-parents or other parent figures who demonstrated Axis II defense mechanisms that influenced therapy process and case management. Eleven of these thirteen defenses above could be identified among the twenty-four adults involved (twelve cases with one parent and six with both). Because the case selection for this particular evaluation was entirely based on my own judgement in hindsight, previous cautions re: validity and reliability apply.
The two defenses not demonstrated here were suicidal and self destructive behaviors, and extremes of behavior beyond an ability to clinically manage. Over the course of the practice, very few of those particular situations arose. How common or unusual these types of problem defenses appear in outpatient child and adolescent is hard to say. Based on the combined experience of this practice and several hundred consult group case presentations, the these situations are at most uncommon. One case comes to mind as an example of extreme behavior beyond the ability to manage will presented in a brief vignette to follow.
The most common defenses were six cases of a parent being demanding, aggressive, and/or rejecting, and six engaged in splitting. Four appeared to have vulnerabilities hidden by apparent strengths. Clear patterns of manipulating and lying occurred in three.
Three of the cases involved divorced fathers who evoked splitting, manipulating, and demanding/aggressiveness during the treatment processes. These particular cases were among the most difficult type to simply experience. A case vignette in a following post will elaborate.
Another defining factor in these case analyses is the impact that the family dynamics have on the young clients themselves. In doing so, the following typology of psychological mistreatment is offered as definitional system.
The source of this definition is “The Psychologically Battered Child”; Garbarino, Guttmann, and Seeley; Jossey-Bass: 1986. James Garbarino was among the first and foremost researchers in the field of of child abuse and neglect. Beginning in the late 60’s, most research in the field focused on physical child abuse and neglect. While a significant social concern, the definition of psychological abuse and neglect was somewhat amorphous, and the acts were generally not reportable to state children’s protective services. This book helped make that intervention more feasible.
Outlining these five types remains to be a most helpful delineation of the problem. “Battered” is a strong word, and, as applied to the eighteen kids in this study sub-group, could be seen as a little hyperbolic. Particularly, though, in the context of persistent and sometimes volatile struggles between parents over marriage and parenting, custody disputes, or post-divorce child management conflicts that includes heated disagreements about counseling, the child can feel battered, i.e. feel rejected, isolated, ignored, or terrorized as a result of a parent or a couple’s behaviors. From a clinical perspective, the issue is not so much the specific commissions or omissions of the parent, which may not rise to the level of these definitions, as much as how the child’s feelings about themselves and their world evolve, which can rise to those levels. The younger the child, the more difficult the psychological task of sorting through these experiences and feelings.
The same basic therapy approach, a recursive kind of process developed over the years, was the same for all eighteen cases. The parents were seen first appointment, and the child or adolescent of concern for the second. Perhaps 5% of the youth assessments took two sessions to complete. The third was with the parents again for a summary, recommendations, and planning session. The fourth was generally conjoint, including as many siblings as feasible and designed to create a universal baseline for the case by identifying what people wanted to see get better. The fifth and sixth were usually conjoint as well, designed to begin reinforcing change and inculcate the therapy process itself. Cases began to differentiate in terms of format (described in Post 13), thereafter. The few exceptions were usually older adolescents who initiated counseling themselves and were intent on being seen individually. Under those circumstances, that assessment process was abbreviated into two sessions before the therapy, per se, begin.
For the purposes of the analysis, the eighteen cases are divided into four groups. Eight completed successful therapy processes. The other three groups had outcomes less favorable. They included: four cases that unilaterally terminated with moderate to poor clinical results, all embroiled in contention and conflict in which Axis II issues were central and proved difficult to resolve; two cases that ended due largely to chaotic and clinically unmanageable circumstance and severity of the youth’s relatedness problems; and four cases that ended prematurely by client and family decisions that may have involved clinical errors or miscalculations on my part.
The eight successful case outcomes had an average initial CGAS score of 47, almost a full decile lower than that of the remaining forty-eight cases (that include the other ten in this group of eighteen. The average CGAS gain was 21 over an average of 34 sessions. The average per-session gain was .68, well above the study average of .44, and among the highest for any of the study’s sub-groups.
Of the other ten cases, the initial CGAS average was 54.9, exactly that of the study group as a whole. The average gain was 7.7 over an average of 16.9 sessions, both numbers particularly low. The average gain per session is .23, which would be among the lowest of any sub-group. These figures underscore the complicated nature of these ten cases, average in overall presentation but difficult to develop a momentum of change. Again, the one constant was the presence of a parent or parent figure with Axis II complications, particularly with activated defenses while under what is to them the stress and even duress of the therapy.
Note: Additional results and discussion concerning the gain-per-session metric will be presented in the study summary posts to follow these sub-section analyses. One of the interesting findings of the study is the correlations between average initial CGAS scores and the gains per session data, the overall results implying that lower initial CGAS scores take relatively more sessions to achieve significant improvements, hence lower average gains-per-session. This kind of data has as much in the way of social policy relevance as for clinical considerations.
In the spirit of keeping posts shorter, the analyses of case outcomes are to follow in the next two posts. The first will focus on cases that had successful outcomes, and the second on those that were less so.
Extremes Beyond Management
In the late 80’s, a16 year old high school junior was referred by her high school counselor who had been seeing her on an as needed basis for support. She had been having difficulties concentrating on schoolwork and was socially isolated after a best and only friend moved out-of state. More recently, she had been complaining about depression.
As per usual, the intake session was with the mother. Friendly and emanating a self-assurance, she uncommonly began the interview herself expressing thanks for the help.
Bess was an itinerant administrative assistant with a specialty in small corporate office management, working in a dozen settings over her career. Her daughter Lacey was an only child whose biological father had never been involved. She had been cohabiting with a house painter for the past nine months of whom she was fond. Briefly, her relational history suggested that of a serial monogamist. She was quick to add in perhaps her most serious moment that she was scrupulously careful about her daughter’s well-being with her boyfriends and never had any trouble. The persona definitely had a protective instinct, and wanted the help for her daughter. Inferentially, life was not at stake so the urgency was modest and she’d be available but expecting individual work as per Lacey’s intent. The mother would come in either if she had a concern to discuss or for a check-in or review.
Lacey asked that her appointment be the next day, which in and of itself was unusual. She was friendly, composed, organized in her thinking, careful at the session’s outset, but became teary and somewhat dysphoric as she recounted her concerns. Problems included the loss of her friend, dropping school performance, feeling lonely, and feeling distanced from her mother.
Falling asleep, poor mood, inability to focus and concentrate, and feelings of hopelessness indicated a moderate adjustment disorder level of depression, and occasional stomach aches indicated some anxiety. She reported having no suicidal thoughts. Using the Piers-Harris Self-Esteem Questionnaire at the time, she scored high in both behavior and physical appearance and attributes, average for intellect and school performance (presumably a combined result of high intellect and low grades, and low in anxiety, peer skills and social status, and overall happiness and satisfaction. Her socio-moral development evaluation, based on Kohlberg’s Scale, was at a solid stage 4, very good for a high schooler, and, for all that matter, for a large proportion of the population.
As a matter of note, anxiety problems were quite a bit less frequent in the late 80’s than today, so the evaluation of that problem area was typically less comprehensive. I used headaches and stomach aches as the primary indicators unless the presentation suggested one of the several types of anxiety disorders or seemed particularly pervasive. In this instance, her mother was unaware of the stomach problems. Lacey said the aches were not that bad, and she would let her mother know if they became a problem. Attention to that issue could be deferred, but her quietly firm stance was somewhat puzzling.
We confirmed a weekly individual format with the understanding that her mother would come in separately from time to time about which Lacey would be informed and briefed.
My client proved to be a quick leaner, not surprising given the evaluative results and overall impression she left. That kind of pattern is commonly mentioned at some point as feedback and positive regard.
Having already used the school counselor and now being familiar with the basic process, Lacey came into the office with specific issues, events, or problems to discuss. Over the course of the first few sessions, the focus curved toward the loss of her friend and the impacts, and a certain lack of social confidence. The conclusion of the meeting would always include a recommendation of some sort in regards to the particular issue she presented at the session’s beginning. By the fourth or fifth individual session, she was reporting on improvements at the beginning of a session, which was presumably in anticipation of the question she knew would be asked.
The sleep had improved, though not resolved, and the stomach aches had lessened, though not resolved. Not on the problem list at all, Lacey’s levels of energy had improved. My sense was that school work would start getting better as well. She initiated a change in lunch tables, and found that group more inclusive. The mood seemed to be getting lighter, but the gap between her capacity and her confidence was still evident. That would likely take time. Having now gotten beyond the first few sessions with some movement and the insurance coverage being comprehensive, time would likely be available.
The main focus began to shift toward her biological father, in some part spurred by critical comments she had made about a previous boyfriend of her mother’s who had inserted himself as a father-figure. That led to conflicts and, quite probably the man’s departure. She did yearn from time to time, and thinks about trying to find her father at some point in the distant future. Taking a bit of a risk, I wondered if that might have something to do with her occasional stomach aches. She considered and thought not. In hindsight, her hopelessness was likely the symptomatic connection.
The clinical relationship was developing. In addition to noting and often examining reported positive change, the random reinforcement and feedback components of the therapy process were well received. They tended to be about her cognitive abilities and evidences of a gradually increasing initiative.
Bess came in about ten weeks into the process at my request for a check-in. She had seen some improvements, citing more attention Lacey took to her appearance, less withdrawn, and initiating kitchen clean-up. With a kind of guilty-girl smile, the mother also related an episode of open door intimacy while Lacey was presumed to be out of the house sand about which she reacted with irritation, all related to me with assurances they were all fine afterward. She did not have any particular questions for me.I did not press beyond asking questions about Lacey’s development and their relationship over time, believing that doing so would sensitize her further to the nuances of the girl and the pair of them.
A month or so later, almost as an aside and with no particular affect, Lacey reported that her mother was sick “with something”. Her own session content had started to shift toward a boy in whom she had an interest. That in turn led to her expressing frustration with what she described as a shambled and unpredictable household that was too embarrassing to bring her interest home. The complaint turned toward what action she could pursue. That discussion led to one about adaption being the ability to both accommodate and assimilate, and recognizing that both were important to settling such a conflict. She worked well with that kind of abstraction. And then recognize to her that ability.
Lacey’s improvement had been steady over the four-plus months into the therapy. She seemed to be entering a plateauing phase. In a couple of the following sessions, she updated her mother’s continued and still undiagnosed medical issue. The therapy was now working more in the area of school motivation issues, per Lacey’s initiation, as springtime brought the end of the school year into sight.
The plan for the next session had been to follow up on the last session’s discussion and recommendations re: schoolwork. At the beginning of the session, though, Lacey let me know her mother was now in the hospital. Still unperturbed but noting my puzzled look, she went on to explain that her mother often had medical problems. I finally began asking questions, and gathered that the problems over time had been often, varied, and as as pattern somewhat inexplicable.
At least from my vantage and given the mother’s presentation, the notion that she could be hypochondriacal seemed very plausible. However, Lacey’s improvements coupled with her apparent comfort with this status quo led to a conservative approach. Rather than pursuing a course of more carefully evaluating her mother with her daughter for her sake, we moved on.
Two weeks later, Lacey reports her mother had been transferred to the ICU and was on a ventilator.
I blurted an alarmed “What?”
An unfazed Lacey said the hospital still didn’t know exactly what was wrong.
My alarm continued “This is really serious!”
With a hint of shortness, Lacey waved me off “Oh, she’ll be fine, this happens all the time”.
“She’s been on a ventilator before?”
“I think so, but you know, she’s been in the hospital a lot and she always gets better.”
A flood of thought raced through. Munchausen’s. She had no idea. I overreacted. Couldn’t tell her why, not a good idea, not my ole. What she’d been through, She’d have to get the understand some other way. Protect the gains. So, just stay with it.
“OK, but if something comes up between now and next week and you feel like coming in, give me a call.”
Bess was discharged a few days later. Barring a relapse, she was returning to work the week following. In debriefing her mother’s hospitalization, the counseling helped define and validate Lacey’s own long standing worry and perplexity, and suggesting her mother know more about her worries.
School ended three weeks later. Lacey was going to be working the summer at a local horse farm and had planned to finish with me. Her progress had continued and from a clinical standpoint she was ready to stop. Since the last few sessions provide the opportunity for culminating work, which some believe the most important of the entire therapy, her mother’s hospitalization provided a fertile field.
The most important clinical step under the circumstances, in my view, was having the client compare how she handled this episode of her mother’s illness to previous ones. Improvements had occurred in all of the diagnostic and problem areas identified during the assessment, from modest changes in overall happiness-and-satisfaction and sleep to resolutions in focus, concentration, school performance, and solving her social isolation. In reviewing the hospitalization experience, Lacey realized that her stomach aches, which we hadn’t touched upon for a while, hadn’t occurred. Being able to talk about her mother during that time provided an outlet for her anxiety. The value of a supportive outlet presumably reinforced the importance of having girlfriends. The summary input stressed a demonstrable improvement in confidence, and her ability to care for herself. One bit of specific advice, taken with aplomb, was to review with her mother at some point the plan for Lacey if her mother became impaired or passed.
A temptation is to link the Munchausen episode with Lacey’s growth toward age-appropriate self-care, thus separating further from her mother’s care during the period of therapy. That could infer a conjoint process.The central conundrum is the assumption that Munchausen’s can be acknowledged. The far greater likelihood is that a psychological problem so highly defended is much more likely to torpedo the therapy, most anything associated with the therapy could have been the trigger. The mother had given signs of having something concerning from the beginning, and a latter adolescent specifically requesting individual therapy is likely to get what they wish. So, the chosen format was a foregone conclusion and in hindsight, I think correct. Having choices in format available in any given child and adolescent therapy is important to the rule of protecting the process.
The defense of extremes of behavior beyond the ability to clinically manage in this instance may also have created an environment where the child’s needs were ignored, not maliciously but negligently. The therapy focused on what the client can do for themselves and how they may better engage the parent, and the parent was not directly involved.
Lastly and to reiterate, you never know exactly what problem is first walking through the office door, and understanding what that problem is can take months and longer.