#35 – WORKING THRU ADULT AXIS II INVOLVEMENTS

Note:   As a reminder, systematically analyzing the impacts and case management considerations of parental Axis II defense mechanisms occurred recently and not during the practice itself. An awareness of the general problem in each case was certainly there at the time of treatment, and decisions were made during case management in their regard. Nevertheless, the analyses here are made in hindsight, so please take that into account.

As per previous vignettes, ensuing short case summaries are likenesses with altered identifying detail.

Eight cases experienced successful therapy processes while having one adult family member with a potentially disruptive defense mechanism.

Seven of the eight youth had anxiety issues among their presenting problems. Three presented with suicidal ideation, all resolved by treatment’s end. Two had relatedness problems that were also resolved during treatment. They were among the only four out of nineteen relatedness cases to do so.

Five families were intact. The participating parent in the cases of divorced parents were mothers, including one remarried with three more children, one re-partnered for several years, and one single mother. Among the intact families, three of the fathers were the primary caretakers and the primary participating parent. They represented an unusual cluster. In another unusual cluster, all three of the divorced mothers had more resources than the fathers to deal with legal problems involving custody, visitation, and other matters as they arose.

All eight cases had one parent with a likely Axis II involvement. Six were fathers, and two were mothers. The manifested defenses of the fathers included: one with suspiciousness and distrust of positivity; one tending to ignore boundaries; one divorced father in denial, a conclusion presumed via reported patterns that occurred throughout a moderately long therapy in which he did not participate; and three splitters, two with an accompanying aggressiveness, and the other with lying and manipulating. 

Of the two mothers, both of intact families, one had difficulties with boundary recognition and had demanding tendencies. Through the first moderately long process of 34 sessions, she evidenced  vulnerabilities hidden by strengths widely noted in her community.

These eight cases are split into three groups. The first is where the defense itself was accommodated. The second is where the defense was modulated. The last is where the defense was essentially held off.

Accommodated

Piaget postulated that the key to healthy adaption is the ability to both accommodate and assimilate. Roughly translated, accommodation is an adaption to another’s manners or needs, and assimilation is the ability to have others adapt to one’s own. The two opposites are also intrinsic components of therapy, a process whose essential purpose is to enhance the adaptability of individuals and families. In simple terms, the therapist assimilates the client/family into new ways or methods of understanding, changing, and managing their realities, and then accommodate their growth and eventual departure. The exception is that the therapist works to accommodate the client’s particular scheduling and other logistical needs. The clients accommodate the therapist’s process at the outset, and assimilate what’s helpful in order to finish. 

Uncommonly, a parent(s) makes an unconventional stipulation or has an exceptional expectation arcing outside the normal therapy process. Occasionally, the dictum of ‘protecting the process’  enters into the internal deliberation of the clinician and the decision is made to meet the client’s insistence. In hindsight, the decision was often a clinical accommodation to an operative adult Axis II defense.

Two cases involved primary caretaker fathers from intact families who evinced inherent reservations about therapy from the outset. One was retired and the other ran a small consulting business out of the house. The mothers were both involved with time-consuming professional work and could only attend sessions sporadically. The parents were caring for troubled sons, one in latter elementary and the other in junior high. 

The younger of the two boys was described as depressed, anxious, underperforming in school, occasionally contemptuous, often defiant and non-compliant at home, and “in a funk a lot.” The older one was similarly having difficulties with anxiety and depressive symptoms, and internalized the stress through odd and unusual eating habits and physical complaints. 

In hindsight, distrust and suspicion about positivity describes one of the fathers, and boundary recognition was something of a problem for the other. Both of the fathers involved here were well read. During the first meeting, the father of the younger boy matter of factly professed doubts about therapy in general, explaining his reservations in terms of a long-standing conservative perspective. The other father was less explicit, but a similar reservation was palpable. 

Shankar Vedantam’s podcast Hidden Brain is occasionally programmed into NPR’s Weekend Edition. In October, 2018, the presentation was Red Brain Blue Brain, a discussion about certain differences in thinking between conservatives and a liberals based on interesting neurological findings. Briefly, when a human is faced with an ambiguous image, neurological scanning identifies disparate responses in two different parts of the brain. One kind of reaction triggers an alert to possible danger. A distinctly different response in another area of the brain activates a search for more information. Neurologically, self-identified conservatives react with anxiety and prepare to defend, and liberals look for understanding toward compassionate responses. The scanning had very high rates of correct identifications, liberal or conservative.

Understanding that going into therapy for the first time is a novel situation, a conservative ls more inclined to take a stance of self-protection. Convincing them otherwise will more likely be the result of an on-going experience rather than words in the first moments and sessions.

To investigate further and gain something of anthropological-sociological perspective, google Red Brain Blue Brain and listen to Hannah Holmes’ piece from 2014 in addition to Vedantam’s.

An open-ended conjoint process would have been the normal recommendation for both cases. Based on several factors, the prognoses for change and resolution would normally have been good. Not surprisingly in their cases, the initial recommendation for conjoint work was declined by both fathers, something of a rare occurrence among the practice’s general clientele. The self-declared conservative wanted individual work for his son, and inferred an expectation of a short process, i.e. fix the child and finish up. The other father also wanted individual treatment for his boy, but said he may want to occasionally sit in at his own discretion, primarily to observe and “perhaps” to participate. The mothers would occasionally come in fo a session. Those sessions would likely be conjoint, but to be determined. I concurred with both.

For his individual assessment, the younger boy was reluctant just to walk through the door from the waiting room, again somewhat uncharacteristic among the overall clientele. In all of my initial child and adolescent interviews, I used a five-tiered sequence of questions designed to generate discussion about the problems that brought them into the office. Despite his initial hesitations, he began talking freely after the third opening question, which was the most common point where the work began in a case.The notes of the third individual session began by describing the boy talking before the office door was shut and then continued from there through the session. He was easily engaged and wanted to be there. 

The problem set was multiple and serious, but he started making progress fairly quickly. The attitude around home improved via father’s comment, he seemed more cheerful at school by the school counselor’s report, he stopped being sent out of class, and had no repeat of the isolated suicidal thought that led to the therapy. All this occurred over eight weeks of individual work. Several problems, though, including school performance, sleeping, and continued sibling conflict at home remained to be notable concerns. The father, who had been quite pleasant throughout, was satisfied that the changes so far were sufficient and gave two weeks notice. He knew the door was open, and given the experience they both had, would probably be more amenable if the suicidal thoughts or some new manifestation of the boy’s discontent arose.

The junior high student made surprising gains over a twenty session process, the CGAS score eventually moving two deciles from 53 to 73. His progress was verified by teachers via the school counselor. Class-based friendships primarily with female desk mates at school, one of whom was a class leader, developed. The male peer mockery and intimidation subsequently dissipated. For the most part, the clinical work was individual. The sick days and in-school visits to the nurse’s office decreased and eventually stopped, and his appetite eccentricities seemed to abate. The father stayed in the waiting room through the first half dozen sessions. The mother came twice, once for an interim review and once for a conjoint session. 

The father began to sit in every other session or so, adding to the narrative on occasion. As per his stated intent, though, he mostly sat further away and observed. When he first did so, the son looked nervous. Rather that woking to involve the father, I asked the boy somewhat light-heartedly if he was concerned his father was judging him. He glanced at his dad and nodded toward me. Without looking at the father, I came back that the father wasn’t there to judge him, but rather he was judging me, and that was fine. Then I looked at the father and he smiled a nod and the boy audibly breathed relief.  Come the twentieth session, the father inaugurated a discussion about stopping. After a good discussion, we agreed to do so in three weeks. I contacted the school counselor, who checked with the teacher, and his progress was confirmed. 

The father sat out the next session, but on the 22d session came in, pulled out a book, and read throughout most of the session. His uncomfortable presence suggested that something of importance had been missed – that was clear – but this being the next-to-last session, the clinical choice was to ignore the behavior and continue consolidating the gains. Keep the door open. The final session unfolded as per usual by reviewing the process, gains, continuing growth, and what to monitor, then more informally fielding remaining questions and exchanging thanks. The boy had always readily talked and continued to the end. The father was more reserved, as always, but mutedly appreciative. Something didn’t feel quite right.

Now in the hindsight of several years and given the odd reaction to the pending termination, attempting to do some family-of-origin narrative work at some point in the process with the father, to explore the possibility of unresolved loss, might have been fruitful. The problem was the accommodated boundary issue that led him to be essentially unavailable, but I did not do enough to assimilate him over the course of treatment. But then, the progress had been really good all along.

Both cases involved accommodating the wishes of defensive fathers. Neither ended like mutually agreed-upon terminations usually do, but at least their progress got as far as it did. Thus the door was feasibly left open for both, and the father of the ten-session case did call three years later to have his younger son seen. That therapy was conjoint with sufficient time to achieve much more in the way of significant gains than the boy’s older brother. In an interesting aside, the process of nineteen sessions incorporated a time-limited therapy approach due to my planned retirement. The father becoming energetically involved and helpful to the point where he was the key to processing a reenactment of the presenting problem, a predictable phenomena of the time-limited approach, a few weeks before the last session. His change was really appreciable.

Modulated

Therapy can help modulate a parent’s own patterns of relatedness that the child may be modeling, or enable the child to be less influenced by patterns that are likely to persist. These three cases involved processes that helped reduce the parent’s defense mechanism itself or mitigated its impact. With the two cases where the Axis II problem itself lessened, one was  through direct work with parent and the other was done through the participating parent. In the third case, the latter adolescent’s age-appropriate individuation and enhanced coping skills reduced the impacts of a defense that was not likely to change in and of itself. 

The work is fairly straight forward. Nevertheless, a bit of caution is advised. The psychotherapy business tends to be mistake-intolerant, but this quality can be more acute when Axis II issues are involved. 

The cases involved boys aged 9, 14, and 20 at termination. Coincidently, each boy was experiencing more depression than anxiety, but both emotional problems were clinically significant. One client returned to therapy after becoming seriously suicidal some four years following his first process, one that terminated with modest gains.  the other two were defiant at home and socially isolated, and one of those was non-compliant at school as well. He would have been seen as oppositional-defiant disordered, but lacked the vindictive and spiteful qualities. He was basically disruptive.

All three were intact families, and importantly, all three involved stable marriages, jobs, and resources. Two of the cases were split processes where the case returned to therapy for continued work, including the client who became suicidal. All three cases were relatively long term, each using more than 35 sessions. Patience is at a premium with this kind of work. These cases represent different methods by which the relevant clinical goal of the child’s mental health betterment can be achieved. 

The problems being experienced by the clients could be at least partially attributed to parental Axis II patterns. Two cases had a parent displaying aggressiveness, one of them contemptuousness as well. Both of those children were modeling their respective parents, one a non-participating father and the other a participating mother. The third case involved a parent with difficulties focusing on the ‘other’ in the context of the self-and-other paradigm.

Directly helping the parent change some of their patterns generated by Axis II traits can be done through conjoint family work, which is certainly preferable, or during individual counseling as part of a split session process. The split-session format is where the child and parent are seen individually during the hour. The mother who was modeling the aggressive and demanding traits  both at home and toward the child’s school could be a typical situation of this group. The elementary-aged boy had become defiant in both settings and and socially isolated. That particular therapy was conjoint throughout. With supportive discussions that included observations from both husband and son during the family sessions. The mother developed alternate ways to have her concerns addressed. In doing so, that the mother changed enough to provide a sufficiently different model that the boy began to assume with both parents’ support and guidance.

 In another type of case, the parent of concern is not participating in the therapy. In this particular instance a father presumed to be ego-syntonic (‘that’s just who I am’) by description.     He was modeling aggressiveness and contemptuousness. The boy had experienced multiple disciplinary actions from teachers and social rejection in multiple settings for similar behaviors. 

As usual in the situation where one parent is participating in therapy and the other is not, the participating parent customarily relays the content of sessions to the spouse. 

Over time, information arising from the therapy includes possible connections between the client’s behaviors and those of the non-participating parent. The impact could be either modeling or conditioning. The participating parent is acting as a kind of clinical surrogate. The therapist helps shape the information being conveyed. The client made his changes quite deliberately, although a significant part of a motivation was to get out of therapy that did not abate much. But he did make changes, as did th father o some degree, as per the mother’s report.

The third is where the client – usually a latter adolescent – works toward individuating and coming to acceptable terms with the parent of concern. This particular case involved a latter adolescent struggling to pursue independence from an somewhat unrequited maternal relationship.

Clinical Considerations

The adult trait/defense problem itself may be best left off the problem list, both in practice and in notes. 

Approach the issues in behavioral terms, both in definition and outcome, both in practice and  also in clinical notes. The guiding dictum is to always make records assuming your client(s) is looking over your shoulder.

In doing child, adolescent, and family work, the first consideration is, obviously, the clinical needs of the youth, your client. The second consideration is the mother – father – child triangle. The basic guiding principle of healthcare being ‘first do no harm’, clinical actions best take into account each side of the triangle.The actions taken are either neutral or supportive to each of the three relationships. Weakening of any side to the triangle as a result of therapeutic input is a problem to the therapy itself, and so ultimately to the child. Do not harm.

Marital stability is requisite for the participating parent to be an informal surrogate. A solid relationship can be enhanced, but a fractured one can be riven.

With latter adolescence, encourage autonomy and independent problem solving

Stress with fathers the importance of expressing approval to their children.

Socio-cognitive work that is focused on the child or adolescent can be equally impactful on the parent(s). The exercise of the child imagining or guessing what the particular parent thought and felt about a problem of one sort or another is a learning experience for the parents as well. They can be asked to reciprocate. The therapist guides as passively as possible.  For most parents, the socio-cognitive work on their part is more or less routine. For parents who struggle in their own relationships, the process can be educative in and of itself. A significant side benefit to this tool is a language shaping process that focuses on the differentiation of thoughts and feelings, again assisted by the therapist. This bit of work in particular facilitates clear communication throughout the therapy.

Reinforce the parents’ coming recognitions of their own patterns and their impacts. The question is whether to do that in front of the child or separately. That decision is mostly one of clinical intuition, so trust your instinct. When in doubt, save the reinforcement for a private moment.

Avoid reinforcing a youth’s anger toward their parents or redefining their feelings as being anger 

toward one or the other or both, particularly so toward mothers. One approach could be a language shaping technique of converting the discussion from anger to worry, guilt, or sadness, and follow that particular path to some kind of inner peace or relational resolution.

Hyacinth

About fifteen years, a high school counselor referred a senior girl for problems with considerable anxiety that included school absences as a result. She had approached the counselor for advice about depressive symptoms that included sleep difficulties and an inability to concentrate. The combination of the two issues led to the referral.

The student was the first of four children spaced over nine years. The younger siblings were all boys. The father was an associate dean at a Seattle university, and the mother was a nursing home finance director who wanted to create a business out of her passion for horticulture. Their daughter’s name was Hyacinth, after the hardy, fragrant Eastern Mediterranean flower of many brightly colored varieties. In mythology, the plant represents rebirth and spring, apparently to be handled with care lest the bulb irritate the skin. The young woman was known as Cintha.

The family lived a traditional arrangement. The mother tended more to the domestic side of life, the father on the durable support of house, home, lifestyle, and future, but sharing back and forth was part and parcel of their pact. The mother and daughter tangled quite a bit, particularly as she reached adolescence. The father provided a balancing impact within that triangle. The boys tended to be more self-directed. By all accounts, the marriage was stable, communicative, and meaningful. The family was cerebral. Cintha could be stubborn.That quality may have added to family tensions, but carried her through truly difficult times over her college years in Seattle. If hyacinths are stubborn plants, as they apparently are, she and her mother differed by shades of a same color.

Beginning in mid-elementary school, my client began to have symptoms like small phobias and terrors. Socially adept with girlfriends throughout her life and boyfriends beginning in ninth grade, she nevertheless began to avoid social activities and parties in addition to family activities, restaurants outings, and extra-curricular activities in order to cope with anxiety attacks. Beginning in tenth grade, her school performance began to suffer. When the problems escalated to include school refusal, physical complaints, a couple of trips to the ER, and frequent visits to the nurses office, the parents sought psychiatric help. A year later she was referred to me.

Cintha’s diagnosis was and remained to be Panic Disorder. She began psychotropic treatments which increased over time in the variety and quantity of medications prescribed, a trajectory that continued well into the five + years that she came to the office. Whatever the exact anxiety problem was, her multi-pronged malady was  complicated and seemed to be beyond one particular diagnosis.

Because the primary intervention was psychiatric, the focus of the outpatient therapy was not the anxiety per se, but rather for support and guidance as she moved through an important year in her education, and as she emancipated through her college years. She indicated a preference for individual work from the outset, but was amenable to being seen with her parents. All three were not interested in having the brothers join the family work. My preference would be to see all five, but their wishes governed. In hindsight, they were right. For the first sixteen months, the work was primarily with the triangle.

Over the first two to three months, a mild to moderate decrease in overall anxiety occurred. Two instances which would have normally resulted in a trip to the ER were managed at home. A two to three week period passed with no panic attacks. School absences decreased. Grades started to rise again, particularly important for college applications in the process of being considered. She ended the relationship with her boyfriend and withstood the loss. 

At the same time, anxiety remained the dominant problem for both her and the family. The pharmacological treatment was still searching for an optimal combination of meds. Her relational problem was with the mother, and like the psychiatric portion of her treatment, the family therapy was essentially searching as well. The three never wavered in support of the processes. 

Now after several months and almost twenty sessions, mother and daughter had been doing somewhat better together. High school was nearing an end, Cintha’s grades were up, a new boyfriend was in her life, and she’d been accepted to a quality university in New York City, the one place outside of Seattle she had yearned to be. NYC never did pan out. Family concerns about finances and distance overrode the dream, as those kinds of concerns have a way of doing, but that was to come later. She accepted the disappointment. The mother was slowing the tempo of her parenting while under duress.

As usual, we’re sitting in a sort of square arrangement, Cintha and mother on the couch, the father in a chair to my left, and me in a stuffed rocker circa 1920. The sheer amount of time together did bring a measure of comfort among us. The clinical benefit of all that work is that comfort buys latitude. The week had been testy, including a number of disputes over time with new boyfriend, uncompleted chores and other household help, completing schoolwork, and handling bursts of anxiety. The metaphorical picture left was that of mother laying down the law, leaving the room shaking her head, and Cintha left smoldering. 

What to do? Now only a month before graduation and by design finishing up the family portion of therapy, we’d done this before. now only a month to graduation. Mentally scanning for an interventional path for a few seconds, probably scratching my forehead, nothing but a blank slate. The benefit of latitude emerged. 

I looked at Cintha and said “So, what’s the problem with someone being angry with their mother…a lot?”

I had completely no idea what I was doing, but this being a family that dwelt well in the abstract, maybe they could figure this out. None of them skipped a beat – for all they knew, this was just normal therapy. Unfortunately, I can’t remember Cintha’s exact response and didn’t make a note later, but her answer was too concrete. So I explained why the response really didn’t deal with the question, and repeated the question again. Again the answer was not going to work, and I explained and repeated the question again. I noticed out of the corner of my eye that the father squirmed a bit. That was actually notable because he was a still sitter. 

Another answer which still didn’t do. Cintha and mother were still focused and interested, so I plowed ahead and repeated the question a fourth time.The father squirmed around even more. Cintha tried another answer which still fell short of some completely unknown point, and I knew this was going to be pushing things, but, you know, comfort is comfort although comfort miscalculated could be a bomb but, well… just this one more time. Repeated.

In his soft academic manner, the father just exploded “Because if you stay angry with your mother, she will abandon you and you’ll die!”.

I was in awe, and “Where did you get that from?”

The father shrugged with raised palms and the accompanying pursed smile of modesty, and said “From the Discovery Channel.” 

So, the question had some substance after all. However metaphorical for human beings the Discovery Channel’s piece may have been, the answer provided an indelible image – don’t take family relationships for granted. Some additional importance may exist for the mother – daughter dyad in particular. Their ability to resolve problems in equitable terms and remain emotionally connected may be the most important model for a species that struggles in its organization. 

Unfortunately, I can’t remember the segue from there that night, that moment had to have had an intrinsic value within this circumstance. The process continued as per usual thereafter. I

think the line was used as a reference a couple of times during the remaining few conjoint sessions. On its face, the clinical event that night did not seem to be a corrective emotional experience or provide a tectonic movement of the psyches, but to be fair, a lot was going on with graduation nearing and a shift in the therapy format on the horizon. I do think the father’s answer caused both mother and daughter to step back a bit and look at what each themselves were doing. If that occurred, the episode may have been as important as anything else. 

Some years after she graduated from college and finished with me, I crossed paths with Cintha in Seattle and spent a couple of minutes. She had gone into mental health work for a community mental health organization. Being smart, industrious, compassionate, and un deterrable, a template of millennial women, she could do well there. She still had problems with anxiety, still taking medications, but managing much better.

Her relationship with her mother? With the tiniest hint of a sigh, “Well, there’s still stuff there, but things really are better”, said without any hint of the frustration and even bitterness that would have characterized a response to the question years earlier.

“Counseling helped.”

Note: The last three cases in this group of eight will constitute the next post.

#35  – Working Through Axis II  – Cases With Significant Gains

Note:   As a reminder, systematically analyzing the impacts and case management considerations of parental Axis II defense mechanisms occurred recently and not during the practice itself. An awareness of the general problem in each case was certainly there at the time of treatment, and decisions were made during case management in their regard. Nevertheless, the analyses here are made in hindsight, so please take that into account.

As per previous vignettes, ensuing short case summaries are likenesses with altered identifying detail.

Eight cases experienced successful therapy processes while having one adult family member with a potentially disruptive defense mechanism.

Seven of the eight youth had anxiety issues among their presenting problems. Three presented with suicidal ideation, all resolved by treatment’s end. Two had relatedness problems that were also resolved during treatment. They were among the only four out of nineteen relatedness cases to do so.

Five families were intact. The participating parent in the cases of divorced parents were mothers, including one remarried with three more children, one re-partnered for several years, and one single mother. Among the intact families, three of the fathers were the primary caretakers and the primary participating parent. They represented an unusual cluster. In another unusual cluster, all three of the divorced mothers had more resources than the fathers to deal with legal problems involving custody, visitation, and other matters as they arose.

All eight cases had one parent with a likely Axis II involvement. Six were fathers, and two were mothers. The manifested defenses of the fathers included: one with suspiciousness and distrust of positivity; one tending to ignore boundaries; one divorced father in denial, a conclusion presumed via reported patterns that occurred throughout a moderately long therapy in which he did not participate; and three splitters, two with an accompanying aggressiveness, and the other with lying and manipulating. 

Of the two mothers, both of intact families, one had difficulties with boundary recognition and had demanding tendencies. Through the first moderately long process of 34 sessions, she evidenced  vulnerabilities hidden by strengths widely noted in her community.

These eight cases are split into three groups. The first is where the defense itself was accommodated. The second is where the defense was modulated. The last is where the defense was essentially held off.

Accommodated

Piaget postulated that the key to healthy adaption is the ability to both accommodate and assimilate. Roughly translated, accommodation is an adaption to another’s manners or needs, and assimilation is the ability to have others adapt to one’s own. The two opposites are also intrinsic components of therapy, a process whose essential purpose is to enhance the adaptability of individuals and families. In simple terms, the therapist assimilates the client/family into new ways or methods of understanding, changing, and managing their realities, and then accommodate their growth and eventual departure. The exception is that the therapist works to accommodate the client’s particular scheduling and other logistical needs. The clients accommodate the therapist’s process at the outset, and assimilate what’s helpful in order to finish. 

Uncommonly, a parent(s) makes an unconventional stipulation or has an exceptional expectation arcing outside the normal therapy process. Occasionally, the dictum of ‘protecting the process’  enters into the internal deliberation of the clinician and the decision is made to meet the client’s insistence. In hindsight, the decision was often a clinical accommodation to an operative adult Axis II defense.

Two cases involved primary caretaker fathers from intact families who evinced inherent reservations about therapy from the outset. One was retired and the other ran a small consulting business out of the house. The mothers were both involved with time-consuming professional work and could only attend sessions sporadically. The parents were caring for troubled sons, one in latter elementary and the other in junior high. 

The younger of the two boys was described as depressed, anxious, underperforming in school, occasionally contemptuous, often defiant and non-compliant at home, and “in a funk a lot.” The older one was similarly having difficulties with anxiety and depressive symptoms, and internalized the stress through odd and unusual eating habits and physical complaints. 

In hindsight, distrust and suspicion about positivity describes one of the fathers, and boundary recognition was something of a problem for the other. Both of the fathers involved here were well read. During the first meeting, the father of the younger boy matter of factly professed doubts about therapy in general, explaining his reservations in terms of a long-standing conservative perspective. The other father was less explicit, but a similar reservation was palpable. 

Shankar Vedantam’s podcast Hidden Brain is occasionally programmed into NPR’s Weekend Edition. In October, 2018, the presentation was Red Brain Blue Brain, a discussion about certain differences in thinking between conservatives and a liberals based on interesting neurological findings. Briefly, when a human is faced with an ambiguous image, neurological scanning identifies disparate responses in two different parts of the brain. One kind of reaction triggers an alert to possible danger. A distinctly different response in another area of the brain activates a search for more information. Neurologically, self-identified conservatives react with anxiety and prepare to defend, and liberals look for understanding toward compassionate responses. The scanning had very high rates of correct identifications, liberal or conservative.

Understanding that going into therapy for the first time is a novel situation, a conservative ls more inclined to take a stance of self-protection. Convincing them otherwise will more likely be the result of an on-going experience rather than words in the first moments and sessions.

To investigate further and gain something of anthropological-sociological perspective, google Red Brain Blue Brain and listen to Hannah Holmes’ piece from 2014 in addition to Vedantam’s.

An open-ended conjoint process would have been the normal recommendation for both cases. Based on several factors, the prognoses for change and resolution would normally have been good. Not surprisingly in their cases, the initial recommendation for conjoint work was declined by both fathers, something of a rare occurrence among the practice’s general clientele. The self-declared conservative wanted individual work for his son, and inferred an expectation of a short process, i.e. fix the child and finish up. The other father also wanted individual treatment for his boy, but said he may want to occasionally sit in at his own discretion, primarily to observe and “perhaps” to participate. The mothers would occasionally come in fo a session. Those sessions would likely be conjoint, but to be determined. I concurred with both.

For his individual assessment, the younger boy was reluctant just to walk through the door from the waiting room, again somewhat uncharacteristic among the overall clientele. In all of my initial child and adolescent interviews, I used a five-tiered sequence of questions designed to generate discussion about the problems that brought them into the office. Despite his initial hesitations, he began talking freely after the third opening question, which was the most common point where the work began in a case.The notes of the third individual session began by describing the boy talking before the office door was shut and then continued from there through the session. He was easily engaged and wanted to be there. 

The problem set was multiple and serious, but he started making progress fairly quickly. The attitude around home improved via father’s comment, he seemed more cheerful at school by the school counselor’s report, he stopped being sent out of class, and had no repeat of the isolated suicidal thought that led to the therapy. All this occurred over eight weeks of individual work. Several problems, though, including school performance, sleeping, and continued sibling conflict at home remained to be notable concerns. The father, who had been quite pleasant throughout, was satisfied that the changes so far were sufficient and gave two weeks notice. He knew the door was open, and given the experience they both had, would probably be more amenable if the suicidal thoughts or some new manifestation of the boy’s discontent arose.

The junior high student made surprising gains over a twenty session process, the CGAS score eventually moving two deciles from 53 to 73. His progress was verified by teachers via the school counselor. Class-based friendships primarily with female desk mates at school, one of whom was a class leader, developed. The male peer mockery and intimidation subsequently dissipated. For the most part, the clinical work was individual. The sick days and in-school visits to the nurse’s office decreased and eventually stopped, and his appetite eccentricities seemed to abate. The father stayed in the waiting room through the first half dozen sessions. The mother came twice, once for an interim review and once for a conjoint session. 

The father began to sit in every other session or so, adding to the narrative on occasion. As per his stated intent, though, he mostly sat further away and observed. When he first did so, the son looked nervous. Rather that woking to involve the father, I asked the boy somewhat light-heartedly if he was concerned his father was judging him. He glanced at his dad and nodded toward me. Without looking at the father, I came back that the father wasn’t there to judge him, but rather he was judging me, and that was fine. Then I looked at the father and he smiled a nod and the boy audibly breathed relief.  Come the twentieth session, the father inaugurated a discussion about stopping. After a good discussion, we agreed to do so in three weeks. I contacted the school counselor, who checked with the teacher, and his progress was confirmed. 

The father sat out the next session, but on the 22d session came in, pulled out a book, and read throughout most of the session. His uncomfortable presence suggested that something of importance had been missed – that was clear – but this being the next-to-last session, the clinical choice was to ignore the behavior and continue consolidating the gains. Keep the door open. The final session unfolded as per usual by reviewing the process, gains, continuing growth, and what to monitor, then more informally fielding remaining questions and exchanging thanks. The boy had always readily talked and continued to the end. The father was more reserved, as always, but mutedly appreciative. Something didn’t feel quite right.

Now in the hindsight of several years and given the odd reaction to the pending termination, attempting to do some family-of-origin narrative work at some point in the process with the father, to explore the possibility of unresolved loss, might have been fruitful. The problem was the accommodated boundary issue that led him to be essentially unavailable, but I did not do enough to assimilate him over the course of treatment. But then, the progress had been really good all along.

Both cases involved accommodating the wishes of defensive fathers. Neither ended like mutually agreed-upon terminations usually do, but at least their progress got as far as it did. Thus the door was feasibly left open for both, and the father of the ten-session case did call three years later to have his younger son seen. That therapy was conjoint with sufficient time to achieve much more in the way of significant gains than the boy’s older brother. In an interesting aside, the process of nineteen sessions incorporated a time-limited therapy approach due to my planned retirement. The father becoming energetically involved and helpful to the point where he was the key to processing a reenactment of the presenting problem, a predictable phenomena of the time-limited approach, a few weeks before the last session. His change was really appreciable.

Modulated

Therapy can help modulate a parent’s own patterns of relatedness that the child may be modeling, or enable the child to be less influenced by patterns that are likely to persist. These three cases involved processes that helped reduce the parent’s defense mechanism itself or mitigated its impact. With the two cases where the Axis II problem itself lessened, one was  through direct work with parent and the other was done through the participating parent. In the third case, the latter adolescent’s age-appropriate individuation and enhanced coping skills reduced the impacts of a defense that was not likely to change in and of itself. 

The work is fairly straight forward. Nevertheless, a bit of caution is advised. The psychotherapy business tends to be mistake-intolerant, but this quality can be more acute when Axis II issues are involved. 

The cases involved boys aged 9, 14, and 20 at termination. Coincidently, each boy was experiencing more depression than anxiety, but both emotional problems were clinically significant. One client returned to therapy after becoming seriously suicidal some four years following his first process, one that terminated with modest gains.  the other two were defiant at home and socially isolated, and one of those was non-compliant at school as well. He would have been seen as oppositional-defiant disordered, but lacked the vindictive and spiteful qualities. He was basically disruptive.

All three were intact families, and importantly, all three involved stable marriages, jobs, and resources. Two of the cases were split processes where the case returned to therapy for continued work, including the client who became suicidal. All three cases were relatively long term, each using more than 35 sessions. Patience is at a premium with this kind of work. These cases represent different methods by which the relevant clinical goal of the child’s mental health betterment can be achieved. 

The problems being experienced by the clients could be at least partially attributed to parental Axis II patterns. Two cases had a parent displaying aggressiveness, one of them contemptuousness as well. Both of those children were modeling their respective parents, one a non-participating father and the other a participating mother. The third case involved a parent with difficulties focusing on the ‘other’ in the context of the self-and-other paradigm.

Directly helping the parent change some of their patterns generated by Axis II traits can be done through conjoint family work, which is certainly preferable, or during individual counseling as part of a split session process. The split-session format is where the child and parent are seen individually during the hour. The mother who was modeling the aggressive and demanding traits  both at home and toward the child’s school could be a typical situation of this group. The elementary-aged boy had become defiant in both settings and and socially isolated. That particular therapy was conjoint throughout. With supportive discussions that included observations from both husband and son during the family sessions. The mother developed alternate ways to have her concerns addressed. In doing so, that the mother changed enough to provide a sufficiently different model that the boy began to assume with both parents’ support and guidance.

 In another type of case, the parent of concern is not participating in the therapy. In this particular instance a father presumed to be ego-syntonic (‘that’s just who I am’) by description.     He was modeling aggressiveness and contemptuousness. The boy had experienced multiple disciplinary actions from teachers and social rejection in multiple settings for similar behaviors. 

As usual in the situation where one parent is participating in therapy and the other is not, the participating parent customarily relays the content of sessions to the spouse. 

Over time, information arising from the therapy includes possible connections between the client’s behaviors and those of the non-participating parent. The impact could be either modeling or conditioning. The participating parent is acting as a kind of clinical surrogate. The therapist helps shape the information being conveyed. The client made his changes quite deliberately, although a significant part of a motivation was to get out of therapy that did not abate much. But he did make changes, as did th father o some degree, as per the mother’s report.

The third is where the client – usually a latter adolescent – works toward individuating and coming to acceptable terms with the parent of concern. This particular case involved a latter adolescent struggling to pursue independence from an somewhat unrequited maternal relationship.

Clinical Considerations

The adult trait/defense problem itself may be best left off the problem list, both in practice and in notes. 

Approach the issues in behavioral terms, both in definition and outcome, both in practice and  also in clinical notes. The guiding dictum is to always make records assuming your client(s) is looking over your shoulder.

In doing child, adolescent, and family work, the first consideration is, obviously, the clinical needs of the youth, your client. The second consideration is the mother – father – child triangle. The basic guiding principle of healthcare being ‘first do no harm’, clinical actions best take into account each side of the triangle.The actions taken are either neutral or supportive to each of the three relationships. Weakening of any side to the triangle as a result of therapeutic input is a problem to the therapy itself, and so ultimately to the child. Do not harm.

Marital stability is requisite for the participating parent to be an informal surrogate. A solid relationship can be enhanced, but a fractured one can be riven.

With latter adolescence, encourage autonomy and independent problem solving

Stress with fathers the importance of expressing approval to their children.

Socio-cognitive work that is focused on the child or adolescent can be equally impactful on the parent(s). The exercise of the child imagining or guessing what the particular parent thought and felt about a problem of one sort or another is a learning experience for the parents as well. They can be asked to reciprocate. The therapist guides as passively as possible.  For most parents, the socio-cognitive work on their part is more or less routine. For parents who struggle in their own relationships, the process can be educative in and of itself. A significant side benefit to this tool is a language shaping process that focuses on the differentiation of thoughts and feelings, again assisted by the therapist. This bit of work in particular facilitates clear communication throughout the therapy.

Reinforce the parents’ coming recognitions of their own patterns and their impacts. The question is whether to do that in front of the child or separately. That decision is mostly one of clinical intuition, so trust your instinct. When in doubt, save the reinforcement for a private moment.

Avoid reinforcing a youth’s anger toward their parents or redefining their feelings as being anger 

toward one or the other or both, particularly so toward mothers. One approach could be a language shaping technique of converting the discussion from anger to worry, guilt, or sadness, and follow that particular path to some kind of inner peace or relational resolution.

Hyacinth

About fifteen years, a high school counselor referred a senior girl for problems with considerable anxiety that included school absences as a result. She had approached the counselor for advice about depressive symptoms that included sleep difficulties and an inability to concentrate. The combination of the two issues led to the referral.

The student was the first of four children spaced over nine years. The younger siblings were all boys. The father was an associate dean at a Seattle university, and the mother was a nursing home finance director who wanted to create a business out of her passion for horticulture. Their daughter’s name was Hyacinth, after the hardy, fragrant Eastern Mediterranean flower of many brightly colored varieties. In mythology, the plant represents rebirth and spring, apparently to be handled with care lest the bulb irritate the skin. The young woman was known as Cintha.

The family lived a traditional arrangement. The mother tended more to the domestic side of life, the father on the durable support of house, home, lifestyle, and future, but sharing back and forth was part and parcel of their pact. The mother and daughter tangled quite a bit, particularly as she reached adolescence. The father provided a balancing impact within that triangle. The boys tended to be more self-directed. By all accounts, the marriage was stable, communicative, and meaningful. The family was cerebral. Cintha could be stubborn.That quality may have added to family tensions, but carried her through truly difficult times over her college years in Seattle. If hyacinths are stubborn plants, as they apparently are, she and her mother differed by shades of a same color.

Beginning in mid-elementary school, my client began to have symptoms like small phobias and terrors. Socially adept with girlfriends throughout her life and boyfriends beginning in ninth grade, she nevertheless began to avoid social activities and parties in addition to family activities, restaurants outings, and extra-curricular activities in order to cope with anxiety attacks. Beginning in tenth grade, her school performance began to suffer. When the problems escalated to include school refusal, physical complaints, a couple of trips to the ER, and frequent visits to the nurses office, the parents sought psychiatric help. A year later she was referred to me.

Cintha’s diagnosis was and remained to be Panic Disorder. She began psychotropic treatments which increased over time in the variety and quantity of medications prescribed, a trajectory that continued well into the five + years that she came to the office. Whatever the exact anxiety problem was, her multi-pronged malady was  complicated and seemed to be beyond one particular diagnosis.

Because the primary intervention was psychiatric, the focus of the outpatient therapy was not the anxiety per se, but rather for support and guidance as she moved through an important year in her education, and as she emancipated through her college years. She indicated a preference for individual work from the outset, but was amenable to being seen with her parents. All three were not interested in having the brothers join the family work. My preference would be to see all five, but their wishes governed. In hindsight, they were right. For the first sixteen months, the work was primarily with the triangle.

Over the first two to three months, a mild to moderate decrease in overall anxiety occurred. Two instances which would have normally resulted in a trip to the ER were managed at home. A two to three week period passed with no panic attacks. School absences decreased. Grades started to rise again, particularly important for college applications in the process of being considered. She ended the relationship with her boyfriend and withstood the loss. 

At the same time, anxiety remained the dominant problem for both her and the family. The pharmacological treatment was still searching for an optimal combination of meds. Her relational problem was with the mother, and like the psychiatric portion of her treatment, the family therapy was essentially searching as well. The three never wavered in support of the processes. 

Now after several months and almost twenty sessions, mother and daughter had been doing somewhat better together. High school was nearing an end, Cintha’s grades were up, a new boyfriend was in her life, and she’d been accepted to a quality university in New York City, the one place outside of Seattle she had yearned to be. NYC never did pan out. Family concerns about finances and distance overrode the dream, as those kinds of concerns have a way of doing, but that was to come later. She accepted the disappointment. The mother was slowing the tempo of her parenting while under duress.

As usual, we’re sitting in a sort of square arrangement, Cintha and mother on the couch, the father in a chair to my left, and me in a stuffed rocker circa 1920. The sheer amount of time together did bring a measure of comfort among us. The clinical benefit of all that work is that comfort buys latitude. The week had been testy, including a number of disputes over time with new boyfriend, uncompleted chores and other household help, completing schoolwork, and handling bursts of anxiety. The metaphorical picture left was that of mother laying down the law, leaving the room shaking her head, and Cintha left smoldering. 

What to do? Now only a month before graduation and by design finishing up the family portion of therapy, we’d done this before. now only a month to graduation. Mentally scanning for an interventional path for a few seconds, probably scratching my forehead, nothing but a blank slate. The benefit of latitude emerged. 

I looked at Cintha and said “So, what’s the problem with someone being angry with their mother…a lot?”

I had completely no idea what I was doing, but this being a family that dwelt well in the abstract, maybe they could figure this out. None of them skipped a beat – for all they knew, this was just normal therapy. Unfortunately, I can’t remember Cintha’s exact response and didn’t make a note later, but her answer was too concrete. So I explained why the response really didn’t deal with the question, and repeated the question again. Again the answer was not going to work, and I explained and repeated the question again. I noticed out of the corner of my eye that the father squirmed a bit. That was actually notable because he was a still sitter. 

Another answer which still didn’t do. Cintha and mother were still focused and interested, so I plowed ahead and repeated the question a fourth time.The father squirmed around even more. Cintha tried another answer which still fell short of some completely unknown point, and I knew this was going to be pushing things, but, you know, comfort is comfort although comfort miscalculated could be a bomb but, well… just this one more time. Repeated.

In his soft academic manner, the father just exploded “Because if you stay angry with your mother, she will abandon you and you’ll die!”.

I was in awe, and “Where did you get that from?”

The father shrugged with raised palms and the accompanying pursed smile of modesty, and said “From the Discovery Channel.” 

So, the question had some substance after all. However metaphorical for human beings the Discovery Channel’s piece may have been, the answer provided an indelible image – don’t take family relationships for granted. Some additional importance may exist for the mother – daughter dyad in particular. Their ability to resolve problems in equitable terms and remain emotionally connected may be the most important model for a species that struggles in its organization. 

Unfortunately, I can’t remember the segue from there that night, that moment had to have had an intrinsic value within this circumstance. The process continued as per usual thereafter. I

think the line was used as a reference a couple of times during the remaining few conjoint sessions. On its face, the clinical event that night did not seem to be a corrective emotional experience or provide a tectonic movement of the psyches, but to be fair, a lot was going on with graduation nearing and a shift in the therapy format on the horizon. I do think the father’s answer caused both mother and daughter to step back a bit and look at what each themselves were doing. If that occurred, the episode may have been as important as anything else. 

Some years after she graduated from college and finished with me, I crossed paths with Cintha in Seattle and spent a couple of minutes. She had gone into mental health work for a community mental health organization. Being smart, industrious, compassionate, and un deterrable, a template of millennial women, she could do well there. She still had problems with anxiety, still taking medications, but managing much better.

Her relationship with her mother? With the tiniest hint of a sigh, “Well, there’s still stuff there, but things really are better”, said without any hint of the frustration and even bitterness that would have characterized a response to the question years earlier.

“Counseling helped.”

Note: The last three cases in this group of eight will constitute the next post.

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