#36 – HOLDING AT BAY #1 – Vignettes

36 –  Holding At Bay #1 –  Vignettes

Continuing the examination of cases involving divorced parents where at least one within the couple appeared to have Axis II issues, in these three situations the contentiousness over child care continued well beyond the divorce itself. The inter-parent struggles involved custody, child support, living arrangements, educational decisions, and/or healthcare authorizations that included those for mental health treatments. The client mental health problems were not solely caused by the wrangling, but all three clients experienced anxiety symptoms and expressed distress over the family splits, parental conflicts, and fright about what could be perceived as unpredictability in their the overall care and basic connectedness with both parents. Given that the relationships between the parents could appear unstable, the relations that the child has with both could be seen as threatened and subject to changes that were out of the child’s control or influence. The on-going situation becomes traumatic in and if itself.

Addressing The Non-participating Parent

Non-participating parents in therapy cases involving divorce were notified about the counseling using a method honed during the first years of the practice. During the treatment planning that occurred at the end of the assessment summary session, the participating parent was asked to notify the non-participating ( ‘other’) parent that they could call and make a one-time appointment to meet with me. The purpose could be for them to share their perspective and concerns about the child, or to find out what the clinical thinking and planning may be, or simply to assess me for their own knowledge. The notification included that they would be responsible to pay the session fee or co-pay at the time of the service. The session could only occur in the office, e.g. not by phone (Zoom, et. al., could change that, and covid-19 would change that, but nothing really replaces the effectiveness of face-to-face for interviews that can easily be tricky to effectively manage). If the other parent did not call, the participating parent would keep the other parent informed about the therapy, as per whatever was required. I would check with the participating parent that the other had been notified.

The participating parent along with the other parent, if they came in, were also told that I would avoid being involved in any legal process to the best of my abilities. If an opinion concerning the client was necessary for legal or administrative purposes, my input could be gathered by a guardian ad litem or other formally involved professional. Most parents accepted that statement at face value. For any parent who asked why, the explanation was that direct involvement with a legal process could be detrimental to the child’s therapy itself. The assertion could be anecdotally buttressed.  For the ‘other’ parent, this notification was a certain comfort, and helped with gaining their tacit support

The purpose of this protocol was to create as much trust as possible with the other parent short of reaching out. Soliciting a session is problematic, even more so under these circumstances. About 10% of the non-participating parents did make this one-time appointment. Over the years, perhaps three or four of these parents over the years asked to be involved in some way. They were accommodated. Aside from the important symbolism of devotion, their involvements were brief and not particularly consequential in terms of clinical gain.  

As an other aside, one result of this notification method was never getting that puzzled call of ‘I hear you’re seeing my kid and I’d like to know what’s going on’, or that angry call that included,  ‘…and I want a copy of the record!” These inquiries or demands are complicating, presumbly unpleasant, and potentially jeopardize the important perception of a clinician’s neutrality, particularly in instances of marital separation or divorce. Also to be mentioned is that while this particular protocol of addressing the other parent was never vetted and perhaps has flaws, the system always worked as intended. The clinical neutrality necessary for a child or adolescent’s trust in the therapeutic relationship was left out of the fray, and that “call” never materialized.

None of the fathers in this group called to make an appointment.  Again though, not doing so was the norm for the ‘other’ parent throughout this practice and need not be seen as a negative critique.

Clinical Summaries

The clients of the group included an early-elementary boy, a junior high girl, and a high school boy. Depressive and behavioral issues were present for all three, but anxiety was their major problem. The younger boy was anxious that something bad would happen, the girl about how she was being seen, and the older boy weighed down by persistent difficulties in his environment and a lack of resolution between his mother and father over the many years after a traumatic divorce.

The two boys had bouts with suicidal ideation. The older of those two was also one of the nineteen youth in the study that presented with a relatedness, or pre-Axis II problem, defined in this study as having three or more of the identified 31 relatedness traits (Post 25). He demonstrated four, thus on the lower end of the study’s spectrum.

Hank

In addition to anxiety symptoms, Hank had bouts of frank sadness and on a few occasions uttered that he “might as well be dead”. He was often irritably defiant at home and occasionally non-compliant at school. Starting therapy in first grade, Hank was a basically affable and usually gentle boy who also had the size and capacity for an offensive lineman’s intensity. He was liked by his peers at school, though he was convinced thought he was disliked. He had two older brothers, one in high school and the other in junior high. The younger of the those two was moderately compromised by a spectrum problem. The older had been similarly diagnosed at one point, but his controlling rigidity in certain circumstances seemed to be more personality than spectrum. Otherwise, he had fair social competence. All three boys posed parenting challenges.

The acidic dissolution of the marriage was a given under the circumstance of oath breaches by the father. The settlement phase was contested to the point that the judgement itself was likely impacted in the mother’s favor. Thereafter, providing sustenance, guidance, and solace for her three boys and defusing random eruptions from and among all four males in her life became an almost ubiquitous juggle. “Tiring”, she would describe.

The mother was a home-based communications consultant. The father was in product development for a small firm. Neither had re-married nor were they in standing relationships. Since the separation when Hank was two, the three boys had been living primarily with the mother. The father was allowed three nights out of fourteen. The older two were now of sufficient age that they often independently chose to stay at their mother’s, particularly so with the older boy whose choices just as often were expressed with characteristic adamance. Hank’s anxieties were clearly exacerbated by the sum of all tensions, tending toward a clinginess around the mother that could pose its own dilemmas. 

The two year therapy began as conjoint with the mother, both sibs, and Hank for eight months, a similar period with the mother and Hank together, and then finished with split sessions for the mother and Hank. They both liked the last arrangement in particular, but the conjoint work helped to resolve broader family relational and behavioral issues that could not have been adequately addressed by using only the last two formats.

Hank’s overall progress was gradual. Once the therapy process began, the suicidal talk did not recur.  Feeling identification followed by the inferred problem solving was the primary modality, the positive results of which were liberally reinforced. Even at age 7, Hank was something of a natural processor once comfortable. That was a major factor in his progress. Reinforcement-of-the-opposite behavior was used extensively, decreasing clinginess and defiance with observances of self-regulation and cooperativeness. Coordinated through the school counselor, Hank’s teacher randomly reinforced changes noticed in school that paralleled those seen during therapy. Hank himself reported about better grades on tests and assignments. His initiative improved, and his self-esteem in regards to peer status also seemed to rise.

The mother’s time during both the family session and split-session phases afforded her an opportunity to gather thoughts and develop actions and responses in regards to the three boys, their relationships, compliance, and cooperativeness.  Some of the work involved separating what she thought she needed to do vis-vis her ex from how she felt about having to do so, because the two would conflate and that dynamic occasionally turned into an escalation between the two. The sessions were a more a sounding board than a source for suggestions. 

The Rub

At least insofar as could be discerned from the mother’s reporting, the father had always been miffed about the decreed custody arrangement. While his negativity toward her could spill into his parenting, his actual pursuit of more time with them had apparently not been withering.  When the episode of  suicidal ideation came out, though, the father began to lobby for a week on – week off parenting arrangement with Hank, citing the overall environment at the mother’s home. She was steadfast about the 11 – 3 day split in child care.

About the time when the parental conflict level rose, Hank became yet more clingy with mother. Part of the work was helping him to speculate and identify what others thought and felt about issues in which he was involved. This particular work almost always begins between client and mother, and that was the case here. Through this tool, the mother was able to clarify questions he had about the stability of custody as a result of the father’s comments. He did seem to be more independent and less guilty. The clinginess subsided over time.

Two years of therapy is a long time, allowing for adequate room for growth and change. What with the mother’s increased clarity in communicating with the father, Hank’s increased comfort with disparate viewpoints between the parents, and his overall change and growth, the father’s  settlement complaints and the entreaties voiced toward Hank, as reported by the mother, subsided. She also kept the older boys in the loop of information, although those two did not appear to be as impacted as their younger brother. To what degree the change was a function of the mother’s efforts, or of a relegation to the facts of reality on his part is difficult to discern. 

Isabel

From the intake with the mother and the assessment wih Isabel herself, the picture was of a pre-adolescent girl who was anxious, insecure, prone to telling tall tales, a bit hypochondriacal, and underperforming at school. She did not talk until age three, impeding early social experiences. She was also the youngest child in her class. The combination of the transient developmental delay and age drawback likely contributed to her insecurities. By the time of her first interview at the age of eleven, though, all that needed to be said was “What can I do for you”, and she immediately talked freely and on topic for an unusually long time. Being the center of attention had some appeal for Isabel, and may have provoked issues like the story-telling, but just based on the flowing and reasonably organized content of her unhesitating participation, her problems clearly seemed workable.

The client and her autistic younger brother were in the mother’s custody. The parents were divorced for incompatibility five years earlier. The mother was a high-end commercial realtor. The father lost a business in the Great Recession and now worked in retail. Both had remarried within two years. The mother’s husband lived in a suburban area of the county while she maintained the original family home in a rural area. The two children were week on – week off between the two parents’ homes, both at the father’s request and to fulfill the mother’s desire for keeping the children in their original school district. The mother essentially lived in two homes as well as the children. Functionally, the primary parent in the father’s home was his second wife, whose apparently unrelenting and verbally aggressive parenting style was becoming increasingly difficult for both children, as per congruent reports and observations by both kids and the mother.

The father, who was portrayed by the imaginative daughter as one who “treats me like a ghost”, was likely anxious about the mother moving the children to her husband’s home. The relationship between the daughter and the step-mother had been fraught since her father married. In the mother’s judgement, the girl had made good faith efforts to please the step-mother and clearly wanted a positive relationship with her father. However, the step-mother’s exasperation and anger increased over time, as did the father’s subsequent criticisms of his daughter. Isabel made a good case for being in double-binds from time to time. The father’s approach to the girl may have been paradoxically aggravating his own marriage as well, as his wife wanted less talk and more punishments. All three sides to that particular parent – step-parent – child triangle were lacking in strength, creating an unstable environment. The father’s frequent irritation toward her was Isabel’s most distressing issue entering treatment. 

The twenty month clinical process followed the same basic format as that of Hank’s, beginning with family work that sometimes included the younger brother, and moving into the split session format about halfway through.The father had indicated to his daughter an intent to contact me, but never did. The tall tales that occurred with some regularity at the beginning of the process ceased after a couple of months without any specific clinical attention. The odd physical complaints similarly disappeared, although taking a longer period of time to do so, again without clinical focus. The interesting experience with her during the individual work that spanned her transition from older childhood to early adolescence was a change in manner of relating to me. She gradually became less disclosive with her personal thoughts and feelings, clearly deciding to share some things and not others. The clinical choice was to let that change be, particularly since she was getting better and they were probably nearing termination. Watching young clients change as they move from one to the next developmental stage was, to me anyway, one of the real treats in this work.

Since one of the mother’s concerns was whether to move the children to her husband’s home, I referred her to a colleague for individual counseling. There she could get advice independent of her daughter’s therapy. Months later and close to the end of therapy, a new problem emerged when the step-mother began making disallowed entries into the mother’s home while dropping the children off, searching for allegedly missing items. The mother decided to move the children to her husband’s house, and their time with the father became limited to every other weekend.

Isabel’s overall improvement was well above average, about CGAS 20 points. Part of the advances were probably a result of continued developmental growth to the point where she had essentially caught up with her average peer, and as a result of the collective therapeutic efforts.

The Rub

Through the intricacies of her own life and the switchovers of her family, Isabel was resolute in keeping the relationship with her father at least viable. The relationship with the father was the first issue she identified during her assessment session. An interesting, speculative question is the degree to which her early developmental deficits contributed to an over-reliance on her father’s presence for approval and anxiety reduction.

 According to the mother, she was distraught for a couple of months after he moved out, but she settled into the two-home routine. Given the age of six or seven at the time, her sex, her personality, and her dependence, Isabel likely tried to care for him in his new home. Given that the father lost his business, the attention had probably had a solace importance. However, the evolution of the father’s living circumstances with his new wife would seem to have significantly increased rather than modulate her anxiety. He seemed to have distanced himself by either being assigned or assuming a role verging on that of an enforcer.

The imbalance of that father – step-mother – child triangle was troublesome. The client is making progress at her mother’s, in school, and socially. One possibility was that both father and step-mother had some Axis II issues themselves, which would make predictability difficult. The common problem with an Axis II parent, particularly fathers and more particularly in cases of divorce, is (untoward) pressure being brought to bear on custody or some other aspect of a child’s life. That was not the case here. The lesser form is to (unintentionally) create havoc in  child’s life by pursuing some alien purpose or goal that negatively impacts mental health statuses. This would be the concern here.

While the question did not arise, the possibility hung in the air. Could he get yet more harsh? Without saying so, in essence she wanted to know that he would not abandon her and would love her at least in his own way. At the same time, she is learning to take care of her own emotions, i.e. not wither away. Her task was equanimity, specifically keeping an anger that could easily erupt within his home at bay, focus more on what was worrying her, and, perhaps most importantly, what she could do. That would include both what she needed to improve upon in that home, and how to address what sounded like harshness.

Jackson

During his assessment interview, high school sophomore Jackson reported restlessness, fatigue, tension, irritability, and inability to concentrate. The accumulated experience of the anxiety symptoms led to mood and other depressive symptoms, eventually to include suicidal ideation. He was occasionally defiant at home, and argumentative to the point of verbal aggression with younger half-siblings. His academic average had declined more than 1.5 points, and later in the long, complicated process, his social life began to fray during his senior year.

The parents divorced when he was three. The marital problems included physical assaults by the father upon the mother. They were twice witnessed by the client before he was 2 1/2. He had no recollection, but was basically aware something physical occurred. The mother had full custody. The father moved to an eastern state where his son would spend a portion of each summer. The mother remarried and had three children while starting a floral business. The youngest of the three children by her second husband was diagnosed with a spectrum disorder. The boy’s irritability often frightened his two step-brothers, generating considerable resentment on the part of his step-father. On the other hand, he was gentle, attentive, and playful with the youngest, an affable girl. Jackson also demonstrated four relatedness traits, making him one of the nineteen study group youth with a relatedness problem in addition to the concerns with anxiety, depression, and behavior.

The father was an independent small plane pilot, mostly crop dusting. He never remarried, but had a couple of cohabiting relationships over the years. Connections between the father’s partners and the son never really materialized. For several years, the father had been imploring his son to leave what he knew to be a difficult situation in his ex-wife’s home and live with him, occasionally complaining about an “unfair” and “stupid” divorce settlement when doing so. He could be vehement, if not fierce, about his wishes. The father’s pursuit did become more of a feasible alternative as problems increased in the mother’s home. He and the father spent summer time river raft fishing, which he enjoyed. As such, the father’s place may have posed an enticing alternative, at least as a flotation, but the only strong relational confidence he had was with his mother. These external and internal conflicts both contributed to the boy’s distressed emotional states.

Jackson’s process was the most complicated. The conjoint phase managed to bring the client and the two older half-sibs closer, reducing in-home clamor to a mild degree. Shaping his “oldest sib” role, done initially thru a play therapy with Jenga, but in large part again by using the consistent reinforcement of helping behavior evidenced during sessions and reported by the mother and step-father toward the two younger sibs. When not irritated, he enjoyed helping.This helped to develop his ability to accommodate others.The relationship with his step-father became somewhat less intense, but the kind of psychological bond one could anticipate after a step-father has been in that role for more than half of the step-child’s life was by no means manifesting. 

The clinical gains through these first few months were modest, but basic trust in people other than his mother, to a degree of indeterminate meaning with his young step-sister, and a couple of school friends was not forthcoming. After a review session with the mother and client, the process switched from the whole family into seeing just mother and son. The anxiety symptoms of fatigue and muscular tension had dissipated, suggesting that the agitated anxiety was at least no longer chronic. His reactivity to negative events and circumstances was a focus, and his reported improvements as corroborated by the mother were systematically reinforced. Those improvements helped to provide an impetus to continue. School performance remained low relative to his high capacity, acceptable, and his social relationships remained intact. However, the progress had essentially plateaued. 

Upon returning from his summer stay with the father, the client arranged to live with his maternal grandparents on the Oregon coast for his junior year. The intent was presumably to seek respite, but quite unusual for a high school  junior who did have decent peer relations where he was. The mother came in a half dozen times during his leave for help in her supportive role.

Jackson returned to live at home the next fall, having had a less stressed but more socially isolated experience. Back home, his social life became conflictual as well. After a particularly bitter fallout with an old female companion, he decided death would be better. Suicidal ideation had not theretofore been a presenting problem or issue. He hastily formed a plan and initiated the preparation, and drove to a selected spot. He had a sobbing breakdown after opening the car door, and returned home to his mother. As they talked through the episode, among other things he asked to resume counseling, this time individually. I hadn’t seen him for almost eighteen months.

The Rub

That work lasted the rest of the school year. As Jackson neared his suicidal act, he appeared to have a corrective emotional experience, altering his point of view. Part of the therapy was a continuation of socio-cognitive work, specifically his perception of how a group of others might see him differently from how he saw himself. Being highly defended in the context of family matters, including those involving his father past and present, accuracy in his perception of others had been something of a struggle in and of itself. 

On her own initiative in the aftermath of the suicidal scare, Jackson’s mother shared with him more details about the father’s temper problems when they were married. He brought the information into session. Slowly, the notion that he might be modeling his father with some of his behaviors toward his step-father and two step-sibs, albeit with much lesser intensity, emerged. No “Come to Jesus” moment occurred, but his insights increased. While he did have the capacity for remorse and empathy, in practice they had not appeared very often except toward his mother and spectrum-disordered half-sib. In its stead, a defensive distrust, defiance, intimidation, and verbal aggression arose. His ability to experience and use empathy and forgiveness noticeably improved. 

In the meantime, the mother was keeping the father updated on Jackson’s progress following his crisis. Just based on following the reported conversations, discussions, and events between the original triangle of mother – father – son, a reasonable inference was that the father was backing off on his harbored anger toward the mother. Verifying that would be difficult, perhaps that conclusion is too rosy, but something had clearly changed for the better.

The sum total of the work on himself led Jackson to become one of only four (of nineteen) relatedness cases in the overall study group to resolve their issues. He actively terminated, and moved on to community college. The question that never directly entered the therapy per se was the connection between having watched his distraught mother being physically manhandled and emotionally mistreated at a preconscious age, and his overall anxiety issues. While the problem itself was largely bettered, that did take quite a while during which a dangerous moment occurred. Some of the new research on PTSD might shed light on the question. 

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