#40 – LEARNING AND EXPERIENCE Re: #38, 39

Prelude

In spite of its novel and progressive origins during the mid-20th century, family therapy tends to be fairly conservative. Understanding that psychotherapy generally has very few absolutes, which themselves are hallmarks of conservatism, the school “tends toward” rather than “ is always”. Conceptually, the basic approach leans more toward the adaptivity model than the disease model; the work tends to be more “with” rather than “on” the clients; is more inclined to point out and reinforce observed change rather than channel toward a certain state; and  certainly operates more collectively than bilaterally. The focus is more on generating accommodation and assimilation, the parallel twins of adaption, within the family unit. The attainment of diagnostic objectives and specific symptomatic resolutions are important, but not the soul of the process.

Still, processes sometimes don’t go well, or right, and as much as our human instincts in difficult circumstance may generate impulses to take certain clients by their metaphorical shoulders and gently shake them into awareness, we can’t and we don’t. So, we get these cases such as the three in Post 39 above that make us pour over strategic and tactical decisions, looking for the understanding or clinical gem through which needed change might have been effected. We go through these exercises if for no other reason than the well being of the child.

Statistical Comparison of Completed (Post 37) vs. Discontinued Cases (Posts 38, 39)

All six cases tended to be more complicated than usual, presumably due the split family factor in combination with the likely presence of parental Axis II issues in all six cases, and pre-Axis II problems for three of the youth. These kinds of cases tend to take longer and use more sessions.

Several similarities between these two small groups are at least notable. The average initial CGAS for both groups were near the study group overall average of 55, as was the average age of the clients at intake. In those modest regards, the six as a group were indistinct from the general study population. Five of the marriages had ended in divorce and one was in the process. In essence, all families were separated. All six fathers were seen as probable Axis II involved. In a way, the overall combination of these disparate similarities can support the clinician’s maxim that at the beginning, ’you never quite know what’s walking through the door.’  

The differences between the two groups are more pronounced. Both the average numbers of sessions and lengths of treatment were 2.5 times greater for the more successful Post 38 group than for the those of more disappointing #39. #38’s CGAS gain was more than four times as high, and the average DA/PA resolutions three times higher. 

The average CGAS gain of 24.7, DA/PA resolution rate of 4.0, length of treatment, and number of sessions for the first group are as high as most any sub-group within the study itself. In contrast, the average CGAS gain for the Post 39 group of 6.1 and DAPA resolution rate of 1.3 are as low as most any other study subgroup

The family-based treatment approaches can result in substantial improvements for those cases involving the presence of Axis II issues, but these levels of gain will most likely take considerable time and sessions, and will also depend on the numbers and severities of the extant Axis II issues in each family.

Please note: a fair assertion is that any treatment approach, family and otherwise, with these particularly complex family issues will require higher levels of resources to positively impact not only the client but the rest of the family environment that is involved in raising the youth and hopefully reinforcing and maintaining client gains. The socio-political issue of inadequate or even no resources available to support such processes for an increasing percentage of families within the national population (circa 2020) is becoming more pronounced.

As another aside, comparing the average CGAS gains and DA/PA resolutions within each of these groups adds a bit of validity to the DA/PA scale in particular, it having been designed for the purposes of the study and never vetted.

Anomalies 

#1 – Double the problem…

All six cases had in common fathers with likely Axis II involvements. One of the mothers was also seen as probably Axis II involved. Three of the boys were assessed as having relatedness, or pre-Axis II issues. Two of the boys were in the Post 39 group while the other was among the clients in the successful group #38. Whether the latter youth was actually pre-Axis II became debatable by the time his therapy ended, he having resolved all four of the relatedness issues presented during his assessment some three years earlier.

Five of the nineteen overall youth in the study who were seen as having relatedness issues were scored with three or four symptoms (Post 26) during their assessments. Both clients with three symptoms largely resolved their relatedness issues, as did two of the three clients with four symptoms. None of the remaining fourteen, those with levels of five to eight relatedness traits at the beginning, achieved significant resolution. Just based on that finding, one could begin to surmise that those who resolved may not have been true relatedness problems from the outset, presuming that real Axis II issues in both youth and adult do not tend to resolve so easily. The boy from #38 who had four symptoms was much better at treatment’s end. The two in the second group, who had six and seven symptoms, resp., were more intransigent and remained to have most of their these issues at treatment’s end.

The major differentiating factor between the two groups was that each of the three cases in the #39 had two Axis II problems. Two included the fathers and their twelve and thirteen year-old sons, and the third included both father and mother but not the client. Thinking triangularly, these were cases in which all three sides were compromised, therefore more prone to conflict and irresolutions. 

When only one Axis II issue is within that triad, at least one side to the triangle can operate more or less normally, that being between the non-Axis II family members. Their work together can often keep at least one of the other two sides from failing, and sometimes both. In the best of circumstance, one which can and does occur, all three sides can evolve to persist on better and stronger terms without necessarily resolving the underlying Axis II problems. One could argue that this was the result in the cases of Hank and Jackson in the first group.

Interestingly, the most serious problem on the surface within the three family members is not necessarily between the two personality problems at any given period of time. In the second group, one was between the mother and the thirteen year old son as she strained to normalize his family, social, and school presences. The other was between the father and non-Axis II mother. The third was between the two Axis II challenged parents. Given the varied structural dynamics, an efficient, overarching clinical program with a prescribed step-by-step nature for the family is difficult to conceive. Each case may call for its own approach or method.

Another aside is that only a handful, maybe ten times during the overall thirty-five years of practice, situations involving likely Axis II issues for all three in the mother, father, and youth triad went through the family process as offered at the time. As recalled, they tended to be eccentric, prone to some of the less potentially malevolent defense mechanisms such as denial, externalizing, ego-syntonic, and/or ignoring boundaries (as opposed to being demanding, aggressive, rejecting, lying, manipulative, and/or splitting). A few tended to do remarkably well during therapy, albeit not necessarily in the Axis II area itself. Others certainly did not.

One such case was seen in four separate counseling sequences over a four year period of time, about seventy sessions in all, as the boy and parents navigated their idiosyncratic way through a tumultuous child-to-teen period of fourth to seventh grade. The boy was defiant at home, inured to grounding and loss of possessions, disruptive in class, often sent to the hallway or principal’s office, annoying and contemptuous toward peers, missing assignments altho passing tests sometimes with class high sores, destructive with items both at home and school, possibly filching small items from parents, peers, and classroom, and apparently prone to telling tall stories. The working parent was a data manager for the local hospital system. The other was a retired civilian military consultant who could be seen occasionally walking a tall, stately Scottish deerhound in the area. 

Some time in middle of the process, the boy matter of factly related a story about the family cat trying to jump over the kitchen sink and getting one hind leg caught in the running disposal, and lived, and I just sat there just looking over my glasses at him, pursing the beginning of an incredulous “what?”, wondering ‘could that have really….?’  as he moved on to something else and I continued to listen and decided this had to be nonsense and ignored it, at least for the time being. The image recurred, and really did kind of ruin the rest of the day. 

The therapy eventually ended for financial reasons, but throughout they remained different and likable. The boy’s more extreme concerns like stealing and destructiveness were reportedly resolved. At least the parents were dighted. Contemptuousness had also dissipated. To a degree, defiance improved at school but not so much at home. He transferred to a district arts and humanities program with its own school counselor. I coordinated the transfer insofar as the individual work was concerned. They were a much longer story, unforgettable but for the most part a positive experience. Not so much the image, sadly still sticking around.

In sum of these generalizations, those cases with one Axis II can be more easily managed and positively effected in a family therapy setting, the exceptions being the more disruptive and controlling types that can be difficult under any circumstance when on a roll. The most difficult cases here were when two people within the basic triad had Axis II involvements. Those situations were the anomalies. The very few cases where all three were Axis II involved either made limited progress in their odd, often friendly, and manageable ways, or left having made little gain during abbreviated processes, i.e. six sessions or less. A portion of the latter were referred to child psychiatrists for medication evaluation and further treatment. 

#2 – Steep falls following substantial gains…

The two adolescent cases in the second group both experienced precipitous declines of gain after a period or more or less steady improvements. In and of itself, that was an unusual pattern.  With ODD cases, as these two were, a degree of vacillation in their upward status line during the first few months of therapy was common, particularly as they go about the business of sorting out their respective autonomy and emotional regulation concerns.

Both demonstrating clinically difficulty ODD symptoms, Nathan and Owen had somewhat unusually quick and substantial gains over the first 10 – 15 sessions. However, they both precipitously declined back down close to their baseline status, Owen doing so while still actively in therapy, and Nathan during the period of time after his first therapy period had stopped (due to insurance coverage), and then abruptly stopped again just before the second period of therapy had the chance to gather momentum. 

These were uncommon drops and, I believe, anomalous losses following periods of gain. The hypothesis is that undue stress had entered the clinical picture. In both cases, the circumstances indicated a paternal antipathy to the processes involving their sons. That, in turn, presents clinical dilemmas of a high sort, i.e. what to do.

#3 – If something happens once…

In Patrick’s case, the father left the mother immediately after the first client interview with his then seven year old son. He was given primary care responsibility by the judge, having the boy nine out of every fourteen days. He then terminated the still productive process when the divorce was finalized some eighteen months later. The initiation and termination of the therapy had the appearance of being preconceived. The conditions of custody and authority were affirmed. The termination appeared to be irrespective of the boy’s particular needs at the time. The apparent faithlessness was somewhat breathtaking, but then, parts of the story were almost certainly unknown, and those could alter perspectives.

Almost exactly the same sequence occurred about a year later with another early elementary-aged boy. Between the client assessment session and the assessment summary session with both parents, a father initiated a separation. Of note, the client assessment session itself went quite well, as was also the case with Patrick. The consensual parenting plan established the father as the primary caretaker, the mother having the boy every other weekend. A nanny had already been hired and the mother was in the process of moving out.

The similarity between the two men was their certainty. This father was particularly assertive where Patrick’s father was further out on the right side of the passive – aggressive continuum. The terminations of the two fairly long processes were unilaterally determined by the fathers around the time of the divorce decree itself. The difference between the two, in hindsight, was in their individual focuses of self-and-other, the first father seemingly locked in on the ‘self’ part where the second had more orientation toward the ‘other’. 

The latter’s concern precipitating the termination was about school placement. Some well established research data was offered that questioned his plan, but the shift in schools went ahead. He simultaneously ended a process he thought had been of some utility, but apparently had also run its course. How much that had to do with the divorce finalization was unclear, but they were close in time. 

The boy had made surprisingly significant progress in his own sense of self-and-other that had been sorely lacking before treatment, but that was short of the father’s expectations re: academic improvement. The nanny brought the boy to sessions, spent some of the time aligning her own style with what was being done with the client, and the father had been peripherally involved. The mistake I had made was not keeping the father sufficiently abreast of the changes that were occurring within his boy, their meaning and implications, and preaching a bit of patience. But in both instances here, the fathers acted quite independently both in initiating the divorces and terminating the treatments.

This particular scenario of beginning a treatment process at the very beginning of a divorce process does make some empathic sense, but in actuality was uncommon. Having the father independently beginning the therapy process was rare. Taking these two cases as one’s “if something happens once, take note, and if something happens twice, you have a pattern”, the clinician may want to consider how to head off the third stanza of “if something happens three times, you have a problem”, because apparently the ‘problem’ can arrive foregone. Keeping the father apprised would appear to be key. 

#4 – Single mothers with ODD children 

Seeing a single mother with an ODD child was not exactly anomalous for this practice, although doing so was far less common than the broad statistics would suggest. Purely coincident and unrelated to each other, single parents and ODD cases both represented roughly 15% of the clientele. That fact would imply about 20 – 25 single mother – ODD cases over the years, but maybe as few as four or five were actually seen. Nathan and Owen’s single mother situations were almost unique, and that’s aside from the problems their fathers brought into the baseline.

Two factors may account for the fewer single mother – ODD cases seen in the practice. Single mothers probably have a more difficult time getting their sons into a therapist’s office at all, they being oppositional-defiant. Secondly and presumably, boys might also be more amenable to take a drug rather than engage in talk therapy, given the ultimatum of one or the other. Beginning around 1990, a watershed time for mental health practice, the burgeoning pediatric bi-polar disorder industry accommodated that preference as ODD was being regularly re-defined as PBD, and PBD was almost exclusively treated with multiple medication combinations that were vernacularly termed “cocktails” (read Your Child Does Not Have Pediatric Bi-Polar Disorder, Stanley Kaplan, MD, 2011).

The conjoint family process was employed in most every case, a shift following an initial four year period of individual counseling in the practice for ODD proved futile. What came to be understood is that having two parents working together with their child in a family setting was the essential element of a successful therapy. Defined by all three sides reflecting stable relationships, a functional triangle is a strong corrective measure, and can better sustain that necessary degree of stability through the inevitable fluctuations and permutations of family life. The nature of the parents’ relationship is foundational. At the very least, the tendency to blame each other for the problem, if present, needs to be resolved. That can be done either in the primary format of conjoint work, as a prelude, or during a short split session treatment period.

The speed with which Nathan and Owen made changes may have been deceptive. When both of them began balking and regressing in their own therapies, the assumption was made that the slides would be transient. The task remained the same, just work through the downturns in spite of their sudden onsets and precipitous regressions.

Not having much experience with the single mother – ODD child configuration, I was possibly slow to recognize that the some of the dynamics involved in both Nathan’s and Owen’s cases were not dyadic in nature, but rather one of a toxic triangle that included the therapeutically uninvolved Axis II fathers. The clinical relationships were meaningful for the mothers and and at least respectfully received by the boys until the course of their treatments went rapidly south. The strength of the clinical relationships and the progresses that had occurred proved to be was nowhere near enough to pull the boys back up to their improvement lines. Hence the clinical dilemma. That third corner of the triangle was impactful and unavailable.

If the fathers are present in the boy’s life, even if not involved in the processes, they best not be discounted.

But, what to do?

The Dark Matter

The first problem is the nature of Axis II impacts on behaviors, communications, and other relationships. A quick review:

Miriam-Webster presents a succinct civilian definition of ‘personality disorder’ that suitably characterizes the inherent dilemmas of clinical work within a family system that is potentially impacted.

“Any of various psychological disorders that are characterized by inflexible or impaired patterns of thoughts and behavior that usually cause difficulties in forming and maintaining interpersonal relationships and meeting the demands of one’s personal and work life.” …and add ‘the patterns are persistent over time and circumstance’.

Emphasize the terms ‘inflexible, impaired, persistent’

Predictability in clinical work is desired, particularly when contemplating between different approaches, strategies, or tactics for a given quandary in a given case. With Axis II individuals, the predictability of an action taken is reduced. While the intention may be the best, the result could be quite the opposite. The reaction to the clinical action can and will be shaped by any one or more defenses from the following list.

The Leider Dictum is also pertinent, that being:  ‘working with a family is like walking through a minefield – they know where the mines are, you don’t, and if you try to lead them through, you can get blown up’. Trying to make untoward Axis II behavior more toward can produce great results, but just as likely if not more so, unleash a torpedo. The sequelae of an activated defense may in some instances be predictable, re-directive, and therefore clinically manageable, but one can fairly assume that case may be among a significant minority.

Clinical Considerations

1. Confront the father problem?

Perhaps the most obvious critique of the clinical management for these three cases would involve the relative passivity toward the apparent paternal oppositions and obstructions to their sons’ therapy processes. Could anything be attempted that did not run a risk of worsening family functioning, a viable consideration in light of the probable determinations and impairments of judgement involved. The therapies had been fundamentally working and the potentials of change manifesting. Would those starts actually be enough for the mothers alone to maintain that upward incline of improvement over time? With the potential up-and-down vagaries of their behavior disorders? 

What would have been helpful was a process by which the fathers individually came to the office to weigh out their own needs versus those of their child, and join in collaborative reasoning toward a way to better meet both? That would be the therapeutic goal if, indeed, they cooperated. 

Two of fathers were aware from the beginning that they could make an appointment at any time, and the third could choose at any time to participate in the on-going family work. They all chose not to do so. 

As a rule in my practice, calling family members not involved with the therapy process of their child to suggest making an appointment for discussion about issues X, Y, and/or Z was not done.  The closest to doing so would be suggesting to a client either in the office or during a call they placed to me to, say, come in sooner than currently scheduled, or increase the frequency of sessions, etc. In this manner, we can talk about the feasibilities of my inputs in the context of their on-going therapy.

Some outpatient therapists do ask people to come make appointments. The social workers’ Code Of Ethics, a 29-page booklet once proclaimed by the NASW as the longest and most detailed ethics code among the health care professions – par for social work’s pursuit of due diligence – does not prohibit entreating someone to make an appointment. To me, the problem was the use of a professional position to persuade an appointment for a family member not involved in the treatment, one that would result in a payment or a use of a session benefit, more likely both, all of which are at their expense. That may not be unethical, but still feels like a misuse of professional authority. 

Another dissuader is that by asking someone to come in, the clinician is essentially responsible for the session’s content. Therapy sessions are designed to focus on the client’s presenting problems or content. 

Calling non-involved family members to argue convincingly the need to make changes also puts the clinician in the role of rescuer. If the session becomes upsetting to the beckoned interviewee, the subsequent objections to family members and maybe others involved shift the therapist from the rescuers role to that of the victim, the one being blamed for the problem(s). As stated in earlier posts, the ultimate victim of unbidden rescuing will likely be the young client if the therapy process itself is ended. Like any family, these operate by their own rules and customs. 

Lastly, If the call is made and a session does occur, the report out by the father to the mother, and/or to their child(ren), and/or to others in the family network may have no resemblance to what was actually said. The impression that the therapist strives to leave can get grossly mischaracterized as their self-protective defense mechanisms of are activated.

More broadly, asking someone to come in over the phone under these circumstances may produce wonderful results, or may completely backfire. One can view aggressive tactics as high risk gambits – they may really work, and they may really not, and accurately predicting when and how Axis II issues are involved is difficult unless the clinician is particularly expert with personalities and their particular, peculiar manifestations.

2. Interim Parental Reviews?

The fathers all knew they could make an appointment at some time, and chose not to do so. Regardless of their actions, that needs to be respected, at least from this point of view. Could they more indirectly be drawn in? 

Addressing the possibilities of paternal opposition was done mostly with the mothers in brief individual side sessions either at the beginning or end of a conjoint session, and the result was usually just a suggestion to talk with the father about some specified issue. To bring the topic of the father into a discussion for either Nathan or Owen had proved difficult, the two boys being avoidant and the mothers judicious. Avoiding a reinforcement of resistance was important, and both mothers were astute. 

The therapies were in early stages for ODD-type problems, still working mostly on the manifest behavior issues.The overall progress was moving along nicely before the issues of paternal opposition became more palpable. In hindsight, floating the idea of a parental review of the process seems reasonable. The mother’s would likely have been favorable. In general, mid-therapy conjoint reviews for separated or divorced parents in this practice general were far and few between, but nevertheless precedented. Including Patrick, all three cases may have benefitted. The mothers would have likely concurred. 

The risk is that manifested Axis II defenses may make matters worse in the aftermath of a review. The fathers could have silently experienced the directions that the therapy as threatening to their own needs or plans, and stopped or sabotaged the process even earlier than they did. Proposing interim parental reviews under these circumstances would need to be carefully considered with the involved parent, perhaps through a separate session with the mother. Protect the process.

3. Stuck on Format?

At the beginning of a particular kind of intake with the parents, the first to speak, usually the mother, would lean forward on the couch with hands clasped on her lap, look down for a moment of thought gathering, then earnestly look at me to utter, almost verbatim, “He’s really a good kid, but…”  

What inevitably proceeded was a description of the behaviors with which they’d been struggling that perfectly described ODD. These were difficult moments for the parents as they often felt shame, frustration, sadness, and lots of worry, anything but unbridled joy. Once started, though, they became comfortable and relatively easy interviewees. Someone knew of that which they spoke, was not taken aback, asked the right questions that helped them expound, nodded an “mm hmm” at their elaboration of their child’s behaviors that spoke to them ‘Right, I’ve heard that before….’ The therapy had already begun.

As said earlier, family approaches were categorically better with ODD than the individual therapy approach, at least as was practiced here. As a secondary benefit, the results of the family therapy work helped drive a reputation. Everyone knew these were difficult cases, A few may not have worked out, but most did. Conjoint had become my ‘standard operating procedure’, to use a military term in honor of the embattlement. Families most often persevered, did better, got happier.

The one recurring strategic error during the last twenty years of the practice, at least of which I am aware, were instances of staying in the conjoint format too long. Whatever the resistance or discomfort issue may be before me, the almost unconscious operative belief was that the family therapy process would facilitate necessary resolutions. Every once in a while, the onset of an inadequately addressed discontent of one kind or another lingered too long. Having had enough, the family would unilaterally stop, not really angrily but certainly disappointed. This did happen in one of the 58 study cases here, neither being Nathan and Owen. Those two could be seen as decisional question marks in this regard.

Regardless of their proximal causes, when family member resistances appear to rise and processing them proves discomforting, would recommending a change from the family format to one of split sessions have prevented unilateral and oppositional terminations? Again in hindsight, Identifiable moments occurred in each process which could have prompted at least the thought of recommending a change to seeing mother and client separately during the hour.

When Nathan wrote on the waiting room’s dry erase board “Run for your life out of this place”, he could have been seen as a candidate for an individual therapeutic process and relationship. Work with the mother would mostly concentrate on parenting Nathan, but also discuss the father and his historical and current family role at greater depth. Something there just did not add up. With Nathan, the initial purpose would be to create a space in which he could develop a dependable trust. An inherent degree of suspiciousness likely contributed to his social isolation, a common underlying dynamic in ODD. Family therapy could help with that, but maybe in individual even more.

When Owen inexplicably buried his head for a minute or two in his sweatshirt and shed tears for the second time after several productive sessions, a change in format could also have well been considered. Some specific issue was certain, but he was more stubborn about disclosure than most. With his demonstrated degree of regard toward me during the latter portions of sessions and when leaving the office, he may have been approachable. The Nash Equilibrium – a person decides what to do based on their perception of what others will do, not necessarily what may be in their own best interests, e.g. Dad will get mad so I won’t (do therapy)  – could have been used as a clinical structure with Owen, enable him to operate more in his own best interests.

For both boys, the purpose would be to establish meaningful individual relationships that may have survived the impacts of the random discontents, irritations, and/or disguised worries that presumably radiated from the fathers and ultimately ended the therapies. The split session format could have allowed for more in depth work with the mothers re: fathers. Doing both perhaps could have headed off these premature terminations.

Had the switch to split sessions for been considered, one prevailing concern applied to both young clients. They were oppositional-defiant, no doubt getting better, but as said, ODD generally takes a longer time to treat with more lability during treatment itself. Those are simply facts. For whatever specific reasons that would include simple stubborn impulse, each could abruptly say ‘no more’ to individual counseling, and getting them back to the conjoint process may prove impossible. They had been cooperative thus far. Under that circumstance, saving the split session process as an option if either refused to continue conjoint for one reason or another would be prudent but would continue individually. The conjoint format may also served as a salutary sanctuary and in that way actually preferable.

The individual concern about moving Owen into individual work was the reality of the father’s veto power over therapy processes. The father may have been threatened by his son developing an individual clinical relationship over which he could feel diminished, and preemptively exercised  his veto. 

While Nathan had also been cooperative being seen with his mother, he was much more hyper-autonomous than Owen and more than likely to ‘put his foot down and out the door’, so to speak, had something gone amiss or the father privately objected.

Both may also have been more manageable being seen with their mothers than individually. One view of ODD kids is that they have disturbances of autonomy. Almost by definition, they can be excessively independent as they act out, and then bewilderingly hyper-dependent when in a practical or emotional need. Hard to sat for a fact, but the process may be safer done as conjoint. 

A split session format would have been more viable for the mothers had they been in particular need. However, neither were at wit’s end in regards to the fathers, and the boys had been clearly making progress in an overall sense. The two or three times each had met with me for a few minutes before or after the conjoint session were at my request, mostly over something administrative. Suggestions they talk with their exes in regards to a specific issue or need for clarification of some sort occurred a couple of times with each. Owen’s mother had her own therapist with whom she was covering issues with the father. Nathan’s mother could generally talk with his father about her concerns and wishes, usually received cooperative responses, if occasionally not a genuine or full disclosure.

4. For future reference….

One mistake was not referring Patrick’s father and grandfather to an adult therapist. The father came in once for parenting help, and the grandfather came in with the father to get help essentially parenting his own son. They did not ask for another appointment. One was also not offered in order to avoid a conflict of interest with the process focusing on Patrick. A more complete closure of the session would be an offer to make a referral if they wanted further input. The father’s father may well have taken up on the offer.

A second oversight may have been not contacting Owen’s mother’s new individual therapist. The informal standard of practice is for the clinician new to a case to contact the current therapist just as a matter of introduction and coordination, if necessary. I did not see the need, but neither did I see the case terminating so prematurely and abruptly.

Also, pursuing the release that went unanswered with Patrick’s mother’s therapist to gain her insights may have helped, but one could also argue in that the contact may have made little difference anyway. The father’s abrupt termination of the process after the divorce was legally finalized would have been difficult for either one of us therapists to anticipate. 

Note: Next post is summary and conclusion of this section including posts 37 – 39

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