#41 – WHO’S WATCHING

At some point an increasing insecurity can merge into the realm of terror. James Garbarino’s definition of terrorizing a child includes “making the world seem capricious and hostile”. Prolonged separation and divorce are universally seen as major stressors for youth. This is tension. Add to the child’s experience an unabated dissension or differences between the parents, particularly when anger is common for one or both, and the stressors will often merge into clinical symptoms of anxiety, depression, and behavior problems. Add to that the specter of losing significant time or contact with one of the parents, or a step-parent becoming emotionally abusive, the child’s experience can become one of terror. Their world is capricious and hostile.

While the therapy process is pursuing symptom relief, higher functioning, improved relationships, all toward more hope, meaning, joy, and love, another concurrent and overarching process is simultaneously operating. Generally, one of the two parents is keeping track of every relationship within a family. These dyads are intrinsic elements of family cohesiveness in the short term, for duration over generations, of survival in the long run. That person is usually the mother. At least in terms of this practice’s population, fathers will often serve this function under the (2% – 5%?) circumstance when the mothers are otherwise occupied with their own particular issues. Two such fathers stand out in this regard within the 56 cases of the study, none of them involved with the cases of this section. Another (2%?) have neither in the role.

A certain natural limit in the scope of tracking is set by the number of children in the group. A family of four has six dyadic relationships; with three children the number is ten; one of four has fifteen with four; five (a family of seven total) has twenty-one. For the observing parent, almost regardless of devotion, to know all the dyads is probably tapped out at fifteen, maybe twenty-one, and certainly with the twenty-eight dyadic relationships within a family of eight. At some point beyond dyadic ability, the tracking parent’s concerns are rather those of interactional flows among all, and the specific attentions are on those relationships that are particularly strong, therein lie the leaders, or particularly conflictual, therein lying the threats. 

The tracking function survives separations and divorces. Noah’s, Owen’s, and Patrick’s mothers were all keenly interested in the relationships of their child(ren) with the formal or informal step- parent figure in their child’s life, and their children, if any. Or do their best they can within the limits of observation and reporting coming from both children and the ex. In my judgement, they earnestly tried.

A small few number of families do come into the office with neither parent really fulfilling the tracking role. A classic example would be a depressed atmosphere with an anxious mother and a preoccupied father. The children’s basic needs are met, but the interactions are otherwise limited. Typically, the boys would be acting out and the girls would inwardly be experiencing significant anxiety. In white suburban 1950s and 60s America when and where I grew up, this pattern was common. The initial treatment objectives of aiding family engagement were obvious, and family therapy a fortunate service where and when available. Invariably, the family therapy process itself models and teaches tracking. 

In the unfortunate circumstance of pathologically centrifugal families, people who generally do not seek out family therapy, probably no one fills the role. In the one seriously centrifugal family that can be recalled here, unfortunately occurring during the first year of private practice, the eighty year-old paternal grandmother at least tried to help and, retributively via her son, ended up with the thirteen year-old, acting out boy living with her. This was a remarkably complicated case made worse by questionable supervisory advice/directive, but the grandmother kept him in therapy as the father and mother/not-the-mother retreated from responsibility. The boy actually did much better with Granny, but “family” probably disappeared when the grandmother passed away, whenever that was. The boy was unforgettable. Crucial information I passed on to him concerning AIDS, this being 1985, quite possibly saved his life, given his nascent proclivities. I’m no sure where else he would have gotten the necessary information in time.

The six mothers in these last two groups tracked, no question. That can save lives.

The Tracker’s Realities

The successfully completed cases of Posts 36 and 37 were not devoid of inter-parenting struggle. Some of the pre-divorce issues and events could have terrified some of the children particularly at early ages. Post-divorce, all three cases involved challenges coming from the fathers either to the established custody arrangements, or to the therapy processes, or both. The divorce decrees had placed the three mothers with primary care responsibility, including key factors such as location, school placement, and healthcare. 

Each of the three mothers also had natural executive skills honed by workplace leadership responsibilities. These factors probably helped stabilize the nature of the parenting relationships with their exes, almost regardless of the paternal complaints. Achieving these states nevertheless entailed a more or less continuous attention on the part of the mothers, and watching by the children

One contrasting factor between the two groups of cases involved the initiation of the separation and divorce processes. In the first group, the mothers had initiated the processes. One mother was physically abused and forced the husband out. Difficulties with faithfulness led to another spouse’s eviction from the home. The third mother had to deal with her own moderately impactful anxiety – depression as the marriage failed to mature and the father became more erratic and oppositional following his job loss. For the wellbeing of herself and the two children, the decision to separate had to be made.

In addition to realigning their original families, the three had to resolve their own issues resulting from the marital difficulties and resultant separations. The physical abuse that the one mother experienced was perhaps on the lower end of that particular and horrific severity scale, but  anything on that range must take serious resolve to overcome and heal. She dealt with symptomatic issues of anger and guilt,  the anxiety about her capacity to manage a household, and the strength to re-engage with the world of relationships, all of which she did.  All three mothers were well along the way to resolutions, or at least in mitigating the damages done within the marriages by the time a family therapy process began for them. The practical problems following their divorces were of less impact than the emotional residues. They nevertheless kept those core family threads intact.

The three difficult cases of Posts 38 & 39 differed from the first group in several ways. The separations were initiated by the fathers, to one degree or another done at the surprise of the mothers. One father overtly left for another relationship. The second left for reasons that were more difficult to understand but included losses of affection and eventually of affiliation, in that order. The third appeared to have significantly devalued his wife and engaged in an emotional disunion. Whether another relationship was involved was not clear, but another family that included his new partner and her two children moved in to his new home within months of his departure.

The fathers in the second group were more aggressive, two of them being overtly so and the third likely being passive-aggressive. In addition, the fathers appeared to exploit certain vulnerabilities within each maternal home to achieve their own desired outcomes. The patterns of suddenly emerging hostility to therapy by the ODD boys, who by definition were prone to resistance but had been generally compliant, were clearly related to times spent with those fathers. The third father used superior resources to maintain custodial control and likely diminished the mother in ways that the young boy observed. His sister had just entered toddlerhood, so while she could not understand the words, she unquestionably experienced the anger in ways that could foment a sense of foreboding. In following the family evolution and patterns, the inferences were that all three fathers engaged in disruptive and misdirecting defense mechanisms, e.g. demanding, splitting, ego-syntonic postures, etc., and while that could also be inferred of the fathers from the successful group, their own particular defenses were less intrusive and for the most part subsided.

All six mothers in the two groups tracked the various dyadic relationships in which their child(ren) were involved. For the three difficult cases, the homes of the exes were more opaque, as the fathers tended to be non-disclosive. Those three mothers were trying to cope with the inadequate information coming from the exes, and the antipathetic attitudes of the exes toward their own parenting that ultimately included the therapies.

The mothers from the difficult cases also had to work through the emotional traumas of their marriages. Given that their exes were likely more difficult and entrenched in their own perspectives than were their counterparts from the more successful three cases, the mothers were more actively working through their own personal issues as their children’s therapies began. Two had their own therapists. The sense given by the third was that her male relationship conducted away from the home was a primary source of personal support.

So, presuming degrees of the fathers’ spousal devaluations, diminishment of the therapies, and their own underlying insecurities they steadfastly disavowed, and the mothers’ concerns about child mental health and the functioning of the original family unit regardless of their spread, what do the mothers do?

Care for self-and child  

Two were in therapy themselves, and the third was in a reliable, long term, confidant relationship independent of the rest of the family. Each client child demonstrated the ability to change during their therapy, two with the mothers and the third individually. The hard part was that two of the three lost significant ground after the impressive gains, and the third was prevented from the opportunity to build on his growth by the father’s unilateral termination of services, twice.

Track and nurture as possible the family relationships 

One mother had only the three relationships between herself, the ex, and the client to consider.  The other two had the fathers’ second families of four, including himself, to follow. Importantly, they were literate about the dyads within the original family grouping and observant of the relationships within the stepfamilies in which their children partially lived. Part of the family therapy is emphasizing the importance of reinforcing changed behaviors and patterns of relating, and they could be seen doing so.

Relate More Effectively With  Axis II-like Exes?

The task for both mother (in these cases) and therapist in these types of cases may seem Sisyphean, particularly so when the defenses are activated in the midst of extraordinary stakes. One’s child can be a stake greater than any other. Perhaps look at language first.

A few years ago, a day-long workshop tour on treatment with personality disorders came to Seattle. The presenter was probably Gregory Lester, but the excellent workshop booklet that was intended to be saved somehow disappeared in one transition or loan or somehow. Based on his experiences, within the handout was a page that paired which personality disorder married which personality disorder. Probably a dozen times over the last few years of practice, I would be disconcerted about some particular couple. Consulting that list invariably provided a helpful perspective. If one were available, that kind of quickie tool could be an aid while working with activated Axis II defenses. what works with what defense. The basic concept is to tailor the language and clinical objective to the particular issues that, say, pertains to these fathers.

The following is offered as a template, and not necessarily a working document. The qualifier is that the suggested content for working with particular Axis II defenses come from a non-expert, that being me. The writing is from the clinician’s working perspective. In helping an ’other’ parent improve the relationship with their co-parent, the clinician would have to extrapolate the relevant content for a given defense and adjust the recommended language toward a common parent to parent interchange.  The other caveat is that helping the client’s mother directly with their coparent relationship was not a significant focus in these six cases, in large part because four of them were reasonably comfortable with how they did so, and the other two were in individual therapies.

Deny a problem exists  

Describing the situation to the point of an even vague concurrence of reality, follow with the question “When would this actually become a problem, in your view?”  Go from there to “what would you like to see done about it?”,  and then work toward some kind of positive movement, reinforcing their acknowledgements, adjustments, and/or accommodations.

Vulnerabilities hidden by apparent strength

Insistence on being correct can be seen as an accompanying problem. In the context of a talk therapy process “Is it possible they may be a little right about this?”, “Is it possible you might feel a little anxious or worried about what’s being said?” Be more light than dark hearted when doing so. Reinforce any recognition of vulnerabilities that others experience, follow up with “Do you sometimes feel (or think) that way?”

Ego-Syntonic (that’s just who I am, e.g. nothing I can do about it)

Two issues: one is difficulty with the perspective of others close to the person, including how they think, what they feel, and how they may react to a given situation; and one can assume that anxiety beneath the commonly smiling patina of self-assuredness is present. Accessing the thoughts and feelings beyond the defense will likely take considerable time. Noting and reinforcing any observable change can soften the resistances.

Demanding 

Ideally, work on an instance or example of demands upon you, work it through, and eventually “does this same thing happen with others”? Also, “what is it you’d like from me here?”, followed by a discussion about what can and can’t be done in therapy, i.e. what are the boundaries of the clinical contract. Reinforce any switch on the client’s part from demand to request. To quote my long passed Wyoming-bred practicum supervisor Carlah Lytle, “Don’t get into a pissing match with a skunk – you’ll lose.”

Stigma of having a problem

Often will refuse to get help. Consider a focus on complicated loss issues, going back to family-of-origin’s attitudes toward having problems work, Feeling identification work, particularly anxiety. Reinforce sense of accomplishments, particularly those in therapy, and explicated senes of pride.

Rejecting

Assume degrees of projection. Integrate family narrative work into the therapeutic lexicon of the case, working toward an acknowledgement of anxiety, particularly about being seen critically. Reinforce any new type of acceptance. Gentle, as they have likely experienced blowback with some frequency.

Lying, manipulative, splitting

When all three operate within a person simultaneously, these defenses are the troika for family infighters with touches of sociopathy. As such, the traits are difficult to change. Those who engage in employing them are unlikely to be involved in a therapy, family or otherwise. At the same time, the afflicted – for they are, indeed, afflicted with a serious, tumultuous disorder- can be very devoted to their children and they stay much in the picture. For the adult involved in the therapy, again usually the mother but not always, the parenting task can be inordinately complicated. Difficult choices between the more aggressive and the more judicious, observant-supportive postures are presented. 

Some situations within their control can be addressed by the involved parent to the challenging co-parent with a firm “this is the way we’re going to do this”. Other situations don’t offer a window of decisional clarity. The parent can do something either this way or that, including a solution that accommodates the wishes or demands of the non-involved parent, or one that assimilates him more into the involved parent’s style of parenting. Compromise does occur, often with therapeutic input. The underlying motivation of the involved parent is usually to keep the original family unit, such as it is, as close as possible and still meet the child’s particular emotional and behavioral needs at the time. The therapist’s role is guiding the process toward a fruitful conclusion, as always, but these are among the most challenging cases to do so, sometimes leading to that difficult spot of “do I push this, or do I let go.” Most all child and adolescent clinicians have experienced the dilemma of letting a heretofore effective therapy go in deference to the family’s need of avoiding an unraveling. A guiding mantra here is “keep the door open.”

Addictive, substance abusing

Obviously, if a problem cannot be safely managed in an outpatient practice, the first act is recommending specialist treatment for the problem parent. Help the ‘clean’ parent, so to speak, toward spousal education, advice, and support as part of the problem parent’s treatment, unless that also is within the clinician’s expertise. Be careful. If the problem parent is not in treatment, look into referring the client’s parent to a specialist or program offering services for their particular educational or intervention needs. Assuming the plan is for the client youth and their parent to remain in treatment with you, coordinate with an involved substance abuse specialist, particularly if their typical practice is to work with all available and suitable family members, minors included. Two concurrent processes working on the same basic problem could possibly make matters worse, hence the need to determine who will be doing what.

Suicidal

Suicidal behaviors that are standing patterns and one of multiple personality disorder defenses are presumed here to be etiologically separate from SI that is a result of depression, anxiety, trauma and other issues formerly known as Axis I disorders. If the pattern is not a hidden problem, known to family, acquaintances, medical professionals, and/or safety personnel, the problem is not very likely to randomly appear in an outpatient child and adolescent treatment practice facility. This would be even more so if the privately practicing clinician or community clinic were a masters-level professional concern. If the case remains with you for one reason or another, the involvement of a psychiatrist or MD with 24 hour coverage and admitting privileges would seem to be a must. Being the clinician of last resort, that person is effectively the lead professional and would expect to be kept informed.

Suspicious of warmth and positivity

By the nature that led into this profession, most of us emanate warmth and positivity to one degree or another. Even if the first sentence of the first session is done with some amount of reservation, within the next 45 minutes that underlying aspect of the ` therapist’s self becomes apparent. Thoughts that the client has suspiciousness about warmth and positivity don’t normally surface for the average clinician, and the client is probably skilled at disguise since adolescence. 

One exercise may be helpful for future reference in regards to this characteristic. Go through the cases in the past that were unilaterally ended by the client for reasons that in hindsight are not apparent, particularly between the third to seventh sessions. Serious, life-impacting suspiciousness of warmth and positivity likely does not appear early on in talk therapies, but looking through those early, precipitous terminations may unearth examples. From those the therapist can learn. If they stay in treatment and a basic trust has been established, logic would suggest that patience is required. This is a serious Axis II problem. Change may be halting and slow. As a 60’s – 70’s priestess of conscious awareness, Barry Stevens asserted, “You can’t push the river.” Affirm and reinforce clear, observable demonstrations of increased trust.

Chaotic life management

Friedrich Nietzsche once intoned “You must carry chaos within you to give birth to a dancing star.” Dancing stars are of questionable value in a therapy office. This trait in a  family adult necessarily becomes a clinical management problem if the problem parent. They would need sufficient organization to make and keep the intake appointment. The effective therapy process then has to survive the chaos of daily activities and decisions at least through the first half dozen sessions. The parent’s problem is likely to become apparent in the history of the afflicted parent, including the areas of relationships, residences, work, finances, health, and education. With that history and a stable first six sessions, adroit reinforcement of organized behavior on the part of the parent may solidify the viability of the therapy and increase the commitment within the family. My first professional role model, Mary Rygg, MSW, a UW School of Medicine faculty member and original member of Virginia Satir’s Beautiful People acolytes, once presented a case of hers that involved a chaotic life management mother of five children that survived the first few family therapy sessions, became a habit for the mother, and lasted more than three years. The older two daughters made sure the appointments were kept, worked with their mother, and she emerged from the therapy a tracker, to use the term. If you ` `are blessed with one of these people that can keep the process going, reinforce changed approaches to situations and patterns.

Self Destructive Behavior

Separate from persistent suicidal ideation/behaviors/attempts, patterns of self destructive behavior will be discussed in a separate post.

Expand Use of Other Formats?

None of the three mothers were seen for individual work during the processes with me. Again, two were in their own therapies, and the third in a helpful relationship. The meetings with them alone were essentially short side bars to the conjoint processes with Nathan and Owen, and the individual process for Patrick. They were intended mostly for administrative issues and limited clinical concerns such as helping them shape their specific approaches to issues involving the fathers, although Patrick’s mother used the opportunity to do some venting in the midst.

Specific events occurred during each process that could have warranted a switch in format. At some point for both Nathan and Owen, negative changes in their affect and behavior aimed at the mothers following time at the fathers’s homes were repeated more than once. The highly antagonistic parking lot confrontation between Patrick’s parents combined with the mother’s positive reactions to her brief update discussions before his individual session could also have led to a consideration of a switch.

What could have evolved in all three cases were split processes. For Nathan and Owen, the process could alternate between conjoint sessions one week and split hours where the client and mother are seen individually during the next, or some arrangement along those lines. Both Nathan and Owen had demonstrated nice changes, and testing out the feasibility of individual work with them would be a reasonable step to take. Simultaneously, the mothers could then deal with individual, post-marital, and parenting work in greater depths. For Patrick, the split hour could be either every week or on alternating weeks. To some degree that was already happening, but formalizing and extending the mother’s session time might facilitate more disclosure, increase the understanding of the family and marital dynamics, and perhaps help her develop a more viable post-divorce parenting relationship. Coordination with the therapist’s for Owen and Patrick’s mother would become more important if the switch to split formats were made.

The problem with switching formats was that the upward gain curves had not plateaued before the rather steep declines. One could argue that an individual therapy for both may have provided some insulation from the paternal enmities, but an attempt to do so may also have led to an earlier termination, one that preceded the gains. Maybe. These are difficult decisions. Having the mothers involved in conjoint processes at least buys the time to facilitate noticeable and hopefully meaningful change. Perhaps a guiding principle would be ‘Do what you can do best.’

Enhance the effectiveness of communication with the fathers?

Remember again that the fathers had been invited to make appointments with me and, as was their perfect right by which one cannot judge, chose to not do so. 

The task of effective communication here may seem Sisyphean, particularly when the defenses are activated in the midst of extraordinary stakes. One’s child can be a stake greater than any other. 

The following is offered as a template, and not necessarily a working document. The suggested specifics to working with particular Axis II defenses come from a non-expert.

A few years ago and once again in need of a few more CEU’s, I signed up for a day-long workshop on treatment with personality disorders. I think the presenter was Gregory Lester, but the workshop handout booklet that was intended to be saved, because the information was really good, somehow disappeared in one transition or another. Within the work was a page that listed which personality disorder married which personality disorder, based on his experiences. Probably a half dozen times over the last few years of practice, I would be stumped about some particular couple, and pulled out the list. Doing so provided a few helpful “…so that’s what’s going on…” moments. If one were available, that kind of quickie tool can be an aid while working with activated Axis II defenses. The basic concept is to tailor the language and clinical objective to the particular defenses that the compromised parent may be utilizing.

The following is offered as a template, and not necessarily a working document. The suggested specifics to working with particular Axis II defenses come from a non-expert.

Deny a problem exists  

Describing the situation to the point of an even vague concurrence of reality, follow with the question “When would this actually become a problem, in your view?”  Go from there to “what would you like to see done about it?”,  and then work toward some kind of positive movement, reinforcing their acknowledgements, adjustments, and/or accommodations.

Vulnerabilities hidden by apparent strength

Insistence on being correct can be seen as an accompanying problem. In the context of a talk therapy process “Is it possible they may be a little right about this?”, “Is it possible you might feel a little anxious or worried about what’s being said?” Be more light than dark hearted when doing so. Reinforce any recognition of vulnerabilities that others experience, follow up with “Do you sometimes feel (or think) that way?”

Ego-Syntonic (that’s just who I am, e.g. nothing I can do about it)

Two issues: one is difficulty with the perspective of others close to the person, including how they think, what they feel, and how they may react to a given situation; and one can assume that anxiety beneath the commonly smiling patina of self-assuredness is present. Accessing the thoughts and feelings beyond the defense will likely take considerable time. Noting and reinforcing any observable change can soften the resistances.

Demanding 

Ideally, work on an instance or example of demands upon you, work it through, and eventually “does this same thing happen with others”? Also, “what is it you’d like from me here?”, followed by a discussion about what can and can’t be done in therapy, i.e. what are the boundaries of the clinical contract. Reinforce any switch on the client’s part from demand to request. To quote my long passed Wyoming-bred practicum supervisor Carlah Lytle, “Don’t get into a pissing match with a skunk – you’ll lose.”

Stigma of having a problem

Often will refuse to get help. Consider a focus on complicated loss issues, going back to family-of-origin’s attitudes toward having problems work, Feeling identification work, particularly anxiety. Reinforce sense of accomplishments, particularly those in therapy, and explicated senes of pride.

Rejecting

Assume degrees of projection. Integrate family narrative work into the therapeutic lexicon of the case, working toward an acknowledgement of anxiety, particularly about being seen critically. Reinforce any new type of acceptance. Gentle, as they have likely experienced blowback with some frequency.

Lying, manipulative, splitting

When all three operate within a person simultaneously, these defenses are the troika for family infighters with touches of sociopathy. As such, the traits are difficult to change. Those who engage in employing them are unlikely to be involved in a therapy, family or otherwise. At the same time, the afflicted – for they are, indeed, afflicted with a serious, tumultuous disorder- can be very devoted to their children and they stay much in the picture. For the adult involved in the therapy, again usually the mother but not always, the parenting task can be inordinately complicated. Difficult choices between the more aggressive and the more judicious, observant-supportive postures are presented. 

Some situations within their control can be addressed by the involved parent to the challenging co-parent with a firm “this is the way we’re going to do this”. Other situations don’t offer a window of decisional clarity. The parent can do something either this way or that, including a solution that accommodates the wishes or demands of the non-involved parent, or one that assimilates him more into the involved parent’s style of parenting. Compromise does occur, often with therapeutic input. The underlying motivation of the involved parent is usually to keep the original family unit, such as it is, as close as possible and still meet the child’s particular emotional and behavioral needs at the time. The therapist’s role is guiding the process toward a fruitful conclusion, as always, but these are among the most challenging cases to do so, sometimes leading to that difficult spot of “do I push this, or do I let go.” Most all child and adolescent clinicians have experienced the dilemma of letting a heretofore effective therapy go in deference to the family’s need of avoiding an unraveling. A guiding mantra here is “keep the door open.”

Addictive, substance abusing

Obviously, if a problem cannot be safely managed in an outpatient practice, the first act is recommending specialist treatment for the problem parent. Help the ‘clean’ parent, so to speak, toward spousal education, advice, and support as part of the problem parent’s treatment, unless that also is within the clinician’s expertise. Be careful. If the problem parent is not in treatment, look into referring the client’s parent to a specialist or program offering services for their particular educational or intervention needs. Assuming the plan is for the client youth and their parent to remain in treatment with you, coordinate with an involved substance abuse specialist, particularly if their typical practice is to work with all available and suitable family members, minors included. Two concurrent processes working on the same basic problem could possibly make matters worse, hence the need to determine who will be doing what.

Suicidal

Suicidal behaviors that are standing patterns and one of multiple personality disorder defenses are presumed here to be etiologically separate from SI that is a result of depression, anxiety, trauma and other issues formerly known as Axis I disorders. If the pattern is not a hidden problem, known to family, acquaintances, medical professionals, and/or safety personnel, the problem is not very likely to randomly appear in an outpatient child and adolescent treatment practice facility. This would be even more so if the privately practicing clinician or community clinic were a masters-level professional concern. If the case remains with you for one reason or another, the involvement of a psychiatrist or MD with 24 hour coverage and admitting privileges would seem to be a must. Being the clinician of last resort, that person is effectively the lead professional and would expect to be kept informed.

Suspicious of warmth and positivity

By the nature that led into this profession, most of us emanate warmth and positivity to one degree or another. Even if the first sentence of the first session is done with some amount of reservation, within the next 45 minutes that underlying aspect of the ` therapist’s self becomes apparent. Thoughts that the client has suspiciousness about warmth and positivity don’t normally surface for the average clinician, and the client is probably skilled at disguise since adolescence. 

One exercise may be helpful for future reference in regards to this characteristic. Go through the cases in the past that were unilaterally ended by the client for reasons that in hindsight are not apparent, particularly between the third to seventh sessions. Serious, life-impacting suspiciousness of warmth and positivity likely does not appear early on in talk therapies, but looking through those early, precipitous terminations may unearth examples. From those the therapist can learn. If they stay in treatment and a basic trust has been established, logic would suggest that patience is required. This is a serious Axis II problem. Change may be halting and slow. As a 60’s – 70’s priestess of conscious awareness, Barry Stevens asserted, “You can’t push the river.” Affirm and reinforce clear, observable demonstrations of increased trust.

Chaotic life management

Friedrich Nietzsche once intoned “You must carry chaos within you to give birth to a dancing star.” Dancing stars are of questionable value in a therapy office. This trait in a  family adult necessarily becomes a clinical management problem if the problem parent. They would need sufficient organization to make and keep the intake appointment. The effective therapy process then has to survive the chaos of daily activities and decisions at least through the first half dozen sessions. The parent’s problem is likely to become apparent in the history of the afflicted parent, including the areas of relationships, residences, work, finances, health, and education. With that history and a stable first six sessions, adroit reinforcement of organized behavior on the part of the parent may solidify the viability of the therapy and increase the commitment within the family. My first professional role model, Mary Rygg, MSW, a UW School of Medicine faculty member and original member of Virginia Satir’s Beautiful People acolytes, once presented a case of hers that involved a chaotic life management mother of five children that survived the first few family therapy sessions, became a habit for the mother, and lasted more than three years. The older two daughters made sure the appointments were kept, worked with their mother, and she emerged from the therapy a tracker, to use the term. If you ` `are blessed with one of these people that can keep the process going, reinforce changed approaches to situations and patterns.

Self Destructive Behavior

Separate from persistent suicidal ideation/behaviors/attempts, patterns of self destructive behavior will be discussed in an upcoming post.

Conclusion(s)

All three cases were essentially unilateral terminations. One bit of the study compared the three termination variables, including: those that were mutually determined by therapist and clients; unilaterally determined the client’s parents for most cases, or by the clients 16 and over (although latter adolescent clients rarely terminated unilaterally); and administratively driven terminations, e.g. moving away, insurance running out or changes, illness, referred out (also rare). Average outcomes were relatively high for the first group, and fair to poor within the second. The third group was too small to draw conclusions. The three cases of discussion here were among the unilateral group. 

Unilaterally terminating cases as a whole were presumed to be customers less than satisfied

with the treatment or levels of improvement. Most, if not all of these terminations were made by phone message, mail, or text. Determining exactly why each had stopped could only be inferred, but a level of discontent or concern was usually discernible. Something had gone wrong.

These three cases ended on a different kind of note, between the mutual and unilateral group. First, the terminations had been pressured in one way or another, or at least that was the best available explanation and was concurred by the mothers. Secondly, the women all wanted last session appointments that could review the processes, to hear a clinical perspective, get input and recommendations, and at best help chart a course for what was to come. This was typical of a mutually terminating process. While disappointed, these particular parnts did not seem resigned or unduly daunted. Their situations at the time of termination were largely unresolved, but they had developed better senses of how to proceed.

In mental health work, when you’re treating a child in the age range of 4 – 18, you’re also treating the family. That may be the furthest inkling from, say, the mind of a clinician administering a 12-session EBT for a 7 year old’s phobia of spiders in southeast Texas where the creatures threaten to take over human civilization along with snakes, mosquitoes as big as bats, and fourteen foot alligators, or of a counselor working in one setting or another, be it school, ecclesiastic, camp, or probation. The impact on the child does ripple, perceptibly or not onto the family, and the family’s reactions between each other, however subtle, have ripple effects back on the child, shaping however slightly the change inaugurated by the therapy. 

Take for granted that everyone in the families of Nathan, Owen, and Patrick were impacted in some way great or small by their changes. In fact, ‘better’ for one member may be ‘worse’ for another, such are more dysfunctional families. The fathers were certainly impacted, perhaps reacting antithetically in their separate ways, using overt, passive, or both types of aggressions to protect themselves from their own insecurities an fears, or so one could imagine. From the vantage of reality’s concerns, the ones who had more panoramic perspectives were the mothers, not to romanticize this because the extant issues were of deep personal meaning to all eleven members of these three families of origin. Trackers follow the ripples, be they imperceptible or tsunamic.

Coming into their last meetings, regardless of the difficult circumstances, the mothers had made several gains of their own. To the degree that they harbored doubts, the early phases of their processes reassured that them their child could get better. Each boy had shown more relational involvements within their families, which also helped improve their moods and self-perceptions. This was particularly true for Nathan.The power of reinforcement and praise to change targeted behavior patterns like joining more and improve self-perceptions was affirmed. The transformative process of the mothers turning anger in its various manifestations into worry’s concerns, and then on to creating directions of positive change had become a staple. That was particularly true for Owen’s mother. Their native abilities to both assimilate and accommodate were more consciously employ. All along they knew that growth is a process, but that’s basic mothering. Keep the faith.

An under appreciated clinical factor of talk therapies is the tempo of sessions. In the interactive session work, therapists tend to be attentive, calm and relatively quiet, contemplative an considerate. The dialogue is usually of measured and unbroken sentences and paragraphs that go back and forth, all toward a mutual clarity and meaning, and hopefully onto a translation into purposeful action or behavior. This manner is almost always at distinct odds with habitual, day-to-day realities of stressed, troubled, or in other ways difficult homes that end up seeking remedy. 

The communication process becomes a model in and of itself. Some clients, certainly not all, will absorb and replicate the experience during moments when the style itself can be a modulator, as much if not more so than the words, The child(ren) may begin to absorb as well. 

While exactly how they had been at home had neither been brought up or explored, the mothers of Nathan and Owen were at home with the office manner. The one person involved in these three cases whose pace, focus, and congruence of thought substantially changed was Patrick’s mother. The degree to which her experience in this family work helped with the growth is difficult to say. She had been in her own individual therapy throughout, and that was likely of greater impact. Regardless of how and why, her interchanges were calmer, more on point, more oriented toward the parenting, and less in expressed helplessness. Her sense of what mattered at the moment had grown. The changes were matters of evolution rather than feedback or spoken discovery, altho the change was part of the feedback given during the last meeting.

The last meetings with each of the three mothers had a certain congruence that went unrecognized all these years, private practice having this “lean forward” momentum that tends to move rather quickly past reflection. The circumstances of the cases at the time of their terminations were rather bleak. Two of the clients had regressed almost back to their baselines, and the third was enmeshed in what seemed to be an impervious, impenetrable new household that foretold possible trouble…maybe or maybe not, but the anxiety in both mother and child over this development were present for the same reasons. 

What was striking in these mothers in their last sessions, again in hindsight, was the composure, thoughtful determination, and continued trust in the clinical feedback they were receiving as they sat there and worked. And while dealing with these very similar process endings, these three pretty distinct personalities now seemed so similar in this regard. 

While clearly bothered by the circumstantial events leading to end of treatment, none came in looking for some kind of reclaiming action or resolving approach on my part.  They were accepting the current status, leaning toward a longer point of view. While I certainly gave each situation some thought. Nothing beyond simply waiting for opportune future moments to meet with each boy and see where that could lead came to mind, and even that might be a stretch.

They were there to work rather than review, which would have been more typical of a final meeting, and generally knew what they wanted from the session. Respecting them and the broader matter of their family’s evolutions, I followed their material and questions they brought up. If there were any clinical theme that characterized all three, it likely would have been the concept of assimilation and accommodation, trying to sort out what to accept an what to push in their child’s needs and in the interest of the family. Also, how keep the long term conversation going as much as possible. Cutting ties never entered any conversation.

Typical for a last session, affirming feedback about them was given toward the end of the hours. Observations about each child’s particular impressiveness were shared. Within the realities of each situation, at least a couple of reassurances that their approaches stood reasonable chances of working. And that they could always return. 

Historically in this practice, about one in ten to twelve cases returned, usually within a couple of years. Had any of these done so, that would have been heartening, but more so somewhat pleasantly surprising. And they did not.

The therapies may have been taken as for as possible, given the intrinsic headwinds. One certainty was that more trust existed between mother and child. Trust had been a basic issue for Nathan, and that would probably continue, but he began cooperating, helping, and on occasion even ardently playing with her. Whether Owen’s issues were trust or an embedded anxiety of some sort was never clear, and whichever probably remained a potential problem as he entered adolescence, but he and mother related much more effectively. Patrick never demonstrated a problem with basic trust, but more one of who would care for him in what way and degree. His mother became more other-focused, which did help reduce his anxiety. Remember that when he was telling stories about the small block constructions he made during sessions, the theme was war between two sides that, for quite a while, ended up in death, but toward the en, everybody made up an “everything was better.”

The mothers knew more about their exes, what they could and would and wouldn’t do, and about their vulnerabilities, how each could feel or be hurt. Those things all mattered to aid in avoiding implacable stalemates and disdain. For Nathan and Owen’s mothers, most of the thoughts snd suggestions reinforced their own thinking. For Patrick’s mother, the feedback was in the vein of continued change. She would be remaining in her own therapy.

From beginning to end, these cases transpired over a period of close to four years. The similarities that prompted this section of posts did not became apparent until studying the data some two years after closing shop. In particular, they stood out within the unilaterally terminating case group. In particular, the circumstances of their particular terminations and the difficulties the fathers seemed to have presented were in common. In the course of the writing itself, the notion of the family tracker emerged, or call the role a center of gravity, or simply the mother, but that’s not necessarily true because fathers can be this also, and in really strained circumstance, an oldest child or closest grandparent. Maybe the saddest of all is the centrifugal group that flings members out alone from each other and no one’s really watching. 

In these difficult cases of relatedness or Axis II issues, splits, custody contests, unrepentant hurt and hostility within people who are unavailable or destructive to the clinical process, and/or sometimes terror, keeping the process going is most always a challenge. Often they end in a minor key, and the interim task is to stay even as the work continues bit by bit. What became clearer here is that in such circumstances, the clinical focus can turn toward the one who’s keeping track of the relationships with the purpose of keeping the family together, even though sometimes split, as much as possible. This is an advantage of family therapy. Among the myriad of aids, the work can help foster the healing graces of gratitude and forgiveness.

Keep the door open.

Lastly, would the concept of the tracker have helped had the thinking been available years go? For the majority of family therapies involving child and adolescent mental health problems, probably not very much. For a few cases, the concept likely would have made significant differences, and I wish the opportunity had been there. But that kind of wist is part of a therapist’s reality.

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