HARD CASES – VIGNETTE #3

Owen

Owen really did not want to enter the office from the waiting room. If he were younger and that resistant, the accompanying parent(s) would have been brought into the assessment session along with the youngster, a rare event in and of itself. But being twelve, volitional, and discreet about disobeying in public, he hung his head and trudged to the couch. Once he started talking, in his case after only the second question of ‘what brings you here’, he was cooperative, forthright, cautiously informative, well spoken, and a bit unconventional.

His view of the issues reasonably resembled his mother’s viewpoint as expressed during the initial parent interview, which is usually a good omen. His list included problems both at his mother’s home and at his father’s place. A voracious reader – he had read 750 pages of Game of Thrones in the two days prior to this appointment – in regards to his father’s home Owen said that his step-mother’s main complaint was that having any kind of discussion with him was very difficult. He immediately followed that with the unsought explanation “but a lot of women are like that”, he of twelve years old. The implicit question of modeling occurred to me. To some degree his jaded quality would continue.

Along with three other symptoms of depression, he endorsed occasional suicidal thoughts. He had no intentions, no plan, no notion of method, and nor any research. The reasons why he would not make an attempt on his life involved significant concerns about how others would be hurt, and he would not want that to “ever occur”. He also earlier denied having problems with sleep, headaches, or stomach aches, those three being the cursory indicators of anxiety used in this evaluation format. If two or three of those were endorsed, the evaluation would move to a more comprehensive inventory (actually using the 18-symptom list out of Generalized Anxiety Disorder in the old DSM IIIR, in my judgement the best instrument for the purpose of an outpatient initial assessment). This was not necessary. The basic symptomatic problems were depression, behavior, and relatedness.

His self-esteem was over 5 (on the scale of 10) for five of the six categories. His self-perceived greatest strengths were his intellect and his school performance. Owen gave himself a score of 4 for peer status and social skills, an assessment that corresponded to his reclusiveness. Early life stress/loss have heightened reactions to perceptions of peer rejection (Peutz, et. al.; J. of Amer. Academy of Child and Adol. Psychiatry; Dec ’14). His hesitances to come into the office would suggest a problem with anxiety, but his self-rating in that category was 6. His overall self-esteem as gauged by this evaluative test was almost average for early adolescent living in the north Eastside area.

His ego-development evaluation came out at a mix of Stages 4 and 5, high normal for his age. The socio-moral eval came out at another high-normal stage 4, altho his answer to the question was unorthodox, to say the least. A version of the Heinz Dilemma was used as the challenging  situation presented to the client, where an aged husband was faced with either stealing a pharmacist’s unaffordable life-saving cancer medication for his ailing wife or watch her die.  Given the question ‘Should he or should he not steal the drug?’, Owen paused for a few seconds, started off by saying “It’s against the law”. He then answered more directly, proffering  a utilitarian point of view that the “old man should not steal the drug because they’re old and their time is up”. Categorically, his was a Stage 4. Utilitarian thinking for a 12 year old is good, to be sure, but I quickly worked to stifle what would have been an entirely inappropriate laughter. This response just could not have been anticipated, so what emerged was a bowed-head “good answer” to this bright, brooding youngster, he being all of an aged twelve. 

After asking him if he had any questions he wanted to ask me – and there were not – he was posed with the choices of being seen alone, with his mother, or with mother and brother all together. He quickly chose being seen with his mother, doing so without any umbrage. I concurred, and the session ended on the upside.

He walked out of the meeting more confidently than when he entered, and left with a spontaneous ”thank-you” as he walked out the office door. Right behind him, the mother  querulously did a searching look at him-then-me-then-him-then-me, and gave a surprised nod of gratitude herself. 

In the summary-and-planning session with the mother, she concurred first with the overall assessment that suggested either a primary problem with depression or ODD, leaning toward depression. His anxiety portion of the symptomatic problems was based more on his own overall presentation rather than his self-descriptions or results of the evaluative exercises. The source of the anxiety was not clear, although the moodiness and more recent reclusiveness were also evident during toddlerhood. A harbored clinical hypothesis was that he now had either some identity issue, and/or was being impacted by the difficult intra-parent struggles. The mother also concurred with the recommendation that the two of them be seen alone. She also had relayed the information to the father that he could make an appointment for himself. 

The first meeting with both was productive in outlining the problems that needed to be addressed from the mother’s perspective, including moodiness, withdrawal, disrespect, chores, and non-compliant classroom behavior, defined in terms of their opposites, to wit: more pleasant around the house; more time with family; more appreciation of others; more compliant with chores and requests; and meeting expectations in schoolwork and behavior. The only complaint of Owen’s was that the mother would often get angry with him. The mother’s hopes included generating better communications, develop a better understanding of how to help her son become “a healthy, happy, confident young man” and other challenges of parenting, and managing her own feelings. Still, having enough time to “do everything” was problematic. Owen remained attentive. He could or would not identify anything he would like to see get better other than his mother’s irritation, but the mother agreed with his observation and asserted that she would work on that. 

Both were involved and verbal. Some topics gained Owen’s genuine interest to the degree that almost the entire hour was used. That meant the promised game of Jenga, to which Owen had looked forward, would have to be postponed. He left contented and dropped another “thank-you”. This being progress, Mom was pleased.

The next session began with reviewing the progresses and changes that had occurred over the week. The mother reported him to be more talkative, picking up after himself, doing his chores, receiving no complaints from school, a couple of high quiz scores, and a more pleasant mood. Owen concurred with what his mother said, added that she had not been irritated ‘very much’. He did participate, however minimally, about what led to the changes. However, elucidating why he was ‘less stressed’  was difficult. The underlying anxiety remained unexplained. Talking about himself seemed painful.  Pursuing what led to that stress in and of itself provoked irritated silence, so we moved to the next step of ‘what can I do for you today?’. 

The mother brought up about the amount of time reading in his room. In short order Owen became teary, and buried his head in clothing. When asked about his feelings at the time, he said he “didn’t know”, and then emerged from his sweatshirt. He slowly began to participate. The next step would normally be a return at some point to the question of what led to the tears earlier. The problem is that “I don’t know” usually means “I do know but I don’t want to tell you”, and, given the client’s ambivalence and apparent lability, pushing the envelope carried unnecessary risk, So with 20 minutes left, we finally arrived at the step of playing the Jenga game. What emerged a vast difference.

The heretofore unseen side of Owen, the one that the mother declared existed during the intake, emerged as a happy, energetic, engaged competitor. The game could be played one of two ways – who would make the stack fall, thus creating a “winner”, or collaboratively build the stack together as high as possible. In this therapy, the decision or inclination about how to play the game was split about half and half. All I would do is observe, maybe give a tip here and there, but mostly take advantage of the opportunity to ask more informal questions, to get to know them better, and they me.

The two chose to see how tall they could create a tower, and animatedly worked their placements of the individual tiles up to 29 levels before the building crashed to the carpet as the mother applauded, Owen covered his ears and leaned into her as she put her arm around his shoulders. 29 levels really was a very good result. Letting them know that, they beamed. At heart, this kid was really likable, emotionally young but with a certain charisma. At the moment, and speaking uncritically,  he seemed about 8 or 9 years old.

The next five sessions had a certain pattern. Save for one session where his entry and exit were more normal, Owen was reluctant to move out of the waiting room and slowly entered the office. At some point he would become wordlessly teary for a short period to himself, then re-emerge and re-join. He was not in that much distress in the aftermath. His refusal to engage in the pursuit of understanding the pattern became presumed. Exploring if the pattern that began when the parents were upset with each other in his presence, before the separation when he was about 1, was a reasonable pursuit, but at this early point in the therapy the foray could be too provocative. In pure diagnostic terms, the problem was unclear as he did not rise to a clinical depression, nor to ODD, nor to PTSD. The overall clinical evaluation at this point of six sessions was still on-going, common with the more difficult kids. The work was to address whatever presenting problem of the week that the client or mother or father – almost always one of the parents – brought into sessions. 

The work was a standard combination of behavioral, cognitive, and relational methods. Owen would become more involved, although not to the point of engaging much in the affective work that he had minimized and avoided. Simply noting that pattern in and of itself, which with a bright early adolescent male would normally work, did not result in a deepening of the substance. But, by the end of the sessions, he was generally more relaxed, and on occasion said “Thanks” as he left the office.

Most of the presenting problems had been directly addressed over these seven meetings with both together. School performance and behavior were no longer problematic. Owen had begun to share more about his peer experience at school, both at home and once in session. Chores and help around the house were better, still resisting though if called from his room and reading. Resistances were more in the normal range. More interactions between the three of them, older brother included, were occurring. The irritability and touchiness could still dominate Owen’s mood around the house, but overall had lessened from the presenting state of more often than not, more days than not, i.e. in a clinically depressed state. Social interactions outside of school were still infrequent. Book after book were completed. The father had not initiated contact, and I could only infer that he was not inquiring about the therapy after the occasional brief updates by the mother.

The experience of this practice with ODD cases, or ODD-like cases which seemed more and more the case over time with Owen, effective casework could easily take a year or longer. The clinical strategy was basically to press on with the family work as long as some kind of positive movement was being experienced.The slow but steady initial gains Owen made were common. Regressions occurred, but most would eventually reverse. Some did not, and those would be among the few ODD cases of lesser and occasionally no meaningful clinical gain. With difficult cases like these, success is a combination of primarily clinical skill and secondarily the good fortune of avoiding the land mines in the family’s field. The approach is to get as far down the improvement road as possible by maintaining both creativity and relationships. Such was the case here. The good outcome is still no guarantee.

Following a week in his father’s family home, Owen had been particularly difficult for two days with his mother and brother both, uncharacteristically so with his older, mild mannered, and self-directed sib. For the first time, the defiance toward his mother included some physical intimidation. While school behavior and work quality continued to be better, at home he had regressed almost to the baseline. The session itself was marked by instances of aggressive  argumentativeness with his mother. The relational skills and socio-cognitive development tools which had been previously effective resulted only in a lessening of the overt contentiousness. The mood persisted. Rather than getting sharply corrective herself, which would be more reflective of her old pattern, the mother continued in a vein that was calmer and directing her interactions toward understanding what Owen was feeling and trying to guide him toward more accommodative behavior. The last ten or fifteen minutes were spent by the mother discussing a range of family concerns and events. Owen remained mostly silent. Gone, though, were the tears. He left in moderation, with eye contact and a nod.

During the ensuing week, Owen found a middle ground, between his most ornery of the previous week, and the high point of his growth three weeks earlier. He was more withdrawn in his room, sporadically defiant, hesitant to cooperative, easily irritated. At the same time, he was not aggressive at home,  and school seemed to be going well as he brought home two high grade papers and quizzes each. Resistance to the therapy appointments continued, but he ultimately came, as per usual. More uncharacteristically, resistance to participating in session was high and did not dissipate. He became mildly but irritatedly interruptive in the office. Still no pattern was discernible, at least to me, of what provoked the testing behaviors that announced his displeasure, like lying across the green overstuffed chair that he customarily used, feet dangling over the left side and head hanging backward over the right, which, when done in the office, was more typical of the eight year old. I suggested to the mother to ignore the provocation, only for the sake of the appointment if her rules at home were different. He later sat up. No tears again. The acting out seemed to supplant them.

I asked to talk with the mother alone for a few minutes at the end of the session. Owen stayed in the waiting room rather than taking the option of going down to their car. The pattern of these past two weeks suggested something relative to the process here was percolating with the father. The father remained aloof, as he had been all along, had maintained a dubious attitud, probably at best, toward the counseling. Owen’s only comments to her were that the tensions among the father’s second family of four were annoying, leading him to stay in his room there, apparently even more so that at her place. She also shared a thought, taken from moments of greater candor from Owen, that the step-mother was pursuing a family-of-six atmosphere in which neither Owen nor his brother had much interest, his older brother being sixteen and into his social and athletic life and often not going to the father’s home at all. Owen distanced because he was Owen. I asked her to check with the father about anything being different there. She was doubtful that he would be candid but would do so after Owen returned from his week there, reflecting her generally foresightful judgement. I walked the mother to the waiting room. Owen had his back turned away from the office door, building something in the way of a medieval enclosure with the ancient set of small wooden blocks. I asked him to leave the structure there, that others may want to add to what he’d done. Normally, kids will be excited to one degree or another when asked to preserve their work, but he nodded without turning around and wordlessly left.

If something happens once, take note. If something happens twice, you have a pattern.

Coming from the week with his father again, the next session was the most difficult. Owen’s refusal to engage continued for the second consecutive session. He had protested vehemently about coming, and was persistent in seeking an early ending session ending. Some work similar to that which had been done in the past was accomplished, but when a lull occurred in the interchanges, he began acting out. This time he engaged in a mimicking echolalia, repeating word for word what had just been said by either me or his mother.

Once again, Owen did begin to settle down, and left in a state just below that of equanumity, not polite, but not in derogation. In my running commentary notes, part of the entry was  “the return to previous levels of resistance is verging on an on-going problem. As long as he’s in counseling, though, we can deal with it.”

If something happens three times, you have a problem.

Indeed. That was the last session. For another session following the week with his father, Owen refused to return. A day later, the father wrote a long email to the mother which was quite contemptuous about the therapy, about counseling in general, and presumably toward me personally. The mother didn’t venture those, and I didn’t ask. She had grace, the same form she exhibited during the intake when, in response to the question ‘what led to the divorce?’, she simply identified “incompatibility”. She always exhibited devotion, but something really deleterious must have happened in this marriage, and then to dissolution and his relatively swift re-marriage that must have hurt, something presumably being managed in her own therapy. At the same time, she is the matriarch of this family, divorce or no, and her most vested interest is in keeping the basic family bonds and six relationships between the four of them as intact as possible, a mother’s task of joy and curse. Owen had retained some of his gains through the last difficult weeks, important gains. Mother had made changes quickly and easily. 

Several recommendations were made to the mother relative to the management of Owen, and toward family relationships in general. The door was left open. She was disappointed but observed that the sessions had demonstrated her son could, indeed, get better, and she believed he would do so. I mentioned research that suggests the biological maturation process of youth continues until age 28. She had plenty of time, plenty of skill, and at heart a good kid.

In sum and in spite of Owen’s current tensions from his ‘exhausting struggle’, I had reasonably certainty that he would be fine in the long run.  Although assessed as a pre-adolescent with a moderate – serious pre-Axis II problem, he was one of only four (out of nineteen) who resolved most of those issues. His reactivity to the father’s clear, personalized antipathies toward the therapy process appeared to inaugurate a return of a defiance and disruptiveness that had largely dissipated for several months. Otherwise, the young man was more normal, had too many strengths and skills to become permanently troubled in his social relationships, and with the continued maternal guidance and modeling, stood a good chance of having a meaningful relationship and quite possibly a family of his own as an adult. The hard part is that the therapist doesn’t find these things out except by the odd and uncommon circumstance of a chance encounter. The door was left open. 

The cases of Owen, Nathan, and Patrick nevertheless all leave process questions, as these types of cases necessarily do. The experience of difficult endings is unsettling, but nevertheless provide rich learning opportunities that can lead to more effective case management.

Analyses and comments are in the next post.

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