#37 – Holding At Bay #2: Analysis and Comments

The therapies for these three cases had a few basic similarities. They were all relatively long, each being more than thirty sessions and lasting more than eighteen months. The anxiety and depression symptoms were largely resolved. The clinical processes all began with conjoint formats that included their siblings, and moved into split-session formats where the mothers were seen first and the client second. The older boy also finished his work by being seen individually following his bout with suicidal ideation. From a statistical perspective, his therapy was one of the most successful within the whole study group, gaining thirty CGAS points and being one of only four relatedness cases to resolve his problematic pre-Axis II traits. 

The mothers all had strong relationships with their children. They also had more than adequate resources and skills to negotiate the vicissitudes of post-divorce struggles. Each of them took advantage of their individual clinical time in the split-session format to sort out their own concerns, decisions, and communications with their children, and also in regards to the fathers along the way.

None of the fathers made an appointment, but appeared to track the processes. As per the mothers’ infrequent comments, none seemed enthusiastic. They ranged from expressed doubts to passive opposition. But again, the men tended to have relatedness difficulties themselves and likely entertained a more conservative view about therapy in general. At least with Hank’s case, the father lessened his antipathies. The other two fathers were difficult to discern at termination, but suffice to say, the clients resolved much of their anxiety about parental conflicts and their fears of changes in their parental relationships.

Clinical Considerations

Though not directly involved in the therapy processes, the divorced fathers remained to be central considerations. For the ‘other’ parent to be being at least neutral toward their child’s involvement is a positive. These particular cases, though, involved parents with likely Axis II involvement, leading to a greater likelihood of post-divorce troubles that could both exacerbate their child(rens) adjustments to the new family arrangements, and/or complicate the therapy. The intensity of the conflicts may rise with the severity of the parental disturbances themselves, complicated by the reality that the level of severity is almost impossible to ascertain from a distance. The fact that most non-participating parents are male and as a result tend to be less enthusiastic about therapy in general could further add to the challenge. Developing reliable clinical methods and tactics that aim at fostering and maintaining at least the neutrality of the non-participating parent may help to produce positive clinical outcomes, but at the least may offset torpedoing the processes involving their children.

The following concepts and guidelines proved helpful:

Support the basic triangle

First do no harm

Protect the process

Maintain boundaries

Use discretion re: judgements 

In a family-based therapy approach to child and adolescent mental health issues, all three sides to the parent-parent-child triangle are taken into account. In cases of divorce where co-parenting continues in one form or another, the professional relationship with the  ‘other’ parent not involved in the therapy can be still be seen as resembling something fiduciary in nature. The therapist wants the other parent to have trust and confidence in their professionalism. For the parent – parent – child triangle to solidify in some way or another as a result of the therapeutic interventions, the triangles involving the therapist and the family members are best being supportive and neutral. First do no harm toward the relationships of the child and the active ‘other’ parent uninvolved directly with the therapy. For example, focus on behavior change rather than speculating or deciphering the other parent’s motivation. These can lead to judgements, and family feedback loops will persist beyond divorce. This can also be seen as protecting the process.

Using the different available formats within the family therapy structure proved to be particularly helpful in these post-divorce child therapy cases. The family work focuses in part on the relationship between the participating parent and the child. Particularly in the split-session format, where the clinician meets with the parent and child separately during the hour, the involved parent can work on the relationship with the ex. The third side of the triangle – that of the child and the non-participating parent – can get addressed with the child at any point in the therapy regardless of the format.

After the six years of community NPO mental health work that began my career, another six years was spent as an in-patient medical social worker at Seattle’s venerated Children’s Hospital, a far cry from outpatient mental health. Two invaluable psycho-social nurse colleagues mentored me about how the floors and bays operated, e.g.’the doctors diagnose and prescribe treatments; the nurses run the place.’ One eternally helpful advice was to “write chart entries as if the patient and parents are looking over your shoulder.’  Likewise, assume that what the therapist says in the office can and will be quoted to others. 

Words matter. Clinical statements the therapist may make regarding the non-participating parent and subsequently conveyed by the participating parent, child, or possibly even someone else can pose problems. Particularly In helping adult clients understand the nature of their experiences vis-a-vis difficult relationships, some therapists will suggest diagnostic terms to describe the other parent such as “narcissistic” or “paranoid”, suggest characteristics like “self-absorbed” or “manipulative”, or define patterns as being  “demeaning” or “contemptuous”.

The problems in employing this tactic are threefold. Perhaps they are accurate – only perhaps  – but at worst they can be interpreted as insults, gibes, or sarcasms when conveyed to the other parent.The more insecure that parent may feel about themselves and their relationship with the child, the greater may be their opposition and even direct interference. Such characterizations do not provide a feasible plan of what to do about the concrete problems the terms are intended to encompass, so they can easily become an idle, even snide critique that may somehow build the client’s confidence in the therapist’s knowledge, but in effect do little else except to denigrate a bit. The more serious consequence is when the terms are later quoted in the midst of, say, a hard or heated argument between the divorced or separated parents. However uncommonly that may occur, that does happen and runs the risk of further destabilizing that parent – other parent – therapist triangle. Protect the process.

The Karpman Drama Triangle concept was developed in the early late 60’s and incorporated into Eric Berne’s Transactional Analysis therapy in the early 70’s (ref: Wikipedia entries on Karpman and Berne). To me, anyway, TA seemed to be an attempt to create a relational diagnostic taxonomy as a parallel to the DSM system of individually-based diagnoses. Popular at least in the western states during the 70’s as an alternative therapeutic narrative, TA faded as a treatment about the same time as mental health treatment began to industrialize in the 80’s. The one remaining operative vestige, to my knowledge, is Karpman’s victim – rescuer – persecutor triangle. Karpman’s hypothesized that a dysfunctional threesome would necessarily fall into these three roles. The dynamic is that a victim would be oppressed by the persecutor, and then the rescuer would enter to save the victim. T/A postulated a very specific shift within the triangle where, after being ‘rescued’, the vengeful victim becomes the persecutor, the rescuer becomes the victim, and the former persecutor now rescues the rescuer-turned-victim. The roles continually shift in that pattern. And around and around again and again as the threesome live out their pathologies.  Berne had data to support the hypotheses. The main point is that while helpers help others get better and stronger, if the ‘helping’ verges into ‘rescuing’, the well intended ‘helper’ who misguidedly rescues can end up being the victim, e.eg lose the case. And the original perceived persecutor  – the other parent – certainly won’t rescue the therapist. When this phenomena occurs in child therapy, the ultimate victim is the child him themselves. The process is injured or finished. The client stops getting help. This does happen.

Every once in a while, a therapist is asked to write letters of support or provide testimony of some sort in support of a parent’s legal or administrative defenses or pursuits, or even offer to do so. In the context of child and adolescent cases involving two divorced parents, a prudent approach is to defer, particularly so in those cases in which the contentiousness persists long after the dissolution. Letting the participating parent know at the outset of the therapy process that, as the child’s therapist, the clinician will work to avoid direct involvement in a legal process will serve to diminish the possibility of being approach by that parent to help. Rather, the parent will seek counsel about where to go, or the therapist can recommend to whom to turn.

Whatever the request may be, someone in the system is likely to be more suited to provide the service than the therapist, e.g. guardian ad litems, community advocates, forensic clinicians. They will usually contact the therapist for confidential input. To get involved runs the risk of being in the rescuers role by leaving the course of neutrality and broaching into the maelstrom. Becoming one more item on a list of complaints from the ‘other’ side can jeopardize the therapy itself. Be judicious and maintain boundaries.

The three children in this group were each subjected to frightening scenarios by the fathers: one had passive-aggressive tendencies that undercut the mother’s attempts to meet her responsibilities; one subjected his children to an onerous home environment; and one created an environment of terror early in his child’s life, one likely permeated the child’s being.

As Isabel’s academic and social improvements progressed, the pressures within the father’s home were not abating, and possibly worsening. The mother’s dilemma about whether to move Isabel and her brother into a different school system was pronounced. Her portions of the split-sessions were becoming more focused on the father’s environment and less so on parenting, per se. Communications she was having with him were discussed, shaped, honed, and re-shaped to little avail. Her own distress was becoming more central as her daughter was gaining a nice sense of herself and not requiring as much support and attention. 

The mother did not overtly ask for an opinion about whether to move the kids, working more on the details of helping them negotiate the disquieted atmosphere. In essence, her parent time during the session was verging into a separate therapy for herself. Although this turned out to probably be not the case, the question of whether she might be having commitment issues with her husband also entered the clinical thinking. In deference at the moment to the maxim ‘unsolicited advice is worse than no advice at all’, a unilateral suggestion she seek therapy for herself was not forthcoming, but eventually a referral would be necessary. Just about this time, the mother openly wondered about going into counseling herself. With concurrence, I gave her a colleague’s name with whom she did begin her own work.

When employing this split-session format, the distinguishing line between counseling an adult in their role as a parent and conducting individual therapy for the adult’s own problems is admittedly fuzzy. Unless the therapy being provided is a systems-oriented process based on circular causation, one in which the family is the “identified client”, the youth is the therapist’s client, and the participating parent is a collateral. In taking the parent as a client working on problems separate and different from those of the child, two basic problems can emerge.

The first is the possible impact on a child of feeling displaced, which is not out of the question. Secondly, for children in the 10 – 16 year old bracket, and particularly if separate appointment times are set, the client can develop mistrust about the maintenance of confidentiality. This possibility would just about be a given if mistrust is a issue spread through the family. While these developments can be managed clinically, creating et another presenting problem to be resolved is also an issue.

Even if the therapist has gotten to know the parent through the periods of conjoint and split-session formats, and trust has been established, and the segue into personal therapy seems natural, you still don’t know exactly what you’re taking on. The problems may simply be extrapolations of what you have already learned and experienced, no problem. They also may be far more complicated and reflective of a side about which you were unaware. The process may go well, but by the same token, the course of events could go decidedly off-kilter with unanticipated consequences. Again, this would be particularly of concern if the parent involved possibly has Axis II issue. The negative impact on the child’s work could include a premature termination of both the child and parent processes by the parent.

Using the guidelines outlined, accepting the involved parent as a simultaneous client for their own personal problems runs the risk of unbalancing that  client – parent – therapist triangle. The possibility then exists of rippling tensions within any one or combinations of the three sides, not the position in which the therapist wants to find themselves. While this kind of outcome would seldom happen, the possibility of an inhibitor introduced into the child’s therapy needs to be taken into account. Hence the referral to a colleague for Isabel’s mother. Maintain boundaries.

The Child – ‘Other’ Parent Side

Hank, Isabel, and Jackson all spent some time during their therapies on their complicated and sometimes distressing relationships with their fathers. Of the three, only Isabel was both in a position and had an interest in talking directly with the father about her concerns and complaints. Hank was too young to take this on directly, and Jackson was in a different place in his life, both in terms of his emancipating developmental stage and by virtue of his father living in a different part of the country.

Being six-to-eight years old during his time in therapy, Hank was simply too young to take on the task of talking with his father individually. Understanding his own feelings in regards to his father, what he could say to him, and how to manage himself were issues addressed in the conjoint work with his mother. She would make suggestions about what he could say or do differently, sometimes with my input to her. During his individual time, I would help him process his own feelings, and, generally, suggest that he talk with his mother about what to do. 

Jackson had abandoned thoughts of moving in with his father as his own attentions were drawn toward the social life and relationships of latter adolescence. Father’s antipathy toward mother seemed not far from the surface when the two interacted, either during the summer or on the phone. That veiled attitude of the father’s may have served to reinforce Jackson’s irritability toward his half-sibs, resentment toward step-father, and a sense of being the victim. Jackson’s difficulties seeing himself in his father was not particularly approachable until he returned to treatment following the suicide plan.The sheer fright of that episode helped soften the edge against painful insights. The relationship surely continued, probably around fishing, but other than issues stemming from the modeling, no direct work involving his paternal relationship was necessary at that time he terminated. All appeared settled, without underlying resolutions, but also without calumnies. 

As per Alan Leider, “Working with a family is like walking through a minefield. They know where the mines are, and you don’t. If you try and lead them through, you’re likely to get blown up.”

On the other hand, Isabel wanted to talk to her father. Offered here is, very roughly, one side of an interchange. She gave a session-opening description of a spiky Sunday afternoon at her father’s home a few days earlier. The previous session involved somewhat similar content, mostly descriptive and disburdening. As she got up to leave this session, she mused about talking to him. As I shook her hand going by, I just said “good enough, maybe next time”. To begin the next appointment, Isabel reports almost disconsolately on the last time at her father’s home. What follows is the clinical portion of the therapeutic interaction. She was then close to 13.

Note: The style of the following vignette is anode to Shelley Berman

“Well, listening to this, those were a couple of hard days. Kind of painful, really. So, is this the kind of stuff you want to talk with your dad about?”

“So, how can I help?”

“Well, what sort of thoughts have you had so far about what you’d like to say to him?”

“You want me to call him in here? I’m glad you’re smiling. I can’t call him in. It’s a sort of rule. Maybe I can help you figure out what you’d like to do with him and how to go about doing it?”

“So, again, what have you already thought about saying”?

“OK.You want to talk with him about your relationship, how he sees you, that sort of stuff?”

“So, let’s start off with the problems being in his house, how you feel, the ones you’d like him to think about. What might they be?”

“OK. So far, that seems to be right on target. What else?”

“OK, what else?”

“Anything else?”

“Well that covers quite a bit…it’’s a good start. Now, your step-mom is involved here, so, whenever this happens, would you like to talk with the two of them together, or your father alone?”

“Alone? Right. I totally agree with that. Doing this for the first time with both of them sitting there sounds like it could be hard. What exactly do you want to see better with your dad?”

“List, say, five things.”

“What comes to mind when you list those things is that you really want to be seen differently by your dad, like you want his approval?”

“And the same with your step-mother?”

“I don’t know, maybe she could surprise you.”

“Well OK. One way or the other, we’ve got some work to do. So, let’s start off with what you’d like to see different over there.”

“What else?”

“There you go. Good. What else?”

“Anything else?”

“That’s even better. It’s certainly enough to start with. Most of those were things you’ve mentioned are things you’d like to see stopped. So, let’s re-define it into what it is you’d like to see get better? You remember us doing this in the first family meeting with you, your mom, and your brother? Right, so, go ahead.” 

“OK, what else?”

“And what else?”

“Does that cover it?”

“OK, I’m writing all this down. Now, that does cover a lot of what you’ve been talking about. I’ve got another question, though. In what ways does your dad do what you like, and more importantly, in what ways does your dad see you that you like?”

“What else?”

“Anything else?  No? OK. In what way does your step-mother see you positively.”

“Nothing at all?”

“Not a single thing? Well, what’s the closest thing to positive she’s said, even if it’ like, ‘I’m glad you like my spaghetti.’

“OK, that’s better. Every one has at least some bit of light. Last question along these lines. What do you think you can improve upon when you’re at your father’s?. What else?”

“Anything else?

“Alright, good, that’s really is very helpful. At some point you may want to acknowledge that to him, you know what I mean?

“Right, and maybe say, if you mean it, you want to work on that?” 

“Good. Very last question about this stuff – what can your brother do better around that house that you could remind him about? How can you help him?”

“That’s good, too. What you could do better are just things to keep in mind whenever it is that you decide to talk with your dad. So, you have this list of things that aren’t going well, and then a list of things you’d like to see get better, and some things you could do better. By the way, that last one is called ‘taking the high road’.”  

“So, can you list a few of each group in your head?” 

“And you’d like to have time with him, a couple of things you’d like to do with him – like maybe he could go and help you pick out a coat?”

“No way? I’d think about it, anyway?” 

“OK. So, pick out maybe two or three things in each group – things that aren’t going well, things you’d like to see better, what you could do better, and maybe what you’d like to do with him alone. I’ve got them written down here, so we have a record you could use if you want, I just have to copy it, give it to you when you leave.”

“Good. Put them together in a way that you’re comfortable, and then talk to me like you’re talking to your dad. Just to test it out.”

“Good start. And how did you feel saying that stuff?”

“Alright, try it again, maybe with a bit more detail about what you’d like to see better. ”

“Yes, yes. You know, these things you’re pointing out may help him sort things out, too. The remaining thing is that what you’re saying does not include much of how you feel when things are gong badly, and like when things get better, and when you’re getting along with your dad. And remember what we’ve talked about before, that beneath being angry is being worried about something.Your feelings are the most important thing to you, what you worry about maybe the most important and hopefully to him, too. So, try to put in something else about your feelings. Do one more time?””

“Oh, really good. You’re a trooper. How do you feel when he’s  angry with you?”

“Good – no, not good, but you know what I mean.  And remember that beneath the anger is worry. You have a pretty good idea?’I think it’s really getting there.” 

“OK, you may want to check out what you want to say to your dad with your mother, because she knows him best. She may help you change something here or there. I think it’s good on its own,  and you’re certainly old enough to do it on your own. That’d be up to you. Your mom may be a good double-check.””

“Good. So, it’s possible that you’ll decide not to do it right now. That’s OK, too. If you do talk to him, though, I’d be interested to hear how it went. I’m learning about what works here, too. At some point either now or in the future, though, I’m pretty sure you’re going to be doing something like this. Any questions?”

“Yes, you’ll be nervous. What I’ll tell you is that most of the things that are really important you’ll

remember at the time, as you talk. Those you forgot can always be said later. It’s always OK to take deep breaths. You know, you don’t have to solve the problems right then, you just want to get a conversation going. The point is making the effort…to help your family. And it may not work, at least the way you want, but this is a first try, and you’ll have lots of opportunities as life goes on. Right?”

“OK. So, I think you’ve done really nice work today, and I hope it helps.There’s one more thing I want to bring up, and that’s this…what really impresses me is your sense of loyalty to your dad, and to your family,  and I think to your good friends, too. I know they mean a lot to you as well. That firm sense of loyalty is a great value to have, and It will help you out in the future, so, you know, stay with it.”

An exercise like this would probably take most, if not all of a split-hour session. The alternative is that at almost any point early in the recitation of problems, the clinician could unilaterally interject, ‘what I’d recommend for you to say (or do) is _________”. The quick dispatch would allow for a more efficient use of the 25 – 30 minutes, could be just as good, maybe even more to the point. 

Two advantages of taking the longer route are worth considering. First, the client would be using her own thoughts. Going on 13 and having the relationship with her mother that she does, she’d likely talk with her about this as well. The therapist has been helping her figure out her own words and manners rather than providing the direction. Less likely to get blown up.

Secondly, this kind of exercise can become a ripe opportunity to provide some random, unanticipated positive reinforcement, which can never hurt as long as the observation is demonstrably true.

Once in a while, a twist of fate pushes toward a resolution. In this case, while dropping Isabel and her brother off at the mother’s home one Thursday summer night, Isabel’s step-mother entered the house to search for missing items.  Doing so was not allowed. The mother notified the father. A repeat occurred two weeks later. Isabel in particular was upset with the allegations toward her and breach into her room, more so with the accusations. Her room was apparently always presentable. Enough was enough, and the mother decided to move the children to her husband’s home. They would stay with the father every other weekend. 

The therapy process ended a month later. Although the move itself made continuing less feasible, the client was ready anyway. She had not yet talked with the father, but she did have had a kind of template when the moment called. The door was open to return.  Her mother was continuing her own therapy.

Thanks to Connie Dunn, Transcriptionist, for years of faithful work

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