Dave: Here is a clinical case which expands on my ideas from the last two posts (see post on Therapeutic Conditions for Healing from 1/26 )
Case: When Ellen M. called for an appointment, she wanted a second opinion about her son Allen’s hyperactivity. As usual, I asked her to bring the family, which included two sons and their father, from whom she was divorced. “Would the father come?” I asked. “Yes, he would, but he is very unreliable.” I suggested she invite him. Mrs. M. and her two sons, Nick, 12, and Allen, 9, came to the first interview. Mr. M. said he would come, “but he is always late.” He never did arrive. Ellen, 40, was well dressed, energetic, handsome, articulate, Italian, and Roman Catholic. The boys attended a Catholic school and were neatly dressed like little men in white shirts with neckties and navy pants. Nick was Mother’s favorite and her valued partner, the one she “depended on.” He got all A’s. He even talked about how he was trying to help Allen get along better with his mother. Allen, 9, was enigmatic. Mother did not know how to relate to him and his moodiness. And despite his being on Ritalin and Clonopin, the school had daily problems with him.
Mother was obviously responsible and cared deeply for her children. She was organized, smart, and attentive to details. But she was moralistic and did not like double meanings. Her thinking was clear, but too clear. There was a lack of equivocation and no sense of irony (irony deficiency). She hid from ambiguity. For example, when I asked her about her family of origin, she acknowledged distress, but avoided details about pain. The picture was one of considerable rigidity and emotional restriction.
As we neared the end of the interview. I told her to tell Father, from me, that it was important that he be included, and she should warn him to be careful because I was already mad at him for standing me up this time. Mrs. M. blushed, tears appeared in her eyes. “I’m sorry, I wasn’t telling the truth. I didn’t tell him about the meeting. He is a liar; I didn’t want him to come.” She confessed she had not told him about the interview because he was so smooth. “I was afraid you would not be able to see my side of the story. That’s why he isn’t here. I’m sorry.” She was embarrassed. The boys looked at her, puzzled by her upset, not comprehending the cause.
Father, Jim, age 40, came to the second interview. He was handsome, simultaneously anxious and cool. An accomplished athlete, he was a local hero from his college days. He got caught up in some ‘80s schemes for making fast money with stocks and bonds and did two years in a federal penitentiary. My impression was that he had been humbled by his encounter with the law and jail, helped by Alcoholics Anonymous, and was working at being honest with himself and his sons. He was not the con artist I expected from Mrs. M.’s description. In fact, with Father there, Mother, whom I liked a great deal, suddenly seemed harsh and over-rigid. She sounded like a Mother Superior who did not believe confession really mattered because the priests were too soft-hearted. (Ironically, she worked as a claims manager for a managed care company.) She was good at saying “no,” there was not much “yes” in her. She was good at making certain the rules were followed. It was hard to avoid her concrete requests for advice and questions of medication and side effects. But in order to shift the focal point, it was important to palpate regions of pain and disappointment.
Father was earnest in his concern about Allen. In Allen he saw fragments of himself as a boy and he feared Allen would turn out like him. Allen was like his father; he had his natural athletic gifts, but he also had his penchant for sudden temper outbursts. Father worried he never did enough with the boys, and on the other hand, he was concerned his involvement with them was harmful, and interfered with Mrs. M.’s relationship to the boys. Many question my interviewing method which involves talking about the kids while they are in the room. The fact is, every one gets put into the third person at some point during the therapy. Children gain a great deal from hearing themselves talked about.
Allen was always well-behaved in my office. But based on his demeanor and the stories they told about him, he seemed like a pet wild cat. The young man looked and sounded as if he had the “it” we call ADHD. He had a nervous energy, an alertness about him that suggested a nervous system never at rest. Yet, he sat like an altar boy on the sofa, legs stretched out, not touching the floor, throughout each interview. His mother had difficulty talking about anything other than him. Their anxiety about him shaped my transference to him. But my assumption, which I shared with them, is that a kid like Allen is in more pain than anyone realizes.
In the third interview, Mrs. M. was reiterating her great concern that Allen would turn out like his father. I said, “Well, it could be worse you know.” “What do you mean?” she asked. “He could turn out like you,” I answered, poker-faced, tongue in cheek. She looked puzzled, started to ask a question, then physically flinched, as if flooded with awareness of how lonely, constricted, and bored she felt.
In the fourth interview, I learned the boys had spent the weekend with their father and his new woman partner. At one point, Father discovered Allen lying in the driveway behind the car. He was upset about something and said he wanted to die. Father was shocked by this. In the interview he wanted Allen to say more about what he meant. Allen reiterated that he wanted to die. The parents looked to me for reassurance that he did not mean it. I did not give it to them. “I think he hurts a lot. You can only underestimate his pain about this. What do you think would happen to your family if you died?” I asked. His hands, palms together, were between his knees. He clasped his hands tightly with his knees and shrugged, holding his shoulders up to his ears for a long time. He didn’t say anything. “When children are suicidal it is because they think someone wants them dead,” I said to the parents. Then to Allen, “Do you think someone would be happy if you were dead?” He lowered his shoulders and with head down, but eyes on me, nodded yes. “Who would it be?” I asked. He held his hand against his chest surreptitiously pointed at his mother. She gasped. “Allen, no!” He nodded yes again. “How could you think such a thing? The father said he thought Allen was just being manipulative. “I don’t,” I said. I liked it that Jim was uniting with his ex-wife, even though I disagreed with him.
During the course of six interviews in ten weeks, the family doctor weaned him off the medication. I was apprehensive that when the medication was stopped I would see another child, this might be the case that would force me to see ADHD as something intrinsic, and little affected by family relationships. By the fifth interview he was no longer on medication. Nothing untoward happened. In fact, they had one of the best weeks in the last year and a half in all relationship vectors. Father was still concerned that Allen was being manipulative, and I disagreed, emphasizing the danger in that position because it underestimated the pain of his son.
After the sixth interview, they decided not to come back. Things were going well enough. I admit I was apprehensive about how they would do. Eighteen months have passed and I speak with the family physician from time to time. Allen is doing well. Mother who used to talk about him all of the time rarely mentions him. He sounds like he is still moody, but he is not automatically impossible. Father and Mother have developed a parenting pattern that she finds very helpful, and her anxiety about Father is much reduced.
This case is a sample from my clinical experience illustrating the use of family therapy in the treatment of a boy diagnosed with a chemical imbalance. My message is not that medications are inappropriate, but rather that medication produces a different outcome from family systems work. While effective in reducing ambiguity, medication interferes with growthful integrating encounters with the unknown. It also suggests that the indications for medication and the indications for family therapy are in the practitioner.
Did this case force those humbling self-reflective questions on me? A few. I was concerned the family doctor was too strong in his upset with the medication. I thought he was seeing me as a champion of the anti-medication cause. Mother had this clarity about her, and had been indoctrinated into the language of ADHD. I felt dumb about my poorly articulated alternative view. I was also apprehensive about her connection to managed care. I felt that the father from his business man/athlete’s view of experience was skeptical about me. The point is that anything that causes me to second-guess myself and my methods leads to the temptation to use the ambiguity-reducing medical system. This will sound churlish, but one of the advantages of being a biological psychiatrist is that you do not have to question yourself and patients do not have to question themselves. For family therapists the questions are unending and unavoidable.