Child and Adolescent Counseling

¶ … 1989-1990 antidepressant medications were not approved for use on nine and ten-year-olds and this poor kid is put on antidepressants immediately after his father dies. Then of course the kid experiences mood swings which get worse and he is eventually diagnosed with bipolar disorder (of course no one considers that a fairly common side effect of antidepressant medications is mania). Secondly, we have a troubled young man that comes from an unstable home who is immediately tossed into grief therapy right after the death of his father. I cannot think of a more obvious way to tell a nine-year-old he is sick- that there is something wrong with the way he feels. So I guess no nine-year-old ever went through such an incident without professional help-I mean what did kids who experience tragedies do before we had professional counselors? I guess they all went crazy and then grew up as maladjusted adults. Third, the author says that grief is indistinguishable from major depression. I strongly disagree, although depressed mood is often part of grief, they are diagnostically distinct, that is why one is called bereavement and the other is depression. The author should at least read the DSM (here it would have been the DSM-II-R) if he is going to work with clients in a mental health setting. And then of course later they hospitalize the poor kid- too much.

Let's look at the description of Martin's home life before he was diagnosed with all these issues "chaotic due to his father's alcoholism and bipolar disorder" (Golden, 2002; p. 143). One is left to wonder how much of his issues were family related (a "revelation" that appears to occur to everybody after about two years of misguided treatments) and premorbid. The kid's father dies and mom decides to toss him into treatment even with all his premorbid issues? Where was the concern prior to all of this? We are also left to wonder about other potential disorders that may have complicated things such as ADHD that appear not to have been considered. Perhaps Martin's mother could have provided more attention and nurturing to him once his father died instead of shuffling him off to all these doctors (of course a little more love, attention, and care before his father died might have helped also). We will never know how a little understanding, love, and consideration would have worked for him. All in all this case is handled very poorly, but fortunately has a happy ending. This ending is more a result of Martin's resiliency than to the interventions involved.

Katie

The first issue here is the diagnosis of an adjustment disorder when the therapist acknowledges that Katie is going through some fairly normal adolescent changes/feelings. According to the DSM-IV-TR adjustment disorders are characterized by marked distress in excess of what would be expected given the nature of the stressor (American Psychiatric Association, 2000). Typically, insurance companies do not pay for V codes like relational issues, but certainly that is the real issue here. From the case study it looks like the mother could use a little therapy in addition to the family therapy. The mother is obviously projecting issues onto her daughter that result in much of the distrust and control that she exerts on her daughter. The mother does not realize this, and it would require some delicate maneuvering to get her into individual sessions, but perhaps disguising the session by bring in the wife and husband under the guise of helping them work with Katie would work. Again, many insurance companies are hesitant to compensate for marital issues, so this would need to be accomplished skillfully. It is clear that the therapist recognizes these issues, and addressing them with mother may have the effect of reducing future problems.

Having said that, the therapist in this case does a skillful job of increasing communication between Katie and her parents, especially her mother. It is important to establish that Katie is not suicidal, and this was performed early in the therapy and skillfully. Secondly, is important to help this family learn to say what they mean instead of lashing out or trying to hurt the other party. This was also done very skillfully. I also think that setting up some real contingencies for Katie not following her parents' instructions was very important. One of the important goals of therapy in this case is not to side too much with the child (as might be the case here) and to recognize the need for the child to conform to the rules the parents set. Another goal is to have the parents display more trust in the child as long, as the child or adolescent earns that trust. Adolescents are often so egocentric they forget the merit system that they themselves impose on others, and expect entitlement to have what they want just because they want it. In this case the therapist does a good job of recognizing resistance in both the parents and Katie, facilitating communication between the parents and Katie, setting up a proper contingency program between parents and Katie, and maintaining the proper balance of power in the family thorough only a few sessions. However, a couple of follow-up sessions should have been included to check the progress of the family and "tweak" any issues that need to be resolved. Perhaps a brief one-moth and six-month follow-up would have been useful here.

Mark Thomas

This is a suicide assessment. I find it interesting that the therapist here does not appear to listen very well and seems to draw conclusions in the wrong places. For instance, when he asks Mark to give an example where his mother blames him he gives an example, but admits it may have been his fault. The therapist points out that this may be an example or sign of his low self-esteem (huh?), but in the very next snippet of the interview Mark tells the therapist he does not fit in with any group at school. The therapist does not recognize that this is a sign of low esteem and isolation, whereas the other example could be interpreted in many different ways (the therapist never follows on his hunch despite using a client-centered approach which is designed to facilitate communication). In the next excerpt he wants to see if Mark is depressed so he asks Mark if ever gets down in the dumps and Mark replies no, but states that he gets depressed if he cannot figure out something or how to do something. Our therapist then remarks that he is surprised that Mark does not admit to depression. Huh? The kid just says he gets depressed at times. Where is the reflection on the therapist's part? Instead the therapist follows a confirmation bias through this whole process. He also puts words into the mouth of the client ('hopelessness") instead of asking how the client feels or asking him to describe his feelings-very amateurish in this respect.