The Kingpin

We'll just go right to the story.

A few years ago I got a call from a colleague who wanted to refer me a patient. Not just any patient, of course. A really, really difficult patient, a complicated patient (like there are people who aren't difficult, who aren't complicated).

The details and demographics in this post have all been changed, so no, this isn't about you or anyone else that you know; it's fiction, and even if you think you're the colleague, believe me, you're not.

We'll make the identified patient a teenager, a girl of 14 who acts more like a 4-year old with an advanced vocabulary. She's physically violent, verbally abusive, self-centered, infantile, and ALD, A Little Different, although I think my friend's exact words were,

"She's very weird."

Some kids can be a little weird. They're kids. I don't like diagnosing them or making them into outliers* because they're just kids. A little different is much better than a little weird, but we're colleagues, and when we get to talking we might get a little loose, may not always be so p.c.

But we like different. Or we should. Why go into this field if not to meet all kinds of people? Don't tell me it's to help. Help is the process, that's what we do. It's not necessarily our motivation for doing it.

I get these kinds of consults on occasion. The colleague will say,

I've never met anyone like her in my life!

Code for,

Surely you want to take her off my hands!

Sometimes, when I listen to the details of the case, I'll whisper under my breath, Marvelous. I'm not saying the case is marvelous or happy, or good. I'm saying: This is so interesting. And it is.

So I'll listen and then I'll make some suggestions, tell the doc what to try to do differently, maybe even take the case. But I try to avoid kids who are reputedly violent, unless they're under a medical doctor's care, as in a psychiatrist. And I need to know that the kid's been quiet for awhile, has moments of wellness, as this little girl, the one my colleague wants to refer to me, has when she's in school. And I need to know that the family is willing to pop the kid into the hospital if necessary.

Why would I be abused? One lamp flying at a person in a lifetime (by a nine year old, I ducked) in a career is enough. Kids can do that, beat up therapists, both physically and verbally. And they come in with weapons. We live in a violent world. Kids have showed me their weapons. I say, Leave your knives at the door, and they smile, take out knives, leave them at the door.

"Tell me about the case," I say.

The 14 year old has always been different, socially inappropriate, Asperger's-like, angry, sad. Whatever it is, the emotion that's expressed is always extreme. But that's only with family, rarely with peers, and it's escalated, her anger, her mood swings, her attention seeking, her non-stop dependent behavior and whining around her parents.

But in school she's under control. The girls in her class aren't mashugee** for her, but they don't socially ostracize her, either.

Let's say, to make it interesting, that she has four or five other siblings, two with severe developmental delays. One aunt has schizophrenia; her mother OCD, an uncle has bi-polar disorder, and her father has ADHD and depression. It's a vegetable soup of diagnoses, and this is just a phone consult. I've yet to ask a question.

My colleague has seen the patient and her parents in various combinations for over a year. The symptoms have escalated in the past few months. Parents get along with one another well, but they're both overwhelmed with their lot, their children.

"Any recent changes, deaths, perhaps?" I ask.

"No."

"Separations?"

"Uh, uh."

"Who pays for all the therapy?"

"Grandpa. He's loaded."

"And where does Grandpa live?"

She names a wealthy suburb.

"Is he involved in the patient's life?"

"He used to be, but since the kid got really bad, and since he read the psychological tests, he's distanced himself. The tests are packed with ugly diagnoses, a negative prognosis. And the kid insulted Grandpa, literally kicked him. Gramps can't take the disrespect. I understand the two of them were really close when she was a little younger."

"You have to get Grandpa into the therapy."

"They're afraid to stress him, afraid he'll stop paying the bills."

"They are? Or you are?"

"They're afraid of rocking the boat."

"So the kid does it for them. She won't get better without him. And with him, it's likely she will. There's your missing relationship. She needs him. Her parents are busy with the other kids. Sometimes if it looks like a duck, it's a duck. And they already love one another. Include another sib if you can, too. Maybe all of them in different combinations. People spend money on lesser things."

End of consult. I gotta' go.

It's funny. My father-in-law (OBS)*** believed that if you paid the bills, you called the shots. It's not true, though, when you have a sick kid, is it? When your kid or grandkid is sick, you can't will things to get better. You can't make a sick kid behave, make a kid show respect. You can't buy the cure.

But in a case like this one, the person who is paying the bills has some power, some leverage. He's left, he can come back. How hard is this?

He may have to change the way he is with his granddaughter, may have to change the way he talks to her, lower his expectations, add new ones. You're only a family therapist; he's the kid's grandfather. That's what you tell him on the phone. Who knows the kid better than him?

He's pumped up, respected. You tell him you're very sure that he knows how to work this kid, and you're interested in his opinions. People will obviously have to change the way they respond to her behavior, you suggest. Then you ask, Who should change what? How?

He has so much to tell you. He starts the ball rolling. You stop him somewhere in the middle. You say you have another patient. When can he come in? Soon, of course, he wants to continue to help. He makes an appointment.

Then the two of you strategize. He is the kingpin. You are a shlepper,**** a professional who knows nothing about this family system. We professionals are nothing without family input. The family has the answers. He, Grandpa, is your man.

More than likely you'll come up with this plan, or a variation of it.

He should expect to be called names. He should respond with kindness. "I won't reject you if you don't reject me," is his best response. He will need to say this over and over again, say it in different ways.

Everything, everything, depends upon his love. He can't give up on his granddaughter when she needs him the most.

You bring him into the therapy. You yourself, as a therapist, give him the respect he deserves. You engage that person who's paying the bills, who wants to call the shots, and you work the angles you know have to be worked, the relationship angles, the sweetness, the love.

You pull Grampa in and the kid has half a chance.

All that and a nickel, my father-in-law would have said, will get me a cup of coffee, which she owes me, come to think of it, my colleague.

therapydoc

*an outlier in a data set is a score that's Way higher or Way lower than the rest of the distribution.

**mashugee* is Yiddish for out there, but in this case it means, head over heels excited about, or wild about

***OBS is something like, Up in Heaven, or he should go up in peace

****Shlepper literally means someone who shleps, carries things, but here a shlepper is someone who is clearly not an executive.

Staying Connected

I'm not going to get too wordy here because it's Monday and the implications are scary, so much to do. But the lesson here is worth a quick post.

The "he" in the story could be a female or a Martian, there are no true identifying features in this post.

Several years ago I had a professional acquaintance who called to give me a head's up that she had referred her father to me for therapy. Her father's sister committed suicide and she worried her father was at risk.

He called that day, and I couldn't get him in immediately, told him it would have to wait a couple of weeks (!). Could he wait? Sure. I've waited this long.

He presented with two Axis I disorders, severe anxiety and dysthymia (ever-present depression, the low-grade fever thing). You would think the two can't co-exist, but they can. You're never depressed ALL of the time. You're never anxious ALL of the time.

His sister had just committed suicide. I should have done that a long time ago, he whispered

Would you want this case?

Past retirement age, our guy still worked, very responsibly, even though each day he felt inadequate.

He had been in and out of therapy for over thirty years.

His crippling anxiety, which surely did come from severe childhood emotional abuse, made parenting (and partnering) very difficult. His wife left him while the children were small (she took them with her), and he never had any meaningful contact with the kids after that, even though they begged him to talk to them, to be a part of their lives. He just didn't have the social skill to listen or to talk. There were four children. Four children, no contact. It really does happen.

Never had anyone discussed repairing his cut-offs with his children. The therapies, according to him, all addressed his relationships with his parents, his marriage, and his childhood problems, his lack of sexual/relationship attachment.

See, it's not that difficult, this case. There is a universal need to be loved by one's parents, and a universal need to be loved by one's children, and that can be repressed, of course. But it's there. And it has to be addressed if meaning in life is at all important.

Tiny steps, of course, he had to make the first moves, the calls, the visits, the toys for the grandchildren, the birthday cards and gifts. He didn't have to really talk very much at all to anyone in this therapy, but he eventually did, all on his own. It's a behavioral family therapy. Say hi, visit, go to the grandkid's baseball games. Quick guerrilla visits. Hi, Bye.

Put yourself on the map. You don't need to be a star.

No idea what those other therapies were about. Don't care. He did so well.

It's just an example, right? Anyone could see the need for that kind of intervention.

Was he still at risk? I thought so. You know how it is when people feel a little better. They have the strength to hurt themselves, whereas they hadn't before. But the thought of hurting the little ones like that, the grandkids, served as a deterrent. He said as much. And I lay on guilt big-time when it's deserved.

But I kept an eye on him over the years.

What's lovely is that I never even had to bring any of his children into my office to do that family therapy. The family system was in the room, everyone was in his head.

That's how you need to think.

Copyright 2007, therapydoc