Intensive Structural Therapy

Patient Details:

17 year old male inpatient.

Presenting problems:

• No officially diagnosed past history of psychiatric issues except for anger management.
• In the inpatient unit post suicide attempt where he made a superficial laceration to his wrist for the first time due to feeling overwhelmed from stress in his home life.
• Interpersonal difficulties including with his girlfriend but particularly with his mother

Family information and background:

• Patient lives at home with his parents, he has a 4.0 GPA and has already been accepted for some early admissions to college but mom is really demanding and pushing him to work harder. He finds this overwhelming because he doesn’t know what else he can do to keep her happy.
• Dad plays more of a supportive role, he pushes more sports but he’s not forceful in terms of what he does or doesn’t do.
• Described some difficulties with his girlfriend but he said the biggest issue was home life.
• The boy described the family unit as relatively good, they get along, have several more good days than bad but when they are bad mom is really on his case and it really irritates him. Mom and dad seemingly get along with each other.

Clinician’s formulation:

The clinician believes the dynamics in the family must be accountable for some of the boy’s current difficulties.

What has been tried clinically?

Mom is the one that comes in to see the patient. Dad has not yet come in. Her perspective was that she wants the best for her son, but that he’s not necessarily doing the things she asks him to do all the time.

They had an argument in a family session about the chores, the boy is asked to do a few chores around the house. His view was that he gets asked to do them when it is inconvenient. He said he gets it done 80% of time but Mom said it was more like 30-40%.

One marker the therapist was looking at was whether the boy could do things mom is asking him to do, mom in turn could pull back on how critical she is with the school work. It’s snowballing – she thinks he needs to keep working hard at home and hard at school. It’s a separate issue but she combines it into one thing, it’s what the therapist identified with how they interact with each other.

Specific concerns:

The therapist is unsure what to make the clinical focus for this family.

How this consultation can help:

The therapist would like some ideas for treatment.

Dr. Fishman’s advice to the therapist:

Here is an adolescent boy who is on the cusp of leaving home and going to college. This transition presents a great stress to the boy and the family. It appears the boy is the center of mom’s attention, what a big loss for her when he leaves.

I reiterate my position on suicide and suicidal behavior in systems (as mentioned in one of the other cases on this website). The threshold of change is so high the young person has to do something as dramatic as suicidal behavior. In terms of the family therapy, work with the family as a laboratory for learning negotiation skills, have enactments in the therapy where the young man is able to negotiate for what he wants.

What is more difficult and complex is helping mom with the transitions, where does her energy go? This brings you back to the issue with the father that needs to be addressed, to the extent that the mother is so focused on the boy she is less focused on her husband. The goal would be to reverse that process. Father’s lack of availability even after his son has had a suicide attempt speaks to the rigidity of the system and perhaps his exclusion from the close dyad of mother and son.

Example of the IST clinical scorecard applied to this case:

Objectives/goals:

To have the boy be well-functioning with no depressive symptoms.

Plans:

Family therapy (focusing specifically on the rigidity of the system and the closeness between mother and son), see the boy with his girlfriend (she may be a negative force in the system).

Targets:

20% improvement in scores on these instruments in one month.

Measures:

CAFAS, Symptomatic measures of depression such as Becks’ depression inventory, Triangulation Scale.

Homeostatic Maintainer:

This is likely to be the father but it is difficult to tell for sure at this point.