Intensive Structural Therapy

Patient Details:

15 year old Japanese/ Caucasian female.

Presenting problems:

• Conduct problems
• Diagnoses of bipolar disorder and substance-induced psychotic disorder

Family information and background:

• Biological mother lives in Japan, she recently moved there alone
• Bio-mother was verbally abusive to father. Served father with divorce papers once she arrived in Japan
• Father has full custody
• Father’s girlfriend has recently moved into the house
• Client does not like father’s girlfriend living there and she tries to get her to move out
• Father really wants girlfriend to stay, however, when he sets limits with his daughter, she acts out more
• Father has called the police numerous times because of his daughter and many trips to the ER because of drug induced symptoms
• Daughter reaches out to mother via text frequently and sees her secretly every now and then but mother is not doing any overt parenting

Clinician’s formulation:

The clinician is “lost.”

What has been tried clinically?

In beginning stages of treatment, not much has been done other than assessment.

Specific concerns:

The therapist is unsure how to begin with this family.

How this consultation can help:

The therapist would like some ideas about how to proceed with this family.

Dr. Fishman’s advice to the therapist:

This is a complex system. It is a system in transition: the father’s girlfriend has moved in, creating a new system. Introducing a new person to the system who may or may not be there long-term creates different dynamics in the system. This is all the more difficult given the age of this client, 15.

The second issue, and the more difficult to address is the split system with the bio-mom and the girl, seemingly aligned against the father and his girlfriend. It’s noted the girl talks to her mother frequently and so this is clearly a severely split system with the adolescent girl in the middle. The girl is also activating to perhaps diffuse the parental conflict and thus stabilize this difficult system.

With father’s permission, I would connect with the bio-mom and gradually bring her into therapy. As the therapist you would need to add intensity with the very real concerns with her out of control behaviour and the attendant drug abuse. Also that this girl may not succeed in high school, not to mention in college or any other further education.

In addition to the triangulation, the relationship between the girl and her mom needs to be explored; the girl may be experiencing rejection from her mom and perhaps vice versa. An important therapeutic goal may well be strengthening the relationship between them.

The diagnosis of bipolar always makes me suspicious, it is widely misdiagnosed in young people. I would ignore this diagnosis and revisit only if he family therapy interventions do not ameliorate her symptoms.

Example of the IST clinical scorecard applied to this case:

Objectives/goals:

To ensure the girl well-functioning and symptom free.

Plans:

Family therapy with the goal of including bio mom. Sessions also with the father and his girlfriend.

Targets:

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

Measures:

CAFAS, Triangulation scale, valid and reliable scale measuring bipolar symptoms

Homeostatic Maintainer:

Without having seen the family I would suspect one major factor may be the clandestine calls to the girl from the mother and not feeding them back to father but this will need to be explored more by the therapist.