You are currently browsing the category archive for the ‘Case Studies’ category.

There comes a point and time in every growing therapist’s development when they have to let go of all the tools and tricks. They have to trust that what they have learned is now second nature, and rest into the moment, into the relationship with their client. The following story details that moment in my life.

When Tony was just two days old, the Department of Child and Family Services removed him from the care of his mother as she tested positive for cocaine and other substances. He was immediately placed into foster care and into the home of a foster mother with at least four other children. He was removed from that home due to allegations of neglect when he was eleven months, and over the next two years spent time in at least three other foster homes. By the time Tony was three, the impact of multiple placements, neglect, and exposure to drugs when in his mother’s womb was obvious. He would rock himself, bang his head on the wall or headboard of his bed. He was difficult to soothe, oppositional, would have several severe tantrums every day. His caregivers at the time struggled to find ways to control him.

Tony stayed in one foster home from the time he was three until he was six and entered grade school for the first time. Unfortunately, with school came a whole host of other problems. Unlike other kids his age, Tony had no idea how to get along with friends, how to understand their feelings, how to show empathy. He would tease, threaten, bully, physically attack, and provoke his peers. His teachers struggled to control him, and eventually Tony was expelled from school in the first grade, still at the age of six. Also at this time, his foster family had had enough and gave what’s called a 7-day notice. This basically means that they are giving DCFS a week to find a new home for Tony. They did, and Tony was placed in a residential care facility, an RCL-14 facility, the highest level of such care in the state short of psychiatric hospitalization.

At the young age of six, Tony was placed in a facility with 60 other boys, ages 6-17. He was the youngest and the smallest. This is when I met Tony for the first time. I had just started working at this home as an intern, and had been assigned a caseload of 7 boys. Tony was now one of my clients. My job, as a clinician, was to provide individual therapy. My background had been in somatic psychology, and I was used to working with high functioning adults. I had no idea what to do with these kids. We received some rudimentary training and were advised to stick with cognitive behavioral approaches, as they were shown to be the most efficacious. I felt like a foreigner in a strange land.

And so, I started to work with Tony in such a manner, working specifically on his behaviors, creating behavior charts, incentive programs, dissecting his thinking and his decision making. I had mood and feeling charts, anger management games, and consequential thinking development tools. Yet I knew I was missing something. Somewhere in the back of mind, or maybe in my heart, I knew that I wasn’t reaching him, that I wasn’t meeting his needs. He was frustrated with me, bored. Our sessions were tedious, I hated them. I didn’t look forward to seeing him and began to resent for the feelings I was having. How dare this little kid make me feel so inadequate!

One day, I received a call from our crisis unit. Tony had run away again, left school in a rage, and ran out into the neighborhood. He was gone for several hours before they found him and brought him back. As was standard protocol in such situations, I was required to come down to the crisis unit and perform a safety and risk evaluation with Tony. I brought him back to my office and started to ask him the standard questions on the form, “On a scale from 1-10, how angry are you?” “10!” “OK, 10. Complete this sentence, I feel like hurting myself never, sometimes, or all of the time.” “All of the time!” Tony was getting angrier and angrier. So was I. This wasn’t working, and I knew it. As I proceeded to follow the standard protocol, to keep within the bounds of what was expected of me, he began to escalate. Finally, he had enough, stood up on top of his chair, and screamed through his tears “Why won’t you just be with me!”

In that moment, I melted. I dropped all the cognitive behavioral facade, and I trusted my body and my feelings to do what was right. There before me was a tiny, tired, terrified little boy. He had never had a mother, or a father, he didn’t know how to get along with people, he didn’t know how to be civilized. He did however know that he need something. In an instant I saw the infant in him, crying to be held. I cried. I put down my clipboard, looked deeply into his eyes. I opened my arms and said nothing. It took only a moment, he felt the shift, and came running towards me, falling into my arms. He sobbed and so did I. My body knew exactly what to do, and it was not on any chart, or form, or strategic plan. He needed to be held, as if he were an infant. And so I held him, rocked him, soothed him for what felt like hours. He eventually fell asleep in my arms.

This story illustrates what has been shown to be the most important predictor of a positive therapeutic experience. When all is said and done, it is not the theoretical orientation, nor the specific interventions, that make therapy good. It is the quality of the relationship, the attachment, between therapist and client, that allows the client to feel safe, respected, accepted, and builds the ground for change. Tony was met by me when I simply allowed myself to be with him.

I worked with Tony for several years after that. After that moment, our work deepened, and I kept trusting myself that I knew instinctively what to do for this little guy. When our paths parted, his life continued to be a struggle, in and out of group homes and foster care. I’ve lost touch with Tony. He is now probably 18 or so. I can only hope that those moments of deep attachment and attunement made some difference in his chaotic life.

Chris Tickner is a Pasadena psychotherapist, child therapist, and clinical supervisor practicing holistic psychotherapy, where he combines mindfulness psychotherapy,  somatic therapy, neuroscience, and good old fasion humor and compassion to form a a powerful treatment that is transformative and holistic.  There are thousands of California psychotherapists, and finding a counselor or finding a therapist can be daunting. On his website, Chris provides a primer to help you find the therapist that is perfect for you! Chris is also a Pasadena therapist specializing in anxiety psychotherapy and depression psychotherapy.

Every year around this time, as the days of summer come to a close, and school gets underway, I get a series of phone calls from concerned and panicked parents. Often they’ve received a phone call from a teacher or school counselor, or returned from a parent teacher conference, and have learned that their child is having trouble at school! It can be a painful moment. Filled with confusion and at times embarrassment, these parents reach out for help.

Problem-Child_lOne such case sticks out in my mind as a clear example of how our system for helping kids is extremely misguided, and often does more harm than good. James was an 10-year-old boy whose parents called me one October day, expressing their frustration with him, with his school, and with themselves. Up until this point, James had been a star student, was well liked by his peers and teachers, and expressed joy and satisfaction with his own progress at school. However, as he entered the fifth grade, everything seemed to change.

One day, his parents received a phone call from his new teacher, informing them that James was disruptive in the classroom, was often out of his seat and seemed to be unable to pay attention. He was observed to stare off into space, and often didn’t respond to his teacher’s prompts. Additionally he often talked out of turn without raising his hand, and was a distraction to the other children. As a quick remedy, the teacher had moved James to a desk that was away from the other kids, in the back of the room. The teacher thought he might have Attention Deficit Disorder and suggested they have him evaluated by a doctor. Both parents reported that at home James was also showing some new behaviors. He didn’t want to go to bed at his bedtime, he was often short-tempered and clingy.

The parents called me for a consultation, not wanting to have their child placed on medication. I sat down with the two of them, gathered my usual background information, and provided an overview of child behavior to the parents. When a child’s behavior changes this is a sign for us as adults to pay close attention. Without the ability to communicate what is bothering them, a child will express his fears, or angers, by acting out. In this way, child behavior becomes a code of sorts that adults must learn to decipher. What is James trying to tell us by this behavior?

We reviewed the past several weeks and I learned that James had not had the usual restful summer that he was used to. Most parents often minimize the impact significant events will have on their children, and this was no exception. They both indicated that  the summer seemed to be a pretty good one.  Jim, the father, explained that his mother had been ill for many years, and finally passed away in August. The family traveled back to her home in Chicago, and attended the wake and funeral. They both indicated that James seemed fine, didn’t really cry, and was very polite and grown up. Susan, the mother, then explained that they returned to their La Canada, CA home just in time to witness the Station Fire burn over 160,000 acres! “It was amazing. We were fine, I mean, we had to be evacuated for about three days, but it was really OK. We got all the important stuff, our pets, papers, and all piled in the car and treated it like an unexpected bonus vacation. James seemed really excited and had a great time!” 

While James appeared to be “fine” and seemed to enjoy himself or not be too significantly impacted, he clearly was, and was now showing signs of traumatic impact. Many children who go through painful, even frightening experiences, will show little if any initial signs of suffering. Like James, it might be weeks later, when confronted with a stressful experience, that these emotions will surface as behavior. What’s more, children are significantly impacted by how their parents react to various situations, and while his grandmother’s death was a great relief to the family, it was also a significant event, and both Jim and Susan responded with the expected grief, sadness and even anger. While these emotions are understood as normal to an adult, to a child, who has never experienced death, they can be terrifying. Throw in the fire and the evacuation, and you have a clear case of a child who has been overwhelmed by fear, stress and trauma.

James’ behaviors in the classroom were the gateway to understanding that he was having a hard time focusing on school because he was still trying to process the difficult experiences he had at the end of his summer. Once we figured that out, I worked with the parents to help them make room for James’s processing of his grief and fear. Art projects, games, looking at pictures of Grandma, talking about the fires, were all ways they helped James make sense of what had happened to him. I worked with James in therapy for several weeks, primarily using play therapy to help him process, express and understand his feelings. Additionally, the parents approached his teacher and explained what was going on. They asked him to be patient with James, and instead of isolating him in the back of the room, to consider moving his desk closer to him. What James needed was comfort and understanding, not punishment and shame.

This case illustrates how easy it is for teachers and parents to quickly make assumptions about a child’s behavior. If Jim and Susan had taken James to their doctor, a stimulant like Ritalin would most likely have been prescribed to help James focus in the classroom. And while that might have helped, the underlying issues of grief and trauma would have gone untreated. This is often the first step down a long road of medication adjustments, special education classrooms, Individualized Education Plans (IEP’s), non-public schools, and more.

The moral of the story? Listen to your child’s behavior, become a detective. Ask yourself what is he trying to communicate? What would make anybody act the way he is acting? Find the missing piece, figure out what the need is (ie to express underlying painful emotions), and then provide it. Once the missing experience is had, the child will begin to return to themselves, the behavior will begin to diminish and he will return to the confident, health and happy child he deserves to be.

Chris Tickner is a Pasadena psychotherapist, child therapist, and clinical supervisor practicing holistic psychotherapy, where he combines mindfulness psychotherapy,  somatic therapy, neuroscience, and good old fasion humor and compassion to form a a powerful treatment that is transformative and holistic.  There are thousands of California psychotherapists, and finding a counselor or finding a therapist can be daunting. On his website, Chris provides a primer to help you find the therapist that is perfect for you! Chris is also a Pasadena therapist specializing in anxiety psychotherapy and depression psychotherapy.

Twitter Updates

    follow me on Twitter
    June 2017
    M T W T F S S
    « Jan    
     1234
    567891011
    12131415161718
    19202122232425
    2627282930