OUR CHILDREN ARE IN TROUBLE today because our families are in trouble. I write this at the start of 2010. America’s economic future is uncertain, and jobs are still being lost at an unprecedented rate. People who have played by the rules—worked hard, paid their bills, saved for their children’s education—are losing their homes and often their hope. I am already seeing the toll this is taking on families
As more families lose their jobs and their homes, I worry about a worsening mental health crisis for our children. I expect that children will take on the task of distracting their parents from their painful losses, and will have even more profound troubles than they are having now. And if something does not change in the mind-set of our society, parents will continue to turn to pharmaceutical solutions for their children because drugs are the mainstream choice.
I am already starting to see a wave of children whose parents are breaking down under the stress of having their hours and salaries cut or losing their jobs altogether. These young people are desperately worried about their parents’ fights over money. Recently a mother called me for an emergency weekend appointment after her eleven-year-old son, Drake, tried to hang himself from the post of his bunk bed. Earlier he had threatened to jump out of his bedroom window.
In my office, Drake’s parents spoke frantically, between anxious tears, about depression and medication and hospitalization. Of course, I take any threat of suicide, even a symbolic one, very seriously, and I listened closely, pondering what the next step should be. Then, in a private conversation with Drake, he confessed to me that his feet were on the floor while he pretended to hang himself. He told me straight out that he just wanted his parents to stop arguing about money.
Drake was sad to the point of despair because his father had been laid off from his job and his parents didn’t know if they would be able to keep their house. Drake’s parents were responsible people and usually took care not to argue in front of their children. But these catastrophic issues loomed so large in their daily life that Drake couldn’t help but know what was going on.
Despite the gravity of Drake’s gesture and his parents’ plight, I was able to help. I framed Drake’s behavior as sadness—indeed, an appropriate emotion under the circumstances—and I explained to his parents that I thought Drake was unhappy and worried but not suffering from a psychiatric disorder. I encouraged his parents to reassure him realistically that they would be able to manage and were working together to come up with good solutions.
His mother said she would probably be able to increase her hours at the insurance company where she now worked part-time. And she thought her parents might be willing to help them with a short-term loan until her husband found another job. Drake’s father, who had worked as a manager at an aerospace company, said he would look into taking classes that would enhance his resume. Drake’s parents were very cooperative when I told them how important it was to keep their problems and arguments away from the children. After a few sessions of family therapy, Drake was back to normal.
But many parents are not as fortunate as Drake’s, whose health insurance paid for family therapy and whom I was able to help without resorting to medication or hospitalization. In a society where so many mothers and fathers have reached the breaking point from stress and worry, a lot of parents embrace medication, for themselves and their children, because they are not aware of an alternative. The pendulum has swung very far in the direction of pharmaceutical cures, “cures” for what—as I’ve pointed out—are usually not “diseases” at all. It would have been all too easy to diagnose eleven-year-old Drake with depression or even bipolar disorder, and to recommend that a psychiatrist be consulted for medication. But this would not have eased the sadness and stress that were the real causes of his suffering.
Autism researcher Simon Baron-Cohen reminds us that the Diagnostic and Statistical Manual of Mental Disorders (DSM), with its shifting and changing content from edition to edition, is not a truly scientific classification system because it does not address the question of causes: “Psychiatry is not at the stage of other branches of medicine, where a diagnostic category depends on a known biological mechanism.” Baron-Cohen points out that in the diagnosis of genuine medical disorders, such as Down syndrome, the biological cause of the abnormality—an extra copy of chromosome 21—is the specific basis for the diagnosis.
Psychiatric diagnoses, on the other hand, are more or less arbitrary clusters of symptoms that are given a name. These so-called disorders come and go with the times, with each new generation of psychiatrists deciding what the diagnostic categories will be in the newest version of the DSM. According to historian of psychiatry and author Edward Shorter, “In psychiatry no one knows the causes of anything, so classification can be driven by all sorts of factors”—political, social, and financial.
Certain diagnoses, such as bipolar disorder, have not been classified as childhood disorders in any version of the DSM since its inception in 1952. Yet more and more children are diagnosed each year with bipolar disorder. In branding children with this adult diagnosis, psychiatrists are not even abiding by their own manual of classification. This is a very slippery slope because, as we have seen, what looks like abnormal behavior in adults—such as impulsiveness, explosiveness, or believing in the tooth fairy—are perfectly normal behaviors in children. Even extreme mood swings or irritability, characteristic of bipolar disorder in adults, can be seen in normal children who may be reacting to family discord or other stressors in their lives. But giving a child the label of bipolar disorder can prevent that discord or stress from even coming to light and being addressed.
Gabrielle Carlson, director of child and adolescent psychiatry at Stony Brook School of Medicine, says, “Problematic conditions in a child’s home life are less likely to be addressed if the child’s behavioral issues are attributed to bipolar disorder…. Many people, when they hear bipolar disorder, their brains slam shut.” In a New York Times Magazine article (09/12/08) about childhood bipolar disorder, a psychiatrist gives two examples of what he considers manic behavior in a child: dressing outlandishly and talking to strangers. With this definition, we would have to diagnose Huckleberry Finn as manic (among other things), because Huck dressed in rags, avoided school, ran away from home, occasionally told lies, and freely talked to strangers. He would no doubt also be diagnosed with attention-deficit disorder because he hated school and with oppositional defiant disorder because he disobeyed one rule after another.
Huckleberry Finn, with his free spirit, his humor, and his ability to build warm friendships with the fascinating characters he meets along the river, was for many decades a boyhood hero for American youth. Huck symbolized freedom from the shackles of society and a spirit of adventure and self-reliance, along with a great capacity for empathy. But today, in our society, Huckleberry Finn would be diagnosable with several serious psychiatric conditions.
We must seriously ask ourselves where in the world of psychiatric diagnoses do “naughty,” “mischievous,” “headstrong,” and “free-spirited” end and the diagnoses of manic, bipolar, and ADHD begin. There used to be some allowances in the way children were expected to behave, and some degree of consensus that childhood was a time for breaking rules, getting caught, being punished, and moving on. Teachers and parents alike recognized that normal children have a shorter attention span than adults. But today the DSM casts such a wide net that it would surely ensnare Huckleberry Finn, along with countless other “rascally” children.
What determines whether a condition finds its way into the DSM? The answer is more complex, and more disturbing, than one might expect. In meetings held over several years, diagnoses are hotly debated by the DSM panelists charged with creating each new edition; and these diagnoses are often politicized according to the temper of the times (not so long ago, homosexuality was considered a mental disease). The final decisions come down to the votes of these panelists.
This “classification by consensus” rather than by biological causes has been fiercely criticized by the media and by professionals, including some psychiatrists and psychologists. Yet this method of classification has prevailed, not the least because the panelists—the very doctors who decide how to name and classify psychiatric disorders—have powerful financial ties to the pharmaceutical industry. This industry, of course, stands to profit mightily from the insertion into the next DSM of pediatric bipolar disorder, or any other childhood psychological problem not previously classified as a disorder, and for which, conveniently, a drug treatment has been found to be effective at reducing symptoms.
Because of the heated debate about financial ties of DSM panelists, scientists who are working on the new DSM-V have agreed to limit their income from pharmaceutical companies and other sources to $10,000 a year for the duration of their work on the manual. This limitation does not extend to their accepting payments from pharmaceutical companies preceding or following their tenure as panelists. Some critics argue that this policy is not strict enough and that panelists should take no money at all from drug companies, to avoid conflicts of interest.
According to one study, 56 percent of the psychiatrists who wrote the DSM-IV had one or more financial links to a pharmaceutical company, and they did not have to disclose conflicts of interest. The DSM panelists are theoretically free to create new pathologies—for children or adults—in the service of the companies that finance them. Before 1980, for example, ADHD did not exist as a diagnosis. Then DSM-III panelists decided to give fidgetiness a medical name and deemed it a disorder—for which a drug treatment was readily available. Now, DSM-V panel members working on childhood disorders are expected to hotly debate the merits of adding “pediatric bipolar disorder” as a distinct diagnosis. In my view, this addition would be tragic, as it would open the way for more children to be prescribed antipsychotic drugs for no sound medical reason. Even more troubling is the fact that children from low-income families, whose parents do not have private health insurance that covers family therapy or other counseling, would be drugged disproportionately. According to federally financed research by scientists at Columbia and Rutgers universities, children on Medicaid are given antipsychotic drugs at a rate four times higher than children whose parents have private insurance. And children on Medicaid receive the drugs for less severe conditions than middle-class children—for conditions such as ADHD or school conduct problems.
One fifteen-year-old New York girl on Medicaid was prescribed an antipsychotic drug after a single consultation, in which she was diagnosed with bipolar disorder. The doctor’s diagnosis was based on the fact that she had arguments with her mother and stepfather and she suffered from insomnia. The girl decided to stop taking the antipsychotic because she discovered that she could control her moods without it. Nonetheless, she consulted another psychiatrist who accepted Medicaid to make sure she did not need the medication. After listening closely to the girl’s story, this doctor told her that she was a normal teenager and did not need antipsychotic medication.
Medicaid provides antipsychotic drugs free of charge to covered children, at a cost of $7.9 billion as of 2006 (the most recent year for which data are available). Antipsychotics are the single biggest drug expenditure for Medicaid, and, surprisingly, they are sometimes prescribed by primary care physicians rather than psychiatrists.
As I’ve emphasized throughout this book, no matter how successful medication is in controlling children’s behavioral symptoms, there are myriad downsides to kids taking psychiatric drugs. These range from immediate or delayed side effects of the medications (including cardiometabolic risks) to the drugs becoming a crutch and undermining a child’s motivation to try to control his behavior and moods by himself.
Troublesome behaviors are not the only worry of today’s parents. Mothers and fathers are also deeply concerned about their children’s school performance. In a culture where the pressure on children to perform at peak levels is increasingly intense, I’ve heard otherwise sensible parents fret about their first-grader’s chances of getting into Princeton or Harvard. Children are often forced into stressful situations over which they have no control. Indeed, some parents are so intent on their son or daughter succeeding academically that they forget about the child’s uniqueness and aptitudes that are not measurable by standardized tests. These parents do not seem to notice that their child is empathic or generous or creative. They have little tolerance for their child’s free-spiritedness. This attitude can have profound consequences.
In their willingness to use drugs to give their child a better chance of academic success, parents receive a lot of support in our society. By means of a psychiatric diagnosis and the latest designer drug, a child who is unruly or inattentive can be transformed into a well-behaved, studious child who will do his parents proud. An ADHD diagnosis means that a child will be allowed extra time on college entrance tests and in completing classroom assignments and exams. This will give him a better chance of doing well and being admitted to a good college or university. If he needs to take amphetamines to accomplish this, his parents reason that the end justifies the means.
But parents are often shortsighted when they think that entrance to an Ivy League university or a prestigious preschool will ensure their child’s future success or happiness. Like swimming champion Michael Phelps, many children compensate for a weakness in one area by developing their talents in another. If a child focuses all his attention on keeping up academically, with academic success and admittance to an elite college as his only goal, he might never develop other unique aspects of his personality.
Sometimes parents have their heart set on a particular college or even a particular middle school or high school for their child—whether or not the child wants this for herself. This is what happened to a young girl I saw a few years ago. Eleven-year-old Shiloh came to therapy with her father, Larry, a widower who was raising his two children by himself after the death of his wife three years earlier. Larry sent Shiloh and her older brother to an exclusive private school that was regarded as the best in the community. He hoped that they would graduate from there and go on to a good college or university. He felt that he owed his late wife his best efforts to help Shiloh and her brother succeed in life.
But Shiloh had been getting D’s and F’s for more than a year at the new school, and Larry didn’t know what to do. His daughter was bright enough to have been accepted by the school, and she had always been an “A” student in public school. He didn’t understand why she was failing now. When Shiloh’s teacher told him she thought Shiloh might have ADHD, Larry brought Shiloh to therapy hoping to get her back on track.
Shiloh confided to me that she hated the private school because the girls there were “really mean.” They formed tight cliques and would gang up on one girl after another, gossiping and spreading nasty rumors. From one day to the next, Shiloh never knew who her friends were. Recently, two of her so-called friends had joined a clique of popular girls and turned against her.
With tears in her eyes, Shiloh told me that she just wanted to go to the public school in her neighborhood where she would be with the friends she had known since kindergarten. She was sure her old friends would be loyal to her, would never turn on her, and would never gossip about her behind her back or pick on her. She felt she could be herself with them and not have to put on an act in order to be accepted. I asked her if there were any mean girls at the public school, and if so wouldn’t she have the same problem there. Shiloh thought about this. Then she replied that there were mean girls there, but she knew who they were and didn’t count them among her friends. Shiloh promised she would get straight A’s if her father sent her back to the neighborhood public school.
When I explained this to Larry, he was bitterly disappointed. He wanted his daughter to have all the advantages he never had. He had to go to work right after high school because his parents couldn’t afford to send him to college. I told him that it would be easier for Shiloh to get into a good college with A’s from a public school than with D’s and F’s from a private school, however exclusive.
“But doesn’t she have ADHD?” Larry asked. I explained to him that I believed Shiloh’s problem was not medical but situational. I thought she would do better in a different school—and especially a school where she wanted to go. If she continued to get bad grades there or if she demonstrated the typical symptoms of ADHD—distractibility, difficulty focusing on her schoolwork, or trouble sitting still—we could always reconsider. But, I added, I didn’t think this would happen. Eventually Larry had to agree with me. Shiloh transferred to their neighborhood school and was much happier. Soon she was getting straight A’s.
I do not dispute the fact that many adults have been helped by psychiatric medications, especially antidepressants. Antidepressants can help chronically depressed people function normally, and many seriously disturbed adults live normal lives thanks to medication. But children are another story. I have never seen a single child who could not be helped by family therapy if the child’s parents were able to cooperate and follow my advice.
We must also keep in mind that there is an important ethical difference between prescribing psychiatric medications for adults and prescribing them for children. An adult can read and research the drug company’s warnings and cautions. He can make an informed decision, weighing the benefits of the drug against the potential risks. A young child—even one old enough to read the words on the label—is not capable of understanding the message. (Adolescents, on the other hand, can understand the potential dangers of medication, and I’ve seen them refuse to take drugs that they think may harm them.) Although most parents are well intentioned, some can unwittingly medicate a child unnecessarily and can even increase the dosage to dangerous levels in order to keep their child under control.
The ethical responsibility of whether to trust a child’s parents to use medications wisely is at present left to the conscience of the prescribing child psychiatrist. This means that the prescribing physician needs to accept more responsibility. She must be responsible for contacting other professionals involved with the child, such as pediatricians, teachers, therapists, and social workers. Unfortunately, the psychiatrist’s medical training may not have prepared her for this responsibility, nor would she necessarily welcome this new obligation. The prescribing psychiatrist also has the responsibility of making sure that parents understand the labels on the drugs that warn of serious side effects, and that they understand the dangers of increasing dosages.
The drug industry has a huge stake in keeping psychiatrists prescribing their products for children—and understandably they do not emphasize either the side effects or the need for parental and medical vigilance. On the contrary, they are vigilant about denying any charges against them.
The pharmaceutical industry spends hundreds of millions of dollars a year on federal lobbying and has more than a thousand registered lobbyists. Our country’s children who are being diagnosed and medicated with antipsychotics and other psychotropic drugs do not have a single lobbyist in Washington to protect their rights. They cannot organize and stand up for their own best interests. Human rights groups, such as the Nurses for Human Rights and the Council for the Human Rights of Children, feel that this inequity must be corrected. These health professionals maintain that policy makers have a responsibility to protect weak and vulnerable groups such as children. They believe that medicating a child with a psychotropic drug—except in the case of a biologically based illness—is a violation of a child’s human right to security of person, a right that is spelled out in the United Nations 1948 Declaration of Human Rights. Many health professionals, from nurses to the family therapists and psychiatrists on the Council for the Human Rights of Children, believe that we cannot be value neutral in the face of violations of children’s rights by psychiatrists, pharmaceutical companies, and insurance companies.
Apart from these groups, other doctors and therapists are becoming aware that there are ethical issues involved in medicating children. Pediatrician and family therapist Lawrence Diller, MD, points out that there is an ethical dilemma in giving a child a psychiatric drug because children “do not make the choice for themselves to take or not take a psychiatric drug.”
These humanistic concerns make us mindful that there are weighty ethical questions involved with giving children psychiatric medications: the drug might cause the child harm or even death; the child cannot make an informed choice about taking the drug; drugs at best only mask the child’s symptoms and do not solve the real problem in his life; and there are far safer and more effective solutions to the child’s problems, such as the family therapy approach that I have described in this book.
The American Psychological Association recommends that non-drug treatment be considered first for childhood mental disorders. They suggest that professionals first try techniques that focus on parenting skills and that they enlist help from teachers and other school professionals before considering medication. According to a report in the New York Times (12/22/06), even the American Academy of Child and Adolescent Psychiatry, “an organization whose members favor drug treatment,” recommends that “children receive some form of talk therapy before being given drugs for moderate depression.”
Drug companies are not likely to change business practices that generate tremendous profits. But there are some encouraging signs that we are entering an era of increased accountability and transparency for institutions that receive public funding, such as medical schools, medical research centers, and federally funded health insurance programs such as Medicare. Senator Charles Grassley, the ranking member on the Senate Finance Committee, has tenaciously pursued what he views as improper conflicts of interest by psychiatrists conducting research on drugs that are approved for use by patients with Medicare and Medicaid. Grassley is working toward the passage of legislation that would require drug companies to publically report the money they give to doctors and medical researchers.
Fortunately, too, not all psychiatrists embrace the biological model, and a few are sounding the alarm. Chicago psychiatrist David Kaiser, MD, who is affiliated with Northwestern University Hospital, argues that for psychiatry to regain any semblance of legitimacy and integrity, “it must strip itself of false and hubristic claims and humbly submit itself to the urgent task of listening to individual patients with patience and intelligence.” Dr. Kaiser finds it tragic that biological psychiatry has reduced patients to abstractions, “black boxes of biologic symptoms” that are disconnected from the patients’ real life stories.
Increased accountability and transparency, along with the testimony of human rights groups and of psychiatrists like Dr. Kaiser, constitute the good news. But there is bad news as well. Child psychiatry continues to be dominated by a narrow medical approach. And much of the support for it comes from evidence that may be spurious or skewed. I have described in Chapter 1 some of the abuses of pharmaceutical companies, including concealing negative research results that put their products in a bad light. A recently revealed trend is the drug industry’s practice of using company employees to “ghostwrite” articles in respected medical journals. The articles bear the names of doctors recruited by the drug company. According to University of Minnesota bioethicist Carl Elliott, this unethical practice has created “a huge body of medical literature that society can’t trust.”
This passionate debate between humanistic and biological views of human suffering is not new in the history of psychiatry. Philippe Pinel, a nineteenth-century French physician, is credited with being the first to release the mentally ill from their chains and treat them with talk therapy. Pinel believed that even severely disturbed patients could be helped by having a good relationship with a benevolent and compassionate human being. His therapeutic approach became known as “moral treatment.”
Although moral treatment practitioners were originally medical doctors like Pinel, from the beginning they had a deep distrust for both organic explanations and pharmaceutical cures. They were more interested in the art of healing than in the medicaments of science. According to Robert Whitaker, author of Mad in America, one successful moral treatment asylum in the United States did not even allow physicians to sit on their board, “being fearful they might effect some innovation.”
Social historian Michel Foucault tells us that the moral treatment cures of the nineteenth century were remarkably effective. Their effectiveness, Foucault argues, came from two essential elements of their practice that have all but disappeared in modern psychiatry: the therapeutic benefit of a good doctor-patient relationship, and the framing of even the most extreme forms of mental illness in the context of the patient’s real-life experience. Loss of loved ones, financial ruin, poverty, betrayal by family and friends—all these misfortunes could transform human experience into forms of madness.
The remarkable successes of moral treatment came to an end in the late nineteenth century, when neurologists such as Charcot and Freud sought to make the cure of human suffering into a science. Doctors of the mind stopped listening to their patients’ life stories and started attuning their ears instead to signs and symptoms of “disease.” This led to another important and tragic transformation. Moral treatment therapists regarded their patients as moral equals. They took meals with their patients and strolled with them on the parklike grounds of the asylums. With the advent of “scientific” psychiatry, patients once again became morally inferior to their doctors.
The humanistic tradition of moral treatment, somewhat dormant during the rise of Freudian psychoanalysis, resurfaced in the middle of the twentieth century in the work of a few exceptional psychiatrists like family therapist Milton Erickson. Erickson, as we have seen, relied more on the curative power of a good therapist-patient relationship and on ordinary common sense than on the classification of human problems as mental illnesses. Like the moral treatment doctors a century before, he framed so-called psychiatric problems in relation to the patient’s family life and social environment. In the same tradition, today’s family therapists are taking more interest in the therapist-patient relationship, and they have a new concern with humanism and human rights.
Family therapists are mindful that the observer always influences the observed and, however elegant and effective our strategies may be, we must—as Foucault argued persuasively—make strong connections with our patients in order to help them. The therapist must be, as Pinel pointed out more than two hundred years ago, benevolent and compassionate. But she must also convey competence and authority. With children, the therapist must be gentle. Yet she must instill confidence in the child that she is capable of helping her parents, because that, in my view, is why the child is in the therapist’s office—to get help for her parents. We must ask children questions that will draw them out, and we must pay close attention to their answers. As I have shown, children are the best experts on the difficulties in their families. The therapist must be humble enough to allow a child to be a co-therapist and guide her to the heart of the family’s problem.
I am reminded of a six-year-old girl named Beth who, in the second family session, suddenly told me that her father was a doctor. She was letting me know that not only did I have to win her trust, I also had to win her father’s trust in my behavioral approach to what he believed was his daughter’s biologically based ADHD. I imagine Beth heard her parents discussing this issue at home and, quite rightly, she brought it to my attention in the session. As it turned out, her father was open-minded enough and cared enough about his daughter to give my program a fair try—with excellent results. After five weeks of family therapy, Beth’s teacher said she was doing much better at school and stopped sending home notes about her misbehavior and slow academic progress. When it comes to their children, doctors are my best patients. They follow my directions to the letter because they trust professionalism.
The father of ten-year-old Brian was not a doctor, but, like Beth’s parents, he trusted professionals and had an open mind. Brian and his family lived in Australia. Brian’s father, Ron, was in Los Angeles on a business trip and had lunch with a former client of mine. When Ron talked about the problems his son was having, the client recommended me as a therapist who might be able to give him and his wife some ideas about how to help Brian. Ron called me immediately.
When we met, Ron told me that his son was desperately unhappy, and neither he nor his wife had any idea what was wrong or what might help him. Brian woke up every morning sad and teary eyed and refused to go to school. When his mother, Mary, tried to help him get ready for school, Brian threw himself on the floor and sobbed. This had been going on for six months. Mary took him to a child psychiatrist, who diagnosed him with depression and school phobia. The psychiatrist saw Brian once a week for talk therapy. But after six months there was little change in Brian’s behavior or his sadness. Occasionally, Brian’s mother could get him to walk with her to school. But soon the school would telephone and ask her to pick up her son because he was so miserable. The psychiatrist talked to the parents about starting Brian on antidepressants, but the parents were not happy with this solution.
“Brian has always been such a happy-go-lucky kid,” said Ron. “His depression seemed to come from out of the blue. And I don’t know why he would have school phobia all of a sudden. I mean, he’s been in the same school for four years, and he always seemed to like it.”
I said I thought I could help Brian if both Ron and his wife would follow the instructions that I would write down for them. On hearing this, Ron became upset. “It’s something that I’m doing wrong. I knew it all along,” he said. I reassured Ron that neither he nor his wife had done anything wrong. From what he had told me about their family, I could see they were terrific parents. I was just going to suggest different patterns of communication and behavior that had helped children with problems similar to his son’s. Ron agreed to give my suggestions a try when he went back home to Australia. He felt they had nothing to lose since Brian’s problems had not been resolved in six months of therapy, and seeing their son so unhappy was breaking their hearts.
Here are the directions I wrote down for Ron and his wife. (1) In the evening, after the children were in bed, they would make a list of Brian’s positive qualities. Then every day, each parent would tell Brian five positive things about himself. (2) Every morning on the way to school, Mary would tell Brian why she was looking forward to her day. She had to be truthful, so she had to plan an enjoyable activity every day. When Mary picked up Brian from school, she was to tell him at least one thing that she had enjoyed during the day. (3) Ron was to spend a half hour every evening alone with Brian, either reading to him or helping him with his homework. Ron said that he could adjust his schedule by working a little from home later in the evening after the children were asleep. (4) During their evening time together, Ron would tell Brian at least one thing that he had enjoyed in the course of his day. (5) Neither parent was to yell at Brian or criticize him. They were to be patient and tender with him. (6) If the parents had disagreements with each other, they were to discuss them away from home, preferably in a restaurant. In fact, I asked them to schedule lunch or dinner out once a week to discuss Brian’s improvement. Also, Ron and Mary were to take walks together in the evening to talk about Brian’s positive qualities.
Finally, I asked that the parents contact me in six months to let me know how Brian was doing. They were to continue to do all these things until Brian’s problems entirely disappeared. As for school attendance, I recommended that they let Brian go to school only when he was ready. They should expect him to go to school, and wake him up in time; but if he refused to go they should let him stay home. I didn’t think it would take long for Brian to be back at school if his parents cooperated with me.
This was the first case I had ever conducted long distance, using only written instructions to the parents without ever meeting the child. I put Ron and Mary entirely in charge of their son’s treatment. And I waited, with some trepidation, to see if Brian got better. My thinking was that Brian was protecting his mother and wanted to stay home from school to keep her company. He was worried about his mother’s loneliness, with his father spending so many hours at work and traveling so often. My directives were aimed at releasing Brian from worrying about either of his parents and also involving father and son more so that Brian could disengage from his mother in a healthy way. I was also getting Brian’s parents more involved with each other by asking them to spend more time together alone.
I did not hear from Ron and Mary for several months. Then one morning I received a letter from Mary. Here is what she wrote:
At last I am writing to you. I’m sorry I haven’t been in touch earlier to let you know how Brian is progressing. Until about two months ago I was still feeling a little on edge that his problem would return. However, touch wood, he seems to have resumed his old confident self.
We followed your very valuable advice, which thoroughly intrigued Brian. He couldn’t understand why we were being so nice to him. After a few weeks we started to see a marked difference and eventually the problem disappeared altogether. Now Brian is confident, loud, naughty, cheeky and thoroughly objectionable—a return to the Brian we know and love! He is happy at school and getting good grades. So a big thank-you to you, Marilyn
I never stop learning from the families that consult me. Brian and his parents gave me two precious gifts: first, the realization that I could help a child entirely through his parents without ever seeing him; and second, a wonderful description of a ten-year-old boy as “naughty, loud, cheeky and thoroughly objectionable.” What a refreshing picture of a healthy, happy boy!