Family Therapy

Greater Surrey Children's Services

Gemma D. Walker, Ph.D., Psy.D. Psychologist UK License PSY17946

Progress Note: October 29, 1989

Session#5 Present: Ind, same-age cou[sin], L[egal] G[uardian]s

Treatment Goals: Reduce individual's [ind's] depressive symptoms [sxs] by teaching ind to recognize sxs, use appropriate coping skills to reduce negative feelings. Teach ind to appropriately express negative feelings at least 1x/wk w/[with] th[erapist].

Session Goals: Investigate ind's relationship w/ cou. Obtain appropriate med records as listed, previous sessions.

Symptoms: Low mood, guardedness w/ th[erapist] in session, undereating, hoarding food, verbal aggression towards same-age cousin, lack of peer relationships, poor relationship quality w/ maternal Aunt & Uncle & same-age cou.

Interventions & Response: Uncle began session by loudly declaring that he had "forgotten" any medical reports for th & what would th be doing about it? Th ignored bx, as fire alarm sounded in immediate hallway. After brief interruption to secure building, fam assembled again in th's office. Th welcomed cou to session. Cou presents as Caucasian male, very obese for height and age, dressed in expensive clothing, well-groomed, considerably larger than ind. Cou sat close to LGs, while ind distanced chair as much as office space allows. Th moved th's chair closer to ind's. Cou smirked at th, said, "I don't have to tell you anything, Yank. My Dad says Yanks are too stupid to understand proper English anyway." Uncle sneered at th, Aunt smiled at cou for remark, said "Dudders will have his little jests.". Cou made fist, smacked quietly into open palm of other hand, made this gesture behind chair towards ind, apparently hiding gesture from th. Ind silently stared down at hands in lap. LGs ignored or did not see gesture. Th smiled at cou, explained to cou that he [cou] was already busily telling th everything she wanted to know. LGs shifted in chairs, eyes narrowed towards th. Th explained that over 80% of human communication occurs w/o words. Cou demanded proof. Th suggested LGs leave session so th could explain to cou. Pars refused to leave "our precious boy alone w/ some freak Yankee shrink." Th agreed, smilingly, used strategy of meeting resistance w/ acceptance and warmth, continued to explain to cou how, for example, th can see from body language that a "strong, proud boy like him" would not accept taking "second best" from someone like ind, who clearly had "no rightful place in your [cou's] home." Cou smirked, said, "Him? All he needs is a bit of this [fist striking open palm gesture clearly made] and he'll behave all right." LGs panicked, Uncle rose from chair, screaming at th, making threatening physical gestures over seated th, threatened report to th's supervisor, "You tricked him!", etc. Aunt rushed cou out of office. Th asked to speak privately w/ uncle.

Plan: Make child abuse report asap. Continue trust-building work w/ ind. Work on goals, including helping LGs perceive ind's strengths, use at home.

Collateral contact: October 29, 1989

Uncle accused th of "baiting" cou unfairly, tricking him into untrue admissions, etc. Uncle reports that he will "take this to the highest levels." Th agreed that this would be fine idea, again met resistance w/ acceptance. Uncle repeated threats; th used "broken record" strategy w/ uncle, repeating "That's fine, sir, and you do understand that I am required to make a child abuse report against your son" in soft voice to force Uncle to lower voice to listen. After approx 15 repetitions, Uncle heard th and became more flushed, screamed "Against my son?" Th explained that, due to size and physical power differential between ind and cou, cou's obvious physical threats as witnessed by th constitute child abuse towards ind & cou is thus a child abuser under British law. Uncle gaped, turned purple. Th continued to explain that, under British Child Protective Statutes, both ind and cou could be removed from LG's care, as LGs have failed significantly to provide appropriate physical protection for ind from cou and failed to appropriately discipline cou. Uncle raised fists to th's face; th informed Uncle that she has right under British law to "take him down" if attacked and that would result in criminal assault charges against Uncle. Th asked Uncle in respectful tone if he understands American term "take him down" and offered to explain procedure, assuring Uncle that he would not be able to stop th if th began process. Uncle collapsed in chair, some difficulty breathing. Th offered to call for paramedics. Laughter from under th's desk. Th ignored. Th offered Uncle glass of water; Uncle accepted. Th gave Uncle water, which he threw over th & left office.

Progress Note: October 29, 1989

Session#6 Present: Ind

Treatment Goals: Reduce individual's [ind's] depressive symptoms [sxs] by teaching ind to recognize sxs, use appropriate coping skills to reduce negative feelings. Teach ind to appropriately express negative feelings at least 1x/wk w/[with] th[erapist].

Session Goals: Prepare ind for possible negative consequences of child abuse report.

Symptoms: Low mood, guardedness w/ th[erapist] in session, undereating, hoarding food, verbal aggression towards same-age cousin, lack of peer relationships, poor relationship quality w/ maternal Aunt & Uncle & same-age cou.

Interventions & Response: Th invited ind to come out from under th's desk. Ind accepted, smiling at th. Th advised ind that LGs may react w/ anger towards ind, offered ind th's card, asked ind to call th asap 24/7 if family threatens him. Ind nodded agreement, took card, staring at th entire time wordlessly, big eyes. Th explained to ind that th would take responsibility for ind's delay for this "extra" session. Th prompted ind to express feelings, concerns, etc, around session. Ind wrapped himself around th's waist silently. Th attempted to comfort ind, found that ind was laughing silently w/ tears. Th prompted ind to articulate feelings. Ind only repeated "brilliant!" 3-4x. Th explained that goal of therapy was to help ind verbally express needs, that ppl [people] need to be able to speak their feelings, wishes, etc. Ind asked if questions allowed; th explained that questions always allowed. Ind asked re: "take him down." Th gave graphic description, including significant body parts attacked as part of th's self-protection from large, aggressive male. Ind sat on floor hard, laughing w/ tears. Th encouraged emotional release, sat on floor w/ ind. When finished, ind asked th why th "doesn't ever get mad" at ppl such as Uncle. Th explained that th does get angry, but uses "special tricks" to handle "difficult ppl." Ind asked to learn "tricks;" th agreed, but explained that th does not teach "take downs." Ind laughed again for several mins. [minutes], agreed to not ask for take-down lessons. Ind asked th why th helps ind "when nobody else ever does." Th explained that th is "special friend" who helps ppl solve "normal life probs." Th instilled hope, explained that th thinks ind is "normal kid in tough situation," explained that teacher also seems aware of ind's situation, encouraged ind to try trusting teacher more as well. Ind silent, then asked th if th is a sort of "nanny for older ppl." Th explained that Americans generally have weak concept of "nanny", but th thinks of nanny as caring for babies. Ind explained that th ds not seem to care for babies, but ind admires th's cat, thought maybe th was person who cared for "everyone, even cats, like a spare mum." Th asked re: cat; ind pointed to window sill, surprised, explained that large, striped cat sits on sill at each session, so ind thought cat belonged to th. Th expressed surprise, explained that th had not noticed cat, does not know cat. Ind said cat is th's friend, same way ind is--maybe cat visits th once a week to play games too? Th thanked ind for calling th "friend." Th prompted ind again to phone th if LGs aggressive after session. Ind agreed w/ some hesitation. Ind hugged th quickly W/ no eye contact at leaving office.

Plan: Make child abuse report asap. Continue trust-building work w/ ind. Work on goals, including helping LGs perceive ind's strengths, use at home. Change of diagnosis to eliminate ODD.

Collateral contact: October 29, 1989

Th escorted ind to Uncle's car. Uncle threatened th; th replied that she would gladly escort Uncle to office of th's supervisor immediately to report th's behaviors. Uncle refused. Th explained that LG's or cou's efforts to bully ind as result of this session might well impinge on child abuse report th would now be making. Uncle began screaming; th walked away from car.

Documentation of Time Note: October 29, 1989

Ind's chart reviewed; Report of Suspected Child Abuse phoned and filed w/ Protective Services office; cou as primary abuser, th's concerns re: ind's clothing, glasses, small stature and low weight also reported. Lack of medical records re: potential head trauma also cited.

Collateral contact: October 29, 1989

Th called ind's teacher, informed of child abuse report, gave no other information, but asked teacher to monitor ind's interactions w/ cou at school. Teacher agreed.

Change of Diagnosis Note: October 29, 1989

Original Diagnosis/Diagnoses:

Axis One:

300.4 Dysthymic Disorder:

Ind presents as having low mood present for most of day, more days than not, for at least 1 year, as indicated by LGs. Ind reported to have inappropriate appetite, although ind appears to undereat & LGs claim he overeats. Low self-esteem, low energy. Feelings of hopelessness. Ind does not seem to have ever been without these sxs since age of 18 mos. No Major Depressive Episodes or manic Episodes evident or reported. Sxs cause impairment in home functioning and some distress at school.

313.81: Oppositional Defiant Disorder:

By LGs' report, ind has pattern of negativistic, hostile, and defiant bx, lasting more than 6 months, including frequent loss of temper, frequent arguing w/ LGs, refuses to comply w/ adult requests, deliberately annoys people, often angry & resentful, spiteful, & vindictive. Criteria not met for Conduct Disorder.

Axis Two:

V71.09 No diagnosis.

Axis Three:

No significant health issues reported.

Axis Four:

Bxs cause impairment in the following: social settings, home, school, ability to maintain peer relationships.

Axis 5:

60 out of 100: Moderate sxs.

Revised Diagnosis/Diagnoses:

Axis One: 300.4 Dysthymic Disorder

Axis Two: V71.09 No diagnosis

Axis Three: No significant health issues reported.

Axis Four: Bxs cause impairment in the following: social settings, home, school, ability to maintain peer relationships.

Axis 5: 60 out of 100: Moderate sxs

Rationale:

Rule out Oppostional Defiant D/O. Ind does not manifest sxs reported by LGs re: Oppostional Defiant D/O. Ind's negative feelings towards LGs, cou seem to be justified by conditions of secondary neglect, bullying w/in home. No similar defiance reported by teacher.

Consultation Progress Note: October 29, 1989

Present: GD Walker, Ph.D.; Jan Schiller, Ph.D.

Reason for Meeting: Dr W reported events of day's sessions to Dr. Schiller as supervisor, reported making child abuse report. Dr Schiller reported complaints by ind's LGs against Dr W.

Discussion: Dr W described content of recent sessions, including concerns that ind is wearing oversized clothes, has broken glasses frames, large and visible scar on forehead, was apparently never treated after car accident or examined for head trauma, poor quality of relationship w/ LGs, discrepancies between LGs' presentation of ind and ind's own presentation, both w/ and w/o presence of LGs. Dr W reported physically threatening bxs of ind's cou towards ind & of ind's Uncle towards th in most recent family session. Dr S explained that Dr W's action of "threatening assault in return" on Uncle unjustifiable in British system, reports that Uncle has reported incidents to Dr S and threatens to go over Dr S's head if no disciplinary action taken against Dr W. Dr W requested info re: protection and rights of th filing child abuse report in Britain. Dr S educated Dr W, explaining that licensed th protected by British law from prosecution when filing child abuse report. Dr W expressed willingness to accept any "disciplinary actions" deemed appropriate by Dr S for th witnessing physical threats between children in her office and for th being physically threatened by adult LG of patient, as well as for th filing child abuse report under these conditions. Dr S excused Dr W from his office "to consider this matter further."

Plan: Dr W will continue to monitor situation.

Personal process note, October 29, 1989

Go ahead, Schiller: discipline me. Ind's Uncle won't be the only one going over your head, if you try. Let's see you explain any "disciplinary measures" to a review board after today's meetings and an abuse report. Even your country's laws protect me right now, regardless of what you think of Americans.

HP will obviously not be allowed to call me; I hope he's okay. I hope that wart of an Uncle is too scared by the thought of a home visit from Protective Services to bully the kid or to let the cousin bully him more.

If nothing else, I got to see 2 noxious British males turn purple today.