Adam’s Story

The first step in social change is the identification of a problem, something to begin, something to change, or something to stop.  This is a story about a student who suffered symptoms that often lead to institutionalization and / or a life of heavy duty medication. 

Therapy-as-usual would have focused on Adam’s internal state, yet the key to his recovery was creating a learning environment that met his social and emotional needs, thereby allowing focus on his academic growth. 

Thanks to the efforts of others, the Special Education process already exists, and using it allowed us to change the school to meet the needs of Adam.  Something to change:

 Adam

Adam stood on the landing, facing away from the flight of cement and steel stairs that descended behind him to the second floor.  He balanced on his toes like a platform diver.  “What do you think would happen if I just let myself fall backwards?” he asked his stunned teacher who looked at the twenty cement stairs running down to the landing below and tried not to imagine the outcome.

She already knew that Adam heard voices telling him to do self-destructive things, because Adam had told her and his school counselor during previous episodes.  She was able to talk him away from the stairs and into class, and then she rushed to tell Adam’s school counselor and school nurse who decided that he had to be sent to the ER again, for another evaluation.

Several years ago, working as a therapist for a local social services agency, I was seeing students in the public schools, mostly for issues related to school.  When summer came, my supervisor demanded that I continue to see the students in order to sustain income for the agency.

With a few exceptions, the students had no interest in being seen during the summer months.  My supervisor did not ask if I thought it was clinically important or useful to see them.  Instead, her focus was on productivity, billable hours, and revenue for the agency.  I realized that my supervisor was asking me to fulfill her and the agency’s needs, and she was not even considering the students’ needs.

I arrived at a “problem, needs identification, action” perspective of psychotherapy from several sources.  Former labor activism and current sympathy for the Occupy movement leads me to generally ask, “What is needed and whose needs are currently being served by an institution?”

Training in Collaborative Family Therapy (Andersen, 1991; Harlene Anderson, 2007; Harlene  Anderson & Gehart, 2007), and in Collaborative Problem Solving (Greene, 2009) with their skepticism about the usefulness of a diagnostic approach, and positive emphasis on relationship, curiosity, listening, and empathy, causes me to carefully consider clients’ expressions of need.

A systems and ecological approach allows me to examine the ability of the institution to meet the client’s needs in addition to the ability or desire of the client to conform to the institution’s needs; are their needs congruent or dissonant?.

Adam, thirteen years old, was brought to my attention by a school Adjustment Counselor.  When I first met him, Adam’s life was going poorly and he was threatening to hurt himself or others.  Adam was in the seventh grade.  He was on an Individual Education Plan (IEP), was not doing his school work and was in danger of failing all his subjects.  He was referred to me by his adjustment counselor because Adam was hearing voices telling him to do harmful things to himself and to others. She wanted him to get more help than the school was equipped to give him.

She and other school staff wondered if Adam’s problems were due to terrible but unreported conditions or events at home.  When students have emotional problems, it is not unusual for school staff to wonder about conditions at home.  Some staff questioned if Adam was at the beginning of schizophrenia, a diagnosis that often leads to a life of heavy duty medications and disability.

When I first met Adam’s mother, she wondered, “What are they doing to him in that school. Everything is fine at home. Then he goes to school, and I get calls about all these problems.” She emphasized that Adam never had any problems at home.  She had no way of understanding the severity of what was happening in the school because she had never seen anything similar at home.

Both the school and the parents suspected each other of creating Adam’s problems and each hoped that I would be able to help sort out the relevant issues and recommend a way forward.  It was not unusual for me to find school and parents alienated from one another and blaming each other for a student’s problems.

Adam was happy to meet with me because he got along well with adults and I provided some relief for him from the classroom that he found so troublesome.  While we talked in the classroom the school had assigned to me, he liked to toss a ball back and forth with me.

He was a soft spoken and kind young man, always looking for ways to be helpful, somewhat like a Boy Scout in a Norman Rockwell picture; nice but out of step with the rough and tumble culture of the urban middle school.

Adam was forthcoming about what he was experiencing, which made it easy to identify his symptoms; he was sure that all the other students were making fun of him, and at times he was hearing voices that were telling him to hurt himself or others.

His symptoms were consistent with those expected in adolescents who had been exposed to violence and included an inability to learn while simultaneously desiring to learn (Bragin & Bragin, 2010). The family denied any history of violence.

His symptoms, in particular his hearing commanding voices, led to a diagnosis, which I needed to make in order to secure reimbursement from his insurance company and deal with other mental health professionals.  But symptoms and diagnosis told me nothing about what was causing his symptoms and what his actual needs were.

In graduate school, a professor of mine had cited Freud who said that “Symptoms have meanings”.  Until I understood what Adam’s meant, besides trying to keep him safe, I had no idea how to help him, his family, and the school.

Psychosis, from a medical perspective, is considered a biological disturbance, brain dysfunction, and/or chemical imbalance to be treated with medication.  For Adam, I hoped that listening carefully to him, his mother, and his teachers would allow for understanding his needs and possible ways to fulfill those needs.

Adam’s classroom teacher said that Adam did not know how to join a large conversation, how to make friends in school, or, especially, how to respond when other students said ambiguous or mean things to him.  Even though his teachers tried to be vigilant, Adam had become a target for bullies. Worst of all, she told me that in gym class, some boys had pulled his pants down in front of the girls.

She said that sometimes “he just stared out and up”, he would “fixate on a few girls in the class” and seek their attention.  The girls told the teacher that they thought him strange and they avoided him. He had no friends in the class.

Adam told his teacher that he was going to give a drawing to every student in the grade who, seeing what an excellent artist he was, would want to hang his work in the hallways and be his friend.   Jaakko Seikkula and Tom Erik Arnkill write that “the social relations of our clients can be included in many forms” in their difficulties, and that  “social networks can be seen as relevant in defining the problem itself” (Seikkula & Arnkil, 2006, pp. 54, 55).

Twice, school staff had become so concerned that they had sent Adam to the hospital to be evaluated.  The first time, neither his mother nor the hospital staff could understand why he had been sent to the Emergency Room.

Just as his symptoms disappeared when he returned home after school, his symptoms also disappeared when he arrived at the emergency room.  The ER staff declared him “safe” and authorized his return to school. This phenomenon dramatically contradicts the medical model of mental health, which sees brain states as persistently manifested biologically and chemically.

When I was informed about the stairs incident, I told school staff that I would “prime the system” by speaking with the evaluator in the emergency room and providing a diagnosis in the language they required.  Otherwise, he might have been sent home again and sent back to school the next day with the very real risk that he would hurt himself.

While hospital emergency room evaluations are supposed to be based upon current presenting symptoms, the evaluator accepted my description of symptoms as Adam had suffered them at school earlier in the day.

I saw that, even though I had doubts about the efficacy of diagnosis and diagnosis based treatment, (see for example Overholser, Braden, & Fisher, 2010, p. 191), my credentials and “expert” diagnosis were necessary to get the system to protect Adam until we could get to the root of his difficulties.

He was hospitalized, without objection from him, which kept him safe, and which gave us more time to understand the causes of his distress, what Adam needed, and what the school system could offer.

Adam’s adjustment counselor and other school staff agreed that Adam was lacking important social skills (For a discussion about a “lagging skills” approach, rather than a diagnostic approach, see Greene, 2009), like knowing how to interpret and react to different conversational content and tones of voice including sarcasm and ambiguous remarks, coping with large and complex social group interactions, and being able to read facial expressions.

We agreed that causes of his symptoms included his distress at being lost, confused, and bullied in the social environment of large classrooms and even larger gym, cafeteria and hallways.  These factors made it impossible for him to succeed in school (Konishi, Hymel, Zumbo, & Zhen Li, 2010).

Adam reported that while he was hospitalized there were therapy educational groups in which he learned some social skills to enable him to better cope with school and his reactions to it. I thought, and his mother and most of the school staff agreed, that it would take more than what he had learned in the hospital plus weekly meetings with me to keep him safe and able to learn.

We agreed that he could not stay in his current classes and that what Adam needed was for the school to find or create a smaller, emotionally safe, nurturing school environment in which he would have fewer fellow students to interact with, in which he could experientially learn the social skills he lacked, and could experience social and academic success.

After hospitalization, Adam was placed in a special out-of-district program to evaluate his social, emotional and educational needs.  He was in that program for the remaining months of the school year.  Since that program was small, supportive, and focused, none of Adam’s symptoms reemerged and the resulting report from the program was not helpful.  In June, there was an IEP meeting to determine his placement for the next school year.

Nelson and Prilleltensky argue that “individual interventions are prone to blame victims, to be ineffectual, to stigmatize and to deflect attention from structural predicaments” (Nelson & Prilleltensky, 2005, p. 165).

The Special Education process as we utilized it gave us access to the structural predicament and allowed the expression of the parents’, school staff’s, and my values in an open meeting. We were successfully swimming against the “prone to blame victims” tide.

While a diagnosis, which does blame or pathologize the client, was necessary to make a diagnostically oriented medical system do what it needed to do, it was not helpful in looking beyond Adam to his environment.

And, although the interim assessment program Adam went to was helpful to understand some other students’ needs, it was not in Adam’s case.  No amount of psychological treatment was going to give Adam what he needed.

At the IEP meeting, the school nurse, because she was not planning to be at that school in the fall, was politically able to support the parents’ and my assertion that Adam could not succeed in any of the classroom environments then available in the school.

The teachers and adjustment counselors, while agreeing with our view, also needed to be sensitive to the political realities of the school system, which limited their ability to request solutions outside of what was currently available.

Everyone remarked after the meeting that they were glad that the nurse, the parents, and I were able to advocate strongly for Adam’s needs by making it clear that no existing classroom would suffice.

The IEP law and resulting practices and process is the result of a social and political movement led primarily by parents of children identified as having unmet educational needs due to physical, leaning, or social emotional limitations.

It required a political movement to identify the injustice and push for legislation that changed the existing practice (Waldegrave, Tamasese, & Campbell, 2003) by speaking to the unmet needs of the children.

Fortunately, through the IEP process, we were able to collaboratively describe the environmental problem, which motivated the school principal and the Special Education leadership to formulate an alternative that would help Adam and other students in a similar predicament.

Prior to this meeting, the only separate classrooms in the school were for students who acted out with poor behavior.  Adam was not the only student who internalized his distress and who would not fit into the existing class of students with behavioral difficulties.

Thanks to the requirements of the Special Education law and the perceived threat that Adam would require an expensive out-of-district placement if an appropriate placement could not be found in-district, for the next school year, new classrooms were created to allow Adam and other children with missing skills and manifestations of distress, to gain those skills emotionally, cognitively and experientially in a safe, supportive environment.

The school was able to create and provide an appropriate setting for Adam within the Special Education system, which had itself been established after parents, lawyers, academics, and legislators engaged, waged conflict, and forced cooperation with existing previously non-responsive institutions to meet student’s emotional and educational needs (Rose, 1998; Scott, 1990).

Adam loved his new teacher, felt safe in the smaller, more supportive class, stopped hearing voices, and blossomed as a student.  In that and subsequent years he was able to make the honor roll, then the high honor roll.

He volunteered to help in a classroom with struggling younger students, got a girl friend, a driver’s license, and a job.  He looks forward to going to college.  In my role, I helped enable the school to respect the parents and vice versa, I was able to formulate the problem as systemic rather than exclusively psychological, and the IEP process allowed us all to consider and to negotiate appropriate accommodations to meet Adam’s needs.

Without a skills, needs, and systems perspective, Adam could have ended up with a major mental health diagnosis and disability.  Adam and his family were empowered to live fuller, happier lives.

I was considered an outside counselor because I did not work for the school.  I went into the school to meet with students as a result of an arrangement between the school and my new employer, a local social services agency.

The school counselor, overwhelmed by too many students with too many problems, got help from agency therapists like me.  The agency was able to fulfill part of its mission to provide counseling to youth while getting paid through the student’s health insurance.  My services did not cost the school anything.

I had completed graduate school and gotten my Masters of Social Work degree in 2004.  In 2005, I took a job with a child and family agency, even though I had not focused in those areas in school.

I found a local post graduate family therapy program that utilized Tom Andersen’s Reflecting Team therapy and philosophy as well as Collaborative Therapy as developed by Harlene Anderson and Harry Goolishian (A&G) and heavily influenced by Tom Andersen.

Both “philosophies of psychology” emphasized careful listening, empathy, reflection, making the client the expert of his or her care, and looking at relationships within families rather than supposed individual pathology.

I saw that I could apply ideas of family therapy to the school, and consider the fit between the student and the school rather than be limited to the individual student.

I listened carefully to what my student-clients told me, helped them to assess their own needs (A&G), to understand the needs and expectations of their parents and teachers, to advocate appropriately for themselves, to interact myself with the various systems that affected them, like Special Education, DCF, Probation; and to advocate within the school to discard non-collaborative practices and to adopt collaborative ones.

I worked closely with teachers, school counselors, and other school staff to both help the student acquire needed skills and to help adapt the school environment to meet the needs of the student.  Where school staff has been willing to work with me, there have been some wonderful outcomes of matching student and environment.

Initially, I found his parents and school personnel to be alienated and mistrusting of each other. The IEP process was ineffective.  While the traditional therapy focus would have been upon creating a diagnosis reflecting Adam’s internal, mental condition, and “treating” that condition one-on-one, in school we also focused on what it was like for Adam in his classroom with teachers, his Adjustment Counselors, the school nurse, and others.

Adam, suffering psychosis, SI and HI, was hospitalized and then was sent to the Consortium “for evaluation”.  Understanding that school was “driving him crazy”, the vital question was where he would go for the 8^th grade.

Working as an ad-hoc team, we were able to develop an environmental, familial, and social understanding of his difficulties.  Despite administration budget pressures, the nurse, Adam’s mother, his adjustment counselor, and I were able to convince the Team that Adam could not be placed back into regular education, and could not be placed in the “behavioral” room.

The creation of the new classrooms helped not only Adam, but many other students.