Hallway Therapy

Last year, when a local public school district approached me about becoming the director of their Family Support Center, a free, in-house counseling service, I was intrigued. I wondered what it would be like to provide family-oriented mental health services in the hurly-burly of a school setting. Besides, after almost 20 years of teaching in a family therapy training program and practicing as a medical family therapist, I was ready for a change. After I began my new job, I felt the same excitement and sense of encountering the unknown that I’d felt in the mid-’80s, when I’d started working as a medical family therapist.

It’s a year later now, and we’re in the middle of a new school year. I’ve learned a lot since last year and, just in case you’ve forgotten what the world of a public school is like–and how many unknowns there are to encounter everyday–let me take you on a brief tour of the ups and downs of a typical week.

Monday

My main “customers” at the center are actually school personnel–school counselors, social workers, psychologists, teachers, and administrators–struggling with kids whose behavior makes it difficult for them (and often anyone around them) to learn. The implicit demand is always to resolve problems quickly–preferably immediately–so that the everyday business of education can proceed unimpeded, but sometimes that isn’t possible.
“You fuckin’ bitch!” Natalie screams at her mother, who leans forward in her chair and rails just as harshly in return, “You little sonofabitch!” Her father takes a deep breath and looks at me, his face red. “This goes on all the time. It never ends,” he sighs.

Natalie is a petite middle schooler. She talks with a streetwise, urban accent, despite her decidedly small-town background and experience. She was suspended recently from school for telling a teacher to “Go to hell!” after being caught punching a girl in the hall. “She fuckin’ asked for it!” Natalie says, unrepentant and defiant. She lashes out and then cries and then lashes out again, refusing the Kleenex I offer, wiping her tears on her sleeve. When she turns on me–“Who the hell are you, anyway?”–my first, nontherapeutic inclination is to grab her arms and shake her, but I also know that’s exactly the reaction she’s already getting at home.

I see a lot of Natalies. They’re obstreperous, infuriating, and often mean, but also articulate, and at times sensitive and even likeable. They don’t like rules and won’t follow them. They resent authority and blame the world for everything that goes wrong in their lives. They’re easily frustrated and decidedly inflexible when cornered. In short, they fit the popular diagnostic category of oppositional defiant disorder.

By the time they come to me, they’ve usually run roughshod over their teachers, school counselors, principals, and anyone else who gets in their way. I worry about labeling kids like Natalie, though, not because it’s inaccurate, but because, like the diagnosis of borderline personality disorder, it’s a license for insisting that change is impossible and just giving up.

“I’m always the one that screws up in the family,” Natalie readily admits. I wonder how she managed to be elected to that office.

“Yes, I know that when something goes wrong at home, I blame her before I blame anyone else,” her mom says, somewhat embarrassed by the admission.

Her father acknowledges that when he’s angry, he either explodes or, more often than not, withdraws, sometimes for weeks, and doesn’t talk to his daughter.

What options has Natalie learned for showing her anger? Is she depressed, I wonder, as she finally takes several tissues from the box.
Natalie would be a towering challenge to even the most creative public school. Public education is impossible unless the vast majority of children are able to follow simple rules, take responsibility for their behavior, make reasonable choices, and respect authority. Natalie can’t do any of these consistently. “Can’t” is the key word here. I’ve already learned that her family genogram is filled with relatives who behave like Natalie, persuading me that there may be a biological component to the problem.

Mom and Natalie now have been fighting for several minutes. It’s taken me that long to stem the tide of my own frustration. Finally, I lean forward into the fray and say, “Let me interrupt you for a minute.” To my surprise, they stop. Dad, who’s already announced he “hates therapy,” makes eye contact. “Is this usually the way things go?” I ask.

They all say “Yes.”

“Do any of you feel like you’re understood?”

They all say “No.”

“Do any of you feel like you get the respect you want?”

“No,” again.

“That’s too bad, because I think each of you deserves to be understood and respected.” Natalie reaches for another Kleenex. Mom looks at me doubtfully. Dad takes a deep sigh.

There’s a lot of work ahead, but the first step is simple–get in touch with the key “customers.” I e-mail Natalie’s counselor and teachers saying that I’ve met the family and that this will be a slower process than any of us would like. I insist, though, that slower, in this case, may be faster in the end. I call the principal directly and discuss the option of having Natalie leave her classes when she’s out of control. The principal agrees. This, at least, will let some of the steam out of the kettle. I expect I’ll probably be working with the family for most of the school year.

Tuesday

When I started my new job, I was amazed by the amount of bullying that goes on at all levels of school. As it turned out, however, I didn’t know as much about bullying as I’d thought. To me, bullies were ruffians who pushed smaller kids around, but usually backed down when confronted. I’ve learned that today’s bullies are much more sophisticated, often using the internet as their primary tool for tormenting their victims. The internet is the ultimate in responsibility-free communication, forcing some kids to routinely confront rumors, exclusion, and humiliation from sources that may remain anonymous to them.

Mike, an eleventh-grader, is slumped in the loveseat, his father beside him. Mike has a pie face with big eyes and a shock of bright-blonde hair that stands up straight. This isn’t a fashion statement, just unruly hair. The braces on his teeth bulge, and his lips look chronically chapped. His gigantic feet dangle at the end of spindly legs. He’s small, bright, and quiet–an easy target.

Mike’s father tells the story as Mike shrinks further into the corner: “He was in gym, and some kids started pushing him around and tried to lock him in a locker. No one did anything! The other kids, even his friends, just watched. Finally, one kid, what’s his name, Mike?” Mike shrugs. “Anyway, this kid up and kicks Mike for no reason!”

As we talk, I learn that the incident is more complicated than it appears. Mike and the other boy had been instant-messaging each other for days, making threats and counterthreats. The other boy went on MySpace and circulated a rumor that Mike was gay. He also started an “I hate Mike” website.

Although Mike was internet-tough, he wasn’t face-to-face tough, and the other boy and his friends finally caught up with him in the locker room. This incident is just the latest installment for him–he’s been bullied since late grade school. It’s finally wearing him down, and his grades show it.
Mike’s parents have been separated for more than a year, and the tension between his parents is high, making his attachment to both of them complicated. His father is trying hard to connect with his son just when Mike, like most teens, isn’t nearly as interested in connecting with his dad.
Dad confesses that he was bullied as a kid. “I used to get beat up regularly,” he says, embarrassed. “I hate to see my son go through this. He’s gone through enough already. I tell him all the time he’s got to stick up for himself, and when he can’t, he’s got to tell me. He never tells me, though. I have to find out from school!”

I worry that Mike is feeling bullied by more than the guys in the locker room. He’s been slapped in the face by circumstances beyond his control. His parents are continuously at odds. His father overwhelms him with his concern. And now school feels like an unsafe place.
Before this session, I spoke with Mike’s school counselor. She’d set up a mediation meeting between the two boys that went well. Apologies and promises were made. Mike felt good about the outcome because he was able to exercise some control over the situation, something that he’s unable to do with his worried father. He shrinks from his father’s clutching love.

“Is there anything that your dad can do to help you with problems at school?” I ask.

“Not really,” says Mike.

“Is there anything that your dad can do to help in general?”

Mike looks up, making rare eye contact.

“He could listen.”

Dad quickly responds. “I know I tend to lecture,” and then goes on giving advice for a few minutes, proving his point. This will be the focus of our work in the weeks to come. So will coaching Mike on some of the basics about how to stymie bullies–sitting at the front of the school bus, never being the first or last off the bus, avoiding dangerous school hallways or unfriendly corners of the cafeteria, and walking with friends whenever possible. For now, though, I feel like a small step has been taken by helping Mike and his dad begin talking to each other.

Wednesday

Last week, an elementary school principal invited me to a meeting about Nancy, a fourth-grader. Around the conference table were her principal, school counselor, school psychologist, primary teacher, father, and stepmother. I introduced myself to Nancy’s father and stepmother. They responded stiffly, obviously intimidated by the throng of helpers.

Everyone agreed that Nancy has been more oppositional at school. Dad said she seemed fine at home, but Stepmom disagreed, saying Dad would hardly know since he’s never there. Nancy’s teachers were worried because her grades had fallen, along with her motivation. They also felt she was “sad.” I made my pitch for the Family Support Center and the next day the stepmom called our secretary to make an appointment.

At today’s meeting with the family, I quickly connect with Nancy as she draws. Dad is overly friendly and comments on the photos on my walls and the knickknacks on the bookshelves. Stepmom is a more difficult read. While Dad talks, she sighs deeply, her arms folded. When I ask who’s at home, she jumps in.

“I have my two from my first marriage. They’re 10 and 12. Then there’s his two. And we’re expecting.” With this, she makes eye contact as if to say, “Are you getting the picture?”

“You two are handling a lot, that’s for sure,” I say. “Can you tell me about Nancy’s mom? Is she involved?”
With this, Nancy responds in a flat, sing-song voice, “Mommy died.”

Two years ago, her mother died in a freak accident at work. At the time, Dad and Stepmom were about to be married. The death meant that Nancy and her older brother had to move into an apartment with their father while a new house and wedding plans were being completed. The upshot was that, within six months, Nancy lost a mother, moved twice, began living with new stepsiblings, and was in the care of a stepmother who was less than pleased that her honeymoon included two unhappy stepchildren.

Nancy’s grief about her mother’s death was lost in the chaos of multiple changes. Worse, her father became less involved with her when work demands increased the distance between him and home. That left Stepmom, who, after a year, didn’t understand why her stepdaughter couldn’t “just get over it.” With a baby on the way (a girl), Nancy’s displacement would be completed.

While the details of the picture are unique, the picture itself is common. Many students sitting in classrooms are overwhelmed by the changes in their family lives that don’t match a neat picture of family transitions and developmental processes. These changes are marked by sudden rips and tears, with little time or emotional resources available to integrate them or heal.

I have a fantasy that if I stood in front of a classroom of students and flicked a magic switch, I’d see a surprising number of red flags waving over their heads. The flags indicate that life at home is disintegrating and that the only place where the signs of that disintegration can be seen is school: sudden drops in grades, homework left undone, angry outbursts in the cafeteria and on the bus, withdrawal or aggressiveness in the classroom, and disrespect for all adults.

If I were working in a traditional mental health setting or in a private practice, I’d probably start with Nancy’s palpable grief and the discord between dad and stepmom. But because I’m working in a school setting, my initial focus is on how to help the teacher deal with the child’s behavior and slumping grades. I later observe the class and see that Nancy is in slow motion compared to the other kids. I meet with the teacher and we discuss how to give her more individualized attention and a leadership role in the class, so she’s more engaged. This works almost immediately, which provides a model for how the parents can approach her at home.

My heart aches for Nancy, who misses her mother greatly, but I comfort myself with the notion that she’ll remain in the school district, and that I’ll work with her again in the future.

Thursday

Cutting and other forms of self-harm are an epidemic among teens. Like eating disorders, cutting is often a group phenomenon in which the behavior is sanctioned by other group members. For a few, there’s something chic about it; for most, it’s a sign of despair and depression.

Cindy looks like a leaf that’s been blown into my office from the tree outside–fragile, delicate, and turning brown around the edges. All the green, all the life seems to be draining from her. Her parents are beside themselves with worry, unable to understand why their daughter is cutting herself. Mom says the counselor at the high school called her at work. “She told me that Cindy said she’s been cutting herself for months. I said, ‘Where?!’ I haven’t seen a thing. I can’t believe she’d tell someone else and not me.”

Cindy’s father is quiet. I ask him how he found out. “I was at work and Cindy called me. I had to leave a meeting. Her mother wanted her to tell me herself. So she told me she’d been scratching her arms. I didn’t have any idea what she meant.”

Mom looks angry and dad looks lost, feelings that may reflect their daughter’s emotions.

“I don’t think it’s such a big deal,” says Cindy, barely audible. She’s been cutting herself with pieces of plastic for almost a year. More recently, she’s been putting salt on her forearm and rubbing it with ice.

“She told me they were burns from gymnastics,” says mom. “How could you do this to me?!”

Dad leans in and takes his wife’s hand. Cindy looks at me.

After clarifying confidentiality, I meet alone with Cindy to assess risk. “No way,” she says, when I ask about suicidality. “I’d never do that!” Her reasons for cutting are simple. “I don’t feel the pain when I cut. I learned it from my friend Marcy. Everyone does it. It’s not a big deal, really.”
When I ask about the “pain,” she says, “I don’t know, I just don’t feel anything.”

Turns out she hasn’t been sleeping well for months. She admits that her grades are dropping, although her parents don’t know this yet. She’s upset with her parents for “always fighting” since her father got a promotion almost a year ago. He’s seldom around. Cindy is depressed, but can’t name it.
Cindy and I let her parents know that she isn’t suicidal, but that she’s feeling a lot of pain, something that confuses her parents because their daughter won’t say more. Mom begins to cry, and dad just stares. Although I don’t know it at the time, this family session is just the start of a long series of meetings, with long gaps in between.

A week later, I sit alone in my office waiting for Cindy and her parents, who don’t show up. I e-mail her counselor, who has nothing new to add. I wait a day and call Cindy’s home. Her mother says they’d had a big fight after our first session and don’t want to “force her to come.” I feel like I failed them in some way–that I didn’t give them a handle to hold onto for even a week. I talk to the school counselor, who agrees to continue seeing Cindy once a week in a lunch group.

The family comes back three months later, when Cindy is suspended for missing classes. I see them twice, and they disappear again. They return a third time, and I see Cindy for three visits. She’s still cutting intermittently. I suggest that she keep a log of the times she cuts and also write a brief description of how she feels when she cuts. I also suggest she place Post-It notes in her room, bathroom, and on her daily planner to remind herself to count to 10 every time she thinks of cutting. I’m convinced that she’s depressed and could benefit from medication. I suggest this to her parents, who say they’ll contact their primary care physician, but I’m not at all sure they’ll follow through. Cindy’s cutting decreases over the next two weeks, and then they’re gone again.

This is the kind of case that’s frustrating because I feel like water is slipping through my hands no matter how tightly I grasp it. I know that if I chase them, they’ll withdraw even more quickly. So I wait, which is very difficult for me, since I’d like to think I can always make a difference. By this point in my work with the family, I can only stay connected with her school counselor and principal, and provide whatever consultation I can.

Friday

I’ve spoken twice by phone and three times by e-mail to Robert’s school counselor and his classroom teacher. Robert is an excellent fourth-grade student who’s unruly in class. “Sometimes he just laughs when I ask him to do something,” says his teacher. “I’ve tried to contact the parents, but they’re very hard to reach. In the meantime, he’s getting worse in school, and is becoming very distracting for the other students. I can’t spend all my time trying to manage him.”

Robert’s counselor had e-mailed his mother several times, and often waited a week or more for a reply. They’d tried to set up meetings with no success. The school was doing its best, but frustration was running high. Since the counselor had mentioned the Family Support Center to the mother, I called her to see if there was any way we could help. Robert’s mother insisted that her son didn’t have any problems at home–that the school was the problem. “The only time they ever contact me is to tell me something bad about my kid,” she added. “I know he’s a good kid. Sometimes I feel like they don’t think I’m trying. I’ve got three other kids and my husband is on disability. I’m lucky the kids get to school at all!” She went on to add that Robert was her “little helper” at home. He had lots of responsibilities with the other kids and did a great job, so she really didn’t know why the school was “complaining.”

Mom seemed surprised that I didn’t disagree with her or challenge her concerns about the school. She then began to relax and backed off from blaming the school, confiding that she wondered whether she was doing anything “wrong.” I replied that most good parents ask themselves the same question. When I suggested a meeting at the school, though, she hesitated. “All they do is blame me,” she said again. I asked her to think about it while I learned some more from Robert’s school counselor and teacher.

Both of them said they liked Robert, but they were at their wit’s end with mom, whom they experienced as “difficult” and “unreasonable.” I responded that I could see exactly what they meant, but that I wondered if mom might be more frustrated than anything else. I floated the idea of a meeting if mom was agreeable. They thought that was a good idea. I called mom again, and, this time, she said okay.

Today I start by thanking everyone for coming in, at which point, mom turns to the teacher and asks why she doesn’t like her boy. Mom then starts to criticize the school, in fact all schools everywhere, for ruining so many kids’ lives. Unfortunately, my arms aren’t long enough to reach across the table and clamp her mouth shut. But I succeed in drawing her fire by asking her to explain her concerns to me, which slowly calms her down. I say, “All of this is very hard, isn’t it?” and she starts to cry. This has given the teacher time to gather herself. She rises to the occasion: “I can see how much you want things to go well for Robert.”

No decisions are made at this meeting. Afterward, the teacher thanks me for jumping into the middle. “I was so angry I couldn’t speak,” she says, laughing now. Later in the day, I follow up with mom, who says she was embarrassed to cry, but that it felt good to get things off her chest and to feel like she was heard. It’s a start to what I hope will lead to better communication between mom and Robert’s teacher.

I often feel that my work is much like applied anthropology: each day I get the chance to learn the rituals and rites of the school culture and try to intervene in ways that make a difference for kids, families, and school personnel alike. I’m struck by the balancing act I often perform. Simultaneously, I address the needs of the many players in the system (including the school board), often mending broken home-school relationships and addressing longstanding family needs that don’t change quickly. When I see that I’ve made a difference for a kid, my spirits soar; other times, I find my head spinning with the complexity of what I’m seeing. But having professionals with whom to collaborate and share a common mission makes all the difference.

I’m glad it’s Friday. I have to answer e-mails from two counselors, one parent, and one administrator before I go home. Two new referrals have come in at the end of the day. I place the sheets on top of my computer. First thing Monday morning!