Treatment Tuesday - Bonding with an Estranged Child

This week’s assessment comes from Anita. She’s writing about Brenda*, a widowed mom whose husband was killed in a hit-and-run accident. Brenda’s 12-year-old daughter, Haley*, was always closer to her dad than Brenda, and Brenda is wondering how she can build a bridge to quiet and introverted Haley.

*Names have been changed to protect the fictional.

This is a fairly loaded question, and by loaded, I mean the possible answers are endless. I think everyone has read a book or watched a movie where one parent is widowed and left with a hurting child to comfort and console and try to “reach.”

Because of this, I think it would be helpful to go down the road of what NOT to do (i.e., what’s been overdone, clichéd, etc.) and then look at some genuine possibilities for Brenda and Haley.

So what are the ways NOT to try to win over the affection/love of a child?

1) GIFTS/MONEY – Giving gifts is so temporary. Yes, the child is thrilled when they get the gift, and perhaps for days after, but this is very much a band-aid solution. A 12-year-old girl would certainly catch on to the pattern, as well. (An aside, I’ve seen this “parental intervention” too often in my line of work as a general way of rearing children, and I’ve also seen it not work…ever.)

2) EXPANDED PRIVILEGES – This would be a desperate parent’s attempt to be cool, hip, down with it, insert-new-21st-century-lingo-word here. The idea being if they can come across almost as nonchalant, then the child will open up to them more or respect them for their coolness. Reality does not support this. The later you let them stay up/go out or the longer you let them watch tv/play video games does not correlate with warm fuzzies in the parent’s direction. More realistic would be for the child to take the rope they’re given and hang him or herself with it later.

3) LACK OF DISCIPLINE – A widowed parent might feel guilty at having to discipline a child, especially if one parent usually did the disciplining and the other did the nurturing. So it’d be easy to conceive of a single woman backing off in this department and letting a child get away with much more than the child normally would were both parents living. This is to do a child a disservice in the worst kind of way. In fact, keeping discipline the same would be more secure for them…something that didn’t change with the death of a parent. But widowed/separated/divorced parents make this mistake all the time…and kids can totally manipulate it out of them.

4) ALLOWING THEM TO SLACK OFF – Say a child’s been doing certain chores. Parent dies, everything is thrown into confusion and chaos. The last thing they might want to do is this chore, and so the surviving parent gives in and lets the child “off the hook,” which is the beginning of the end, some might say. Taking away their responsibilities or your expectations of the child (whether its with chores, grades, dating relationships, friends, whatever) is only a recipe for more rebellious behavior. The child sees the surviving parent’s guilt and soft-heartedness and takes advantage of it because—let’s face it—children can be conniving.

5) MAKING THE CHILD THE PARENT'S CONFIDANT - So not cool. Parents should still keep in mind appropriate conversations to have with their children. There is a mistake in thinking that the more adult-like topics brought up will bond the child to the surviving parent. Children still need to be children, not "peers" with their parents. They don't need to be privy to anything more than appropriate for their age level...and even once they reach adulthood it's important to keep some things sacred to the marital union, even if one partner is deceased (like finances, sex, and other private things).

The list can go on, but these are five basic ways parents can mistakenly try to bond with reticent children.

Now let’s focus on some ways a parent like Brenda could try to bond with Haley in a good way (I’ll be keeping in mind some of the additional things Anita emailed me during an email Q&A “session.”)

Since Haley is a rather quiet, introverted child, Brenda would do well to use ways that fit with Haley’s personality. Understated, consistent methods that eventually will show Haley Brenda’s heart and desire to be there for her daughter.

One way is simply TIME. Being available really speaks volumes to a child, even if during that “available time,” nothing of any real import transpires. Children need to know that even when they’re acting up, being defiant, or worse, being angry and rude, that their parent(s) are there for them. Parents have to be PATIENT with this, especially if the child isn’t used to turning to the surviving parent for comfort or companionship. Brenda wouldn’t want to make Haley feel that Haley has to talk to her. It’ll come in time…two hurting people thrown together in the same house should eventually seek solace with one another. Healing may take years, especially if Haley in any way blames the death on her mother or herself.

FORGING NEW TRADITIONS is also a great way to start fresh in the midst of tragedy. Having a time to remember the deceased parent together, like on the anniversary of his death or on his birthday. Instituting this from the beginning will help it stick. This would be a good time for the surviving parent to make a weekly goal or some sort of FAMILY TIME (or course, to remain low-key at first for the vulnerable child who might not want to feel pressured into talking). Maybe a game night or movie night or just a pizza night where no one has to do dishes. Something like that.

Finding a NEW PASTIME to do together would be helpful, some activity that isn’t like an emotional millstone around the child’s neck to remind them of the deceased parent. If Haley and her father worked in the garden a lot, then I wouldn’t suggest that Brenda try to spirit Haley off to do gardening work. Think outside the box on this one…something fun for a kid and an adult, too. Children know when the parent isn’t have a good time and is just trying to pander to them.

It'll be important for Brenda to also recognize her limitations and to embrace the idea (should this be the case) that perhaps Haley will bond to someone else during her most needy time. Anita mentioned Haley had a fondness for a local librarian, and if she spent a lot of time there, it's not unfeasible for her to latch on to this person as an anchor in her world. Brenda would need to let this happen, and not make Haley feel bad for talking with this woman. It might be hard, but in the long run, Haley will be better adjusted if she has someone to talk to.

So that's a sampling of some things that come to mind as being healthy and appropriate for a surviving parent to try with a distant child.

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist@hotmail.com.

Q4U: What are some other ways--good or bad--that a parent might try to bond with an estranged child?

Don't forget to sign up to win a copy of Mary DeMuth's new book in the Defiance, Texas trilogy, A Slow Burn, and it's prequel, Daisy Chain, at my other blog, Where Romance Meets Therapy.

A Slow Burn Blog Tour

Mary DeMuth's new book, A Slow Burn is an incredible read, people, and I'll give my reasons below.

Here's the back cover copy:

She touched Daisy’s shoulder. So cold. So hard. So unlike Daisy.

Yet so much like herself it made Emory shudder.

Burying her grief, Emory Chance is determined to find her daughter Daisy’s murderer-a man she saw in a flicker of a vision. But when the investigation hits every dead end, her despair escalates. As questions surrounding Daisy’s death continue to mount, Emory’s safety is shattered by the pursuit of a stranger, and she can’t shake the sickening fear that her own choices contributed to Daisy’s disappearance. Will she ever experience the peace her heart longs for?

The second book in the Defiance, Texas Trilogy, this suspenseful novel is about courageous love, the burden of regret, and bonds that never break. It is about the beauty and the pain of telling the truth. Most of all, it is about the power of forgiveness and what remains when shame no longer holds us captive.

Mary, with typical courage and boldness, tackles some difficult issues in the second book in her Defiance, Texas trilogy. My review, coming from a therapist's perspective, will hopefully shed some light on the psychological power Mary conveys with her words.

Emory Chance could very well be one of my clients (in fact, I've definitely seen her in my office before). Addictions are so difficult to deal with (and some would say to write)...but Mary realistically portrays Emory's sunken state after finding out about her child's death. The passages where Emory is standing over the toilet bowl, hesitating over flushing her "little white pills"...that really happens! The dissonance Emory feels in herself when she remembers her daughter's admonishments to quick "smoking that stuff," so at odds with what her body wants and craves...incredible how it jumps out at you on the page.

Emory wasn't a good parent. She feels guilt, shame....you name it. And this will touch the hearts of readers everywhere...because everyone who is a parent can relate (perhaps in smaller or larger ways) to not being the type parent we want to be at least some of the time. There's always room for improvement, and for Emory, that's an understatement. But she comes from such a place of brokenness....her tragic history actually explains her actions in such a believable, tragic way...not to make light of what Emory did or didn't do with her daughter, but to give a backstory that makes you ache for her in understanding.

And parents all over who have lost a child, whether at the cruel hands of someone else or just at the cruel hands of fate, will gravitate toward Emory as she deals with the death of her daughter. The waiting period (about 2 months) before she found out, the shock, hallucinations...these will all speak to parents still grieving. Grief is nothing to be afraid of, and Mary writes it so well. So real. So sad. Her poignant flashbacks from Emory's own childhood and Mama are so well situated throughout the novel, punctuating Emory's current state of emotion with ah-ha type revelations. Excellent. the kind of stuff therapists DREAM would come out in sessions, so thanks, Mary. :)

But this book ends with an incredible message of redemption and restoration and healing. It didn't end the way I wanted, but it was satisfying nonetheless...probably more so the way Mary did it, actually.

So now, with my stellar, 5-star review, I'm sure you're dying to read this book for yourself!

Learn more about Mary at her website (click here). And be sure to visit the Amazon link here to buy a copy for yourself!

T3 - Therapy Basics: Treatment Plans

Therapy isn't therapy without a treatment plan. This goes for fictional therapists and their clients, too. Contrary to how it's conveyed in popular shows like Frasier and In Treatment when the audience is privy to the talking but not the behind-the-scenes, therapy isn't just about the talking.

The conversational direction--i.e., the "talking"--should be towards an end that's already been specified between the therapist and the client. That's what a treatment plan is for.

Treatment plans look different depending on which therapist you go to. Here's the elements mine incorporates and the reason behind it.

1) Goals

Developing goals sounds much easier in theory than it actually is in practice. The reason? To make this worthwhile, the goals have to be specific, observable and quantifiable. So a therapist shouldn't just write down, "To decrease depressive symptoms." Yikes! This could be a legal nightmare were my file on that client to be subpoenaed.

So instead, a better way to put this goal would be: "Decrease depressive symptoms (as evidenced by crying, oversleeping and overeating) from 8-9 times a day to 1-2 times a day, as reported by client and her husband."

Now I've managed to convey how many times the symptom is happening and I've made the goal a measurable one by indicating how many times a day we would like the client to not be exhibiting depressive symptoms. It's often unrealistic to go from a certain number to zero, so I strive for reality in my goal-setting with clients.

Typical treatment plans have room for 2-3 goals.

2) Interventions

Then of course the therapist will want to spell out exactly what's in his or her bag of tricks that she will pull out to address the each specific goal. Interventions are as plentiful as goals, but to give you an idea of what I use frequently, say, with children:

art therapy, play therapy, bibliotherapy (reading books with messages/morals), role playing, modeling appropriate behavior, positive reinforcement, relaxation/anger management techniques, assertiveness training (to combat aggressiveness and teach the different), and so on.

3) Duration of Interventions

For sure we have to have a date we're working toward, if for no other reason than to revisit the goals at that time to see if we're on track. This can be 3 or 6 months from when the goals were initially discussed. Treatment plans expire after one year, so for sure a review needs to happen before then.

4) Termination Dates

Treatment plans expire after one year, so for sure a review needs to happen before then. If at the time of any review, it is determined that the goals have been met, then treatment is terminated, and this date is added to the treatment plan as evidence of the acknowledgment of both ther therapist and the client that treatment was satisfactorily concluded.

5) Changes to Treatment Plan

Sometimes changes are made to a specific goal during one of the reviews. In our example above, say the client's depressive symptoms swung mainly toward overeating. We might want to add as an intervention that the therapist referred the client to a nutritionist and exercise consultant (both of which would make the client hopefully feel better about herself and get her on the right track). I would note the date that this addition was made to the treatment plan and have the client initial it, as well.

This can be a hard one for therapists to remember. I know I did when I started out. But now, I just think of the client. Anything pertinent to their treatment should be noted not only for my own safeguard, but for theirs. A change in a goal or an added intervention is definitely pertinent.

6) Signatures

Signatures should be pretty self-explanatory, but sometimes even this can be complicated. Everyone privy to the treatment goals and interventions signs. So if I'm seeing a married woman, who on occasion brings in her husband, he would need to sign, too. If there are family therapy goals, then the family signs. i'f I'm seeing a minor or dependent adult, then the guardian would need to sign, as well. And every time there is a change, EVERYONE signs, which can be a major pain, just so you know. :)

Now we've covered treatment plans...next week we'll focus on session notes and you can once again enter the inner sanctum of a therapist's world.

Q4U: What are some topics you'd be interested seeing posted for Thursday Therapeutic Thoughts? I'm nearing the end of my Therapy Basics series and want to post what will help you the most. Thanks!

Treatment Tuesday - Death Row Counseling

Today's assessment comes from Jenness. Here's what she sent me:

One of my heroine is on death row and meets with a psychologist shortly after her execution date is set. I have no idea what kind of things she will be asked, and need help from the doctor's perspective. Would you have any thoughts on that?

Of course I have thoughts. :) I only hope that they will be helpful for you.

Likely the psychologist would be processing with her about what she had done to get on death row and her feelings about it: remorse, guilt, outrage (if innocent), etc. I imagine dealing with the fears of dying, or anxiety or whatever else she might feel, would also be discussed. There might be some discussion about what method of execution she'll undergo...some psychoeducational stuff to prepare her (like if by injection, exactly what would happen, how she might feel, etc).

The only thing I don't see the psychologist ASKING, but would probably go into it if the client brought it up, is her background, personal problems or something like that. I mean, at this stage, she's in jail, about to die, and there probably wouldn't be much motivation to delve into all that. But I suppose it's a probability.

I've never counseled someone on death row, so these are definitely suppositions. However, I've counseling individuals who knew they faced death via a terminal illness. While it's a bit different in terms of the "how" and "why" of death, it's not at all different in terms of the waiting. Those I've counseled fixate on how mortal they are. They ask questions of "Why me?" and I imagine those on death row would probably still ask this question (even though the justice system knows exactly "why them").

I think the counselor's role in this type of situation is a much more passive one. I'm not advocating not having a treatment plan, but just listening to the inmate would be the primary goal. Listening to them talk about whoever or whatever they want. They might resent the psychologist trying to take a more active role (then again, they might not). Either way, it's imperative for the therapist to take a person-centered approach to the sessions using unconditional positive regard and empathy for the client.

Q4U: What do you think might be on your mind were you facing execution?

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist@hotmail.com.

T3 - Therapy Basics: DSM, cont.

As promised, I want to wrap up our discussion on the Diagnostic and Statistical Manual of Mental Disorders (DSM). Last week, we talked about what kind of information you can glean from the DSM. You can read about that here.

This week, I want to explain what is called "multiaxial assessment." This is just a fancy way of saying that a clinician assess various fields (or axes) of information about a person. The DSM is set up in a multiaxial format, with the axes listed below:

Axis I - Clinical Disorders
Axis II - Personality Disorders/Mental Retardation
Axis III - General Medical Conditions
Axis IV - Psychosocial and Environment Problems
Axis V - Global Assessment of Functioning (GAF)

The various axes, or domains, provide a convenient way of organizing clinical information and capturing the complexity of problems that people may present in my office. I'll go through each axis and give more explanation. Be thinking about what type of multiaxial assessment your characters may have.


Axis I - Clinical Disorders

Clinical disorders are what we typically think about when we think of mental problems. Depression, anxiety, eating disorders, sleep disorders, OCD, impulse-control disorders, phobias, bipolar, schizophrenia, dissociative (multiple personalities), substance-related disorders, dementia, amnesia, reactive attachment, conduct disorder, oppositional defiant disorder, hypochondriasis, body dysmorphic disorder (Michael Jackson), sexual and gender identity disorders, etc. Just about everything in the DSM falls in this axis.

Usually whatever is coded on Axis I will be assumed to be the reason for the visit, unless it's noted that the reason for the visit is actually on Axis II.

Axis II - Personality Disorders/Mental Retardation

Personality disorders are much more pervasive, and encompass everything in a person's life, rather than just one aspect. For example, a person with generalized anxiety disorder might be able to have meaningful relationships, work productivity and socialization. But these aspects in a person's life may very well be a casualty of a personality disorder.

I'll give a listing of the personality disorders, but I won't go into detail in this post. (If there is one you are interested in, drop me a line.) They are: paranoid, schizoid, schizotypal, antisocial, borderline (Glenn Close in Fatal Attraction), histrionic, narcissistic, avoidant, dependent, obsessive-compulsive (the personality disorder is different from obsessive-compulsive disorder), and personality disorder not otherwise specified. Mental retardation is recorded on this axis, as well, because of it's far-reaching influence.

Axis III - General Medical Conditions

Sometimes, a medical condition can be relevant to understanding or managing an individual's mental disorder. Sometimes one causes the other. For example, if a person has a history of hypothyroidism (which presents as symptoms of depression), then you would record hypothyroidism on Axis III, and for Axis I, Mood Disorder Due to Hypothyroidism, With Depressive Symptoms. If a person has a malignant tumor, this could cause Major Depressive Disorder, Recurrent. Recording a person's relevant medical conditions is just good practice. It would be important for a hospital doctor to know that a diabetic is also a schizophrenic when dealing with an emergency room visit. It would be equally important for a therapist to know that someone they are seeing for an Anxiety Disorder also has asthma.

Axis IV - Psychosocial and Environmental Problems

This axis gives the clinician a succinct way of reporting a negative life event, a familial or relational distress, or a lack of environmental resources. There are 9 categories for convenience, and what each encompasses (taken directly from the DSM). Think about your character's backstory when you look at this list.

• Problems with primary support group - death of a family member; health problems in family; disruption of family by separation, divorce, or estrangement; removal from the home; remarriage of parent; sexual or physical abuse; parental overprotection; neglect of child; inadequate discipline; discord with siblings; birth of a sibling
  
• Problems related to the social environment - death or loss of a friend; inadequate social support; living alone; difficulty with acculturation; discrimination; adjustment to life-cycle transition (such a retirement)
  
• Educational problems - illiteracy; academic problems; discord with teachers or classmates; inadequate school environment
  
• Occupational problems - unemployment; threat of job loss; stressful work schedule; difficult work conditions; job dissatisfaction; job change; sidcord with boss or coworkers
  
• Housing problems - homelessness; inadequate housing; unsafe neighborhood; discord with neighbors or landlord
  
• Economic problems - extreme poverty; inadequate finances; insufficient welfare support
  
• Problems with access to health care services - inadequate health care services; transportation to health care facilities unavailable; inadequate health insurance
  
• Problems related to interaction with the legal system/crime - arrest; incarceration; litigation; victim of crime
  
• Other psychosocial and environmental problems - exposure to disasters, war, other hostilities; discord with nonfamily caregivers such as counselor, social worker, or physician; unavailability of social services agencies
  

Axis V - Global Assessment of Functioning (GAF)

Essentially, the clinician gives a "grade" on the client's overall level of functioning on a scale of 0-100. The clinician can track how well the client is doing based on this number as treatment progresses. There are 10 ranges of functioning within the 100 "points," each based on symptom severity (how much does the disorder effect the person) and functioning. In some cases, the severity of symptoms won't actually reflect the person's level of functioning. For example, a person who is a significant danger to themselves can live an absolutely normal, functioning life. But the GAF number would be below 20. The GAF always reflects the lower of the two components. There are different scales for adults and for children to make the process of selecting a number easier on the clinician.

So, an example of a multiaxial evaluation of someone who warrants information on all axes would look like this (just ignore the numbers):

Client: A.M.
Axis I 296.32 Major Depressive Disorder, Recurrent, Moderate (primary)
305.00 Alcohol Abuse (secondary)
Axis II 301.6 Dependent Personality Disorder
Axis III 278.00 Obesity
Axis IV Victim of child neglect
Axis V GAF = 35 (current)

Say this person came to see me and I requested records from a previous therapist and this landed on my desk. I'd already have a good idea of the client's background from the mention of being a victim of neglect. The obesity might well result in feelings of depression, which initiated the alcohol abuse, and addictions of any kind come easier for a person with dependent personality disorder. I just get a BIG picture snapshot of this person by utilizing this system.

Now there are those who don't like using numbers to define people. Let me say this: I'm a firm believer that no one is identified by their disorder. I don't like it when people are "labeled" or stereotyped by their disorder. Unfortunately, this happens a lot. Insurance companies demand a diagnosis, and if that diagnosis becomes public knowledge (say, the client slips up at tells someone at work), the client could end up the victim of social stigmas.

Still, the benefit of this type of "snapshot" of a person outweighs (in my opinion) the potential abuses of the system. What are your thoughts?

Q4U: What Axis IV problems do you have your hero or heroine dealing with?

Treatment Tuesday - Death of a Fiancé

This week’s character assessment is for Liberty. She wrote in about her heroine, Mandy.*

6 weeks before her wedding, 24-year-old Mandy ended up going to her fiancé Jeff’s* funeral. Shortly after his hunting accident, her parents announce their impending divorce (she’s an only child). As a result, Mandy goes into a tailspin, withdrawing from her friends (including her best friend Rob*, who introduced her to Jeff), changing her job, and moving from her city. 17 months later, she’s still wearing her engagement ring. Rob, who has secretly been in love with Mandy for about 10 years, sees her move to within an hour’s distance from him as a second chance with her. So beginning about 10 months after Jeff’s death, Rob begins to spend time with Mandy. 7 months later, she takes off the engagement ring with the help of her girlfriend, which leads to Rob telling her he loves her. Mandy is amazingly accepting of the fact Rob loves her, although she’s shocked.

* Names have been changed to protect the fictional.

Liberty wants to know what I think about her plot and characters.

Well, kudos on the plot outline, Liberty. You’ve given Mandy a lot of internal angst and external conflict, which always makes for a good read. Let’s look at her mental condition and some other plot points to consider.

Her fiancé dies in an awful hunting accident. Jeff represents her future. Her parents indicate they’re getting a divorce. They represent her past. Likely, the grief would be very overwhelming. See my post here on the stages of grief, or, as I like to say, the phases of grief. Grief reactions are so varied that you can just about write anything and it be believable. So you write in Mandy’s reaction as withdrawal (which seems to focus in on the Depression phase) from her job and friends (and likely her parents, even, though you didn’t mention this). She’s isolating herself because surely no one else can possibly imagine what she’s going through.

Letting others in will not happen like turning on a light switch. But likely she’ll have one person that she can go to (probably the girlfriend?) to keep her sanity. Perhaps the girlfriend is insistent and persistent and won’t let up on Mandy to process what she’s feeling. I’d definitely give Many some sort of grief outlet, even though she’s withdrawing.

It’s interesting that you have her changing jobs. Why? Was there something about her journalism career that reminded her of Jeff? Even better, did she and Jeff share some sort of journalistic aspirations that maybe she felt she couldn’t achieve without him? Were they going to be a dynamic investigative duo? I’d really think about why you have Mandy change jobs, and connect this to Jeff in some way so that it suspends reader disbelief.

I read in your email that she’s now a real estate investor. I’d give a very solid motivation for her going into that field, too. Maybe Jeff was in real estate and had been asking her to join him as an investor. (Of course, realize that there is a lot of training and licensing involved in real estate, as well. Would she be up to taking the classes and tests after such enormous grief?) Or perhaps she was a financial journalist with an earlier background in real estate?

These are just some questions to get the ball rolling.

Now let’s focus on her lasting attachment to her deceased fiancé. 17 months is a long time to wear an engagement ring. Holding on to a loved one happens in many different ways, and to Mandy, the ring is a physical, tangible reminder of the love she shared with Jeff. To take it off would be to devalue her love for him in some way. Keeping it on shows her lasting love and loyalty to him. Her girlfriend would have to be way persuasive to combat this kind of cognitive reasoning, no matter how much of a fallacy it is. So how does she go about getting her to take it off? [Maybe she has her move it to the right hand first? Maybe to a different finger? These are some behavioral therapy suggestions that might work.] I assume you’ll make this a big part of her character arc…the letting go of the past, which includes Jeff. Is there another way Mandy feels she can remember Jeff without the ring? Perhaps her relationship with Rob will be just the thing she needs to keep Jeff’s memory alive between them in a healthy way, since Rob was Jeff’s best guy friend.

My suggestion is this: watch Catch & Release with Jennifer Garner. She loses her fiancé like days before the wedding in a fishing accident. The movie is a romance, though, so there is the aspect of her moving on…and the love interest is her fiancé’s best guy friend. Toward the end of the movie, there is a monologue of just Jennifer speaking that’s truly realistic and very well done. Also, read Karen Kingbury’s Lost Love series. The second book deals with the same issues as your WIP. Excellent, heart wrenching reads, both of the books, and they will give you some ideas how other authors have handled this.

As for dealing with the divorce—and her dad’s subsequent remarriage to someone almost as young as she is—you have to take into context Mandy’s age and life phase. She’s already out of the house, into a career and providing for herself. She’ll still feel the smart from the divorce, no doubt, but it probably won’t be as devastating to her as it would be to a 16-year-old. If you give her some sort of super duper connection to her dad, she could possibly construe it as abandonment. Jeff dies and her dad—the kind of guy she always looked up to and wanted to marry someone like—leaves her mom. This would be a double whammy for sure. Perhaps she picked Jeff for the sole reason that he was so much like her dad. This might make her doubt Jeff’s love for her. (Or an even deeper twist could be that Jeff wasn’t such a stand-up guy, and maybe Rob knew it all along! Maybe he was just like her dad in even a negative way. Perhaps he wasn’t faithful to her? Okay…seriously…go rent Catch & Release today.)

Looking at the time frame you’ve given Rob to work his magic, I’ll give you my two cents worth. Starting 10 months after Jeff’s death, Rob starts to spend time with Mandy. Then you said she takes off the ring, which was at least 7 months later. Jeff would have been dead for 17 months. A good rule of thumb when dealing with spouses of deceased husbands, fiancés and wives moving on is around two years. The reason for this is that usually, it takes about 2 years to psychologically work through the death of a loved one enough to move on (according to most grief research). Anything less than 2 years might cause others to be suspicious. (Let’s face it. We’ve all known someone who got remarried within a year of a spouse’s death…and we’ve all been scandalized. “She must not have loved him very much.” These are the type of thoughts you don’t want a reader having.)

The more time that passes, the better the chance is of the character and the reader being more responsive to a new romantic interest and actually cheer it on. So your 17 months is actually pretty good. It’s believable. If you want to be super safe, tweak the timing. But I wouldn’t have a problem reading it as is. Especially since Mandy and Rob were best friends before she ever met Rob’s friend Jeff. Which leads to a great reason to break the rule of thumb: previous history. She’s got personal history with Rob from long ago…makes it more believable when sparks fly later.

Briefly I’ll touch on Rob’s feelings. His best friend died, leaving the girl of Rob’s dreams suddenly “free,” in the technical sense of the word only, since Mandy’s still totally caught up in her relationship with Jeff. Rob will likely feel a lot of contention within himself about moving in on Jeff’s girl. Perhaps you can have Rob flashback to a conversation between him and Jeff before the hunting excursion where Jeff asks Rob to take care of Mandy while he’s gone. Maybe Rob feels some obligation to Jeff to make sure Mandy’s okay, but he’s hesitant to fulfill his obligation because he’s been in love with her for so long, he’s scared of losing control with her or saying something to make her uncomfortable….something like that. There would likely be some initial guilt when he discloses his love for her, but then I think part of Rob’s character arc could be to realize Jeff would have wanted his two most favorite people in the world to be happy, and if that included being happy with each other, then Jeff would have approved. (Karen Kingsbury’s book is SO good to deal with this. Her book would be a good comparable for yours to include in a proposal.)

Well, hopefully this assessment gets you thinking. I had a lot of fun with this one, actually. I’d be glad to field any questions you have in the comment section, or with another email.

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist@hotmail.com.

Q4U: Anyone care to share what you went through at the loss of a loved one?

T3 - Therapy Basics: The DSM

One thing all therapists, psychologists, licensed clinical social workers, psychiatrists and whoever else might provide mental health services has in common is the DSM. (Oh, and health insurance and pharmaceutical companies, too.)

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (or DSM-IV-TR for short) is called the therapist's "bible," although I'm not thrilled with that association. (I've only got ONE Bible, thank you.) It's put out by the American Psychiatric Association (APA) and the list price of it is about $89, but you can get it from Amazon for $72.

The DSM lists the criteria for mental disorders. Each disorder is given a specific code (i.e. 301.13) and this code is recognized by health professionals everywhere in the US. (Like, I know 301.13 is Cyclothymic Disorder).

In addition to the criteria (list of symptoms to look for in a patient), the DSM provides a lot of other helpful information about each disorder. (Psychiatric terms in bold italics)

1. Diagnostic Features - this is the criteria written out in paragraph form, often with illustrative examples
2. Subtypes and/or Specifiers - gives whether there are different types of a disorder (like there are several types of schizophrenia); specifiers simply give more specifics on the disorder, like when the onset was, or if a certain feature is more prevalent over another
3. Associated Features and Disorders - this gives clinical features that are frequently associated with the disorder, but aren't required to make a diagnosis, as well as associated medical and physical examination findings (i.e., people with an eating disorder are likely to have dental erosion or alcoholics typically can have cirrhosis of the liver)
   
4. Specific Culture, Age, and Gender Features - sometimes people present a disorder in a way that doesn't completely add up with the description on the page, and the reason could be one of the above listed, i.e., their developmental stage or cultural setting
5. Prevalence - the section gives known information for prevalence, incidence and lifetime risk; when it's known, this information includes different settings - community, primary care, outpatient mental health clinics and inpatient psychiatric settings
6. Course - gives the typical lifetime patterns of the disorder: how it's presented, how it evolves, typical age of onset, mode of onset (was it abrupt like PTSD or gradual like Alzheimer's?), whether it's in episodes (episodic) or a continuous course, a single episode v. recurrent, the duration of the disorder, as well as the typical length of the illness and it's progression over time (stable, worsening, improving)
7. Familial Pattern - looks at the frequency of the disorder among first-degree biological relatives compared with the general population
8. Differential Diagnosis - probably one of my most favorite sections, as it gives possible other diagnoses that might be similar as far as presentation and then how to differentiate between the two (or three or five)
   

Not every disorder will include all of this information. Sometimes the information isn't known, and it might be included in the next version of the DSM (to come out in 2012, tentatively). Many times this information changes from publication to publication, as data is gathered from ongoing studies. New diagnoses emerge and some diagnoses get the chopping block or get absorbed into others.

There is talk of including internet addiction, compulsive shopping, or premenstrual dysphoric disorder--that's right, ladies. The real name for PMS, and it's not actually a diagnosis right now!--as well as getting rid of schizoaffective disorder and possible gender identity disorder to reflect the changing times. Major changes within editions usually make the news, the biggest being in 1974 when the APA took out homosexuality as a disorder. As you can imagine, new editions cause LOTS of controversy between professionals in the field as well as political and religious leaders.

But one thing remains the same: this is the therapist's manual. I never see a client when I don't break out this really large book of almost 1000 pages. You can see how this would be helpful in writing, right?

Q4U: Which of the eight sections do you think would be most helpful when writing?

Join me next Thursday as I discuss the multi-axial format of the DSM and why this is extremely useful.

Treatment Tuesday - Identity Crisis

This week’s assessment comes from Susie (by the way, you should check out her new collaborative blog over at Inkwell Inspirations). She writes historicals, so we’re in 1816 England with 25-year-old Trent*, an earl with a tragic family history.

* Names have been changed to protect the fictional.

Trent’s mother and father didn't marry for love, and it shows in his upbringing. His father had numerous affairs and gambled recklessly. His mother was shrewish and revengeful toward her husband. Trent’s father died when he was 19, putting Trent in line for the earldom. The current earl took Trent under his wing, preparing him for the title and leading him to Christ. The earl dies two years later, and Trent steps up as earl and begins a happy and fulfilling role serving in parliament and taking up good causes. His mother, before she dies of some ailment, tells Trent that his natural father wasn’t her husband, leaving Trent to believe he’s not in the bloodline for the title he holds. He feels he’s a usurper, and that were he to marry and have an heir, then the true heir, an infant son to a deceased cousin, would never come to the title Trent thinks rightfully belongs to the infant. So Trent determines to never marry and to tell no one this secret about his paternity.

Due to the guilt he feels, Trent wants to “make up to society” the ill he feels he’s caused by being in a role he doesn’t think he deserves. On top of this, he wants to be loved, but is afraid of it, due to the example he had from his parents. He remembers the example of Christian marriage from the earl, and knows this is something he wants for himself. He’s dealing with anger against both his parents and wants to know who his real father could be. When he falls in love with the heroine, he’s torn between her and his resolve to stay a bachelor.

Susie wants to know:

Does this sound legitimate? How do you think my hero would feel about his paternity and his role?

First, great internal motivation for Trent, Susie! You’ve hit Trent at the core of his identity. I know that back then, honor was a big deal. And if he feels he’s in a position that isn’t rightfully his, then this would provide the exact kind of motivation you want for him to remain single and produce no heir. I don’t think a single reader would doubt the feasibility of this. You’ve portrayed him as a man of integrity, so kudos on taking his internal conflict off the charts when he meets a woman he falls in love with! Ooooh. The tension would just sizzle inside of him. Seriously.

As for how he would feel about his paternity, everyone’s reaction would be different, but there could be some similarities. I’ll dish out a few possibilities and you can pick and choose what you might like to incorporate.

First off, you’ve got a relatively young man (assuming he found out sometime between 21 and 25) and the younger a person is, the more emotional a reaction could be. On the flip side, since he is so young, perhaps he’s still defining his sense of self. Even though a new Christian, he would remember the awful things his father did (the open carousing, blatant overspending, etc) and might feel some relief that that man wasn’t his father. Of course, this might be accompanied with feelings of guilt, as well. But I think this would make for an interesting plot twist. Maybe he had no real affinity for who he thought was his dad. Maybe his dad never treated him with any respect. Certainly sounds like the dad never showed him affection. Instead, Trent might feel more loss at being removed from the bloodline. Since he’s made such a great connection with the earl (who I assume to be his grandfather), when he learns his dad isn’t his dad, then that would make the earl not his grandfather. See where you could go with the internal angst over this? His feelings of unworthiness for the position would even be greater, because he highly esteemed the earl.

Regardless of where you go with the above, I think he’ll definitely want to know who his father is. There’s something inherent in all people to just know who they are, where they come from, where there home is (and consequently, who’s waiting there for them—i.e., parents). In essence, he’ll find out from an angry mother that the life he’s always known wasn’t the truth. He lived a lie and is still living a lie in a position that he’ll think doesn’t rightfully belong to him.

If he feels so strongly about his deceased cousin’s baby being the heir, he might try to set up some sort of trust for the baby, or do something else tangible. I’d think this would make him feel like he was doing something proactive to provide for that baby and his cousin’s family. It could be done on the down low, but this would appear to be a reasonable thing to do on his part to try to right the wrong, so to speak. When it all comes out in the wash (as I assume it will), then he might still want to provide for the young baby.

One idea for how he would feel about his role is that he might treat it like the temporary role it is. You know how when a person thinks they’re going to die, they start to make provisions? Well, he’d make provisions for when the role was no longer his, say, when the baby turns 18 or whatever. This would drive the plot forward for him externally. Even as he falls in love with the heroine, he’d still be making these “provisions” (whatever these might be during that time—you’d know better than me) for when he’s not earl, which might confuse her or contradict her thoughts about him. Maybe he grows more lackadaisical in his attitude toward the position? (That might not fit with the hero’s character, though.) For instance, why go to parliament? Or maybe he’ll start to take on all those causes anonymously, still feeling the need to do good, but yet not to use the name of a title that’s not really his? And perhaps the heroine could find out about his generosity later? Just some suggestions…

Oh. One more thing. His sense of betrayal from his mother would be high. I would think he’d even feel some anger towards her for how she told him. (Brings to mind a book I just read called The Duchess and the Dragon. It’s a historical, too, and I did a review on it here. But Drake, the Duke, finds out at the very beginning of the book while his father is on his death bed that he’s not in line to inherit the title, that he was illegitimate. Drake is ticked, to say the least, even after his dad dies.) So depending on the relationship you’ve developed between Trent and his shrewish mom (I know you mentioned he tries to witness to her, but it doesn’t seem that was received well), then this is an angle you might want to explore.

Drop me any questions or further comments you want me to consider in the comments section. I LOVE brainstorming! Sounds like a terrific premise, though.

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist@hotmail.com.

T3 - Therapy Basics: Assessments

An assessment is a therapist's most basic tool. They all look different, include different questions in different orders. Some are very extensive, up to several pages long, while others are short and to the point (i.e., "Why are you here?").

The assessment I've used for years is around five pages and it includes the following:

Identifying Information Presenting Problem(s)
*Psychiatric Symptoms/Behaviors
Individual's Expectations
Developmental History
Educational History
Marital History
Work/Military History
Medical/Physical/Psychiatric History
Substance Abuse History
Legal/Incarceration History
Relevant Financial Issues
Relevant Ethnic/Cultural Considerations
History of Trauma (best to just know this up front, so I ask)
*Mental Status Exam
*Suicide Risk Assessment
*Assault Risk Assessment
Diagnostic Impressions (where a diagnosis is assigned)
Clinical Summary/Impressions (overall)
Individual Strengths and Weaknesses
*Current Areas of Functional Impairment (to focus treatment)
Treatment Referrals (either to a medical doctor for a physical; a lawyer for legal aide, etc.)
Final Plan (what client agrees to)
*Release(s) of Information Obtained
Therapist Signature

Like I said, assessments differ as widely as the therapists who use them. I happen to like this assessment because it was developed to meet state requirements for someone on MediCal (which is the equivalent of Medicare for those who don't live in California). MediCal requirements are extensive, so I know my assessment is, too.

Breaking it down isn't that difficult because most of it is self-explanatory. I put a star next to those elements that might need a bit more explanation.

As you could see by the list, most of the information I gather is history, plain and simple. I have to know where a client is coming from before I can try to help them to where they want/need to go. So history gathering is extensive, and it can take more than one session to get everything down.

Psychiatric symptoms/behaviors are what I observe to be problematic during the initial interview. What symptoms of disorders are florid (very clearly exemplified)? Are they agitated? Tearful? Which symptoms does the client self-report (it can be that a client has panic attacks that I'd never see in the office, for example)? A knowledge of the Diagnostic and Statistical Manual is imperative for this type of assessment.

A mental status exam is kind of like a mini-assessment all by itself. I basically see if the person is in their right mind or not. Do they know who they are? What year it is? Who is president? What 2+2 is? Can they remember my name five minutes into our assessment after I gave it to them at the beginning? What is their speech pattern like? How are the groomed/dressed? These types of questions, if answered incorrectly, can automatically point a therapist to severe disorders like schizophrenia.

A suicide risk assessment and an assualt risk assessment are included to protect the therapist from litigation. No one would want a client to come to see them only to kill themselves hours later. So I've developed the habit of always broaching the subject of self harm and harm to others in the first session, just to see the client's reaction (are they shocked because they are offended, or because they have had suicidal thoughts?) and be able to note in my case notes for that client their response. This shows that I have acted as a reasonable therapist and protects me should I get sued (which thankfully I have never been!).

Current areas of functional impairment is just a fancy way of saying "What areas does this client struggle with the most?" How severe is the struggle? Moderate? Mild? None? Extreme? Here are the major areas I assess for:

1. Community Living

2. Community Participation

3. Community Contribution

4. Financial

5. Relationships with Others

6. Education and Learning

7. Physical and Emotional Health

8. Legal

And the release of information section is just to know who exactly I have permission to coordinate treatment with. I did a lot of school counseling, so I always had to have a release of information for the school. If you need to be in contact with a medical doctor, their name should be on a release somewhere. Having a list of all these contacts in one place is very handy.

So, this is what all I include in an assessment. This is not to be confused with intake paperwork a client fills out when they come into your office. An assessment is a document likely no client will see. Intake paperwork asks some of the same type information I've listed, and most therapists can compare the information to what the client actually tells them, looking for consistency, as well as use the intake paperwork to help fill in the assessment after the session is over (to spark their memory, etc.). It never hurts to repeat information in different places.

Join me next week as I discuss the Diagnostic and Statistical Manual-IV-TR, also known as the DSM or therapist's "bible."

Q4U: Have you or someone you know ever gone through an assessment similar to what I've described above? What might have been some areas left out of my assessment that were on yours?

Interview with Author Lynnette Bonner and Book Giveaway!

Today I'm doing my first author interview, combined with a blog tour and book giveaway! Lynnette Bonner is with me today to talk about her new release, Rocky Mountain Oasis. I read this book in just a few days and really enjoyed it. Lynnette was kind enough to answer some questions from my therapeutic angle, which I've included below.


First, a blurb about the book:

She's been living in a desert all her life. Suddenly she's come upon an oasis. But is it just a mirage?

Brooke Marie Baker, eighteen, has been sent west as a mail-order bride. As the stage nears Greer's Ferry, where she is to meet the man she's pledged to marry, she tries to swallow the lump of nervousness in her throat. Can it be any worse than living with Uncle Jackson...or Hank? she wonders. All men are the same, aren't they? But with her parents and sister dead, she has no choice.

Sky Jordan, a rancher, holds a single yellow daisy in his hand as he watches the ferry cross the river. Ever since he'd found out his surly cousin, Jason, had sent for a mail-order bride, his mind and heart had been ill at ease. No woman deserves to be left with the likes of Jason. But now he questions his own plans to claim the bride for himself. Why am I drawn to this woman I don't even know?

Rocky Mountain Oasis is Book One in Lynnette's The Shepherd's Heart series.

Jeannie: Tell me a bit about what got you into writing. Readers always love hearing about an author’s journey.

Lynnette: I always loved to read. And after awhile I started having stories of my own floating around in my head. Writing is something I’ve toyed with for a long time. But I didn’t seriously start writing until about 1999.

The oasis is a desert metaphor prominent in Brooke’s life as she thinks about her history with men and how different Sky is from them. What made you choose this metaphor?

I think there are many women today who may feel a little like they’ve been living a dry, parched life. I want them to know that it doesn’t have to be that way. Not all of them can have a nice guy like Sky. But all of them can have the relationship with Jesus that Brooke finds in the book.

What is it about a marriage that brings the hero and heroine prematurely and permanently together early in the book that just touches a chord with women? If this happened in real life, we wouldn’t have such warm fuzzies. Why do you think it’s different when reading about it?

Romance is all about the happy ending. I think we all know how hard that situation would be in real life – so the happy ending is all the more fulfilling when it comes about.

For someone with such a battered past as Brooke, it’s not any wonder that she found trusting Sky hard to do. What primary method did you choose for Sky to win her trust and why?

Sky had to show her he was trustworthy through kindness and patients. She wasn’t going to believe him until she experienced safety and True Love for the first time in her life. I chose that method, because I honestly think it would be the only one that would work in that situation.

It’s said that Christian marriages have 3 partners: the husband, the wife and the Lord. But in Sky’s marriage, there is another partner: Brooke’s baggage. How hard was it writing Sky’s perspective as he dealt the fourth party in his relationship?

I don’t think it was any harder than writing the other scenes in the book. In a sense we all bring some baggage into our relationships.

Brooke suffers from terrible nightmares about her past. These are bad enough to effect how she views her present. In effect, she has post-traumatic stress disorder. Did you know anything about this disorder when you were writing?

No. I’d heard of it. But had no firsthand experience with it. I just tried to put myself in the shoes of someone who had been treated in that way and imagine how that might affect Brooke and her relationships with others.

What kind of research did you do on the effects of opium withdrawal?

I did most of that research online. There is so much information available online now. It is wonderful for writers. If you are typing a scene and you don’t know what the symptoms of opium withdrawal are, within 5 minutes you can have your answer.

Usually there is only one salvation experience in fiction books. What was behind your decision to include two?

I didn’t originally intend to redeem Jason. But as the story unfolded I just fell in love with him. And I knew I couldn’t leave him wallowing in his misery. He is the hero in the second book in The Shepherd’s Heart series, High Desert Haven.

Where did you find And Five Were Hanged: And Other Historical Short Stories of Pierce and the Oro Fino Mining District by Layne Gellner Spencer from which you based your book?

I lived in the town of Pierce, the setting of the book. That book was in our local library. The history of Pierce (previously known as Pierce City) was so interesting that a story begged to be told.

I want to add a note of thanks to Jeannie for allowing me to be here today. I’d also like to give away one e-copy of Rocky Mountain Oasis to a winner drawn randomly from this post's commenters. The winner will be announced next Wednesday the 9^th of September.

Big congratulations to Lynnette for her book release and thanks for being on my blog. You can find Lynnette's book at Amazon or CBD.com.