September/October 2008 Issue

Therapist’s Notebook: Case of Denver and Claudia
By Camille Call, LCSW
Social Work Today
Vol. 8 No. 5 P. 24

Social Work Today presents a case vignette with input from three social workers—a case presenter and two discussants who offer their insights on the presenting problem, case background and family history, and initial phase of treatment.

Denver and Claudia seemed to be the perfect clients, particularly for a private practice setting. They were always on time, were respectful of my time as the clinician, and they paid their bill regularly. They were both well educated and able to articulate the purpose for seeking therapy, communicate their concerns, and listen to one another as easily as they listened to me. But I had a troublesome suspicion at the back of my mind that there was more to their story. However, as a professional, I followed one of the basic tenets of social work: begin where the client is.

Denver and Claudia had been married for nearly 23 years. They had three children: Emily, 19, who was living away from home while attending college; Aimee, 17, a soon-to-graduate high school senior; and Connor, 14, who kept up with his sisters scholastically but had begun presenting serious behavioral problems. Denver and Claudia considered treatment for their son, ultimately deciding to seek help for themselves first in order to assist them with parenting, dealing with a rebellious teenager, and helping bring peace back into their home.

Denver and Claudia spent years developing a successful business that had spread throughout the state, with call centers in several other states. They planned their family well, stating that by the time their first child was born, they were in an excellent financial position.

Because recent years brought in a significant amount of business profit, they decided to move away from the metropolitan area in which they had been living and into a more rural setting. They would keep an apartment in the city for Denver when he needed to spend the night.

This decision to move was not made impulsively; rather they considered all family members and any subsequent effects. They purchased a beautiful home with 2 acres of land. Emily was excited about the move and looked forward to coming home from college to ride horses and go four-wheeling. With parental support, Aimee decided to live with close family friends so she could graduate with her class and friends at her high school.

Denver and Claudia thought the move might be helpful with Connor’s recent behavioral changes, and although he balked at having to leave his friends, he finally agreed. He wondered if this would be an opportunity to make new friends and “start over,” especially because he would be entering high school.

Beginning the therapeutic relationship, both Denver and Claudia made it clear they did not want Connor involved until a later date, perhaps even with a referral to an adolescent specialist who could effectively work with him. Our weekly sessions focused on parenting, how their style had adapted and/or changed while raising three children, and how they might be using a different parenting style with their only boy than they had with their two girls.

While creating the treatment plan, we included individual homework assignments for Denver and Claudia to complete separately, as well as others for them to complete together. For example, many weeks into treatment, each parent was to privately complete a questionnaire related to how they viewed their own parenting style with Connor, comparing it with how they viewed their spouse’s style.

Working as a therapeutic team, we established the questions together, with both Denver and Claudia agreeing to maintain the confidentiality of their own answers until the next therapy session. By this time, we had established basic goals and parameters, had delved deeply into Connor’s specific troubling behaviors, and worked hard on maintaining consistent rules and consequences for inappropriate behaviors and adding dependable rewards for all positive behaviors.

As they returned with this assignment in hand, the earlier niggling in the rear files of my brain began coming to fruition. Denver’s written comments on the questionnaire compelled me to ask even more intimate questions about the couple’s relationship than had previously been addressed. Slowly, the realities of Denver’s true purpose for seeking treatment began to arise. For the first time as he spoke, he avoided Claudia’s eyes, turning his comments only to me. Several sentences into his monologue, I watched Claudia’s face turn from her usual calm to surprised then shocked. She was speechless. When Denver finished speaking, I asked him to turn to Claudia and tell her what he had just told me. Hesitantly, he did so.

He began to tell his wife how difficult he found it trying to set a good example for Connor. This, Denver said, was because he had finally admitted to himself that he believed he was homosexual. It had taken most of their marriage for him to realize he was even questioning his sexuality. Once he had moved his family out of the city, Denver began acting on his internalized fantasies. Yes, he told Claudia, he had already been with two different men as he explored who he truly was.

Claudia, unable to speak, began to weep silently. The weeping turned to sobbing as she attempted to leave the office in as dignified manner as possible. After Claudia was gone, Denver returned to his discussion with me, appearing to justify his behavior. I let him speak until he was finished. I then asked if the move from the city was purposeful—that is, with the intent to live his “other” life without the knowledge of his wife and children. He thought about his response, finally stating, “No, I moved the family here so that I could feel good about divorcing Claudia because I had given her a beautiful home with new neighbors and friends. I guess I just didn’t realize how quickly it would happen.”

To his credit, Denver had been forthright in our discussion. But now, therapy was no longer about parenting a child with behavioral problems. It became a lengthy process of Denver disengaging from Claudia, and Claudia accepting the decision that was made without her input. We worked together for about five more weeks before Denver stopped coming to therapy and was reportedly moving completely out of the house and into his apartment in the city. Claudia continued in treatment to try to come to terms with not only the seeming suddenness of Denver’s admission but peripheral issues that accompanied such a traumatic change in her life.

— Camielle Call, LCSW, maintains a consultation and contract supervision practice in Sitka, AK.
 
Discussion No. 1
By Donna M. Ulteig, MSSW, LCSW, ACSW, DCSW

Denver and Claudia’s case is an example of what keeps our work as therapists so fascinating—the “perfect clients,” yet a “troubling suspicion.” We learn to listen to those gnawing feelings in the back of our brains.

This is a couple that said all the right things, acted with a plan, listened to each other, and communicated with warmth. Now, why would they have an acting-out 14-year-old son? Our education about family therapy teaches us that acting-out teens are but a symptom, and early on we assign ourselves the task of unearthing the underlying family dysfunction. So, we begin with a gut feeling, and our subsequent work involves making sense of the intuitive information.

We cannot underestimate the importance of intuition. I am supported in this assertion by Malcolm Gladwell, who proposes in his book, Blink, that our clinical (and other) judgments are made within seconds and quickly formulated by focusing on just a few salient details. I suspect that the contradiction between the presenting problem, a parenting issue, and this conflict-free presentation of the parents raises those primitive hairs in the back of our heads.

Intuition seems to be psychologist John Gottman’s strong suit. This couples therapy guru predicts marital longevity with an astounding degree of accuracy. His judgments are based on the “four horsemen” (criticism, defensiveness, shows of contempt, and stonewalling), and a 5-to-1 ratio of positive communications vs. real or perceived critical comments. Denver and Claudia treat each other respectfully, boast financial solvency, and have raised at least two apparently healthy children but fail to present evidence that they belong in Gottman’s “doomed” group. In spite of their “outlier” status, I suspect that Gottman might have had something like a “troubling suspicion.”

As it turns out, this “perfect case” is actually quite complex. The gnawing secret is that Denver, who has prided himself in being a good father, husband, and provider, now realizes he is gay. We know this is a fairly new awareness but that he has acted on these attractions with two different partners. He also acknowledges that he planned the new home in the country as a way to alleviate his guilt about divorcing Claudia. For Denver, therapy was not just about parenting Connor; it was about getting to the divorce.

Denver wants his family to be happy but approaches their happiness in a kind but rather paternalistic fashion. He decides that a move is best for the family without Claudia or his children having full information about how this change would meet his needs. He has continued to stay in his marriage while having other partners, potentially exposing Claudia to sexually transmitted diseases. Is it more than a coincidence that he is having trouble parenting an acting-out son at a time when he is also secretly acting out? Although we do not know the timing or nature of Connor’s behavioral problems, I am curious about the relationship between Denver’s sexual orientation struggle and his son’s behavioral changes. While I do not want to minimize Denver’s dilemma about how to care for a family he loves and also meet his own needs, coming out is an emotional experience for a family.

And so it is for Claudia. She is so distraught initially that she sobs and leaves the session. She has worked closely with her husband to build a successful business, raised their three children, and the couple has had a seemingly pleasant, collaborative relationship. The reality of Denver not being who she thought he was has a multitude of ramifications. She may wonder about her own femininity and sexual attractiveness, she may have rage about the extent of Denver’s deceit, and she may feel betrayed by his choice to be with other partners.

Denver and Claudia now have to pick up the pieces of their lives, and their three children have feelings and needs that must be addressed. Connor has undergone a move to the country, the loss of his friends, the loss of both sisters, and now with his father gone, an additional change in the family constellation. While Emily and Aimee may have a bit less to lose than Connor, family therapy is in order to help them adapt to these life changes.

Denver’s secret reminds me that it is often best to schedule individual sessions with each partner in couples therapy to first take a thorough family of origin history for each person, and second, to flush out potential bombshells early on. Obtaining information about intergenerational patterns and dynamics (in either individual or conjoint sessions) helps clarify that troublesome suspicion when it arises. Who knows? In a one on one with the therapist, Denver may have confided his sexual identity issue, allowing the therapy to move to the underlying issue without having to spend weeks on parenting skills.

— Donna M. Ulteig, MSSW, LCSW, ACSW, DCSW, has been a partner in the private practice group Psychiatric Services SC in Madison, WI, for 23 years.

Discussion 2
By Julia L. Hankerson, PhDc, LCSW
Clients often enter therapy with an underlying issue that is too difficult for them to discuss. Fortunately, Denver and Claudia chose a therapist with this insight who had the patience to allow the underlying, primary issue to be disclosed and subsequently addressed.

This requires developing a therapeutic alliance with the client (in this case, both clients). Denver was married for nearly 23 years, had three children, and a successful business. He had been a member of mainstream America for many years, and the change that he was contemplating would be drastic. Denver may have actually been interviewing the therapist to determine whether he could trust her to be objective and determine if she had the skills required to help his family.

Although the therapist recognized that Conner’s behavioral problems may not have been the primary issue for seeking therapy, she chose to follow the basic tenet of social work to “begin where the client is” rather than attempt to refocus the clients. She established a therapeutic alliance, completed a social history, and developed a treatment plan addressing the identified issue with evidence-based techniques, such as parent education, homework assignments, and relevant questionnaires.

By following this plan, the therapist apparently provided Denver with the evidence that he needed to disclose his primary reason for seeking therapy and to allow the therapist to help his family to come to terms with his admission and cope with any other related issues.

Several factors may have helped this therapist to develop insight into the fact that the presenting problem was not the main issue. First, Denver and Claudia’s disinterest in including Connor in the sessions indicated that helping him with his issues was a secondary concern. This information suggests that perhaps Claudia was also aware that there was a marital issue but was afraid to face it. When two people have been involved in a long-term intimate relationship and infidelity occurs, the affected partner recognizes the signs but often uses defense mechanisms such as denial to cope. Should confrontation occur too soon, alienation from the therapist and abandonment of the therapeutic alliance could occur. It is a therapist’s responsibility to develop a trusting and supportive environment so that the true process can begin. Claudia may have also been trying to determine the therapist’s ability to help her.

This situation was very delicate and traumatic and required delaying the confrontation or pursuit of the underlying marital issue. Subsequently, in dealing with Claudia, the therapist should continue to proceed with caution. It will be necessary to help Claudia to cope with her loss, grieve, and develop tools that will help her to rebuild her life.

Cognitive behavior therapy may be helpful. This therapeutic intervention could offer Claudia techniques that will allow her to confront her pain in small doses, understand her feelings, and change her perception of what happened, and how and why it happened so that her thoughts become more manageable. The therapist will need to help Claudia recognize that her feelings are normal. This will be only the beginning of the treatment that is required for Claudia to begin stabilizing her life.

Each child should have the opportunity to speak with the therapist to determine how the changes in family life are affecting them and the level of intervention required. Ideally, the goal is to have Claudia and Denver coparenting and have this family functioning again as a unit despite the many changes.

— Julia L. Hankerson, PhDc, LCSW, is in private practice at the Wellness Center in Woodbine, NJ.