Patrick entered treatment at the age of 14. He was cutting school constantly, smoking marijuana daily, and involved in no activities outside of "hanging out". He was unresponsive to adults except when he exploded in violence at which times he would commit minor acts of vandalism. Interestingly, those acts damaged his own property as often as it did othersí. In the past he had exhibited behaviors that marked him as a very poor prospect for any kind of successful adjustment. He had been cruel and violent towards animals and he used to bang his head quite loudly on the lockers at school to get attention. He had been hospitalized twice for such disturbing behavior. Statistics show that children with histories like this often do not respond to any kind of treatment. They end up in jail or worse, and change only as adults if at all. 

Patrickís behavior was irrational; he damaged his prize drums as readily as he stole his motherís five-dollar bills. He admitted enjoying the latter behavior, and the marijuana, but acknowledged his confusion over why he would wreck his own property. In one of his few utterances during first months of treatment, he was painfully articulate about being lost. Of his outbursts, he said, "I canít stop it. It just happens. I donít know why". Patrickís mother was very confused as to where to draw the line with her sonís behavior, and how to enforce her wishes once she decided on that line. 

Patrickís father was a chronic alcoholic who had moved out of the house just before I met Patrick. Apparently, at a family meeting at the hospital, father was pressured by therapists and his wife to stop drinking; Patrick spoke up about resenting it as well. Father said he wasnít about to give up drinking, and he left. 

Patrick was blank, listless, almost zombie-like during our sessions. If a patient doesnít relate to you in some way, even if not by speech, you canít have a relationship. No relationship, no psychotherapy. So I brought his mother in and the three of us talked about what was needed for the household to be sane, functional, and under appropriate adult control rather than her sonís. Patrick didnít contribute much but at least he heard the process. Mother was very unsure of herself, and I ended up being a kind of surrogate authority figure in the house for a while. She called me frequently to ask if she was handling things well. 

During that year, Patrick was sent to the hospital, to court, and eventually to long term placement because he was so out of control at home. He called me several times from placement, and finally change began to happen. When he returned home, he slowly became a real psychotherapy case. We began to talk about things; we uncovered feelings, thoughts, and especially behaviors of which he was previously unaware; we saw together how his fatherís attitude and behavior over the years had so perplexed and hurt him; we discovered all the myriad feelings and attitudes that were causing his various behaviors; and Patrick worked through all of these with substantial results. He now has a life full of activity, pursuits both academic and extracurricular, a girlfriend he has been with for over a year, a new circle of friends who are drug free, and he is rapidly turning into a responsible adult.

At the beginning of treatment Patrick flat out refused to deal with me. Later his resistance took on more subtle forms. In all cases I had to confront him rather harshly at times to break through it. Even years into our relationship, he had a habit of treating me and our conversations as if he were being interrogated by a hostile school principal. Sometimes, we could both see this resistance as a reaction to quite agonizing self-consciousness and feelings of inadequacy -- it was easier to make an enemy of me than to experience those horrible feelings. Other times, we couldnít get anywhere. Meanwhile, I had to strike a balance between being the stern authority he and his family needed, and providing the understanding, support, and guidance that would allow him to get beyond his pose of disinterested hostility. I had to confront harshly yet remain accepting and sympathetic, helping Patrick and his mother articulate the many confusing feelings, thoughts, opinions, and frustrations that were entangling their lives. I think I talked more in my sessions with Patrick than I did with any other patient. Contrast that with Mikeís course of treatment.

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