Young adult client reports that mother hit, put hand around client's throat recently. How should I conceptualize/handle?

[NewTherapist1964]

Hi all! I've been a licensed and in a group pp for two years but this is a first. Will bring to supervision but wanted to ask for some perspective/advice here as well. I am a bit stuck with where to go with adult client, living with parent, who reported a fairly recent incident of being hit and grabbed on the throat. Client seems to be downplaying things, but is clearly fearful of parent (not of being injured physically, but more so emotionally terrified and devasted by every comment).

There is a history of emotional trauma and a lot of dysfunction and chaos in childhood and throughout entire life, and the relationship between them is extremely enmeshed (mother moved into client's dorm room at one point).

We are working on developing a sense of self and setting boundaries, with the eventual goal of independence. We are starting really small but even setting small boundaries seems impossible to client and exacerbate client's anxiety and hyper-vigilance about pleasing/disappointing me. Moreover, client often seems unaware or conflicted about whether she has a right to things like privacy, spending her own money how she wants, the right to not being screamed at/intimidated/called names, since she is still living in parent's home.

What can or should I do with a client like this?

EDIT: Just wanted to add that I'm not asking about reporting as client is not a minor and not in life threatening danger. I'm more asking about how to move forward with her treatment given what I know about her situation.

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[WisNeuro]

Is the patient a vulnerable adult? Legally speaking?

 

[NewTherapist1964]

Is the patient a vulnerable adult? Legally speaking?

No.

 

[PsyDr]

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[NewTherapist1964]

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October is Domestic Violence Awareness Month. Help us raise awareness of this silent epidemic which victimizes more than 12 million people each year.

www.unitedway.org

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You think this is that serious, really? Even if it was provoked by dishonesty on my client's part (I only ask because client seems to believe she is partly responsible and wanted me to know she did something ****ty to provoke her mother)

 

[WisNeuro]

You think this is that serious, really? Even if it was provoked by dishonesty on my client's part (I only ask because client seems to believe she is partly responsible and wanted me to know she did something ****ty to provoke her mother)

So, domestic violence is ok as long as the other person did something to annoy/offend/anger you?

 

[NewTherapist1964]

So, domestic violence is ok as long as the other person did something to annoy/offend/anger you?

No I don't think so. My client does though, or at least says she does. She is extremely afraid of "exaggerating" or "seeming like [she's] playing the victim" or blaming her parents. She feels like she has no right to "complain" when she is the adult child living at home with her mother and still dependent on her financially (though mom is herself dependent on her own parents and ex husband, and client does pay mother 500 a month). I completely agree with you but I just wanted to make sure other professionals are on the same page when I gently confront client about assumptions and fears that she is "exaggerating" or "making it sound worse than it is." And she made sure to tell me it was very unusual and not normal behavior from her mother though it's clear the relationship on the whole is unhealthy and damaging to client.

I just wanted to get some perspective as I have never encountered an adult child who is financially dependent on parents being hit before and client herself is hesitant to keep blaming her parents when she knows she has made a choice to live at home and not take on adult responsibilities.

 

[PsyDr]

You think this is that serious, really? Even if it was provoked by dishonesty on my client's part (I only ask because client seems to believe she is partly responsible and wanted me to know she did something ****ty to provoke her mother)

Well, that's usually called a "felony". And the intimate partner domestic violence literature says that non-fatal strangulation is associated with more than a SEVEN fold increase risk of homicide (Glass, et al., 2008).

So, I think it is a bit serious. And trending in the wrong direction.

If this person ends up murdered, do you really want your documentation to say, "Yeah, I told them to go back into that dumpster fire. "

 

[NewTherapist1964]

Well, that's usually called a "felony". And the intimate partner domestic violence literature says that non-fatal strangulation is associated with more than a SEVEN fold increase risk of homicide (Glass, et al., 2008).

So, I think it is a bit serious. And trending in the wrong direction.

If this person ends up murdered, do you really want your documentation to say, "Yeah, I told them to go back into that dumpster fire. "

Thank you for replying. I appreciate it and I agree. I just wanted to make sure I wasn't overreacting. I noticed on some other threads (like the Jenna McCurdy one) you seemed to think her abuse was less severe/serious than other people on that thread did, so I was surprised by your response here.

Even if client herself doesn't believe or won't admit that it is serious, and that any real harm would come to her, I do still think you are right.

 

[BuckeyeLove]

Definitely get good consultation tomorrow. But as others have said, DV like this is no joke. The violence risk literature is about as robust we have comparatively in the field, I’d familiarize with some of it (don’t need to be an expert) and consult with colleagues.

 

[NewTherapist1964]

Definitely get good consultation tomorrow. But as others have said, DV like this is no joke. The violence risk literature is about as robust we have comparatively in the field, I’d familiarize with some of it (don’t need to be an expert) and consult with colleagues.

Thank you. I'd never encountered or read about DV among adult children and parents (particularly mothers), so this is a bit new for me but I suppose it is not that different from other types of DV.

 

[Fan_of_Meehl]

Hi all! I've been a licensed and in a group pp for two years but this is a first. Will bring to supervision but wanted to ask for some perspective/advice here as well. I am a bit stuck with where to go with adult client, living with parent, who reported a fairly recent incident of being hit and grabbed on the throat. Client seems to be downplaying things, but is clearly fearful of parent (not of being injured physically, but more so emotionally terrified and devasted by every comment).

There is a history of emotional trauma and a lot of dysfunction and chaos in childhood and throughout entire life, and the relationship between them is extremely enmeshed (mother moved into client's dorm room at one point).

We are working on developing a sense of self and setting boundaries, with the eventual goal of independence. We are starting really small but even setting small boundaries seems impossible to client and exacerbate client's anxiety and hyper-vigilance about pleasing/disappointing me. Moreover, client often seems unaware or conflicted about whether she has a right to things like privacy, spending her own money how she wants, the right to not being screamed at/intimidated/called names, since she is still living in parent's home.

What can or should I do with a client like this?

EDIT: Just wanted to add that I'm not asking about reporting as client is not a minor and not in life threatening danger. I'm more asking about how to move forward with her treatment given what I know about her situation.

Regarding treatment...sounds like a strong possibility of dependent personality disorder. Conceptualize and treat. Be wary of 'triangulation' dynamic (e.g., when ya'll are working on assertive behavior, boundaries, etc. within an enmeshed family system, her presenting her new disturbing behavior of assertive communication as 'my therapist told me to say this.'). I'd definitely take a more Socratic approach and let HER articulate her goals in this direction. Go heavy on the motivational interviewing stuff. Unfortunately, due to her growing up in that enmeshed/dependent system without meaningful boundaries, it's going to be a real struggle for her (and she will feel real ambivalence toward) to separate/emancipate herself. Mom's gonna hate you. Good luck.

 

[summerbabe]

I just wanted to get some perspective as I have never encountered an adult child who is financially dependent on parents being hit before and client herself is hesitant to keep blaming her parents when she knows she has made a choice to live at home and not take on adult responsibilities.

Glad that you are bringing this is in supervision. Hard cases should not be gone at alone.

You can start by calling a spade a spade. An adult putting their hands on another adult is an arrestable offense. And between downplaying things and lack of disclosure, there’s likely more that you don’t know about which may be even more concerning.

One step would be to utilize the therapeutic relationship that you’ve developed with this patient to highlight your genuine concern for their well-being while also providing a reality check of the gravity of their situation that they may not receive anywhere else or can do for themselves.

For your own introspection, I would recommend exploring what you are bringing into this situation and how it has shaped your response, including choices you have not made or considered.

To take a conceptual page from DBT, a therapist should always be reflecting on where they are landing on the acceptance to change spectrum.

When we are off (such as being too accepting of maladaptive behavior because we emphasize with somebody circumstances or being too change focused when the patient needs something else like validation), our effectiveness decreases until we regain a more appropriate balance. And in most cases, we should be doing both but temporarily lean in one direction or the other based on circumstances and then continuously readjust as situations shift.

We are starting really small but even setting small boundaries seems impossible to client and exacerbate client's anxiety and hyper-vigilance about pleasing/disappointing me.

Moreover, client often seems unaware or conflicted about whether she has a right to things like privacy, spending her own money how she wants, the right to not being screamed at/intimidated/called names, since she is still living in parent's home.

If the latter is happening, some type of cognitive and emotional shift is likely needed before positive steps such as the former can occur.

To take another page out of DBT, sometimes in these scenarios, we can provide an extreme example and force the patient to grapple with it. Like what should happen if the patient was to choke you because they disagreed with something you said/did?

I mean, they are paying for your time and some people in our field even suggest having unconditional positive regard for our patients so that behavior would be totally cool, right?

Good luck with consultation tomorrow.

 

[Fan_of_Meehl]

Glad that you are bringing this is in supervision. Hard cases should not be gone at alone.

You can start by calling a spade a spade. An adult putting their hands on another adult is an arrestable offense. And between downplaying things and lack of disclosure, there’s likely more that you don’t know about which may be even more concerning.

One step would be to utilize the therapeutic relationship that you’ve developed with this patient to highlight your genuine concern for their well-being while also providing a reality check of the gravity of their situation that they may not receive anywhere else or can do for themselves.

For your own introspection, I would recommend exploring what you are bringing into this situation and how it has shaped your response, including choices you have not made or considered.

To take a conceptual page from DBT, a therapist should always be reflecting on where they are landing on the acceptance to change spectrum.

When we are off (such as being too accepting of maladaptive behavior because we emphasize with somebody circumstances or being too change focused when the patient needs something else like validation), our effectiveness decreases until we regain a more appropriate balance. And in most cases, we should be doing both but temporarily lean in one direction or the other based on circumstances and then continuously readjust as situations shift.


If the latter is happening, some type of cognitive and emotional shift is likely needed before positive steps such as the former can occur.

To take another page out of DBT, sometimes in these scenarios, we can provide an extreme example and force the patient to grapple with it. Like what should happen if the patient was to choke you because they disagreed with something you said/did?

I mean, they are paying for your time and some people in our field even suggest having unconditional positive regard for our patients so that behavior would be totally cool, right?

Good luck with consultation tomorrow.

I'd just say to be aware of the dangers of being maneuvered, as her therapist, into the role of her 'rescuer.' Obviously, you want her to be safe and can/should advocate for that and encourage her to take steps to increase her safety. Know any pertinent policies/procedures of your organization/ hospital, know your state's statutes word for word (any that apply to this kind of situation). Provide her all kinds of avenues, options, support, names/numbers of agencies or programs that can help, etc. But I'd just be aware of the fact that in the process of emancipating from mom, she's gonna have a tendency to pull you into the direction of a role as 'savior' in ways that may not necessarily be therapeutic. But obviously, following the law and also advocating for your patient to be physically safe take priority. It's a fine line to tread.

 

[NewTherapist1964]

I'd just say to be aware of the dangers of being maneuvered, as her therapist, into the role of her 'rescuer.' Obviously, you want her to be safe and can/should advocate for that and encourage her to take steps to increase her safety. Know any pertinent policies/procedures of your organization/ hospital, know your state's statutes word for word (any that apply to this kind of situation). Provide her all kinds of avenues, options, support, names/numbers of agencies or programs that can help, etc. But I'd just be aware of the fact that in the process of emancipating from mom, she's gonna have a tendency to pull you into the direction of a role as 'savior' in ways that may not necessarily be therapeutic. But obviously, following the law and also advocating for your patient to be physically safe take priority. It's a fine line to tread.

Thanks for this advice. What in particular about this patient or patient's situation make you think she will have a tendency to pull me into a savior role?

 

[Fan_of_Meehl]

Thanks for this advice. What in particular about this patient or patient's situation make you think she will have a tendency to pull me into a savior role?

I mean, I don't know her but it's just kind of a 'pattern recognition' at this point based on experience as well as a bit of logical deduction. Nature abhors a vacuum. Enmeshed dyads tend to turn into triangles (triads) with a predictable 'victim,' 'perpetrator,' and 'savior' dynamic. Again, I'm NOT saying she's NOT a victim in a very real sense. Just highlighting the protons/neutrons and electron clouds involved, lol. She sounds like, from birth (literally before the ground of her consciousness even developed) she has been in an environment that likely sent her signals that she isn't capable of fending for herself or making it without mom (or an alternative savior/protector) and she's likely developed schemas consistent with this (see Beck et al.'s book on the cognitive profile of dependent personality disorder). I'm not saying I'm diagnosing her or anything, just saying these are hypotheses that would be on the table for further exploration. She's going to have to discover, for herself, what those implicit 'rules' are that she's been living her life by, what the consequences of keeping or changing those rules are, and what she would like her life to look like from here on out and you can't do that work for her (though you can ask good questions and create a space conducive to her doing that work).

I'd also bet dollars-to-doughnuts that you're not necessarily getting a 100% accurate accounting of her relationship with mom. You're only seeing it through her eyes. She's also obviously getting some pretty powerful reinforcement (negative or positive) from staying enmeshed/dependent or else she wouldn't be in that situation long-term. She will need to identify for herself the implicit rules/schemas that govern her cognitive/emotional/behavioral patterns and that make it so difficult for her to emancipate from mom (and not rely on someone to replace mom). It's just how these things tend to work.

That being said, I've never examined her or her record and I am definitely not in the role of supervisor so just take my off the cuff musings with a mountain of salt, lol. Consultation with your supervisor and/or appropriate trusted colleagues will be key.

 

[NewTherapist1964]

I mean, I don't know her but it's just kind of a 'pattern recognition' at this point based on experience as well as a bit of logical deduction. Nature abhors a vacuum. Enmeshed dyads tend to turn into triangles (triads) with a predictable 'victim,' 'perpetrator,' and 'savior' dynamic. Again, I'm NOT saying she's NOT a victim in a very real sense. Just highlighting the protons/neutrons and electron clouds involved, lol. She sounds like, from birth (literally before the ground of her consciousness even developed) she has been in an environment that likely sent her signals that she isn't capable of fending for herself or making it without mom (or an alternative savior/protector) and she's likely developed schemas consistent with this (see Beck et al.'s book on the cognitive profile of dependent personality disorder). I'm not saying I'm diagnosing her or anything, just saying these are hypotheses that would be on the table for further exploration. She's going to have to discover, for herself, what those implicit 'rules' are that she's been living her life by, what the consequences of keeping or changing those rules are, and what she would like her life to look like from here on out and you can't do that work for her (though you can ask good questions and create a space conducive to her doing that work).

I'd also bet dollars-to-doughnuts that you're not necessarily getting a 100% accurate accounting of her relationship with mom. You're only seeing it through her eyes. She's also obviously getting some pretty powerful reinforcement (negative or positive) from staying enmeshed/dependent or else she wouldn't be in that situation long-term. She will need to identify for herself the implicit rules/schemas that govern her cognitive/emotional/behavioral patterns and that make it so difficult for her to emancipate from mom (and not rely on someone to replace mom). It's just how these things tend to work.

That being said, I've never examined her or her record and I am definitely not in the role of supervisor so just take my off the cuff musings with a mountain of salt, lol. Consultation with your supervisor and/or appropriate trusted colleagues will be key.

Yeah that's true about not getting an accurate accounting of her relationship. I think she knows this because she keeps emphasizing that it's not that bad, and that she doesn't want to play the victim and that she is an adult and shouldn't be dependent on her mom. In other words, she seems to really want to avoid me bringing any of the issues you mentioned to light by preemptively accusing herself? But yeah I agree.

I think she would never admit to feeling or seeing herself as a victim, and claimed early on that she was worried about being prone to self-pity and hated herself for that, and that she didn't want to blame her mom for her own problems. Yet I see what you're saying.

 

[Fan_of_Meehl]

Yeah that's true about not getting an accurate accounting of her relationship. I think she knows this because she keeps emphasizing that it's not that bad, and that she doesn't want to play the victim and that she is an adult and shouldn't be dependent on her mom. But yeah I agree.

Even if she moves away from mom, her schemas will follow her. She's going to have to emancipate herself from her own core beliefs, most of which she may not be consciously aware of at this point. All I'm saying is that, as her therapist, I would be wary of anything that I did (even with noble intentions) that might ultimately inadvertently reinforce any schemas related to, say, powerlessness, dependency, shame, not being 'good enough,' or lovable.

 

[PsyDWannabe]

Thanks for this advice. What in particular about this patient or patient's situation make you think she will have a tendency to pull me into a savior role?

Somebody will need to replace mommy if/when she saves herself from mommy and removes mommy from her life. At least, that will be her impulse. And you are way too easy an option, for quite a few reasons.

 

[NewTherapist1964]

Even if she moves away from mom, her schemas will follow her. She's going to have to emancipate herself from her own core beliefs, most of which she may not be consciously aware of at this point. All I'm saying is that, as her therapist, I would be wary of anything that I did (even with noble intentions) that might ultimately inadvertently reinforce any schemas related to, say, powerlessness, dependency, shame, not being 'good enough,' or lovable.

No I completely agree thank you. I will be wary about this. It's just interesting because I can see those schemas in her but she is so scared of and ashamed of her tendency to "play the victim" (something her mom has, perhaps correctly, accused her of doing)

 

[NewTherapist1964]

Somebody will need to replace mommy if/when she saves herself from mommy and removes mommy from her life. At least, that will be her impulse. And you are way too easy an option, for quite a few reasons.

Right. I think this will be interesting to talk about with her. I have already tried and she gets very angry at herself and expresses deep shame and embarrassment about her dependency. But this itself can be therapeutic. It's just hard to navigate when every time we try to work on something, she berates herself. And then berates herself for berating herself because she knows she is being manipulative in a sense, trying to get reassurance, and defend against me bringing up anything "negative" about her first, like she's trying to beat me to the punch.

 

[Fan_of_Meehl]

No I completely agree thank you. I will be wary about this. It's just interesting because I can see those schemas in her but she is so scared of and ashamed of her tendency to "play the victim" (something her mom has, perhaps correctly, accused her of doing)

I'll let you in on a little secret. It's speculative (at this point), but...I'd speculate that mom herself has 'taught' her to 'be/play' the 'victim' so mom can be in the role of 'savior' so daughter doesn't think she can make it without mom. Mom probably only uses that accusation (that daughter is 'playing the victim') to shame her when she disagrees with or has conflict with mom. Otherwise it doesn't make any sense.

Of COURSE mom wants her powerless/dependent. So she'd be unlikely to chastise her 'not to play the victim' vis-a-vis other people in her life (that would actually be encouraging her to become more resilient/independent/assertive and capable). It is far too often the case that mom plays the role of 'excuse-making' for the daughter and 'villainizes' others (i.e., my poor daughter is never at fault [playing 'savior']). Mom has probably bent over backwards to make life as 'easy' as possible for daughter (free of responsibility, rescuing her from financial trouble, providing finances, a place to stay, cooking her meals, etc.) and daughter is going to have a tough time giving all that up. The bargain is usually some form of, 'I'll make your existence as painless and effortless as possible as long as you never leave me.' And the easiest way to ensure daughter never leaves is to keep her helpless and unable to do for herself (or believing that she's incompetent).

 

[NewTherapist1964]

I'll let you in on a little secret. It's speculative (at this point), but...I'd speculate that mom herself has 'taught' her to 'be/play' the 'victim' so mom can be in the role of 'savior' so daughter doesn't think she can make it without mom. Mom probably only uses that accusation (that daughter is 'playing the victim') to shame her when she disagrees with or has conflict with mom. Otherwise it doesn't make any sense.

Of COURSE mom wants her powerless/dependent. So she'd be unlikely to chastise her 'not to play the victim' vis-a-vis other people in her life (that would actually be encouraging her to become more resilient/independent/assertive and capable). It is far too often the case that mom plays the role of 'excuse-making' for the daughter and 'villainizes' others (i.e., my poor daughter is never at fault [playing 'savior']). Mom has probably bent over backwards to make life as 'easy' as possible for daughter (free of responsibility, rescuing her from financial trouble, providing finances, a place to stay, cooking her meals, etc.) and daughter is going to have a tough time giving all that up. The bargain is usually some form of, 'I'll make your existence as painless and effortless as possible as long as you never leave me.' And the easiest way to ensure daughter never leaves is to keep her helpless and unable to do for herself (or believing that she's incompetent).

Yes, this is probably true. I know I need to confront my client about this. Client absolutely hates the fact that people assume she is coddled and once said she wants to kill herself when she thinks about being "spoiled" but that may just be another way of trying to get me to avoid confronting her about her own contributions to her problems and her trying to avoid painful realizations about herself.

 

[Fan_of_Meehl]

Yes, this is probably true. I know I need to confront my client about this. Client absolutely hates the fact that people assume she is coddled and once said she wants to kill herself when she thinks about being "spoiled."

I would at least explore it with her. Help her develop an explicit conscious awareness of these rules/schemas operating within her (and maybe even where they came from) and how they affect her thinking/emotions/behavior. This (optimistically) will give her a burgeoning ability to exercise some rational conscious choice in how she responds and some personal agency. It's a balancing act, though, because it sounds like she is beset by shame-related beliefs and has a habit of lapsing into that other extreme. Help her walk the middle path. Some of the folks on this forum with more expertise and experience with a dialectical behavior approach may be able to chime in.

 

[Sanman]

Thank you for replying. I appreciate it and I agree. I just wanted to make sure I wasn't overreacting. I noticed on some other threads (like the Jenna McCurdy one) you seemed to think her abuse was less severe/serious than other people on that thread did, so I was surprised by your response here.

Even if client herself doesn't believe or won't admit that it is serious, and that any real harm would come to her, I do still think you are right.

What do personal opinions have to do with professional responsibility? One way you keep your license, the other way you do not.

 

[borne_before]

Lol. Sounds dysfunctional. Maybe it’s time that child move out and be a big boy/girl.

Sounds like every dysfunctional failure to launch family I’ve ever encountered. Start with expectations and boundaries.

 

[smalltownpsych]

I agree with the posters that said call it what it is: a felony. That is typically where I start with a case like this. Then I start talking about safety plans. I don’t care if the patient wants to downplay it, I take their well-being very seriously and will say that explicitly. That being said, I’m not going to do for them what they need to do for themselves and foster dependency, I will just not let them minimize or sugarcoat violent and abusive behavior and as they are a capable adult, then let’s start figuring out what to do. I have a couple of interns that I can have help them make some plans and phone calls and if money is an issue, I wont charge for the case management especially since the interns could use the experience.