In last week’s post, we began a discussion about how conscience development is impeded in some individuals, especially those with prominent narcissistic or aggressive traits in their personality makeup (see: Aggressors, Narcissists, Conscience, and Character). This week’s post presents an example of how someone with traits associated with aggressive personality formation can have difficulty forming the kind of conscience that will enable them to exercise responsible control over their emotions, impulses, and behavior.
Before I present today’s illustrative vignette I need to make some disclaimers. The “case” you’ll be reading about describes a young boy I encountered in a psychiatric facility. But the fact is that in my early years of practice I consulted to several institutions and dealt with hundreds of young persons manifesting various degrees of character impairment and displaying many similar behaviors and problems necessitating their treatment in a restricted setting. And to ensure complete anonymity and confidentiality the story your about to read is not only a “composite” of different happenings but also contains some deliberate distortions with regard to identifying information (names, gender, places, age, etc.). Nonetheless, there are no distortions of the psychological dynamics and realities the story is meant to illustrate. And the intervention techniques I describe using in this particular vignette are actual techniques I’ve used hundreds of times in many cases.
The Case of Jonathon
Jonathon was an 8 year-old whose parents had been at their wits end for a while. He’d been suspended from school many times over his first two years and had been recently suspended from an “alternative” classroom. He had a habit of biting, hitting, and kicking other children, throwing temper tantrums, and cussing at his teacher. He rarely followed directions and was a one-man instrument of pure disruption in the classroom. As you might suspect, he’d been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and placed on Ritalin. The medicine helped a little, but his behavior was still so unmanageable he simply couldn’t seem to function at school. His parents had tried everything. Spanking never worked and there were simply no “privileges” left for them to take away. They were reticent to view him as someone needing psychiatric hospitalization, but they saw few options left. The boy appeared to have no conscience and no empathy or remorse. Whenever he hit anyone or did anything wrong, he tried to justify it, blamed others, and seemed to shrug off any concern others expressed to him about his behavior. And he never seemed to stop and think about what he was doing or what his actions were costing him or those around him.
To Jonathon, his first day at the hospital, seemed like just another day and a just another place. And despite all the structure built into the ward’s milieu and the presence of highly trained staff ready to intervene and impose consequences, nothing seemed to impact him. The treatment program operated on a “level” system whereby patients gained privileges by meeting certain goals and demonstrating good control over their behavior. But Jonathon had been there two weeks already and hadn’t advanced at all in the program.
The Jonathon’s attending physician had asked me to interview him, administer a battery of tests, render my own opinion on diagnosis, propose some therapeutic interventions, and consider taking him on as a therapy client. So I went to the unit in which he was housed to escort him to the interview and testing room. Before I knew it, however, Jonathon was leading himself down one of the hospital corridors, having absolutely no idea and seemingly not caring where exactly we needed to go. I waited patiently and in silence at the beginning of the corridor and he eventually came back and just looked at me. Then I slowly started down the corridor and once again, he raced ahead. I stopped immediately and again waited. Eventually, he came back. We did the same behavioral “dance” in the hallway 3 or 4 more times until finally he looked at me quizzically and appeared more receptive. “Follow me,” I said, and led him a few steps down the hallway to the room I planned to use. “Good.” I proclaimed. “Very good. You did well, so we’ll try this again.” I went back to the unit, asked him to have a seat in the day area, and made a few notes in his chart. Then I asked him to come with me again. Thinking he knew right where to go, once again he raced ahead, going straight to the room we’d been to earlier. But once again, I waited at the beginning of the hallway. Eventually, he came back. And of course, for awhile we did the “dance” again. But when he finally waited for me to lead, I ushered him to a room different from the one before. When we entered, I again commended him for following my direction and promised that we’d do it yet again, then took him back to the unit. I also deliberately made him wait a little longer in the waiting area before coming to get him once more. I’m not exactly sure how many times we did our unusual “dance” down the hallway and returned to the unit before Jonathon decided to simply let me lead and then follow my direction. But it did eventually happen. Instead of racing ahead on his own, he just looked at me and when I said “Let’s go,” he followed me to the place I decided we’d go. And when we got to our destination and before we began our tasks, I reinforced him heavily for paying attention to me, following my lead, and controlling his urge to simply “do” and think later. We played many other “games” like this over a period of weeks and before long the staff was noticing some real differences in Jonathon’s behavior.
Jonathon had two traits in his makeup that my experience taught me increase the risk of him shaping up to be a relatively aggressive personality (for more on the aggressive personalty and aggressive personality sub-types see: Aggressive Personalities: An Upcoming Refresher Course and Aggressive Personalities: The Sub-Types). And if these aspects of his personality weren’t modified soon, I knew he could eventually develop a personality disorder, perhaps even an antisocial personality disorder. So in my interactions with him, I chose to focus on his deficient impulse control and predisposition toward aggressive modes of functioning (not violent aggression motivated by anger, but rather overly energetic, aggressive, pursuit of goals – even undefined goals). Like many who have aggressive personality traits, Jonathon was like a car whose gear shift is always in “drive” mode, gas peddle is always full to the floor, and has no brakes. He simply had to learn to how to exercise voluntary control over his impulses – a real challenge for a kid “wired” to act first and think later. He also had to develop a conscious willingness to submit to a higher “authority,” accept guidance and direction, and to pay attention to directives given him – a challenge for anyone predisposed to be so self-directed. And I needed to find a benign but reliable ways to help him learn these lessons. I also had to remember that teaching these crucial lessons and securing compliance is always accomplished most effectively when the focus is kept on the relatively small and innocuous aspects of life. Firmness and persistence is also a must. So in my interactions with Jonathon, I took care not to lord my authority over him or ruthlessly demand his subservience or surrender. But I sent some very clear, consistent messages about where the authority resided (i.e., who would lead or set direction and who would be expected to follow), and the importance of him exercising control over his impulses, the need for him to pause and take time to stop and think about things before jumping into action, and most especially, the value in him displaying a willingness to submit to guidance and subordinate his will to that of some authority. All these things were done in small, innocuous exercises, similar to the “dance” down the hallway that characterized our initial encounter. I also crafted some special lessons on the benefits of making an effort to pay closer attention (which didn’t come easy for Jonathon). Toward that end, in those lessons, and indeed in all my interactions with Jonathon, I used the technique of selective speaking and reinforcement that I outline in both In Sheep’s Clothing and Character Disturbance). And whenever Jonathon made the effort pay attention and stay engaged with me or to meet any of the objectives I set for him, even in a minor way, I reinforced him quite generously. Gradually, he not only “bought into” the regimen I crafted for him but also came to relish the time we spent together – largely, I think, because it was full of something he had experienced very little of in the past: reinforcement.
Jonathon stayed in the hospital longer than most of his peers. But by the time he was discharged he not only had become much better mannered but also didn’t seem to have as much trouble focusing. And after two years of intensive follow-up, he was not only doing okay in a regular classroom but also was no longer taking medication. It’s always preferable for children to develop sufficient inner resources to self-manage as opposed to being forever dependent on external structure or medication.
Next week’s post will feature an vignette about a young man whose self-image was so distorted (inflated) that he simply couldn’t form a healthy relationship with any “higher power,” solidify a healthy conscience, and keep himself from inviting disaster into his life and the lives of many others. The vignette does not have the kind of positive outcome that the one presented in this post did. However, it’s a case that illustrates well what can go wrong when someone’s self-image gets pathologically out of balance.