July 23, 2012, summary progress note

I have by all appearances made no progress with a 16-year-old boy who’s come consistently to therapy for seven months, though often ten minutes late. His presenting problems were depression and anger. He hasn’t talked about anger in a while. Maybe he “turned it inward,” Freudian fashion, as his depression comes across as heavy as the world, Eeyore-fashion but worse: tearful, seeing himself as a failure, doggedly, insistently hopeless. He can’t force himself to do any homework, which has now backed up into an extra burden owing to pathological procrastination.

There may be Asperger’s or birth trauma, but I can’t tell. There was colic, incubator instead of bonding time, failure to latch, was “unaffectionate” at the start (though he has warmed up to some people since then, is no “callous / unemotional child”). According to his mother – and this is quite odd – he had a contemptuous and dismissive attitude about classwork and ignorant teachers as early as first grade! Because of that, I’ll have to provisionally factor in a toxic original home environment, sick and snide enough to give even a small child a burnt bent attitude.

Be it all as it may, I have found no opening to the depressive, hurting self. That would be understandable if this were just the Depressive Personality Disorder circular system of ego-syntonic misery. There are no normal inroads into the Narcissistic Personality (this wouldn’t work: “Picture, Mr. N, just being a person, and not having to be ‘superior’”), into the Borderline’s stable childishness, into the Antisocial’s rottenness or the Depressive’s moroseness. But the young man comes across as depressed more than “personalitied.” And depression can be approached by appealing to the pain that grew scar tissue over it – potentially even in a teenager.

But that hasn’t worked.

At this juncture, I believe that both major depression and depressive thinking and logic (the personality disorder) have entwined each other with equal force, forming a suffocating straitjacket. I’ve rarely felt this impotent to budge anything. And yet there are times when he has a grudging mordant sense of humor. He enjoys a volunteer service position he’s had for half-a-year – appears to covet it. Unfortunately, his main “joy” (his word) is escaping from reality (his description) in fantasy play and games. We’re not looking at the average kid who loses himself in games. My client’s emphasis is on not liking reality. That’s a big difference.

His chart shows no current medications. There is that possibility, plus the electronic gizmos such as neurofeedback and Saribalas’s TMS. But what if none of them work? It is hard for me to imagine his grey universe turning sunny, owing to that airtight syllogism of argument and depression. I want to argue back: “Look at your promising future” (he is intellectually gifted). “How can a teenager call himself a ‘failure’?” “There must be, there will be some things in the world that jazz you.” But I’ve tried that, and it doesn’t work, either.

I wonder: Would it make a difference if his mother pressured him less to meet his academic potential? And there’s the Catholic faith which I didn’t know he ambivalently endorsed until five months into therapy. He seems so agnostic. What does that do for, or to, him?

I will have to talk at depth with his mother, and probably with the not-heard-from father. One almost hopes they can reveal some trauma splinter that stuck in him many years ago, some terrible event that can be shaken, that we can shake loose.