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“We need therapeutic intervention . . . We don’t need insight. Our best parenting got us to where we are, so we need help.” ~ Julie and Robert B.* ~
Nora B.* is a 13-year-old female who was referred to Equinox for intensive treatment services by her parents Robert* and Julie* B. Nora had significant history of emotional dysregulation which included frequent anger outbursts at school and home since she was a young child, oppositional behavior, and self-harm/suicidality. In middle school, she became increasingly isolated at home, exhibited extreme self-loathing, and primarily sought social connection via online communication with both friends and strangers. Nora is very bright but has struggled each school year to regulate in class, make friends, and connect with her teachers.
Parents and Nora had worked with multiple providers and tried various interventions over the years without lasting outcomes. These included sensory and psychological evaluations, occupational therapy, individual and group therapy, family therapy, and hospitalization. Prior to enrollment with Equinox, Nora was admitted to an adolescent psychiatric inpatient hospital for suicidal thoughts and cutting. At discharge the family was referred to Equinox for more intensive therapeutic services as an alternative to out of home placement. Parents specifically needed help to address safety risks while Nora learned sustainable skills to increase long-term social, academic, and emotional stability. They were open to parent coaching and family therapy as part of the program to increase parent confidence and address family trauma from years of chronic distress in the home.
“It had to be her way or no way. She had big emotions and big feelings that were scary to others.” ~ Julie ~
Nora was adopted at birth by Robert and Julie through open adoption. She attached well to her adoptive parents and also maintained positive relationships with her birth family. As a toddler, Nora began to exhibit temper tantrums (with head banging, screaming), had difficulty with transitions from preferred activities, and would self-inflict pain with biting and scratching to soothe herself. Robert and Julie used various strategies and read parenting books which were ineffective in addressing the extreme nature of Nora’s behavior. They approached Nora with compassion, logic and reason, and eventually built parent habits of accommodation to prevent meltdowns.
Nora and her parents presented as closely connected, committed to the well-being of their family, and embracing of Nora’s desire to express her identity in unique ways. They enjoyed time together when they were not in conflict and described, “we are our biggest fans and there is no end we won’t go for one another.”
When Norah was 8 years old, she was diagnosed with Bipolar Disorder, with short duration manic and depressive episodes. Her parents were always unsure if this diagnosis was accurate for their daughter, although it was clear, when emotional demands outweighed her ability to cope, she became dysregulated and reactive. In pre-teen years, Nora presented with suicidal ideation, poor self-esteem, and extreme distress in school/social settings especially when she experienced anxiety or perceived rejection from others. Nora’s outbursts at home escalated and after further psychological testing, she was diagnosed with anxiety, ADHD, and oppositional defiance. Nora would often turn to self-harm or threats of suicide when she was in distress or limits were set. Individual and family therapy were not effective due to Nora’s resistance to fully engage and be honest in treatment.
“The wheels on the bus really came off this year (middle school). Kids were no longer forgiving her, and parents were telling their child to stay away from Nora.”
Throughout her school, Nora exhibited daily emotional outbursts in class, was disruptive to other students, defiant with teachers, and was in trouble for yelling, slamming doors, and confronting others with aggression. She did not respond to typical incentives or behavior programs implemented in the classroom and was suspended twice. Conflict with parents around homework was consistent as she required supervision to stay on task and complete work. If Nora did not see value in homework, or following a teacher’s directions, she simply would not do the work. As Nora transitioned to middle school, her behavior hindered her ability to make friends. She was bullied and often provoked conflict with peers. Julie and Robert reported that the schools were very supportive but by the end of 7th grade when they found Equinox, Nora was struggling with grades, motivation, and rigid thinking about the value (or lack thereof) about school. Parents were needing specific services to help with school to reduce parent/child conflict in the home by transferring academic accountability to outside professionals.
“I was influenced by my own anxiety of how she would act with others, and so I stopped us from being in social situations when possible.”
Nora often drew negative attention from others, struggled to read social cues, had poor social filters and boundaries. Kids would provoke Nora’s outburst as a form of entertainment. She would yell, scream and become confrontational which often intimidated others.
Nora “cycled through friends”—having one close friend at a time; but because of her inability to problem solve social conflict, cooperate with peers, and regulate when frustrated, others began to avoid or reject her. Nora pursued people relentlessly, had a high need to be “right” or prove others wrong. By 2nd grade she was rarely invited to birthday parties or play dates with peers. Her mother reflected on her own anxiety and how it impacted parenting Nora. “I was influenced by my own anxiety of how she would act with others, and so I stopped us from being in social situations whenever possible.” Nora could also be helpful and funny with others when she's not focused on performing or trying to get what she wants. Nora’s parents believe she is desperate to connect and wants to be liked.
Nora was dependent on social media and online forums to connect with peers. Nora described “I constantly use it; it is isolating, and my parents think I'm choosing bad people.” Nora also connected with others who were sad and depressed. Although her parents attempted to put parental controls and a “teen safe” app on the phone, she knew how to bypass all of these safeguards. Robert and Julie have attempted to set technology rules and boundaries, had conversations with Nora about safety, but they still struggle with appropriate levels of supervision, what is inappropriate content, and how to manage this content.
“Our changes as parents were the most important factor that contributed to the change of our daughter and family.” ~ Julie & Robert ~
Nora and her parents participated actively in individual and family therapy, which included both talk and action (experiential) based modalities. Nora also participated in a DBT informed girls rock climbing group, a mindfulness movement group, adventure wilderness programming, and school-based support focused on executive functioning skill building. Equinox worked in close collaboration with the counseling department at her school to manage suicidal threats or emotional outbursts. Nora’s unsafe technology practices and parent accommodation that reinforced her unhealthy power in the home was immediately addressed. Julie and Robert now reflect on their Equinox treatment journey and have spoken to other parents about the foundational aspect of parent coaching. “Our changes as parents were the most important factor that contributed to the change of our daughter and family.”
Nora never returned to the hospital after admission to Equinox and within the first 6 months of treatment, she no longer exhibited suicidal ideation. Robert and Julie’s confidence increased to where boundaries were held despite Nora’s angry/reactive outbursts; this gradually contributed to her motivation and ability to regulate and learn new ways of communicating her wants and needs.
Nora successfully completed middle school with passing grades and positive relationships with her teachers. She then transitioned into a blended high school/college program where she is flourishing. Nora’s self-deprecating thoughts and comments transitioned to compliments, pride in her accomplishments, and sharing her successes with others. Socially, Nora learned competencies that contributed to developing and sustaining healthy friendships. She regulates social media use in healthy ways, enjoyed in person vs. online interactions, and followed the family Healthy Technology Plan without incident. Parents reported they continued to deal with typical teen/parent challenges, but the conflict is minimal, outbursts are non-existent, and their relationships are closely connected. In fact, Nora wanted to speak to other parents and share that despite “hating to admit that EQ helped me, it changed me and my relationship with my parents.”
Summary: Nora, Robert and Julie B.
Behavioral Symptomology: Significant history of emotional dysregulation which included angry outbursts, self-harm behaviors, and suicidal ideation. Opposition, disruptive behaviors, impulsivity, mood swings and negative “self-talk” at an early age. The family has experienced 1 hospitalization for self-harming/suicidal ideation and multiple therapeutic providers.
Therapeutic treatment environments prior to Equinox:
School placements prior to Equinox:
Equinox treatment outcomes:
"I have found myself having mock conversations in my mind with parents who may be considering Equinox for their family. I want to tell them there is hope, that it works and that it is worth the commitment, both time and financial, that it takes. I remember how hard that first phone call was to make. In-spite of having made so many similar phone calls in the past trying to find someone or something that would finally be the help my family so clearly needed." ~ Julie & Robert ~