Psychotherapy For The Gifted
Jerald Grobman M.D.
Madelon Sann L.C.S.W.

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Case Study: Moral/Ethical Dilemmas in a Gifted 6-year-old Girl – Susan

Susan was 5½ years old and halfway through her kindergarten year when she was referred to me by the psychologist in her school for gifted children. Although she was an attentive student and followed instructions, she didn’t want to participate in group activities. More troublesome, however, were unpredictable episodes of anger or inconsolable crying. Neither Susan nor her teachers understood what set her off. Her parents were alarmed by the teacher’s concerns because Susan had always been a quiet and cooperative child at home.

During the assessment process, the parents provided Susan’s developmental history, but when it came to more personal details of their marriage, their relationship with Susan, and their family life, they were more guarded. They had never had any experience with psychological assessments or therapy. They were skeptical, didn’t know what to expect, and weren’t sure how to proceed, but they accepted the school psychologist’s recommendation that their daughter receive therapy.

Susan began to read at 19 months, at about the time her brother was born. She was content to be by herself in her “reading corner” while her mother took care of her brother and her father finished up his day’s work on his computer. This family pattern seemed to satisfy everybody until the brother began to walk and Susan entered school. At this point, her mother returned to work, and Susan had less individual time with her.

Although Susan came to her weekly therapy sessions willingly, she was cautious about being engaged with me. She didn’t include me in her play, which consisted of silently cutting out paper figures and outfitting them in simple dresses of her own design. My efforts to discover who these figures represented were met with silent shrugs. My suggestions that we give them names and identities and make up a story about them were also quietly rebuffed. When she used other material, the meanings of her play were difficult to decode. After several months of weekly therapy, Susan’s behavior in school had not improved. In fact, her “meltdowns” had become more frequent and intense. In order to calm down, she needed to spend a good part of the school day alone with the school nurse in her office. When things got really bad, her parents were called to pick her up early. Susan’s parents agreed with my recommendation that the sessions should be increased to twice a week. I anticipated that more frequent contact would increase her comfort level in therapy sessions. I also increased my contact with the teachers and the school psychologist to help them better understand Susan’s meltdowns. These episodes seemed to occur when she felt “cheated” out of what she thought was her fair share of recognition. The teachers assured me that Susan was an excellent student, and they always recognized her many accomplishments. Her feeling that she was being cheated didn’t seem to have a basis in reality.

Once we began twice-a-week sessions, Susan became more comfortable and interactive. Instead of paper dolls, she began to use the dollhouse and a family of dolls to play out different scenarios with a mother, father, baby, and a little girl. The themes revolved around activities in which the baby was pampered and preferred to the little girl, who looked on from the sidelines (much as Susan did in class). I now had enough information from Susan’s play and from her teachers to establish a psychodynamic formulation of Susan’s problem.

Susan’s basic problem was an inability to resolve her conflict about acknowledging and expressing her jealous feelings toward her brother and her angry feelings toward her parents on the one hand and on the other hand, her worries about hurting their feelings if she let them know how she felt. Although I now felt I understood the basic psychodynamic formulation, conveying this to Susan would need to be a slow and careful process.

As the weeks passed, I gradually suggested that she might feel left out at home like the little girl in the dollhouse play. While not confirming my hypothesis, Susan didn’t deny it. For many children, this lack of denial constitutes agreement. Now I felt that the door was open to suggest that the dollhouse girl might feel angry about being left out. Although Susan didn’t confirm this suggestion either, the little girl’s dollhouse play began to include yelling at the parents and the baby. At some point, I commented that the little girl seemed to be able to express her angry feelings without feeling guilty. As had become usual, Susan didn’t object. Although the therapy was progressing nicely I still felt it was too soon to ask Susan if she had angry feelings like the little girl in the dollhouse. The school year ended, and I continued to see Susan twice a week throughout the summer. She was more relaxed in sessions and tentatively began to talk about the “slights” she experienced at home. Another change that took place was that she could now acknowledge when she was annoyed.

Unfortunately, when school began in the fall, her meltdowns resumed. One disturbing aspect of all these explosions was that Susan was convinced that the reason the teachers didn’t give her enough attention was that they simply didn’t like her. The teachers were unnerved and confused by the nature and intensity of her reactions. The psychologist even wondered whether some of her extreme reactions were “paranoid.” It was at this juncture that I explained how the symptoms that highly sensitive and intelligent, gifted children exhibit could be confused with the symptoms of serious psychiatric disorders. Were the teachers, in fact, getting fed up with Susan, who was picking up on their irritation? Where were her feelings coming from?

Discussion with the teachers revealed that this was patently untrue: they thought she was charming, clearly gifted artistically, and one of the most insightful children in this special setting. From the teachers’ perspective, the problem was that Susan couldn’t ask for the individual attention she needed.

To help the teachers and Susan manage her outbursts, I offered them the opportunity to call me in my office when they occurred. The school provided the director’s cell phone number so that we were assured of getting through to each other. In the meantime, the nurse and her office continued to be available as an emotional oasis.

Despite the continued meltdowns, Susan’s treatment was progressing. Susan was now capable of reviewing the events leading up to the meltdowns. This, in and of itself, had a calming effect. Equally important, she was able to use her sessions to express how angry she was at the teachers and how she felt betrayed by them.

During Christmas vacation, Susan took a major step in her therapy. Although she was still unable to express her angry feelings toward her parents, she could complain about them in her sessions. She described how bored and angry she was for two weeks because her parents planned recreational events organized around her younger brother’s needs, not hers. She felt left out and discounted by her parents but was unable to tell them—she was worried she would hurt their feelings. Now that she was able to verbalize her feelings of anger at her parents in our sessions, it was a matter of weeks before she could see how she had similar reactions to the teachers in class when they paid attention to the other students.

Another major step in the therapy occurred when Susan realized that expressing her angry feelings to her teachers might prevent meltdowns in class. (In my work with the teachers, I explained how important it was for them to accept the expression of her angry feelings, even though they were unwarranted.) On several occasions, she began to take some chances, expressed her angry feelings when she felt left out, and noticed that the teachers weren’t hurt when she got angry. Along with this, meltdowns decreased in frequency and intensity. Visits to the nurse’s office were now used to call me before her anger got out of control, and early pickups by the parents were less frequent.

We were now three-quarters of the way through the school year, and although Susan was doing significantly better in managing her anger, her anger at the teachers was still inappropriate and unrealistic. Her parents, the teachers, and I were in agreement that next fall, a smaller school where Susan could get more personal attention without having to ask for it would be beneficial. Despite her many advances in the treatment, Susan could still not connect her anger at the teachers with her unexpressed anger at home.

The new school had a much more favorable ratio of teachers to students, as well as a “mentorship” program in which they connected professionals in various fields with students with specific interests. Susan was assigned an accomplished artist who visited the school weekly specifically for Susan and taught her skills that the other school did not have time to teach her. The academic work was individually tailored, and Susan zoomed ahead intellectually and artistically. For the first time, Susan had a feeling of personal pride.

Meltdowns were mostly a thing of the past. Sessions were reduced from twice a week to once a week and were used by Susan to discuss the occasional episodes when she felt misunderstood by her parents, teachers, or friends. The rest of our time was used to try and understand why she wasn’t using her artistic gifts more assertively, instead retreating into video games.

The remaining therapeutic goal for Susan is to realize that although her parents may be busy and occasionally unempathetic, it doesn’t mean they don’t care or love her; they can change if they know what she needs.

Discussion and Summary

Susan is an example of a highly gifted and sensitive child who kept all of her jealous and angry feelings out of her family’s awareness in order not to burden her already overwhelmed parents or make her brother feel she didn’t love him. These moral-ethical considerations are common with highly gifted and sensitive young people and can stand in the way of their processing their feelings in adaptive ways. Since such strong feelings can never be fully hidden, Susan’s neediness and anger broke through in disruptive and frightening meltdowns at school and eventually at home. Once Susan and I knew and understood the derivation of her meltdowns, we could discuss her hurt feelings and even predict the outcome of holding them in. She became significantly more direct with her parents, who were then better equipped to adjust the family environment to meet her needs. I explained her emotional processes to her new school so that they, too, were able to understand the dynamics in the classroom that set her off, tolerate her anger, and intervene appropriately.

Moral, ethical, and altruistic concerns are among the many admirable qualities of gifted young people. When they are pursued with missionary zeal, however, academic and emotional problems often develop.

Susan felt that asking for “more” from her busy, hardworking parents to satisfy her intense curiosity and develop artistic interests would be unfair to them and take away time (and money) they could be spending with her younger brother. She also wanted to be “fair” to him so he could have that special time with them that she once had. Trying to be fair to her brother seemed like a good thing to Susan, but what she was unaware of was how angry she had become in the process.

Unable to reconcile these family dynamics, Susan’s conflict became an unconscious one. Psychological mechanisms to defend against the anxiety of this dilemma displaced the conflict onto the dynamics of the classroom. A psychodynamic assessment of Susan’s situation helped explain the origin of Susan’s hysterical and angry explosions that “came out of the blue” and seemed so unwarranted: they were not symptoms of a paranoid personality disorder, or impulse or conduct disorders, but the end point of a conflict about how to appropriately ask for more time and attention and express displeasure when she didn’t get it. Because these conflicts and feelings were too painful to resolve on a conscious level, they became unconscious—completely out of her awareness—and were displaced and transformed into powerful feelings of deprivation and anger against her teachers. She simply couldn’t appreciate that she was a valued and well-liked student who was getting her fair share of their attention along with the other students.

Consultation with the teachers and the head mistress helped them understand Susan’s dilemma and avoid harsh punishments, and rigid limit-setting strategies, and helped them handle her meltdowns in compassionate and understanding ways. The psychodynamic assessment helped everyone avoid a misdiagnosis. Susan was not a case of a spoiled, narcissistic child who wanted more than she was entitled to. Consultations also helped the teachers understand that the goal of the treatment was not only behavior change but also to get to the root of the problem.

Susan’s Therapy: The Use of Play Therapy

As with all gifted children, Susan came to therapy cautiously. The initial therapeutic alliance developed around play. At first, the symbolic meaning of Susan’s play was difficult to understand, but as the therapeutic relationship became more comfortable, the themes became more transparent.

Dollhouse characters were used to act out and express anger in make-believe, safe scenarios. A crucial point in the therapy arose when the therapist observed that the little dollhouse girl didn’t seem guilty when she expressed her anger. Susan’s silent agreement seemed to be an acknowledgment that she too was angry prior to her explosions; however, she could not see that her anger at her teachers and her sense of betrayal were largely inappropriate and that the actual source of her anger was feeling betrayed by her parents. The therapist, however, felt it was too soon to press on these points.

Ongoing meetings between the parents, the teachers, and the therapist helped everyone realize that even a class of 15 students would still be too much for Susan. Contacts with the parents made clear that their busy schedules could not change, and the limited time they had for their children would have to be in the form of family activities.

The new school setting provided Susan with the individual attention she desperately needed. As a result, her meltdowns have all but disappeared, and her intellectual and artistic gifts have flourished. Gratified and proud of her newfound insights and her ability to control her feelings in school, Susan has risked becoming more open and expressive in her therapy sessions. She is able to talk about what she needs from her parents and how angry she becomes when she doesn’t get it.

Although Susan is still somewhat troubled by her moral-ethical dilemma in dealing with her family dynamics, her unresolved feelings no longer result in hysterical meltdowns, no longer get projected onto her teachers, and no longer interfere with developing her gifted potential.

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Jerald Grobman M.D.

Madelon Sann L.C.S.W.​

We offer our sessions through Zoom’s virtual platform, providing flexibility to participate from any location.