The Fascinating Case of the Birthday Twins 

When I think of the interesting and challenging young clients with whom I’ve worked over the years, my mind invariably re-visits what I call the case of the birthday twins. 

I never really thought of naming this particular case until now, many years later as I finally sit down to write about it. Why now? I’m not really sure, but the timing seems right; time being the keyword in this instance. 

The Same but Different 

The two Melanies, as I have remembered them over the years, were 13-year-olds, each hospitalized by their parents on the adolescent psychiatric unit of an urban hospital where I was doing my residency. Aside from sharing the same first name, a minor seeming coincidence, they were born on the exact same day, month, and year—hence, birthday twins, or for the more cosmically inclined, time twins or astro twins. 

While each of the Melanies shared both a name and moment of entry into the world, they couldn’t be more different from each other. Then again, why should this cosmic confluence and their presence in the same place at the same time 13 years later be any more than a sheer coincidence? But what if it wasn’t? What if the clinical universe was speaking to me, and yes, I realize I am being dramatic, and more than a bit self-centered, but humor me.  

Oh, I neglected one “small” detail! Melanie I was physically mature, outwardly a high school senior. Melanie II was the absolute opposite and could easily be confused with an elementary school child.  

I was a fledgling therapist, barely into my career when these two particular teens made quite a splash on the adolescent unit. Everyone on the multidisciplinary treatment team was fascinated by the glaring coincidence and was looking for ways to make meaning of it––including me!Still, I had absolutely no idea of what to think about them or what their clinical needs were.  

My immediate supervisor, John, was trained to focus on intrapsychic dynamics and presenting pathology. For him, Melanie I was deeply confused by the often unwanted and uncomfortable attention she was receiving from older boys both at school and in her neighborhood. Insecure, self-conscious, and caught between confusing and conflicting social, and occasional sexual expectations and pressures, she was “acting out.” She was trapped between two worlds, those of adolescence and adulthood. Her parents were frightened, and in attempts to protect her, they held onto her tightly, and in essence stifled her. She felt smothered and resentful. She became increasingly rebellious. Hence, the hospitalization with a DSM-III-R diagnoses of Adjustment Disorder with Mixed Emotional Features. John suspected deeper personality pathology but chose not to include it in the official records for fear that this label would unfairly and unjustly burden and limit her. His recommendation was individual treatment interspersed with family therapy aimed at behavioral management.   

Melanie II, in his clinical estimation, was also pulling hard against her parents’ efforts to protect her, as she had a history of physical fragility and bouts of medical problems related to her small stature. Her mode of resistance, as opposed to that of Melanie I, took an internalizing route. She often withdrew into herself, from friends, and from her parents which deeply worried them. She had increasing difficulty sleeping, often coming into their room in the middle of the night, demanding to sleep with them.  

She had become more dependent upon them for many of her daily needs, and anxious about going to school. She chose to play with far younger neighborhood children. Unlike Melanie I, who seemed to be hurtling, albeit unprepared, for adulthood, Melanie II was quickly retreating backwards to the safety and security of an earlier developmental haven. John’s DSM-III-R diagnosis was Major Depressive Disorder, with the recommendation for individual and group therapy with some talk about medication. 

Pulling Back the Lens––A Systems View 

My other supervisor, Blake, was as different from John as were the two Melanies were from each other. He was a dyed-in-the-wool systems thinker and family therapist, trained in the era of  Salvador Minuchin, Chloe Madanes, and Jay Haley. I vividly remember the day when the multidisciplinary team met to discuss treatment options for the new admits, foremost among who were the birthday twins. John confidently shared his assessment and treatment followed by Blake who almost instantaneously, and without review the records of either of these teens, recommended family therapy for each of them and then conjoint family therapy, in which the two family therapists would meet with the two families at the same time. The thought of sitting in a room with the two families petrified me. Sensing my fear, he immediately invited me to be his co-therapist. Can residents or interns refuse clinical assignments that are designed to grow them clinically? Probably not. 

I wish I had the foresight to hold onto version of the treatment notes from those half-dozen sessions for use in my own clinical development or as a clinical educator. Perhaps that is why I’m choosing this point in my career to revisit this case as a teaching lesson for the interns that I now supervise. While I cannot recall the details of those sessions, I do vividly remember the themes that emerged, and the developmental trajectories of the respective parents mirrored each other.  

The parents of Melanie I were a little older than those of her birthday twin, as such, they had lived more life, experienced a wider range of challenges both individually and maritally, and had each struggled through tumultuous relationships during adolescence and early adulthood. While we could never corroborate this, the team believed that her mother was hiding a secret, and that her father was withholding critical information about his own early life relational challenges. They knew how difficult relationships could be, especially for a precociously developed teen, and held tight to her developmental reigns out of fear of pregnancy and losing her to the harsh social demands of high school. 

The parents of Melanie II, younger by a decade, were, in many ways, dependent upon their own parents for financial and emotional support. These particular grandparents were very involved in the day-to-day decisions influencing their granddaughter, often marginalizing and infantilizing their adult children. Melanie II was the unfortunate and unwitting recipient of multi-generational, yet well-intentioned oppression and control. Because of her physical stature and both her real and perceived fragility, her parents held her as close as their own parents held onto them. The end result was stunted psychological growth for both the child and parents. 

Looking Back––Thinking Forward       

What I do recall of those meetings was Blake’s skill in supporting both sets of parents in their respective and shared challenges that came with raising their daughters. As they revealed their fears and concerns, with their daughters keenly listening on, spaces for conversation, commiseration, and collaboration opened. In turn, the Melanies spoke more freely of what it was like within their respective bodies and how they struggled to carry those bodies through the complex social landscapes of their lives.  

The parents eagerly listened on offering love and support as their childrens’ struggles became that much more clear to them, and how their attempts to protect them contributed to behaviors that led to their hospitalizations. In their individual therapies, both teens made progress in sharing and making sense of their respective internal and familial struggles, and gained some confidence that their parents ‘had their backs.’ The parents also learned how to balance holding on with letting go, both within their marriages, in their roles as parents, and in the case of Melanie II’s parents; as adult children of controlling parents. 

*** 

I have shared pieces of this story with my own trainees, suggesting to them that there is a time and a place for individual therapy, and that space must be left for family intervention. Only through a systemic lens can we fully appreciate the challenges that children, teens, and their families experience. I’d still like to think that the universe sent me that particular experience to grow me some as a person, clinician, clinical educator, supervisor, and parent.