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Encopresis, the repeated passage of feces into inappropriate places, is an underreported elimination disorder diagnosed primarily in children who have already been toilet trained (Murphy and Carney 2004). Understanding that this is an uncommon diagnosis for physically healthy individuals of average intelligence who have progressed beyond childhood, we hope to show the importance of conceptualizing and approaching a difficult case of this kind from a psychodynamic stance in order to develop rapport and a solid working relationship. Joey, our patient, is a highly symptomatic oppositional-defiant adolescent in residential care. While he suffers from long-term encopresis that has not significantly yielded to psychotherapeutic, psychopharmacological, or behavioral regimens, some progress has been made in the case due to a consistent psychodynamic conceptualization of the case and careful interventions. Notable is the clinically impressive disconnection between Joey's odd calmness and his heightened state of denial regarding the encopresis.
Joey was admitted to a residential facility at fourteen. His uncontrollable aggressive behavior at home and in school, as well as the encopresis, made it impossible to maintain him in a normal classroom. While Joey has always been of normal intelligence, now that he is eighteen and through his level of responsiveness to treatment, he has shown academic progression and has been able to express appropriate distress and insight regarding his chronic lack of bowel control. Secondary to his encopresis, Joey is highly anxious, struggles with chronic bouts of depression, is oppositional-defiant, and is apprehensive with regard to his future.
Joey's history and family dynamics are chaotic and complicated at best. He is an only child born to parents who were never married and only