Saturday, June 23, 2018

5 Ways to Deal with Stress, Sadness, and Trust

The two things common in traumatized children…always there…are high anxiety and a negative view of the world.

That means the brain is pumping out the stress hormones, adrenaline and cortisol, day and night, which means it’s only a matter of time before we see the volcano erupt, not to mention trouble sleeping, eating, learning, along with the very serious long term health effects like heart disease and stroke. This we have to tackle head on. It’s not enough to say “calm down”. We’re not going to wait for our engine to explode to fix the radiator. Daily we have to let off some steam and lower the temperature.

1. Breath and Move

Now start by sitting in a comfortable relaxed position and let’s breath. Focus on the breath as we take in that healing oxygen deep into the diaphragm, a belly breath, sending the good stuff to every cell of our bodies, then without holding it, exhale and send that stress right out of the body. Repeat.

Next, if you are able please stand, let’s raise our arms in the air and reach for the sky. Now out to the side and reach for the walls. The reason we move is that stress and trauma are held in the body. Next assume the superhero position, hands on hips, chest out, head up. Don’t be small, show your power. Now touch your knees and take a bow. How do you feel?

2. Re-write the ending.

We can’t get through life without grief and loss, everybody’s got it. Perhaps the benefit of maturity is that we’ve made it through a few losses and we’re getting better at it. But sometimes there’s a pile-up of loss. Sadness and anger about what happened to our children. Guilt and shame about what happened to their parents. Regret and resentment at losing that deposit at Case de Mucho Dinero where we had planned to spend our Golden Years by the sea. So much seems out of our control. We can’t change what happened. But we can change the ending. We are the authors of our own lives and we can re-write the last chapters. There’s a new movie out now starring Shirley McLaine called The Last Word in which she plays a not-so-nice older woman who wants to make sure her obituary is positive. So she hires a writer who has a hard time finding anybody to say anything nice about her. I challenge you to do the same: write your obituary, write your eulogy, or if you’re not ready for that, write the speech your friends will give to celebrate your 80th birthday…or the next birthday ending in zero. The story can’t help but highlight the ways you’ve overcome your challenges and made lemons into lemonade. Ask your friends for quotes. Give it a title. Like an epitaph. “She went kicking and screaming, just like her kids.” “He left a fortune, working taxpayers.”

3.  Play every day.

Attachment is hard to do with a child or teenager who doesn’t much trust you or anyone for that matter. This is like dating in old age, after divorce. It’s going to take some time. You’ve both been around the block and you’ve both been hurt. Neither of you is willing to put up with much funny business. But you are going to have to lead this dance. So, take it slow and keep it simple. Date your child. Create meaningful moments. Stop talking, except for those funny stories about the old days. And do…hair, nails, drawing, gardening, reading. Have your child teach you how to program your smart phone or to download music. Teach them how to make your favorite family recipe passed down to you. Cheap and simple. Silly is the pathway to solid relationship. Play is a child’s main job, the way they learn. It is more important than discipline. Playing with them will allow you to gain the influence you need to direct and teach them later.

4. Run a tight ship.

As we said, trust is in short supply. So many people have let our kids down. And, if we expect to trust our children, we have to be trustworthy. Do what we say. Don’t make promises we can’t keep. We need to run our homes like facilities, predictable, consistency, structure, beyond anything you think is necessary. Breakfast, lunch, and dinner on the clock, playtime and bedtime scheduled. Also, give children choices, but from a limited number of options. Red shirt or blue shirt. Shower or bath. Eggs or cereal. Keep it routine, simple, no changes, no surprises. We often feel so bad about what happened to our children we want to make it up to them by providing all of these enriching experiences, like the Sea World and Disneyland. They don’t need it and they can’t handle it. What brought them into care was the lack of basic needs, everyday care. Food, clothes, shelter, doctor, school, play. Done! If that’s all you do for 18 years, you have done your job. Now if a play or musical or a road trip to see the desert flowers is important to you, then get a babysitter, call a friend, and go yourself. You and your kids will be happier when you return. They can buy their own ticket when they’re adults. No harm, no foul, no guilt!

5. Communicate care then concern.

Certainly, there are going to be some big challenges, like family conflict, complicated diagnoses, and financial concerns. For the rest of the family who are not parenting your children, including your children who lost their children, be firm. You are not responsible for what happened. The only choice you made was to say yes to the social worker. This is where you turn on the broken record or just shut the door or hang up the phone.

You might get really caught up in the alphabet soup of ADHD, PTSD, ODD, but stay focused on the most important letters… K. I. D. A child is not a diagnosis. Your boy is creative. Your girl is energetic. Your teenager, soulful. Stand back and admire just how unique they are. Find out who that strange kid is, and celebrate the weirdness. Defend the child against those who would label and limit them. Don’t be in a rush to have the child be self-sufficient. Let them be dependent, parent from their developmental not their chronological age. And when they make one or more of their big mistakes, engage don’t enrage. Stop the temptation to lecture. Lead with love not fear. Don’t react, respond. Regulate then reflect. Practice these one-liners.

1. She wants to watch television. You say, “Sure, as soon as your room is clean.”

2. He walks in at two in the morning not sober. You say, “I’m so glad your home. I was worried about you. See you in the morning.”

3. She climbs into the car after school angry with friends. You say, “It looks like you’ve had a rough day. I’m here if you need to talk.”

4. He hands you a report card full of low grades. You say, “I have confidence that you will figure it out. Let me know how I can help.”

5. She threatens to run away from home. You say, “I would be sad if you did that. What would be best for you?”

Finally, you would never think of fixing your own car, taking out your own gallbladder, or roofing your own house. We have people. This is your community. And this is not your typical situation. This is Red Cross parenting. Nobody expects you to be experts. No one can do it alone. That’s not to say that you send the kids off to the therapist like dry cleaning. Or throw up your hands and let others decide. You’re the anchor of this family, you’re the captain of this team. Your kids need you to lead. They’re not renters or roommates. You’re not going to be able to contract out this job. You will need some friends, some babysitters, a back-up plan, some good teachers, a understanding doctor, a good therapy, a skilled psychiatrist, a support group, and some classes. Look up the county’s Foster, Adoptive, Kinship Care Education Program and attend the free classes. Old dogs can learn new tricks. Learning keeps us young. We’re in for a rollercoaster ride instead of rocking chair, time to enjoy the ride.

Relative Caregivers Self Care

  • Taking care of you will help your child
  • Taking care of you will help you parent
  • Your child needs you to take care of you
What we face:

Child trauma: This is not the child you thought you knew.  Take tame to become reacquainted with the child.  With a sense of curiosity and wonder, ask "who is this kid?"

Off-time parenting: This was not your plan nor your first choice.  You're going back in time instead of retiring.

Grief and loss: Some mad/sad stuff happened to get us here.  It will take some time to mourn before moving on to the next chapter.

Parenting from the inside out:  Who are you?  You are not just a grandparent or relative caregiver.  You are a person first, a partner second, a part third, and then there's friend, neighbor, citizen.  Let's get our priorities straight.  These children cannot be the center of our lives.  It's not good for them and it's not good for us.  When we keep parenting in it's place and focus on ourselves we are modeling and teaching what we want our kids to become.  Whole and healed.  This is about perspective, not perfection.

This is a marathon not a sprint, with the finish line in sight we know it takes patience and perseverance not speed.  There have been some ups and downs on this course that take grit and guts.

This is a road trip not a racetrack.  We're not driving in circles ad we're not her to win trophies.  We prepare for breakdowns and flats.  We stop for the roadside attractions and weird food.  We get los and off course before backtracking and correcting our route.  And sometimes we wind up in places we never thought we'd see.  Like planning for California and winding up in Kansas.  And it's only in retrospect that we see the value in our journey.  

Monday, February 20, 2017

Understanding Military Veterans

     Working with military veterans over the last three years has been a rewarding learning experience.  I have worked with more than 50 veterans, both men and women, from 23 to 90 years old, who have served in the Army, Navy, and Marines in conflicts ranging from the Korean War and Desert Storm to Operation Iraqi Freedom and on bases throughout the world during peace time.  Some have served for between three and five years.  Others have served careers of 10 or 20 years or more.  Certainly all of those veterans have experienced traumatic events but it would be incorrect to assume that all of them have post traumatic stress disorder.  In fact, they have experienced everything from depression and social phobia to relationship conflict and parenting concerns.  As we have worked on those challenges I have discovered three factors that influence a veteran's experience of their active duty as well as their readjustment to civilian life after service. Those factors are childhood and family experiences, meaning and motivation for service, and conditions and reasons for discharge or retirement.
     If a service member has grown up in a nurturing, responsive family with adequate resources and support, it contributes to their emotional regulation and positive sense of self.  This establishes a foundation or safe base from which to explore the world.  Positive family relationships provide a source of resilience for service members.  They are patterns for successful relationships developed with other soldiers and sailors that contribute to unit cohesion and teamwork.  They also provide a sense of safety and coping when service members face conflict and traumatic experiences on deployment and in combat.  These early childhood and family experiences cannot prevent post traumatic stress or even injury but may prevent it from becoming a disorder and contribute to healing and recovery.  On the other hand, if a service member grows up in a chaotic or abusive environment marked by parental conflict, lack of resources, violence and separation, they are predisposed to post traumatic stress disorder if they do not already suffer from it.  Their lives are marked by high stress and emotional dysregulation, negative core beliefs and low self esteem.  This makes them particularly vulnerable to the inevitable new stressors of military service.  Rather than inoculating the member against the impact of sleep deprivation, high alert duty, and battle, childhood trauma leads the member to be overwhelmed by military service to the point of developing disorders and disabilities.
     Ironically, so much about military service makes it attractive to people who have experienced childhood trauma.  It offers consistency and structure, a sense of belonging and importance, and the basic needs of food, clothes, shelter, and medical care, just like a functioning family.  Foster and adoptive youth, juvenile delinquents, their parents and advocates often see military service as an attractive option because they perceive it will teach the youth responsibility, lead to a successful career, or reverse a downward spiral. However, these traumatized youth take their underlying hypervigilance and negative core beliefs into a high pressure environment and challenging culture in which individuals are tested to form a fighting force.  Some succeed and achieve while others fail and suffer.  Those who survive basic training and go on to successful service develop relationships with officers and unit members who care for them and watch out for them much like a parent, brother, or sister.  They find the support to develop the resilience to survive isolated deployments and dangerous and deadly events.  They often continue these bonds into post service life.  Those who are not able to develop those relationships often find themselves cut off, targeted, and mistreated, some to the point of harassment, physical and sexual abuse.  Deployments themselves are overwhelming, and sometimes their coping skills including defiance, substance use, and violence get them discharged, reinforcing their childhood script.  They often leave service more traumatized and alone than when they joined.
     When a young man or woman signs up because they see a cause bigger than themselves, such as patriotic duty, or even for education and career opportunities, they are likely to be more successful than the youth who is avoiding the next life stage or escaping from a deprived environment.  The first is likely to find or make meaning from the experience while the second is prone to existential crisis.  The meaning of service is most important in the adjustment back to civilian life.  Adjustment is determined, in part, on how the service member is discharged.  An honorable discharge after a planned period of service or a long career lends itself to closing an important life chapter and starting a new one.  A conditional discharge based on behavior or an abrupt release due to disability or injury leads to a bumpy landing and an extra period of grieving.  If the service member is also dealing with the mental and physical effects of duty, they are likely to experience a pile up of post traumatic stress that started long before they joined.  Just as family support contributes to meaningful service it can also help heal the bodies and minds of veterans. So whether the veteran is young or old, whether they are working through post traumatic stress or relationship issues, I make sure I ask about their childhoods, their reasons for joining the military, and the conditions under which they discharged. 

Tuesday, July 26, 2016



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Lessons Learned
I have learned a few things about running a business and providing counseling, supervision, and training over ten years, and I expect to learn a lot more in the years ahead.  I expect never to achieve expert status, only competence.  That is why they do not call it private “perfect”.
·         In an attempt to build my private practice I joined several therapy directories, purchased advertising in various media, attended many professional forums to distribute business cards and brochures, and sent out e-mail appeals to referral sources.  Most of these investments had no returns.  I still receive most of my referrals from existing clients, attendants at my trainings, and directly from insurance companies.
·         As a social worker and therapist it is sometimes difficult to ask for and talk about money and payments.  However, in terms of professional practice it is unethical not to.  I have learned to make sure up front that I will be paid for each and every session.  I cannot stay in business providing services for free and allowing a client balance to grow interferes with therapy and results in lost income that cannot always be written off.
·         My practice model for working with parents and children includes an assessment of the parents’ trauma history and attachment styles.  Sometimes, when parents are in a hurry to see results, when they seem “too nice and normal” to ask, or when the child is in crisis, I have moved forward with family therapy.  Every time I have gone against my better judgment, it has come back to haunt me and to stall progress.  It becomes a sticking point I cannot ignore and must address, which I could have known up front.
·         While I would like to be on the cutting edge of new media with the use of texting, e-mail, and online counseling, it just does not work for me.  I have no desire to be constantly available to clients by texting.  I started with openness to e-mailing with clients but I quickly learned the hard way that I can misinterpret what a client is asking and clients have misinterpreted my comments in response.  So, while clients may feel the need to explain themselves in detail in an e-mail, I have learned to respond only in person so that I can clarify the client’s concerns and check and correct any misunderstandings.  Now, I tell clients I can make, change, and cancel appointments by e-mail and that I will read client e-mail, but that I will not respond by e-mail but only in person during our next session.
·         Sometimes, you just have to apologize for making mistakes or for not being able to help.  Therapists are human, too.  Despite consultation and supervision, sometimes personal issues interfere and cause a break or disconnection with a client.  It is therapeutic to own it and apologize.  It can even propel the process forward.  Other times, in an effort to be helpful I have accepted clients I could not help and needed to send them on to another therapist.  The quicker I can figure that out and make the appropriate referral, the better.
·         To that end, while, at first, I was anxious to have clients and schedule appointments, I have learned that it saves a lot of time and frustration to conduct a more comprehensive intake interview over the telephone or even an initial consultation before scheduling a first session.  Some of the questions I need to answer during the intake: who is the client and is that person willing to participate.  Sometimes a spouse or parent will try to make an appointment for an adult who is not seeking therapy on their own.  If the client is a child, who has physical and legal custody, who will participate with the child in therapy, who has the legal right to consent to treatment with the child.  I have had step parents and grandparents seek therapy for children for whom they do not have custody or legal rights.  Finally, is the issue or concern something for which I have training and experience.
·         When I started I was intent on being as open and helpful to clients as possible.  And, so I would tolerate clients for therapy and supervision not keeping appointments, cancelling at the last minute, and showing up late.  I rescheduled them time and again, even calling and reminding clients to make and keep appointments.  Then, I decided I needed to keep better boundaries in this regard.  And, so now I do not call clients to remind them or follow up after no shows, do not reschedule clients after two no shows, and collect no show fees before scheduling any more appointments.

Thursday, July 21, 2016

Evaluation and Termination

Chapter Twelve
Evaluation and Termination
            Every session could be the last session, so every session encompasses some elements of evaluation and termination.  Right from the first session I remind clients that based on my professional philosophy and practice model therapy has a beginning, middle, and an end.  The evaluation process is not just part of every session but the essential intervention of therapy itself.  What is working?  What is not working?  What have you tried?  What would you like to try? How can I help?  In addition to following a specific treatment plan that includes exploring trauma, practicing coping skills, and increasing emotional management, I often start each session with, “What would you like to work on today?” or “What would make this session worthwhile?”  The idea that we are always measuring progress in a time-limited process brings energy, motivation, and urgency to therapy, just as assignments, tests, grades, and a semester end bring focus to a class or course.
            Each of the following questions has a purpose as an intervention in and of itself.  What have we accomplished?  In the daily struggle of life and the routine of weekly sessions, clients sometimes do not see how much has changed since they started.  I return to the initial assessment paperwork, the client’s description of their concerns, and the scores they gave specific symptoms.  It is often surprising and gratifying for the client to hear, “Your child’s tantrums have decreased from daily to rare.  How did that happen?”  What is left to do?  Having resolved their most critical and persistent concerns, clients will often turn to higher functioning desires or, having experienced success in smaller ways are now ready to tackle more serious problems.  How might that be accomplished?  If clients have learned new skills, like communication, they may feel more competent to try resolving issues on their own or in another format, like group therapy.  If the client has seen little or no improvement in their situation, the answer may be to change the treatment plan, change the therapist, or try again at a later date.
            The process of therapy is often more important than the content.  The understanding, knowledge, and skills clients learn in session are applicable to many life challenges.  The purpose of therapy is at least two fold, to address current concerns and teach skills to apply to future issues.  The skills I try to teach and model are empathic and reflective listening, keeping boundaries and setting limits, and problem solving that respects individuals and relationships.  What has worked?  The question is meant to prompt the client to identify the specific skills and interventions, to consolidate the gains from the therapeutic process.  What has not worked?  This question is just as important as clients assemble a toolbox of life skills.  The two questions posed together illustrate the very practice of problem-solving; identifying issues, listing possibilities, evaluating options, making choices, trying solutions, measuring progress.
            Evaluating the therapist is not just about rating their work or collecting success stories.  What worked with the therapist?  This question invites the client to give the therapist feedback.  Giving feedback is another communication skill clients may use in the future.  What did not work with the therapist?  The client gets the chance to provide perhaps negative feedback in a positive way, yet another skill applicable to life in general.  More specifically, these questions put the client in the empowering position of being the customer of a service.  They ask the client to consider the nature of that service and what works for them.  In a parallel process, the client learns how to solve their problems and how to shop for services to help them in the future.  The questions allow the therapist to adjust the treatment plan and interventions if the client keeps them engaged or to make a referral if the client decides to hire another service provider.
            Having participated in the therapeutic process the client may have uneven progress in the future and experience setbacks both simple and serious.  What are anticipated challenges?  This question helps clients expect, normalize, and prepare for such challenges.  In the case of mental illness, substance abuse, and trauma, there are stressors, triggers, and relapses.  For couples and parents, families enter different life cycles and children grow into subsequent developmental stages.  Issues like adoption and learning disabilities are life-long.  When to return or seek help?  Clients often seek therapy when they are in crisis or when everything else they have tried to solve their problems has not seemed to work.  This question helps clients specify what circumstances would warrant returning to therapy to avoid a crisis.  A person with mental illness may want to return if they have had a major loss like a death in the family.  A person who relapses on drugs or alcohol may need a quick intervention.  A couple may return before they decide to adopt or have another child.  An adoption family may want to return as the child becomes an adolescent.  I specifically encourage parents and children to return when things are going well to celebrate success normalizing therapy as a support to well-functioning families.
            Because the client-therapist relationship continues in perpetuity after services have ended, it is important to restate the legal and ethical requirements at least during the last session.  I nearly repeat everything I said during the first session with parents and the first session with children.  “I will always have the responsibility to protect your confidentiality because we will always have only this professional relationship.  That means I will still not acknowledge you in public or do other kinds of business with you.  For example, I will not be attending your family weddings and you will not be attending my funeral.”  My responsibility for protecting the client’s privilege and privacy does not end with the termination of services.  I keep files and records for 10 years after the end of services or until the child turns 28 years old.  If I have not heard from the client for 30 days I send a discharge letter offering further services or a referral to another therapist informing them that I will be closing their file to officially end my responsibility for their care.
            Because my practice philosophy is based on the social work value and ethical principle of the importance of human relationships, I try to spend some time in each session and particularly in the closing session to honor my relationship with the client.  The client, whether individual, couple, or family, has taken a chance to share very personal information, to open themselves to examination, and to try news ways of interacting.  They have made themselves vulnerable in an intimate relationship that is by its nature unequal, the therapist has more power and does not reveal themselves in the same way that clients do.  It makes the therapist more responsible.  That is why it requires a license and continuing education, consultation, supervision, and audit, and is subject to complaint, investigation, administrative sanction, and legal action.  At the very least I express my appreciation of the relationship acknowledging what we have done together.  Further, especially with children and families, marking endings is an important therapeutic intervention.  For clients, especially children, who have experienced abrupt changes as a result of their trauma; removal from biological family, moves from one foster home to another, little or no contact with important family members, closure is necessary.  For this, ritual is important.  This can include recalling shared memories; the fun, human, personal, silly moments, blowing bubbles, drawing pictures, playing games in therapy.  Returning routinely to a book, game, or toy in session may seem repetitive as if we are making no progress and should be focusing on something new.  However, these rituals are as important to the therapeutic process as they are to family life.  Of course, I encourage clients and families to return to therapy if crises, changes, or new challenges arise, but I also encourage clients, especially traumatized and adoptive clients, to return when things are going well.  This is also a therapeutic intervention to consolidate and celebrate gains and to reset the role of the therapist from rescue to support.  Especially with children, even adolescents and adults, I like to end the final “see you later” session by reading Dr. Seuss’s Oh The Places You Will Go! (1990), which has a realistic message predicting a positive future.  Reading it models and reinforces the nurturing and positive relationship.
Sticking Points
Particularly with families, and especially adopted families, when healing seems to stall four issues are most likely to be at the route.  Adult trauma: parents have not dealt with their own childhood experiences and they are being triggered in ways that keep them from being warm, nurturing, and consistent with their children.  This often requires putting the family work aside to address the parents’ issues either in consultation or with outside therapy.  Adult relationships: parents have deep unaddressed difficulties in their relationship, differences in their ideas about parenting, and inability or unwillingness to communicate about them.  This requires stopping conjoint parent-child work to avoid further damage to focus on these issues.  Adoption attitudes: due to unresolved infertility issues that make adoption seem shameful, parents are unable to appreciate, communicate, and facilitate relationships with biological family to benefit their children and family.  Theoretical differences: the client, despite adequate psychoeducation, cannot accept and does not agree with a relationship-based non-behavioral orientation.