Chapter Five
Treatment Planning
Depending
on the time it takes to provide informed consent, psychoeducation, and
assessment, treatment planning may follow in the third or fourth session. Having identified the symptoms of
relationship trauma as emotional dysregulation and negative core belief system,
established the target of treatment in the relationship between parent and
child, it is time to set goals with realistic measurable outcomes and to coach
parents to help carry them out. Goals
for conditions like anxiety, depression, and trauma may be rather straight
forward; rule out illness and injury, refer for medication assessment, identify
and manage triggers, develop successful coping skills, and connect to other
supports like family and friends. For
attachment trauma my goals are to increase secure attachment, increase emotional
management, process grief and loss associated with traumatic events, and
increase self-esteem or change the core belief system. The difference between traditional treatment
and my practice model is the central role of the parent in attuning to the
child, providing a safe base, co-regulating the child, helping the child
express and process emotions, and creating positive interactions.
Attachment
Trauma Treatment Plan
Increase secure attachment to
parent as evidenced by help seeking and cooperation using attachment
therapy, narrative therapy, and play therapy.
Increase emotional intelligence
as evidenced by the ability to identify, express, and manage emotions with
parent help using play therapy and cognitive behavioral therapy.
Increase core belief system as
evidenced by the ability to process grief and loss with parent help with
attachment therapy, narrative therapy, and play therapy.
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First,
I like to set parents’ expectations for their child’s behavior in session. Parents facing the difficulties of their
children’s sometimes challenging behaviors are anxious to get started, to see
improvement, sometimes to have a quick fix.
It takes some effort and confidence to stand firm on the preparation of
parents to act as co-therapists; to acknowledge their concerns, to teach about
attachment trauma, to explain what seem to be counterintuitive interventions,
and to convince parents that the time they take to explore their own lives
toward self-awareness and self-care pays off with more effective, healing,
powerful parenting. Because they want to
present their family in the best light, and because they want the therapy to
work, they want their child to behave and cooperate, exactly the way they want
the child to act at home. The funny part
is, most children with attachment trauma can “hold it together” and present
themselves well for a while. This
ability bothers parents to no end. “Why
can’t s/he behave like this at home?”
“You’re not seeing the ‘real” child.”
“He doesn’t act this nice at home.”
“Why don’t you come home with us?”
The reason is not that the therapist has any extraordinary skill but the
therapist is not trying to get close to the child. The therapist is not the parent who loves and
cares for them. For traumatized children
love and care are frightening to accept, first because they doubt it will
continue, and second because they do not believe they deserve it.
That
is why I will not work with a child alone while a parent waits in the
lobby. What does it say to a child to be
dropped off by a parent and to go into a room with a therapist? It says, “You’re the problem.” And, as Malcolm X asked, “How does it feel to
be the problem?” Child trauma is not a
child’s fault and they should not be expected to fix it themselves. To be sure, important topics may be broached
in therapy but the real healing happens in the home; over the breakfast table,
on the drive to school, during a walk in the park, while being tucked into
bed. The parent is present for those
moments and needs the knowledge and skills to recognize and respond to them. For children who do not have a parent who can
provide safety, the therapist may be one of the few who does. But the parent who is unable or unwilling to
learn to provide safety is the exception, so I attempt to teach them
first. I tell the parent I believe them
when they report that the child was “out of control” at home. Traumatized children can do some incredibly
weird and scary things; hit their brother, hide food, take an I-pod, scream for
hours, run away, smoke pot, punch holes in the wall, pull a knife on their
mother, burn the house down. And hurt
themselves, which they think they deserve.
So, helping a child starts with accepting who they are, what they have
experienced, and their behavior as an expression of that pain.
I
let parents know that when I am interacting with their child I am modeling
skills for them to adopt. I will attempt
to help the parent and child feel comfortable and welcome in my waiting room
and office by letting them know the location of bathrooms and exits, what they
may do and use while waiting or participating in therapy, my expectations for
their behavior around sitting and talking.
But I specifically ask parents not to have expectations for their
child’s behavior in the therapy room. I
do not expect children to sit quietly and listen and answer questions. I do not expect children to like coming to therapy
or to show me respect. My goal is to
accept the child (and the parents) where they are and to demonstrate safety in
the space, which does not and cannot happen immediately. I have had children sit like stone unwilling
to talk. I have had children hide behind
the furniture. I have had children lash
out and throw things at me. All behavior
is fodder for the therapeutic process which starts with providing safety and
then joining and understanding the underlying beliefs and feelings that drive
the behavior. The therapy room needs to
be a discipline-free zone. Parents will
often “bribe” their child to behave and cooperate in therapy, “a treat if you
behave”. Nothing could be more counterproductive.
That is not to say I will do
nothing if a child or parent behaves in a dangerous or hurtful way. I have had children nearly knock people down
racing out of the office, need to be physically restrained by their parents in
the waiting room, and ready to run into traffic on a public street. Those are therapeutic encounters, too,
requiring everything from de-escalation skills to police back-up. Sometimes people cannot maintain themselves
safely even with help in an office and require the structure and supervision of
a squad car, jail cell, or hospital room.
I model asking for help.
I
set a few more boundaries to reinforce the parent-child relationship. I do not hug children or adults or touch them
in affectionate ways. Children do need
comfort and hugs in my office but I redirect them to their parent, and that is
not me. Handshakes and high-fives are
just fine. Traumatized children and
adults have often been touched in sexual and violent ways, and I do not want to
trigger them. And, while I may be a
stranger to start, I will not become their friend. Although I try to be friendly, this is a
professional relationship. I am not
coming to their home like a friend, giving or receiving gifts, or celebrating
birthdays and holidays. That is not to
say we will not have deeply felt human interactions, but my whole goal is to
facilitate those interactions between partners, family members, and parents and
children.
I
consider the parent to be a co-therapist for their child. To that end psychoeducation, coaching, and
modeling is about helping parents be therapeutic, in my office and in their
homes. I use Daniel Hughes’ acronym PACE
or PLACE (Hughes, 2007, p.61) as a guide.
PACE stands for playfulness, acceptance, curiosity, and empathy. Playfulness means an attitude of lightness
and pleasure in the presence of the child, even in the face of difficult
behavior and material. This is not easy
to pull off without seeming condescending or cruel but is essential to
recapture the innocence of childhood.
Acceptance means staying present with the child, behavior and emotions
and thoughts all at once, without rushing to correct or judge. We can agree with the feelings and not with
the facts, which makes the whole difference.
Curiosity requires keeping an open mind, questioning messages and
meanings, willing to test theories through trial and error, an interested
investigative parent. Empathy means
seeing the issue from the child’s perspective and joining in their
interpretation of their experiences, not imposing our ideas or sympathies. To PACE, one could add L for love or limits,
setting safe boundaries for work. A demonstration of commitment to the child,
acceptance of their experiences, and joining in their healing are the essential
features of attachment therapy. Since
the goal is a safe connection to the parent, it does not require correction or
teaching, at least not in the moment. This therapeutic stance requires specific
behavior from parents; smiling, touching, eye contact, reflective listening,
and silence among similar skills. Of
course, therapy entails talking but even then, as Daniel Siegel (2003) makes
clear, rhythm, timing, tone, and volume are more important than words.
Then,
I set a pace for therapy. If parents are
the co-therapist, I expect them to be active players, and I do mean play, for
play is the work of children, how they process experiences. I try to align myself with parents, sometimes
physically, by sitting next to them, behind them, or in a position that
supports their interaction with the child, certainly not cutting off the parent
or making them only an observer of the activity. I expect to take an active role in modeling
PACE while deferring to the parent’s role in caring for the child and
explaining the family’s cultural practices.
Parents may bring food, blankets, books, and toys that sooth and
support. My goal is balance during
sessions, or from one session to the next, of delving into serious material for
a while then transitioning into play, going into the trauma then practicing
coping skills. For example, I like
having parents read books to their children then using the book as a jumping
off point for a discussion of the child’s specific situation. I also use drawing, games, role play, and
storytelling. I often consult with
parents alone while the child waits, or check in with parents before bringing
in the child. Even this demonstrates
that parents are working to change, not the child. Sometimes, parents feel the need to leave the
child at home and spend the session on their own concerns. The child benefits here, too. It is important that I join with the parents
and that they feel comfortable expressing their concerns, asking questions, and
letting me know if they do not understand or do not agree with something I have
said or done.
Two
techniques I teach parents and use myself I take from the work of Orlans and
Levy (2006). First, using statements
instead of questions with children and often with adult clients as well. Questions may be the main tool for
therapists, but they also put pressure on the client to answer, pressure that
often leads to stress, stress that leads to silence or worse, answers that stop
the interaction because questions feel intrusive and uncomfortable. Questions sometimes lead to the exact
behavior; silence, lies, aggression, that parents describe as defiance and
opposition that really say the client does not feel safe. Instead, statements do not require an answer,
but allow the client to make a choice; say nothing, agree or disagree with what
is said. “Why do you have tantrums when
your mother asks you to turn off the television?” does not get you
anywhere. Rather, “I think you have
tantrums because you don’t think your Mom wants you to have fun,” is more
likely to result in a grunt, a smile, or a “heck yes”, that says you have
understood and connected. It can be even
more powerful to take the pressure off the child entirely by taking them out of
the loop and overhear a conversation about them. One four year old who tore up my notes and
threw adoption books on the floor hid behind the couch. I asked her parents, “Why do you think the
mother gave birth then left the baby at the hospital?” A small voice answered, “I think the baby
cried too much.” Her statement said
everything about her behavior.
Which
leads to the second technique, making a statement of the trauma story. Parents and therapists alike want to “start
where the client is” and “do no harm”.
So we work on developing a trusting relationship waiting for the child
to reveal their innermost concerns and questions. We wait for the child to be “ready to
talk”. Most of the time parents take a
child’s silence about trauma, including adoption, as a sign that they do not
think about it. This is usually because
the parents do not want to think about it.
It does not mean the child does not.
And so children and families go for years without addressing major
issues while the resulting behaviors and emotions persist. We forget that people, particularly children,
do not necessarily talk about their feelings, they act them out. Even in the absence of acting out, children
are not likely to share their concerns if they do not understanding why they
feel the way they do, or worse, that they will bother or hurt their parents, or
be hurt by their parents for speaking up.
We acquiesce to this arrangement with our silence. When we say, “We can talk about anything
here”, but do not specify what, or dance around the subject with subtle hints
about “sad and scary” events, we are really saying, “don’t tell me, I can’t
handle it.” Loneliness and shame
increase. We want to send the opposite
message, “We can handle it,” and we will not wait and let you to suffer in
silence. The trauma statement is firm
and straightforward: “We are here to help your parents help you with the fact
that you were removed from your biological parents because they did not take
care of you, that you spent time in several foster homes, and then had to be
adopted.” This also helps parents
introduce therapy to their child.
Instead of, “You are going to therapy because of your behavior,” the
parent can say, “We have been working with a therapist to become better parents
for you. We want you to come with us so
we can practice what we have learned.” And
so it begins.
Diagnosis
While accurate diagnosis is an
ethical responsibility, many clients see a label as an end in itself as if a
pill or other quick fix will cure it. For
children and adults, some diagnoses are rather clear cut. Anxiety, attention deficit hyperactivity
disorder, autism spectrum disorder, bi-polar disorder, depression, obsessive
compulsive disorder, post-traumatic stress disorder, and schizophrenia, while
complicated especially if co-occurring, have pretty straight forward treatment
protocols or evidence-based interventions.
Other diagnoses like oppositional defiant disorder, conduct disorder,
and reactive attachment disorder are more difficult to identify because their “symptoms”
are more subjective. Oppositional to
what? Defiant to whom? Reactive to whom? These are individual diagnoses for relational
problems that require looking at the whole family. More accurate names for these might be
relational traumatic stress or dyadic developmental disorder. You would never diagnosis a couple with
oppositional defiant disorder. The
individual diagnosis puts the onus on the person to change when the target of
intervention needs to be on the interpersonal dynamics and interactions between
individuals.
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