Chapter Three
Psychoeducation
Psychoeducation happens
throughout the therapeutic process either as information shared with clients or
information they have discovered or gathered in their research of their
situation. However, I use
psychoeducation as an extension of my professional identity, informed consent,
and practice model and especially with families and children devote the second
session to educating my clients on my theoretical orientation and a more
detailed understanding of possible diagnoses.
In the second and subsequent sessions, I find it helpful to specifically
set aside the first few minutes to hear the questions and concerns of the
client since the previous session. That
first informed consent meeting is rather intense, full of detailed and
sometimes confusing information and full of complicated emotions about expressing
concerns to a stranger for the first time.
It helps to clarify any miscommunication or misunderstandings. Something a client may have felt
uncomfortable sharing the first session might be easier to broach in subsequent
sessions. Clients may also come to the
conclusion that they are not ready and willing to participate in therapy at the
time. And, of course, they may decide
that I am not the best fit for them and they want to try another therapist or
other interventions and services first.
The best reason to set aside time to process is that clients often do a
lot of thinking and work between sessions and often come up with excellent
insight about the issue and what will work for them. They often return with increased motivation
and confidence and willingness to accept coaching and feedback. This client/therapist decision is central to
contracting for service.
The second session I
usually turn into a trainer, complete with PowerPoint presentation, and explain
my conceptualization of the causes of behavior and distressing emotion
connecting it with ways to find relief and growth. This is when I start channeling Ainsworth,
Berg, Bowlby, Burns, Erikson, Forbes, Hughes, Johnson, Kubler-Ross, Levy, Main,
Maslow, Orlans, Perry, Post, Siegel, and Yalom.
Because many of my clients are adoptive families, attachment, trauma,
grief and loss are the issues. For
blended, military, and single-parent families this can also be the case. Even for the rare client, individual, couple,
or family, who have not experienced abuse, violence, separation, or substance
abuse, real challenges like developmental delays and mental illness impact
interpersonal relationships between friends, spouses, and parents and children. It is the impact of trauma on relationships
that is the target of my work. Trauma is
a big word that encompasses everything from in-utero exposure to violence and
removal at birth, to physical injury and multiple caregivers, to natural disaster
and war. Trauma affects physiological,
psychological, and neurological functioning.
It can lead to emotional, cognitive, physical, and social impairment. This often results in maladaptive coping
behaviors with potential long term consequences for mental and physical health,
interpersonal and social problems, even early death. Because trauma happens in the context of
relationships, whether in families or in society relationships are sources of
stress and resilience as well as survival and growth. This is a big change in my thinking since
graduate school when I railed against a professor who taught “relationship is
everything”. Like many people I saw
changing behavior as the point of therapy.
But training and practice has taught me that behavior is driven by basic
needs for safety and belonging and meeting those needs is more effective in
changing those behaviors.
So, I teach about the
brain showing diagrams of the brainstem, limbic system, and cortex. I talk about how the brain reacts to trauma
by releasing the stress hormones adrenaline and cortisol with the classic
fight/flight/freeze response. I explain
that trauma not only primes the brain and body to be super sensitive to stress
but also impacts cognitive, emotional, physical, and social development (Perry and Szalavitz, 2006, p. 21-25). Daniel Siegel, M.D. and Mary Hartzell, M.D. (2003)
explain how experiences, even the earliest ones, shape memory which affects
perception leading to emotion driving communication forming attachment. We grow from the inside out. Because trauma like child abuse, domestic
violence, and death most often happens in the context of relationships, attachment
and trauma are linked. From experiences
we develop coping behaviors, both helpful and unhelpful, and from experiences
with parents we develop attachment styles and associated behaviors to cope
within the relationship. Ainsworth
(1978) and Bowlby (1988) defined four specific child attachment styles: secure,
anxious, avoidant, and disorganized.
Secure attachment is the result of consistent parenting and results in a
child who can self-regulate and has stable self-esteem. Anxious attachment is the result of
inconsistent parenting and results in a child who cannot self-regulate and has
shaky self-esteem. Avoidant attachment
is the result of unresponsive parenting and results in a child who withdraws
from control and sees the world as an uncaring place. Disorganized attachment is the result of
frightening parenting and results in a child with unpredictable behavior who
sees the world as dangerous. Securely
attached children are easier to love and teach.
Children with anxious, avoidant, or disorganized attachment require more
patience and are harder to parent. They
are in fight/flight/freeze mode so often that their limbic brain is on alert,
their brainstem racing, and their cortex unable to make lasting
connections. The goal is to develop
safety within the relationship.
The adult attachment
style of parents is predictive of the attachment style of their children and is
the result of our own childhood experiences (Main, 1985). The adult attachment style influences the way
we relate to others particularly partners and children. Mary Main defines four adult attachment
styles; secure, dismissive, preoccupied, and disorganized. She has developed an interview protocol to
determine attachment style. While I am
not trained to conduct the protocol I do ask a series of questions that suggest
the adult attachment style of parents.
This helps parents develop self-awareness that contributes to effective,
mindful parenting and helps me identify parents’ specific triggers which lead
to reactive rather than responsive parenting.
An adult with a secure attachment style is not someone who experienced no
negative childhood events but someone who has processed painful emotions and
can help others do the same. A person
with a dismissive attachment style may lack empathy for another’s pain because
they are dismissive of their own, that is, they cannot have empathy for
themselves. The person with preoccupied
attachment lives in their childhood pain and feels others’ behavior including
their children’s behavior as hurtful. They
cannot stay present with someone else’s pain without making it personal. The person with disorganized attachment lives
in a state of constant anger and fear that makes helping others’ with strong
feelings very difficult. To be certain
the attitudes and behaviors of adults with less than secure attachment are
about coping, even if they are dysfunctional or maladaptive. This exploration, while sometimes disturbing
and unpleasant can lead to what Main described as “earned security”, an
integrated self-awareness that contributes to interpersonal connection. It is essential in helping children toward
more secure attachment. Daniel Siegel
provides excellent questions for parental self-reflection (2003, p. 133), and I
often suggest his entire book, Parenting from the Inside Out, as homework for
parents.
Whether working with
adults or children, two other topics besides attachment and trauma are
important to investigate, developmental history and grief and loss. Conditions like depression, anxiety, trauma,
autism, and learning disabilities sometimes result from or lead to missed developmental
milestones and loss. Maslow (1943)
theorized that survival and safety needs are prerequisite for feelings of love
and belonging. A person in survival mode
is not free to learn and connect with others.
Brain-based conditions like Post Traumatic Stress Disorder and Attention
Deficit Hyperactivity Disorder impact the ability to read social and emotional
cues. As a result of the presence of a
mental illness or the absence of adequate care a person may miss a developmental
milestone or get stuck in a developmental conflict (Erikson, 1997). A person who was not able to develop basic
trust in a primary caregiver may have difficulty forming intimate relationships
as an adult. Whether the condition is
organic or the result of experience, it leads to loss. Losses include readily identifiable events
like the death of a parent, illness and injury, or more ambiguous less
recognized losses like infertility and divorce.
Kubler-Ross (1969) calls attention to the specific stages of
grieving that are accepted as natural.
Identifying unmet basic needs, missed developmental milestones, and unresolved
stages of grief help target interventions.
Developing awareness and
understanding of attachment and trauma leads to a sometimes uncomfortable realization;
traditional parenting and therapy will not help and often hurt. It requires a real shift in parenting, an “unlearning
curve” that challenges almost everything we have experienced and been taught
about the ways to change behavior and help people heal. If behavior is need-driven, then identifying
and meeting the need is the answer not rewarding or punishing behavior. Points and prizes, charts and stars, tokens
and timeouts, lecturing and spanking will not work to build or repair a
relationship. Fear-based discipline that
describes behavior as defiant and oppositional and insists on compliance and
respect misses the mark and does more harm than good. Treating attachment trauma, grief and loss,
along with neurologic conditions like Autism Spectrum Disorder, Attention
Deficit Hyperactivity Disorder, and Post Traumatic Stress Disorder require
starting from a place of love and safety.
Interventions are counterintuitive and subject to scorn from others who
do not understand the specific situation.
The tantruming toddler needs more time with Mom or Dad; the aggressive
eight-year-old needs more hugs; the screaming teenager needs more play time, and
the angry adult needs more care and empathy. (Cue rolling eyes and gaping mouth.) This is where treatment planning begins.