tag:blogger.com,1999:blog-9119203208064647362023-11-15T07:28:53.114-08:00Michael A. Jones, LCSW - Licensed Clinical Social WorkerMichael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.comBlogger50125tag:blogger.com,1999:blog-911920320806464736.post-85357101529070802742021-02-12T15:32:00.015-08:002021-02-15T13:26:37.836-08:00Tales from Therapy <p style="text-align: center;"> <span> </span><span> </span><span> <span> </span> </span>These real case examples are published with the written consent of the clients and their parents with identifying information changed or removed to preserve confidentiality. </p><p align="center" class="MsoNormal" style="text-align: center;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">Allen
and Andrew<o:p></o:p></span></p>
<p class="MsoNormal" style="text-indent: 0.5in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">Allen and Andrew came
with their mother and grandmother, their adoptive parents, at age five.<span style="mso-spacerun: yes;"> </span>We worked together for 33 sessions over two
years.<span style="mso-spacerun: yes;"> </span>Allen had been displaying
separation anxiety in school, crying and clinging to his mother, relieved only
in the company of his twin brother, Andrew. Their parents wanted help
explaining their adoption and addressing their sometimes aggressive behavior toward
each other and defiance of parents. They could not be apart nor sleep in their
own beds, they screamed in the car refusing to go into stores, and they
demanded their electronic toys and could throw hours-long tantrums. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>The
boys were named Jerry and Joseph by their 18-year-old biological mother Kathy.<span style="mso-spacerun: yes;"> </span>The twins each weighed about five and a half
pounds at birth.<span style="mso-spacerun: yes;"> </span>They were healthy.<span style="mso-spacerun: yes;"> </span>Kathy cared for them for three weeks at her
mother’s home then took them back to the hospital for a check-up.<span style="mso-spacerun: yes;"> </span>That’s when their mother admitted using drugs
and alcohol and the infants were removed from her care, deemed to be
underweight.<span style="mso-spacerun: yes;"> </span>Child welfare services
placed the twins in the home of a foster parent then moved them six months
later to their adoptive home.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Their
biological mother herself had been adopted.<span style="mso-spacerun: yes;">
</span>Kathy and her sister were abandoned on the streets of Tijuana and placed
in separate orphanages.<span style="mso-spacerun: yes;"> </span>At the age of
six Kathy was separated from the children with whom she was raised in the
orphanage and moved to her sister’s shelter.<span style="mso-spacerun: yes;">
</span>From there they were adopted by a San Diego couple.<span style="mso-spacerun: yes;"> </span>At the age of 12 the sisters were removed
from the adoptive home because the adoptive father had molested one of their
friends.<span style="mso-spacerun: yes;"> </span>He was convicted and sentenced
to prison and they were reunited with their adoptive mother.<span style="mso-spacerun: yes;"> </span>At the age of 16, Kathy gave birth to a boy
who was subsequently removed from her care and adopted.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Allen
and Andrew are the smartest, funniest, most articulate, caring boys you will
ever meet. They come up with the most meaningful and thoughtful things to say
and they are interested in everything and everyone around them.<span style="mso-spacerun: yes;"> </span>They are hard to say no to.<span style="mso-spacerun: yes;"> </span>Their mother, Diane, had wanted children but
never married.<span style="mso-spacerun: yes;"> </span>So, she and her mother, Claire,
decided to adopt together.<span style="mso-spacerun: yes;"> </span>Diane is the
breadwinner, and Claire is the stay-at-home parent.<span style="mso-spacerun: yes;"> </span>They each have a sense of humor and plenty of
support from family and friends.<span style="mso-spacerun: yes;"> </span>But
they do come from two different generations.<span style="mso-spacerun: yes;">
</span>Diane’s focus was on making the boys happy.<span style="mso-spacerun: yes;"> </span>Claire needed them to mind her.<span style="mso-spacerun: yes;"> </span>So, whether it was bedtime or chore time
there was a lot of whining and pleading, sometimes also by Allen and Andrew.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>In
the first few sessions as I learned more about the boys and they became more
comfortable in the therapy room and with me, we explored their personalities
and strengths.<span style="mso-spacerun: yes;"> </span>We played games and
explored the topic of adoption in general with books.<span style="mso-spacerun: yes;"> </span>At that point, the boys understood little
about their own biological history and assumed their lives started in the twin
cribs they shared as infants, constantly hungry and eating and growing, until
they could crawl out of one crib into the other and sleep together.<span style="mso-spacerun: yes;"> </span>We drew out their “placement map” and
identified the people and places in their lives including their biological
mother, the unknown father they named “Bill”, and the older brother who went to
another adoptive home.<span style="mso-spacerun: yes;"> </span>To help with the
story, Diane had pictures of the boys and their mother and even found pictures
of their brother.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>It
took no more than a dozen sessions for the boys to be able to tell their own
story and identify all the feelings associated with leaving and moving and
finding a forever family.<span style="mso-spacerun: yes;"> </span>They became
very familiar with the routine of the room: asking for toys and games before
playing with them; excusing themselves to insert comments into adult
conversations; accepting choices about how to leave the room, all planned
attachment therapy interventions. They were totally obedient and compliant
until they could stand it no longer and needed to take charge.<span style="mso-spacerun: yes;"> </span>It was the smallest of requests from Mom,
“Shake Mike’s hand and say goodbye.”<span style="mso-spacerun: yes;">
</span>Nothing.<span style="mso-spacerun: yes;"> </span>Andrew looked at Allen
and the test of wills was on.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Allen
looked at Mom and said, “Come on, let’s go.”<span style="mso-spacerun: yes;">
</span>“Shake Mike’s hand.”<span style="mso-spacerun: yes;"> </span>“No”.<span style="mso-spacerun: yes;"> </span>First Allen and Andrew began begging to go
home.<span style="mso-spacerun: yes;"> </span>In the moment they did not realize
that the door was unlocked and nothing kept them from walking out of the room,
taking the elevator or stairs down, and walking to the parking lot.<span style="mso-spacerun: yes;"> </span>Instead, Allen begged his mother to go then
ordered her to get up and leave with them.<span style="mso-spacerun: yes;">
</span>Andrew watched and then joined in, looking at me and his parents dead in
the eye and began to tear the room apart.<span style="mso-spacerun: yes;">
</span>The twins pulled toys out of the cabinet, dumped puppets out of an
ottoman, tried to overturn a coffee table until the wheels came off.<span style="mso-spacerun: yes;"> </span>First, Diane then Claire pleaded with their
sons to stop.<span style="mso-spacerun: yes;"> </span>“All you have to do is
shake Mike’s hand.”<span style="mso-spacerun: yes;"> </span>“Boys, stop tearing up
the room.”<span style="mso-spacerun: yes;"> </span>The more the parents
bargained the bigger the show became. “You’re ruining my life!” said Allen.<span style="mso-spacerun: yes;"> </span>“You don’t love us!” cried Andrew as the boys
writhed on the floor.<span style="mso-spacerun: yes;"> </span>With an “evil eye”
toward me they moved toward my laptop and shelves as if preparing to do damage
but did not.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Feeling
fairly safe myself and with no pressure to clear the room for another client, I
knew the boys were inviting me into their world and I was seeing what the
parents experienced frequently.<span style="mso-spacerun: yes;"> </span>My
attention, then, turned not to the twins but to their parents and their
attempts to stop the show.<span style="mso-spacerun: yes;"> </span>I reassured Diane
and Claire that I was not judging them or the boys and that we had plenty of
time to work through this together.<span style="mso-spacerun: yes;"> </span>I
encouraged Diane to stop responding to the twins’ cutting remarks and to stay
calm and focus on her smart phone.<span style="mso-spacerun: yes;"> </span>I
gave Claire a book and told her to relax and at least pretend to read and
ignore what was going on.<span style="mso-spacerun: yes;"> </span>It is
important here to say I did not suggest the parents leave the room or threaten
consequences in any other way.<span style="mso-spacerun: yes;"> </span>This is
what happened when the children did not want to leave the car to go into a
store, and it happened when the parents took away electronics to direct the
kids to chores or bed.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Then
over the next 30 minutes the pattern became apparent.<span style="mso-spacerun: yes;"> </span>When the parents responded in an anxious way
to the boys’ behavior, the tantrum got louder and the mess got bigger.<span style="mso-spacerun: yes;"> </span>When the parents stayed silent but present,
the boys became quieter, started chatting with each other about other topics,
and then, surprisingly began to work together to clean up the room and put
everything back as it was before.<span style="mso-spacerun: yes;"> </span>Andrew
told Allen to help him pick up the corner of the coffee table so he could put
the wheels back on.<span style="mso-spacerun: yes;"> </span>They were working
together showing that their overactive right brains and limbic systems had been
calmed, and their left brain and cognitive functions could work together to
solve their problem. Forty-five minutes after their official appointment had
ended, Andrew came over to me, offered his hand, and said quietly, “See you
next week, Mike.”<span style="mso-spacerun: yes;"> </span>Allen, however, looked
sideways at his brother as if he were a traitor to their cause but eventually
did the same.<span style="mso-spacerun: yes;"> </span>I responded, “See you next
week you wonderful boys.” <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Here
is what I understand about that situation.<span style="mso-spacerun: yes;">
</span>Because of the twins’ experience of neglect very early in their lives,
their subsequent removal from their biological mother, and their placements in
two foster homes before they were six months old, these boys have a high level
of anxiety associated with their primary caregivers, attunement to their
internal states, and fear of abandonment.<span style="mso-spacerun: yes;">
</span>This anxiety drives a level of emotional dysregulation when they feel
unsafe in the situation or when their caregivers are anxious.<span style="mso-spacerun: yes;"> </span>This dysregulation looks like defiance as
they test adults and attempt to take control.<span style="mso-spacerun: yes;">
</span>Also, object relations says that an infant does not distinguish
themselves from their caregiver so removal from birth mother at weeks old
leaves a sense of loss of self which can last well into adulthood.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>It
would be easy to think these smart boys know what they are doing and intend to
get their way, in this case leaving the room on their own terms without
following the instructions of their parents, refusing to obey.<span style="mso-spacerun: yes;"> </span>Instead, at our core we seek a sense of
safety essential for survival and for children that safety comes from parents.
When children experience disruption so early in their lives their sense of
safety is shattered and remains shaky even when parents are healthy, loving,
and supported.<span style="mso-spacerun: yes;"> </span>So, the behavior is a
sign or symptom of anxiety.<span style="mso-spacerun: yes;"> </span>And the goal
of the parent or adult needs to be to help the child feel safe and regulated by
staying calm, steady, and soothing.<span style="mso-spacerun: yes;"> </span>When
a parent gives in to their own anxiety by attempting to appease or scold the
child, the parent has lost control of the situation, the child feels it, and
their fear increases.<span style="mso-spacerun: yes;"> </span>Another thing that
increases with children who have been removed from first parents is their sense
of shame that they are damaged and nobody can tolerate or help them.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Now,
most people and parents would not see this situation as a big deal worth
spending an hour and a half to “fix”. They might find it petty to “force” a
child to follow simple directions or even abusive to “make” them shake hands
with an adult.<span style="mso-spacerun: yes;"> </span>After all there are
bigger and more important struggles to tackle and not enough time in the day to
get everything done with kids.<span style="mso-spacerun: yes;"> </span>Who wants
to spend another 45 minutes with crying children when you can make it stop so
fast by giving in.<span style="mso-spacerun: yes;"> </span>The trouble is, this
is about trust, helping children trust their parents, helping parents
demonstrate their reliability so they can develop and maintain influence with a
child in their small choices leading to big decisions.<span style="mso-spacerun: yes;"> </span>Parents are responsible for behaviors that
attach the child to them in a way that fosters security and healthy development.<span style="mso-spacerun: yes;"> </span>If left unaddressed this pattern of trauma,
anxiety, scolding, and acquiescing repeats from the smallest tests of will up
to conflicts over chores, homework, media, drugs, friends and whether the
teenager or young adult can follow the rules to safely live at home.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>The
question was, did setting and keeping a boundary with quiet, compassionate,
consistency pay off in increased trust in adults as demonstrated by the ability
to go along with their directions and expectations?<span style="mso-spacerun: yes;"> </span>The next session with Allen and Andrew
proceeded like any other; checking in on their week, deciding on goals for the
session, finishing their adoption story.<span style="mso-spacerun: yes;">
</span>When it came time to leave, the boys stopped and considered their
options.<span style="mso-spacerun: yes;"> </span>Would they say goodbye and get
on with their day or would they stay and test us more?<span style="mso-spacerun: yes;"> </span>Andrew gave a knowing look to his mother and
me, shrugged his shoulders, shook my hand, and walked out.<span style="mso-spacerun: yes;"> </span>Allen looked betrayed.<span style="mso-spacerun: yes;"> </span>He continued to dig in his heals and began to
whine and cry.<span style="mso-spacerun: yes;"> </span>This time I directed
their grandmother, Claire, to leave with Andrew and wished them a good time
together.<span style="mso-spacerun: yes;"> </span>Allen stayed staring at his
mother and me wondering what we would do.<span style="mso-spacerun: yes;">
</span>He began to cry.<span style="mso-spacerun: yes;"> </span>Not an angry or
frustrated cry, but a desperate overwhelmed cry with real tears.<span style="mso-spacerun: yes;"> </span>Mother Diane pulled him onto her lap.<span style="mso-spacerun: yes;"> </span>The control battle was too much.<span style="mso-spacerun: yes;"> </span>All of his fears and sadness came to a
head.<span style="mso-spacerun: yes;"> </span>His mother had the chance to
empathize with him and offer physical comfort and support. After a few minutes,
perhaps 15 not 45, he was ready to say goodbye holding his mother’s hand.<span style="mso-spacerun: yes;"> </span>The scene has not repeated again although the
boys talk about that day almost every time we see each other. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>The
kind of early experiences Allen and Andrew have had leads children to a level
of ongoing anxiety that most children do not have, although on any given day
full of school and sports its presence is not readily apparent.<span style="mso-spacerun: yes;"> </span>Then even infants, toddlers, and small
children develop some interesting defenses to cope with their invisible but
real fear of abandonment.<span style="mso-spacerun: yes;"> </span>It takes a lot
of energy to maintain that level of hypervigilance.<span style="mso-spacerun: yes;"> </span>Also, intelligent children like the twins have
an innate sense if not a full understanding that they are different from other
people.<span style="mso-spacerun: yes;"> </span>They often attribute this
difference, not to the early experiences of trauma, but to themselves.
Remember, young children are self-centered and egotistical, and they are
supposed to be.<span style="mso-spacerun: yes;"> </span>That means they do not
see much farther than their small sphere and they attribute events to
themselves.<span style="mso-spacerun: yes;"> </span>Their sense of being deeply
troubled or in trouble can be overwhelming. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>The
job of a parent, to the extent possible, is to be that calm, consistent safe
base from which a traumatized child can receive comfort, validation, and
encouragement in exploring themselves and their world.<span style="mso-spacerun: yes;"> </span>The job of the therapist, to the extent
possible, is to support the parent and guide the dyad in managing emotions on
the journey to healing and thriving.<span style="mso-spacerun: yes;"> </span>For
the therapist, it is about developing a relationship of trust with the parent
so they can manage their own anxiety without shame, develop a better
understanding of their child, and practice counterintuitive non-traditional
methods.<span style="mso-spacerun: yes;"> </span>The purposes are to read the
child’s behavior therapeutically, help the child reduce their anxiety levels
and raise their self-esteem, and improve the child’s attachment to the
parent.<span style="mso-spacerun: yes;"> </span>This more secure attachment
gives the parent influence with the child in guiding them toward
self-realization and healthier relationships in the future. <o:p></o:p></span></p>
<p align="center" class="MsoNormal" style="text-align: center;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">Donny
and Henry<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Donny
and Henry were eight years old when their mother Joan brought them to me to work
on adoption issues.<span style="mso-spacerun: yes;"> </span>I worked with Donny
off and on for more than four years.<span style="mso-spacerun: yes;"> </span>I
worked with Donny and Henry together for a time before Henry started EMDR with
another therapist to address his PTSD.<span style="mso-spacerun: yes;"> </span>Joan’s
home was the twins’ ninth placement since their removal from their biological
mother at age two and their third adoptive placement including with their
biological sister.<span style="mso-spacerun: yes;"> </span>The boys had just
moved in when we started working together and they were already displaying the
behaviors of a difficult adjustment; lying, stealing, defiance, and
tantrums.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Henry
was the first twin born weighing not quite four pounds with Donny right behind
him at five and a half pounds.<span style="mso-spacerun: yes;"> </span>The size
difference has been evident throughout their lives, Henry is the smaller
brother. They lived with their biological mother for almost two years with
their three older siblings until child welfare services intervened on behalf of
their older sister.<span style="mso-spacerun: yes;"> </span>After staying in
foster care for two years, the twins were actually placed with the older sister
for adoption.<span style="mso-spacerun: yes;"> </span>It was during that more
than two year period they were exposed to domestic violence and physical abuse
along with their sister’s two younger children who were also removed.<span style="mso-spacerun: yes;"> </span>The boys reported leaving the house as small
children to get away from what was going on inside.<span style="mso-spacerun: yes;"> </span>By the time they got to Joan’s house they
were most concerned about what they would eat, how much they could play, and
where their stuff would go.<span style="mso-spacerun: yes;"> </span>They had
very little tolerance for a new parent’s rules and reminders to do their
homework, clean up after themselves, or go to bed on time.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>In
fact, Henry had the most difficulty going to sleep.<span style="mso-spacerun: yes;"> </span>He would hide, stall, and scream. One day Henry
came into the therapy room with his head hanging in shame.<span style="mso-spacerun: yes;"> </span>His mother followed with an exasperated look
on her face. Joan was raised by a loving mother and critical father, so being
challenged by angry little boys was triggering to her.<span style="mso-spacerun: yes;"> </span>Despite this, she was well educated, well
trained, well supported, and committed to keeping these boys in the
family.<span style="mso-spacerun: yes;"> </span>She also had the help of her
mother who lived nearby and attended therapy with them.<span style="mso-spacerun: yes;"> </span>I asked Henry, “You look upset, what’s
up?”<span style="mso-spacerun: yes;"> </span>With enough time to feel
comfortable in the setting he said quietly, “I kicked a hole in the closet
door.”<span style="mso-spacerun: yes;"> </span>His mother shook her head, “We
had a difficult night.” She understood bedtime was difficult because of the
domestic violence he experienced in his sister’s home. They had already tried
different strategies to help Henry sooth at night including his mother staying
in his room until he fell asleep.<span style="mso-spacerun: yes;"> </span>She
neither judged nor shamed but just asked for help.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>I handed
Henry the telephone and the yellow pages, the big book.<span style="mso-spacerun: yes;"> </span>I suggested he could probably fix his problem
with a simple call and that his mother and I would be nearby to help him.<span style="mso-spacerun: yes;"> </span>Then we listened and watched.<span style="mso-spacerun: yes;"> </span>Henry found the number for Home Depot.<span style="mso-spacerun: yes;"> </span>He called and asked for the right
department.<span style="mso-spacerun: yes;"> </span>He asked about ordering a
new closet door.<span style="mso-spacerun: yes;"> </span>At one point, he turned
to his mother behind him and asked if they needed someone to install the
door.<span style="mso-spacerun: yes;"> </span>His mother told him they had a
family handyman.<span style="mso-spacerun: yes;"> </span>He finished ordering
the door, said thank you, and hung up the phone.<span style="mso-spacerun: yes;"> </span>Now this nine-year-old struggled with school
and homework, was easily irritated and quick to temper, and often shut down
when faced with his mistakes.<span style="mso-spacerun: yes;"> </span>The same
boy spoke clearly, politely, and professionally.<span style="mso-spacerun: yes;"> </span>He calmly conducted business in an adult-like
way.<span style="mso-spacerun: yes;"> </span>I then asked him how much the door
would cost.<span style="mso-spacerun: yes;"> </span>“One hundred twenty
dollars,” he said.<span style="mso-spacerun: yes;"> </span>“How many weeks of allowance
is that?”<span style="mso-spacerun: yes;"> </span>Henry took pencil to paper and
figured out 20 weeks.<span style="mso-spacerun: yes;"> </span>His mother and I
did not need to do anything except praise his performance.<span style="mso-spacerun: yes;"> </span>He solved his own problem.<span style="mso-spacerun: yes;"> </span>The next week the handyman had installed and
painted the new door.<span style="mso-spacerun: yes;"> </span>This time Henry
walked into the room standing tall with a smile on his face.<span style="mso-spacerun: yes;"> </span>The bedtime tantrums decreased and the closet
door was safe because it belonged to him.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Parents
often talk about the damage their adopted and traumatized children have done:
holes punched in the walls; pantries emptied of snacks; parents, siblings, and
pets kicked, punched, and pushed.<span style="mso-spacerun: yes;"> </span>It can
be difficult to make the connection between this kind of aggression and the
child’s underlying sense of safety.<span style="mso-spacerun: yes;"> </span>Trauma
like removal from biological parents, early neglect, and exposure to domestic
violence leaves children feeling desperate, overwhelmed, trapped.<span style="mso-spacerun: yes;"> </span>In these environments it is difficult for the
child’s brain and body to develop the ability to regulate themselves.<span style="mso-spacerun: yes;"> </span>Aggression is the extreme expression of fear
and dysregulation.<span style="mso-spacerun: yes;"> </span>It also comes with a
deep sense of shame that feeds more aggression.<span style="mso-spacerun: yes;">
</span>To deal with both, it is important to help the child regulate by
providing close support from the parent and to facilitate the child’s problem
solving skills.<span style="mso-spacerun: yes;"> </span>Many parents are able to
do the first, but have difficulty following through with the second.<span style="mso-spacerun: yes;"> </span>It might be easier to ignore the damage, fix
it ourselves, or worse, use it as a cudgel to remind the child of their
mistakes, thus increasing their sense of shame.<span style="mso-spacerun: yes;">
</span>It takes more time and more work to hold the child accountable and teach
them how to fix the damage. But the payoff for doing so is longer lasting than
a simple scolding or fixing problems for them.<span style="mso-spacerun: yes;">
</span>The key here is not to try to do the two things at the same time.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-indent: 0.5in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">Traditional parenting and
behavioral therapy hold that the problem needs to be addressed right away to be
effective.<span style="mso-spacerun: yes;"> </span>But this approach backfires
with children who have experienced trauma and need help regulating themselves;
the thinking brain turns off and the emotional brain is firing.<span style="mso-spacerun: yes;"> </span>First, we must take the time to put out the
fire, to calm the child, to help them regulate their bodies and emotions.<span style="mso-spacerun: yes;"> </span>This often looks like the last thing a parent
wants or is capable of doing when the child has done damage or made a scene,
moving in calmly and soothing the child with voice and touch.<span style="mso-spacerun: yes;"> </span>A parent says, “You mean the kid just threw a
shoe and broke a mirror and I’m supposed to go up and hug them and tell them
everything’s going to be OK?”<span style="mso-spacerun: yes;"> </span>Yes,
exactly, and that may be enough to solve the problem once the mess is cleaned
up.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-indent: 0.5in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">However, second, is
following through with the parenting and discipline intervention but only when
you have a thinking brain turned on to receive the lessen.<span style="mso-spacerun: yes;"> </span>Then the parent can build the child’s
problem-solving skills to clean up the mess, repair the damage, replace what is
broken, and make amends with those who have been injured.<span style="mso-spacerun: yes;"> </span>To be effective, it requires separating the
two parts of parenting; first the therapeutic joining then the discipline or
teaching.<span style="mso-spacerun: yes;"> </span>It also requires separating
those two parenting interventions by time, waiting for the thinking brain to
come back online, waiting hours or days.<span style="mso-spacerun: yes;">
</span>The teaching discipline needs to be logically connected to the mistake,
not cancelling the child’s soccer games because she broke the computer but
developing a plan to repair or replace the computer.<span style="mso-spacerun: yes;"> </span>Almost no situation except immediate danger
needs to be addressed right away, and most situations are best addressed later
when cooler heads prevail.<span style="mso-spacerun: yes;"> </span>If we want to
teach a child a lesson, we need to have their thinking brain engaged and it
cannot be when they are emotionally dysregulated and triggered. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>There
was another event early in the therapy experience that would have long term
impact for Donny and Henry.<span style="mso-spacerun: yes;"> </span>With county
child welfare workers still involved, Julie had a connection to the twin’s
teenage siblings.<span style="mso-spacerun: yes;"> </span>The siblings were
seeking contact with the brothers they had not seen in five years.<span style="mso-spacerun: yes;"> </span>The teenage sister and brother were not old
enough to take care of the twins to prevent their placement in foster care at
two or ten.<span style="mso-spacerun: yes;"> </span>The siblings were willing to
meet Joan, Donny and Henry in the therapy room.<span style="mso-spacerun: yes;">
</span>To the first session they brought gifts; photographs of Donny and Henry
as infants, photographs that had been hanging on their grandmother’s wall,
photographs Donny and Henry and their mother had never seen.<span style="mso-spacerun: yes;"> </span>They each stared at the tiny faces of
themselves, beautiful babies, before the events that would change their lives
forever.<span style="mso-spacerun: yes;"> </span>The moment was not only moving
for their mother and me, but overwhelming to their brother and sister who were
shaken by the loss they suffered in separation from their little brothers.<span style="mso-spacerun: yes;"> </span>This connection, however, thanks to Joan,
resulted in the siblings joining the family on a cruise and staying in contact
with their brothers through the rest of their growing up years.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-indent: 0.5in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">This is the way a caring
adoptive parent can help heal one of the deepest wounds of adoption, loss of
identity and family culture.<span style="mso-spacerun: yes;"> </span>Some feel
that keeping adopted children connected to their biological families is
confusing and even dangerous.<span style="mso-spacerun: yes;"> </span>For some
it is a source of fear, fear of losing a child they waited so long to
have.<span style="mso-spacerun: yes;"> </span>Particularly for parents who have
suffered infertility, miscarriage, still birth, or child death, keeping in
touch with biological family feels threatening to the relationship they have
formed with their adopted child like having an ex-spouse in the picture.<span style="mso-spacerun: yes;"> </span>They have worked so hard and waited so long
to have a child that bringing the biological family into the picture is a
painful reminder that their child did not start with them.<span style="mso-spacerun: yes;"> </span>Without acknowledging the denial, they mark
the beginning of their family life at the day of placement or adoption day
instead of the child’s birthday.<span style="mso-spacerun: yes;"> </span>The
biological, birth, and cultural history gets buried in all the adoption
paperwork perhaps to be shared with the child when they are an adult or when
they ask.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal" style="text-indent: 0.5in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">Further, they fear the
child will show traits and behaviors of which they do not approve from the
biological family and their influence.<span style="mso-spacerun: yes;">
</span>In working with more than a hundred pairs of biological parents, I have
only met two who because of serious mental illness or ongoing criminal behavior
were too dangerous to have direct contact.<span style="mso-spacerun: yes;">
</span>Most biological parents who have lost their children to adoption have
struggled with their own trauma and mental illness, feel deep guilt and shame that
they were unable to parent their children, and are wholly appreciative and
supportive of the adoptive parent.<span style="mso-spacerun: yes;">
</span>Rather, it makes parenting an adoptive child easier when an adoptive
family includes biological relatives in their family tree or forest.<span style="mso-spacerun: yes;"> </span>Connecting with biological relatives is the
best way to address all adoptive issues from trauma, grief and loss to culture
and identity.<span style="mso-spacerun: yes;"> </span>It does take extra effort,
like managing multigenerational or stepparent families.<span style="mso-spacerun: yes;"> </span>Biological families are the child’s extended
family and there is no competition for love or authority or legal rights.<span style="mso-spacerun: yes;"> </span>The adoptive parents’ role and influence with
the child actually grows stronger when they incorporate the biological family
into the child’s life.<span style="mso-spacerun: yes;"> </span>This contact can
come along a continuum of safety from written and telephone contact to
celebrations of birthdays and holidays up to shared vacations and routine meals
and family gatherings. <o:p></o:p></span></p>
<p align="center" class="MsoNormal" style="text-align: center;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">Annie<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Annie
was born to a mother addicted to crystal methamphetamine.<span style="mso-spacerun: yes;"> </span>Her mother had lost other children to child
welfare services. So, when she gave birth to Annie, she did not stay at the
hospital long enough to take her home.<span style="mso-spacerun: yes;">
</span>Annie went immediately into foster care and was placed in the home of Celia
for the first year and a half of her life.<span style="mso-spacerun: yes;">
</span>Annie’s father is an undocumented immigrant.<span style="mso-spacerun: yes;"> </span>He and his mother wanted to care for Annie,
but he was deported before he got a chance to participate in services and so
the agency did not place Annie in his care.<span style="mso-spacerun: yes;">
</span>Instead, Angelica was adopted by Jessica and David and I met her when
she was four years old.<span style="mso-spacerun: yes;"> </span>By that time she
was still sleeping in the same room with her parents, was anxious and
argumentative with her parents, and controlling and jealous with other children
at school. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>I
started with the family as I always have, interviewing the parents about their
attachment styles and preparing them to participate in the therapy with their
daughter.<span style="mso-spacerun: yes;"> </span>With Annie and her parents we
read books about adoption and emotions, played games and with puppets to
practice expressing feelings, and explored her own journey to adoption.<span style="mso-spacerun: yes;"> </span>As I always do I started drawing pictures, a
“placement map”, of the places Annie had lived, from the hospital to her
adoptive home.<span style="mso-spacerun: yes;"> </span>But each time I started
drawing her placement map, Annie would come close, grab the paper from the
table, rip it up, and say, “We’re not talking about that.”<span style="mso-spacerun: yes;"> </span>To be sure we continued working on rights and
privileges and discipline, highlighting her strengths and fears, but the moment
I went for the paper and colored pencils, Annie would push them away.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>It
got to the point that she would give me the “evil eye” as soon as she came
through the door, fold her arms in front of her, and go sit behind the sofa
refusing to participate.<span style="mso-spacerun: yes;"> </span>I continued the
conversations with Jessica and David.<span style="mso-spacerun: yes;"> </span>Talking
about the child instead of at the child can sometimes keep the child from going
into defense mode and allow them to take in information indirectly without
being overwhelmed by it.<span style="mso-spacerun: yes;"> </span>Annie’s hypervigilance
meant she was listening to the conversation from behind the couch.<span style="mso-spacerun: yes;"> </span>She was participating in therapy in the only
way she could feel safe.<span style="mso-spacerun: yes;"> </span>I directed my
question to her parents, “Why do you think the biological mother left the baby
at the hospital and never came back?”<span style="mso-spacerun: yes;">
</span>From behind the couch, the little voice whispered, “I think the baby
cried too much.”<span style="mso-spacerun: yes;"> </span>Her parents’ eyebrows
rose.<span style="mso-spacerun: yes;"> </span>My jaw dropped.<span style="mso-spacerun: yes;"> </span>No wonder she did not want to talk about it.
Similarly, I once had a 67-year-old woman who had confirmed her adoption after
her parents died say, “It makes me wonder what was wrong with me.” As with most
adopted people, particularly children, Annie blamed herself for her mother
abandoning her.<span style="mso-spacerun: yes;"> </span>No wonder she was so
defiant when her parents corrected her and controlling with peers. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Annie
had opened the door to her inner world and our work had just begun.<span style="mso-spacerun: yes;"> </span>We accepted, normalized, and validated her
feelings, “I’m damaged goods.”<span style="mso-spacerun: yes;"> </span>We can
agree with the feeling and not the fact.<span style="mso-spacerun: yes;">
</span>We used her considerable four-year-old intelligence to explore other
points of view, other perspectives, other children’s experiences.<span style="mso-spacerun: yes;"> </span>We role played her situation, putting her in
charge of the play.<span style="mso-spacerun: yes;"> </span>I played her
birthmother so that she, and her parents on her behalf, could ask the questions
she needed answered.<span style="mso-spacerun: yes;"> </span>We could not change
the story.<span style="mso-spacerun: yes;"> </span>We would not have all the
answers. In fact, between sessions she would often have break downs and blow
ups related to the heavy emotions.<span style="mso-spacerun: yes;"> </span>But
she and her parents also had moments of understanding and connection when she
shared her confusion and sadness and accepted her parents’ nurturing care.<span style="mso-spacerun: yes;"> </span>She corrected the thought that is was her
fault, however the deep sense of loss and shame would occasionally come back
especially when she made a mistake or suffered failure. <o:p></o:p></span></p>
<p class="MsoNormal" style="text-indent: 0.5in;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-spacerun: yes;"> </span>What we did not do is give up because it was
too difficult to talk about; because she was not willing to do it; or because
the story would make her sad.<span style="mso-spacerun: yes;"> </span>Her first
foster mother refused to talk about Annie’s removal and adoption because she
thought she could not handle it or did not need to know.<span style="mso-spacerun: yes;"> </span>Other parents say their children never ask,
never think about it.<span style="mso-spacerun: yes;"> </span>That is denial.<span style="mso-spacerun: yes;"> </span>Most parents do not want to do this work
because they cannot handle it themselves.<span style="mso-spacerun: yes;">
</span>They need to know that going on this difficult journey with their child
will bring them closer, make them more trusted, give them influence with their
child.<span style="mso-spacerun: yes;"> </span>What children don’t know, they
make up.<span style="mso-spacerun: yes;"> </span>What they make up is worse than
the trust.<span style="mso-spacerun: yes;"> </span>And what they make up that is
worse than the trust is their fault.<span style="mso-spacerun: yes;"> </span>Annie’s
parents learned they could not leave her to suffer in silence holding on to this
mistaken image of herself.<span style="mso-spacerun: yes;"> </span>They could hold
her strong emotions and lead her through it.<span style="mso-spacerun: yes;">
</span>In time, Annie would tell her own story and she put the responsibility
in the right place, squarely on her biological mother who had used drugs and
walked away.<span style="mso-spacerun: yes;"> </span>She began accepting her
parents’ direction and guidance, and she began to let other children be in
charge on the playground. <span style="mso-spacerun: yes;"> </span>She did have
friends over to put on a talent show at her house, for which she was the
director.<span style="mso-spacerun: yes;"> </span>Sometime later she began to
decorate her new room and sleep in her own bed.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Whether
from abandonment or multiple placements, children can develop a form of
relational Post Traumatic Stress Disorder in which forming new relationships
and trusting adults brings heightened anxiety with all the associated symptoms;
avoidance, hypervigilance, flight, fight, freeze, appease.<span style="mso-spacerun: yes;"> </span>Just like treating traditional PTSD, for
example if someone is afraid of the water because of an incident, the plan
includes establishing calming techniques, developing skills like emotional
regulation or, from the example, learning to swim, and approaching and facing
the triggering material a little at a time until it can be tolerated and
mastered.<span style="mso-spacerun: yes;"> </span>For water, learning to breath
and swim, then touching, walking, wading, paddling, and finally swimming.<span style="mso-spacerun: yes;"> </span>For Relational PTSD in a child, using the
parent as a safe base and emotional grounding, developing an emotional
vocabulary and regulation skills, and reviewing the trauma history until the
child can understand and tell their own story without shame.<span style="mso-spacerun: yes;"> </span>This requires revisiting the trauma history
again and again through the years as brain development allows the child to
understand in successively more sophisticated ways. <o:p></o:p></span></p>
<p align="center" class="MsoNormal" style="text-align: center;"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;">Jewell<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Jewell
spent her first six years with her mother, Nickie.<span style="mso-spacerun: yes;"> </span>Her mother did not identify her father, but
Nakala was raised by her mother and her mother’s partner, Kelly.<span style="mso-spacerun: yes;"> </span>Jewell was old enough to remember and
describe her time with her mother including dresses and toys and birthday
parties.<span style="mso-spacerun: yes;"> </span>But she also recalled being hit
when she misbehaved and locked in her room.<span style="mso-spacerun: yes;">
</span>At one point, Jewell’s mother sent her to a child therapist to get her
to behave.<span style="mso-spacerun: yes;"> </span>In therapy, Jewell revealed
the emotional and physical abuse she had experienced.<span style="mso-spacerun: yes;"> </span>Since the therapist was a mandated reporter,
child welfare workers were soon knocking on the door.<span style="mso-spacerun: yes;"> </span>Instead of accepting parenting classes or
other services, Nickie and Kelly drove Jewell to the children’s shelter and
dropped her off telling her they would return for her.<span style="mso-spacerun: yes;"> </span>They never did.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Jewell
was placed for adoption quickly because her mother refused reunification services.<span style="mso-spacerun: yes;"> </span>She had only one placement, the home of Latrece
and Robert with their two teenage sons.<span style="mso-spacerun: yes;">
</span>At first she enjoyed the attention of being youngest and the only little
girl in the home.<span style="mso-spacerun: yes;"> </span>Then she began to miss
her mother terribly and some of the treats her mother used to give her to make
her mind.<span style="mso-spacerun: yes;"> </span>Jewell began to sneak around
the house at night, get into the cabinets and refrigerator and eat up the chips
and cookies.<span style="mso-spacerun: yes;"> </span>Then, when confronted with
the evidence she would lie about her behavior.<span style="mso-spacerun: yes;">
</span>Otherwise, Jewell did great in school, made many friends, and enjoyed
playing sports.<span style="mso-spacerun: yes;"> </span>Toward middle school Jewell
began to seek out other attention by going on line.<span style="mso-spacerun: yes;"> </span>By the time I met her, all electronics
including school tablets were off limits, but she still found ways to borrow
other devices to post pictures of herself in clothes that were not the school
uniform. <o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Latrece
and Robert were trained parents and they had the time to give Jewell.<span style="mso-spacerun: yes;"> </span>The adoption was finalized quickly but the
pain of abandonment was just beginning to surface.<span style="mso-spacerun: yes;"> </span>As we explored adoption in general and her
story specifically, Jewell went along with the program.<span style="mso-spacerun: yes;"> </span>As her attention-seeking behaviors became
more serious, she accepted the consequences and limits her parents set.<span style="mso-spacerun: yes;"> </span>It was helpful that her mother is a
technology company executive and knew her way around the parental controls on
telephones, laptops, tablets, and social media apps.<span style="mso-spacerun: yes;"> </span>But there was nothing they could do about the
most painful part of their daughter’s story, she had been abandoned.<span style="mso-spacerun: yes;"> </span>To their credit they stayed in touch with Nickie
and Kelly.<span style="mso-spacerun: yes;"> </span>They knew that Nickie was
going back to school to become…a therapist . . . <span style="mso-spacerun: yes;"> </span>and that Kelly missed Jewell.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Jewell
desperately wanted contact with her biological mother.<span style="mso-spacerun: yes;"> </span>As time went on, she accepted that she would
be growing up with Latrece and Robert.<span style="mso-spacerun: yes;">
</span>But she held out a dream that she could have a big birthday party and
invite her mother to attend.<span style="mso-spacerun: yes;"> </span>On line, Nickie
was polite to her parents and wished Jewell well.<span style="mso-spacerun: yes;"> </span>At one point, with success in school, with
friends, and the basketball team fueling her self-confidence, Jewell decided
she would write 10 questions to her biological mother starting with why she
dropped her off at the shelter and never came back.<span style="mso-spacerun: yes;"> </span>Latrece intercepted Nakosha’s answers just as
our next therapy session was starting.<span style="mso-spacerun: yes;">
</span>Did Jewell want to see the answers?<span style="mso-spacerun: yes;">
</span>Should Latrece share them?<span style="mso-spacerun: yes;"> </span>How
would Jewell react?<span style="mso-spacerun: yes;"> </span>Could we help
her?<span style="mso-spacerun: yes;"> </span>After months of working together we
had a sense of comfort in the room.<span style="mso-spacerun: yes;">
</span>These questions were central to Jewell’s journey to healing and would
determine whether future contact was possible.<o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>As
she had from the start Nickie blamed Jewell; for misbehaving and causing
problems at school; for telling the therapist and bringing child welfare
workers to her door; for making her and Kelly’s life so difficult.<span style="mso-spacerun: yes;"> </span>Her mother wrote her that when Jewell was
ready to apologize they could talk.<span style="mso-spacerun: yes;">
</span>Silence. Then, this nearly teenage girl, who up to this point had so
fiercely hidden her feelings and put on a happy face and pretended to like her
life, began to weep.<span style="mso-spacerun: yes;"> </span>There was nothing
to say.<span style="mso-spacerun: yes;"> </span>Robert wanted to make it better
but I directed him to squeeze in to the loveseat next to his daughter and his
wife.<span style="mso-spacerun: yes;"> </span>Nickie collapsed into their
shoulders and she cried.<span style="mso-spacerun: yes;"> </span>Silence.<span style="mso-spacerun: yes;"> </span>There was nothing to say, nothing to do,
except hold the space for this powerful expression of grief.<span style="mso-spacerun: yes;"> </span>We did nothing else the rest of the
session.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman",serif; font-size: 12pt; line-height: 107%;"><span style="mso-tab-count: 1;"> </span>Many people
might ask, “Why do you want to make a child cry?<span style="mso-spacerun: yes;"> </span>Why does an adopted child need to talk about
this stuff?”<span style="mso-spacerun: yes;"> </span>The answer is because they
are thinking about it and acting it out most of the time, alone.<span style="mso-spacerun: yes;"> </span>The feelings come out in the strangest ways,
from eating to sleeping to toileting troubles.<span style="mso-spacerun: yes;">
</span>The thoughts are coming out in all kinds of disruptive behaviors from
simple defiance to destruction.<span style="mso-spacerun: yes;"> </span>Crying is
a healthy expression of emotion, right?<span style="mso-spacerun: yes;">
</span>Can crying not be cathartic? Likely the most important skill an adopted
parent can have or learn is managing grief and loss.<span style="mso-spacerun: yes;"> </span>We run the funeral home.<span style="mso-spacerun: yes;"> </span>You cannot get to adoption except through
loss; the child loses their first parents, the biological parent loses their
child, the adoptive parents lose their ideal child.<span style="mso-spacerun: yes;"> </span>We have to know how to navigate through this
swamp of sadness by creating space and rituals to mourn.<span style="mso-spacerun: yes;"> </span>And sometimes you have to prime the pump by
reading books, watching movies, playing music or showing and telling the child
the truth.<span style="mso-spacerun: yes;"> </span>It is like lancing a boil,
massaging the sore spot, releasing the pain in order to allow healing. <o:p></o:p></span></p>Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-26551801407864955152018-06-23T11:11:00.002-07:002018-06-23T11:11:41.496-07:005 Ways to Deal with Stress, Sadness, and Trust<br />
<br />
<div style="text-align: justify;">
<br /><br />The two things common in traumatized children…always there…are high anxiety and a negative view of the world.<br /><br />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. <br /><br />1. Breath and Move<br /><br />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.<br /><br />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?<br /><br />2. Re-write the ending. <br /><br />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.”<br /><br />3. Play every day. <br /><br />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. <br /><br />4. Run a tight ship. <br /><br />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!<br /><br />5. Communicate care then concern.<br /><br />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. <br /><br />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.<br /><br />1. She wants to watch television. You say, “Sure, as soon as your room is clean.”<br /><br />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.”<br /><br />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.”<br /><br />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.”<br /><br />5. She threatens to run away from home. You say, “I would be sad if you did that. What would be best for you?”<br /><br />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.</div>
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<span style="font-size: large;"></span><span style="font-size: x-large;"></span><br />Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-34813978190650593592018-06-23T11:02:00.001-07:002018-06-23T11:02:43.616-07:00Relative Caregivers Self Care<ul>
<li>Taking care of you will help your child</li>
<li>Taking care of you will help you parent</li>
<li>Your child needs you to take care of you</li>
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What we face:</div>
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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?"</div>
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Off-time parenting: This was not your plan nor your first choice. You're going back in time instead of retiring.</div>
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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.</div>
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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.</div>
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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.</div>
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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. </div>
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Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-5355473616562298682017-02-20T15:44:00.000-08:002017-02-20T15:44:54.314-08:00Understanding Military Veterans<div style="text-align: justify;">
<span style="color: black;">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.</span></div>
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<span style="color: black;"> 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 </span><span style="color: black;">pre</span><span style="color: black;">disposed to post traumatic stress disorder if they do not already suffer from it. Their lives are marked by high stress and emotional </span><span style="color: black;">dysregulation</span><span style="color: black;">, 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.</span></div>
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<span style="color: black;"> 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 </span><span style="color: black;">hypervigilance</span><span style="color: black;"> 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.</span><br />
<span style="color: black;"> 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. </span><br />
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<br />Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-39882803144787427752016-07-26T19:12:00.001-07:002016-07-26T19:12:01.012-07:00Bibliography<!--[if gte mso 9]><xml>
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<b style="mso-bidi-font-weight: normal;">BIBLIOGRAPHY</b></div>
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Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-7214554014150894202016-07-26T19:11:00.003-07:002016-07-26T19:11:24.775-07:00Epilogue<!--[if gte mso 9]><xml>
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<b style="mso-bidi-font-weight: normal;">Epilogue</b></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;">Lessons Learned</b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .25in;">
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.<span style="mso-spacerun: yes;"> </span>I expect never to achieve expert
status, only competence.<span style="mso-spacerun: yes;"> </span>That is why
they do not call it private “perfect”.</div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>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. <span style="mso-spacerun: yes;"> </span>Most
of these investments had no returns.<span style="mso-spacerun: yes;"> </span>I
still receive most of my referrals from existing clients, attendants at my
trainings, and directly from insurance companies.</div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>As a social worker and therapist it is sometimes
difficult to ask for and talk about money and payments.<span style="mso-spacerun: yes;"> </span>However, in terms of professional practice it
is unethical not to.<span style="mso-spacerun: yes;"> </span>I have learned to
make sure up front that I will be paid for each and every session.<span style="mso-spacerun: yes;"> </span>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.</div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>My practice model for working with parents and
children includes an assessment of the parents’ trauma history and attachment
styles.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Every time I have gone against my better
judgment, it has come back to haunt me and to stall progress.<span style="mso-spacerun: yes;"> </span>It becomes a sticking point I cannot ignore
and must address, which I could have known up front.</div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>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.<span style="mso-spacerun: yes;"> </span>I have no desire to be
constantly available to clients by texting.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span>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.</div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Sometimes, you just have to apologize for making
mistakes or for not being able to help.<span style="mso-spacerun: yes;">
</span>Therapists are human, too.<span style="mso-spacerun: yes;">
</span>Despite consultation and supervision, sometimes personal issues
interfere and cause a break or disconnection with a client.<span style="mso-spacerun: yes;"> </span>It is therapeutic to own it and
apologize.<span style="mso-spacerun: yes;"> </span>It can even propel the
process forward.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The
quicker I can figure that out and make the appropriate referral, the better.</div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>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.<span style="mso-spacerun: yes;"> </span>Some of the questions I need to answer during
the intake: who is the client and is that person willing to participate.<span style="mso-spacerun: yes;"> </span>Sometimes a spouse or parent will try to make
an appointment for an adult who is not seeking therapy on their own.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>I have had step parents and grandparents seek
therapy for children for whom they do not have custody or legal rights.<span style="mso-spacerun: yes;"> </span>Finally, is the issue or concern something
for which I have training and experience.</div>
<div class="MsoListParagraphCxSpLast" style="line-height: 200%; mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span>When I started I was intent on being as open and
helpful to clients as possible.<span style="mso-spacerun: yes;"> </span>And, so
I would tolerate clients for therapy and supervision not keeping appointments, cancelling
at the last minute, and showing up late.<span style="mso-spacerun: yes;">
</span>I rescheduled them time and again, even calling and reminding clients to
make and keep appointments.<span style="mso-spacerun: yes;"> </span>Then, I
decided I needed to keep better boundaries in this regard.<span style="mso-spacerun: yes;"> </span>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.</div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-45927353198290568202016-07-21T20:06:00.001-07:002016-07-21T20:06:18.728-07:00Evaluation and Termination<!--[if !mso]>
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<br />
<div class="MsoNormal" style="line-height: 200%;">
<b style="mso-bidi-font-weight: normal;">Chapter Twelve</b></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b style="mso-bidi-font-weight: normal;">Evaluation and Termination</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<b style="mso-bidi-font-weight: normal;"><span style="mso-tab-count: 1;"> </span></b>Every session
could be the last session, so every session encompasses some elements of
evaluation and termination.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The evaluation process is not just part of
every session but the essential intervention of therapy itself.<span style="mso-spacerun: yes;"> </span>What is working?<span style="mso-spacerun: yes;"> </span>What is not working?<span style="mso-spacerun: yes;"> </span>What have you tried?<span style="mso-spacerun: yes;"> </span>What would you like to try? How can I
help?<span style="mso-spacerun: yes;"> </span>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?”<span style="mso-spacerun: yes;"> </span>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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Each
of the following questions has a purpose as an intervention in and of
itself.<span style="mso-spacerun: yes;"> </span>What have we accomplished?<span style="mso-spacerun: yes;"> </span>In the daily struggle of life and the routine
of weekly sessions, clients sometimes do not see how much has changed since
they started.<span style="mso-spacerun: yes;"> </span>I return to the initial
assessment paperwork, the client’s description of their concerns, and the
scores they gave specific symptoms.<span style="mso-spacerun: yes;"> </span>It
is often surprising and gratifying for the client to hear, “Your child’s
tantrums have decreased from daily to rare.<span style="mso-spacerun: yes;">
</span>How did that happen?”<span style="mso-spacerun: yes;"> </span>What is
left to do?<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>How might that be
accomplished?<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>The
process of therapy is often more important than the content.<span style="mso-spacerun: yes;"> </span>The understanding, knowledge, and skills
clients learn in session are applicable to many life challenges.<span style="mso-spacerun: yes;"> </span>The purpose of therapy is at least two fold, to
address current concerns and teach skills to apply to future issues.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>What has worked?<span style="mso-spacerun: yes;"> </span>The question is meant to prompt the client to
identify the specific skills and interventions, to consolidate the gains from
the therapeutic process.<span style="mso-spacerun: yes;"> </span>What has not
worked?<span style="mso-spacerun: yes;"> </span>This question is just as
important as clients assemble a toolbox of life skills.<span style="mso-spacerun: yes;"> </span>The two questions posed together illustrate
the very practice of problem-solving; identifying issues, listing
possibilities, evaluating options, making choices, trying solutions, measuring
progress.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Evaluating
the therapist is not just about rating their work or collecting success
stories.<span style="mso-spacerun: yes;"> </span>What worked with the
therapist?<span style="mso-spacerun: yes;"> </span>This question invites the
client to give the therapist feedback.<span style="mso-spacerun: yes;">
</span>Giving feedback is another communication skill clients may use in the
future.<span style="mso-spacerun: yes;"> </span>What did not work with the therapist?<span style="mso-spacerun: yes;"> </span>The client gets the chance to provide perhaps
negative feedback in a positive way, yet another skill applicable to life in
general.<span style="mso-spacerun: yes;"> </span>More specifically, these
questions put the client in the empowering position of being the customer of a
service.<span style="mso-spacerun: yes;"> </span>They ask the client to consider
the nature of that service and what works for them.<span style="mso-spacerun: yes;"> </span>In a parallel process, the client learns how
to solve their problems and how to shop for services to help them in the
future.<span style="mso-spacerun: yes;"> </span>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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Having
participated in the therapeutic process the client may have uneven progress in
the future and experience setbacks both simple and serious.<span style="mso-spacerun: yes;"> </span>What are anticipated challenges?<span style="mso-spacerun: yes;"> </span>This question helps clients expect,
normalize, and prepare for such challenges.<span style="mso-spacerun: yes;">
</span>In the case of mental illness, substance abuse, and trauma, there are
stressors, triggers, and relapses.<span style="mso-spacerun: yes;"> </span>For
couples and parents, families enter different life cycles and children grow
into subsequent developmental stages.<span style="mso-spacerun: yes;">
</span>Issues like adoption and learning disabilities are life-long.<span style="mso-spacerun: yes;"> </span>When to return or seek help?<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>This question helps
clients specify what circumstances would warrant returning to therapy to avoid
a crisis.<span style="mso-spacerun: yes;"> </span>A person with mental illness
may want to return if they have had a major loss like a death in the
family.<span style="mso-spacerun: yes;"> </span>A person who relapses on drugs
or alcohol may need a quick intervention.<span style="mso-spacerun: yes;">
</span>A couple may return before they decide to adopt or have another
child.<span style="mso-spacerun: yes;"> </span>An adoption family may want to
return as the child becomes an adolescent.<span style="mso-spacerun: yes;">
</span>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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>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.<span style="mso-spacerun: yes;"> </span>I nearly repeat
everything I said during the first session with parents and the first session
with children.<span style="mso-spacerun: yes;"> </span>“I will always have the
responsibility to protect your confidentiality because we will always have only
this professional relationship.<span style="mso-spacerun: yes;"> </span>That
means I will still not acknowledge you in public or do other kinds of business
with you.<span style="mso-spacerun: yes;"> </span>For example, I will not be
attending your family weddings and you will not be attending my funeral.”<span style="mso-spacerun: yes;"> </span>My responsibility for protecting the client’s
privilege and privacy does not end with the termination of services.<span style="mso-spacerun: yes;"> </span>I keep files and records for 10 years after
the end of services or until the child turns 28 years old.<span style="mso-spacerun: yes;"> </span>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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>It makes the therapist more
responsible.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>At the very least I express my
appreciation of the relationship acknowledging what we have done together.<span style="mso-spacerun: yes;"> </span>Further, especially with children and
families, marking endings is an important therapeutic intervention.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>For this, ritual is important.<span style="mso-spacerun: yes;">
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game, or toy in session may seem repetitive as if we are making no progress and
should be focusing on something new.<span style="mso-spacerun: yes;">
</span>However, these rituals are as important to the therapeutic process as
they are to family life.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>This is also a therapeutic intervention to consolidate
and celebrate gains and to reset the role of the therapist from rescue to
support.<span style="mso-spacerun: yes;"> </span>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
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Sticking
Points</span></div>
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Particularly with families, and
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experiences and they are being triggered in ways that keep them from being
warm, nurturing, and consistent with their children.<span style="mso-spacerun: yes;"> </span>This often requires putting the family
work aside to address the parents’ issues either in consultation or with
outside therapy.<span style="mso-spacerun: yes;"> </span>Adult
relationships: parents have deep unaddressed difficulties in their
relationship, differences in their ideas about parenting, and inability or
unwillingness to communicate about them.<span style="mso-spacerun: yes;">
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to focus on these issues.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Theoretical differences: the
client, despite adequate psychoeducation, cannot accept and does not agree
with a relationship-based non-behavioral orientation.</span></div>
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<span style="mso-tab-count: 1;"> </span></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-71986539398798793222016-07-20T13:20:00.002-07:002016-07-21T20:08:09.936-07:00Problem Solving<!--[if !mso]>
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<b style="mso-bidi-font-weight: normal;">Chapter Eleven</b></div>
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<b style="mso-bidi-font-weight: normal;">Problem Solving</b><span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"></span><span style="mso-spacerun: yes;"><!--[if gte mso 9]><xml>
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<![endif]--><span style="font-family: "times new roman" , "serif"; font-size: 12.0pt;"> Sometimes the therapeutic process seems to
stall.<span style="mso-spacerun: yes;"> </span>The client sees no progress, and
the therapist feels frustrated.<span style="mso-spacerun: yes;"> </span>The
therapist begins to feel the client’s hopelessness in facing nagging persistent
problems.<span style="mso-spacerun: yes;"> </span>We feel like blaming the
client for not trying.<span style="mso-spacerun: yes;"> </span>The client feels
like blaming us for not helping.<span style="mso-spacerun: yes;"> </span>We feel
stuck together. <span style="mso-spacerun: yes;"> </span>Sometimes it is about
goodness of fit.<span style="mso-spacerun: yes;"> </span>I may have reached the
limits of my knowledge and skills.<span style="mso-spacerun: yes;"> </span>Another
therapist may bring a new perspective, a new start, and new skills to meet the
challenge.<span style="mso-spacerun: yes;"> </span>If, however, we can work
through this period together the results can be quite satisfying.<span style="mso-spacerun: yes;"> </span></span><span style="mso-tab-count: 1;"> </span><span style="mso-tab-count: 1;"><span style="mso-spacerun: yes;"></span></span><br />
<div class="MsoNormal" style="line-height: 150%;">
<span style="mso-tab-count: 1;"><span style="mso-spacerun: yes;"><span style="mso-tab-count: 1;"> After assessment, psychoeducation, and
treatment planning, after identifying trauma, expressing emotions, and
practicing coping </span><span style="font-family: "times new roman" , "serif"; font-size: 12.0pt;"><span style="mso-spacerun: yes;"></span></span> skills and sometime between the first and tenth session
specific problem behaviors come to light that require individual attention.<span style="mso-spacerun: yes;"> </span>Children have difficulty going to sleep and
adults have difficulty staying asleep, children take food and adults overeat, and
children have tantrums and adults have conflict.<span style="mso-spacerun: yes;"> </span>These issues are of central concern and
deserve to be the focus of work.<span style="mso-spacerun: yes;"> </span>Some
further investigation is in order: What comes before the behavior?<span style="mso-spacerun: yes;"> </span>What do people do during the behavior?<span style="mso-spacerun: yes;"> </span>What is the result of the behavior?<span style="mso-spacerun: yes;"> </span>What has been tried to resolve the
behavior?<span style="mso-spacerun: yes;"> </span>What seems to have worked to
reduce the behavior or its impact?<span style="mso-spacerun: yes;"> </span>What
does the client believe about the cause of the behavior?<span style="mso-spacerun: yes;"> </span>What is the client willing to do to resolve
the behavior?Some
attention needs to be given to the understanding of problem behaviors.<span style="mso-spacerun: yes;"> </span>First, some problem behaviors are symptoms of
the condition itself.<span style="mso-spacerun: yes;"> </span>Problems with
functioning; sleeping, eating, elimination, sex, energy, mood, pain, conflict,
thinking, socializing are symptoms of diagnoses like depression, anxiety, and traumatic
stress.<span style="mso-spacerun: yes;"> </span>Second, other problem behaviors
are attempts at coping with the condition; alcohol, drugs, fighting, isolation,
poor hygiene, spending, stealing, and self-harm.<span style="mso-spacerun: yes;"> </span>Third, other problems are the result of
either the condition or attempts to cope with it; employment, financial, social
and legal issues.<span style="mso-spacerun: yes;"> </span>Understanding behavior
goes back to beliefs about humans themselves.<span style="mso-spacerun: yes;">
</span>Interpretations of behavior as good or bad, positive or negative,
appropriate or inappropriate, are meant for punishment not for healing.<span style="mso-spacerun: yes;"> </span>Behavior is need driven.<span style="mso-spacerun: yes;"> </span>It is either helpful or unhelpful.<span style="mso-spacerun: yes;"> </span>Behavior is purposeful, but not always for
the purpose we think.<span style="mso-spacerun: yes;"> </span>We do things to
increase our pleasure and decrease our pain.<span style="mso-spacerun: yes;">
</span>The underlying needs according to Maslow (1943) are, and the order is
important, survival, safety, love, and belonging.<span style="mso-spacerun: yes;"> </span>The more sophisticated attachment needs
described by Johnson (2008) are safety, attention, value, validation, respect,
and love.<span style="mso-spacerun: yes;"> </span>To these I would add sovereignty,
the individual right to one’s own body, mind, and spirit.<span style="mso-spacerun: yes;"> </span>Given this understanding, trying to stop,
start, or replace a behavior without looking at underlying needs will have
limited success.<span style="mso-spacerun: yes;"> </span>We must be proactive in
meeting the need not reactive in focusing on behavior.<span style="mso-spacerun: yes;"> </span>The big four behaviors that parents are most
concerned about are lying, stealing, aggression, and manipulation.<span style="mso-spacerun: yes;"> </span>I will take them one at a time.<span style="mso-spacerun: yes;"> </span></span></span></div>
</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Lying is a
developmental defense that we all use as we grow.<span style="mso-spacerun: yes;"> </span>A securely attached five year old will lie to
avoid the consequences, an eight year old to avoid interrupting their plans, a
teenager to avoid letting down parents, and a securely attached adult will not
lie because of a well-developed conscience that says, “I am a person who tells
the truth.”<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Lying is also a socially acceptable way to
avoid hurting people’s feelings as when we are asked, “Do I look fat in
this?”<span style="mso-spacerun: yes;"> </span>Or, “How do you like my
dinner?”<span style="mso-spacerun: yes;"> </span>For people with attachment
trauma lying is not so much a learned behavior as a defense.<span style="mso-spacerun: yes;"> </span>Lying to an abusive parent may be a moral
imperative.<span style="mso-spacerun: yes;"> </span>So, telling the truth is about
safety.<span style="mso-spacerun: yes;"> </span>A child, or an adult, tells a
lie because it does not feel safe to tell the truth.<span style="mso-spacerun: yes;"> </span>Their subjective sense of safety in the
place, with the person, in the relationship is about perspective.<span style="mso-spacerun: yes;"> </span>Punishing a traumatized child increases
anxiety and jeopardizes safety.<span style="mso-spacerun: yes;"> </span>The onus
is not on the child to tell the truth but on the adult to make themselves safe
enough to hear the truth.<span style="mso-spacerun: yes;"> </span>It starts with
not setting up the child to lie by asking questions.<span style="mso-spacerun: yes;"> </span>The parent who asks, “Did you clean your
room?” when they know the answer is no is laying a trap to catch the child in a
lie and cannot be trusted.<span style="mso-spacerun: yes;"> </span>This is not
focusing on safety, the first of human needs.<span style="mso-spacerun: yes;">
</span>If a child or person has developed the habit of lying to figuratively or
literally save face, it will take some time to build or repair the
relationship.<span style="mso-spacerun: yes;"> </span>We can be sad about
that.<span style="mso-spacerun: yes;"> </span>We will not be able to believe
them.<span style="mso-spacerun: yes;"> </span>We can practice, “trust but
verified.” <span style="mso-spacerun: yes;"> </span>But, we must be ready to hear
sometimes harsh “truths” without reacting and rejecting.<span style="mso-spacerun: yes;"> </span>It does not mean ignoring the facts.<span style="mso-spacerun: yes;"> </span>If the room is dirty, it needs to be
cleaned.<span style="mso-spacerun: yes;"> </span>When the partner says, “No, I
do not like your cooking,” the response needs to be, “Thanks for your honesty.”<span style="mso-spacerun: yes;"> </span>Focusing on compliance over connection leads
only to more stress for both parties.<span style="mso-spacerun: yes;">
</span>Prioritizing relationship over power leads to healing.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
In the same way,
stealing or “taking” is best viewed as a survival skill.<span style="mso-spacerun: yes;"> </span>If you are in a war zone needing to feed a
child, breaking into a store to take food to keep the child alive is the moral
thing to do.<span style="mso-spacerun: yes;"> </span>This is a rather stark
example that does not seem to fit with the everyday behavior of a child who
hoards food in their room or takes toys, electronics, or cash from friends and parents.<span style="mso-spacerun: yes;"> </span>In order to address this problem we must take
the person’s perspective.<span style="mso-spacerun: yes;"> </span>For an infant
or small child, abandonment, hunger, and violence are life-threatening
experiences.<span style="mso-spacerun: yes;"> </span>This trauma is stored in
the pre-verbal, pre-conscious amygdala or limbic brain and drives these
fight/flight/freeze responses.<span style="mso-spacerun: yes;"> </span>That is
why traumatized children seem to take issues around bathroom habits, eating,
and sleeping to the extremes.<span style="mso-spacerun: yes;"> </span>The person
with a negative core belief system simply does not believe that their needs
will be met.<span style="mso-spacerun: yes;"> </span>They are on their own in
the world.</div>
<div class="MsoNormal" style="line-height: 200%;">
Tackling stealing starts with
making sure basic needs are met and doing so in a very dramatic nurturing
way.<span style="mso-spacerun: yes;"> </span>Parents make sure children with
food and other neglect issues always have access to food; a designated drawer
in the refrigerator full of nutritious food, a stash of non-perishable food in
their backpacks and rooms, and frequent snack breaks throughout the day.<span style="mso-spacerun: yes;"> </span>No locks on refrigerators and cabinets.<span style="mso-spacerun: yes;"> </span>If it is not meant to be eaten, do not buy
it.<span style="mso-spacerun: yes;"> </span>The same goes for items that are not
basic needs.<span style="mso-spacerun: yes;"> </span>Leaving cash, electronics,
and valuables within reach and expecting a traumatized child not to touch them
is setting them up to fail, and that is the way they see it.<span style="mso-spacerun: yes;"> </span>We have no trouble “babyproofing” a home for
an infant so why is creating an environment safe from temptation for an older
child so different?<span style="mso-spacerun: yes;"> </span>Expecting a person
with sticky fingers to make it through a store without taking something is an
unrealistic expectation.<span style="mso-spacerun: yes;"> </span>When is the
last time you left the big box store with only the item you went in for, or
only ate the recommended serving size from a bag of chips or quart of ice
cream?<span style="mso-spacerun: yes;"> </span>Can a traumatized child or adult
stop stealing?<span style="mso-spacerun: yes;"> </span>Yes, if they feel that
their basic needs will be met, if they feel safe in their home.<span style="mso-spacerun: yes;"> </span>An older child may not be able to go to a
friend’s home or to a store or out in public without close supervision.<span style="mso-spacerun: yes;"> </span>A parent may need to help the child return,
replace, or repair the stolen items as restitution using allowance or extra
chores.<span style="mso-spacerun: yes;"> </span>Ultimately, the community may
weigh in with arrest, charges, and sentencing the parent needs to support
without rescuing the child from the consequences.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>The
same may be true for aggression especially if it goes beyond verbal assaults
and tantrums.<span style="mso-spacerun: yes;"> </span>We have to acknowledge
that our society has a strange attitude toward aggression.<span style="mso-spacerun: yes;"> </span>We condone it in many areas; in physical
discipline, in sports, and in war.<span style="mso-spacerun: yes;"> </span>Similar
to lying and stealing there are times when aggression may be morally necessary
to save our lives.<span style="mso-spacerun: yes;"> </span>This again is often
the perspective of traumatized people who have faced truly life-threatening attack
in the form of rape and other violence.<span style="mso-spacerun: yes;">
</span>So, again, while we wish for everyone in the family to feel safe, it is
the person who uses aggression who does not.<span style="mso-spacerun: yes;">
</span>Often, what starts as a minor irritation escalates to complete
dysregulation, the person is out of control, they have “lost their mind”.<span style="mso-spacerun: yes;"> </span>Back to the hand/brain demonstration from
Siegel (2003), the sympathetic nerve system is activated, releasing adrenaline
and cortisol, and the cortex, neo-cortex, and pre-frontal lobes all but shut
down.<span style="mso-spacerun: yes;"> </span>If the brain of a traumatized
person is always producing these hormones, and the body’s set point for stress
is always high, then preventive measures to burn off the excess are necessary
in the form of both vigorous exercise and intense soothing practices.<span style="mso-spacerun: yes;"> </span>We recall the “vents” of the “angry
volcano”.<span style="mso-spacerun: yes;"> </span>These are coping skills.<span style="mso-spacerun: yes;"> </span>They cannot be assigned to the child but need
to be lead and shared by the parent.<span style="mso-spacerun: yes;"> </span>The
parent or another adult lends the dysregulated person their self-control.<span style="mso-spacerun: yes;"> </span>In session, this means teaching, modeling,
coaching, and role playing de-escalation skills through the use of reflective
listening and therapeutic joining.<span style="mso-spacerun: yes;"> </span>In
practice, it means administering large doses of empathy, to the aggressive
person.<span style="mso-spacerun: yes;"> </span>We check in briefly with the
injured party and move quickly to attend to the aggressive child.<span style="mso-spacerun: yes;"> </span>It does not mean keeping a calm voice.<span style="mso-spacerun: yes;"> </span>Two year old tantrums require soothing.<span style="mso-spacerun: yes;"> </span>You take the child out of the situation and
sit with them until they settle.<span style="mso-spacerun: yes;"> </span>The
initial non-violent intervention with aggression needs to match the intensity
of the situation, “Stop!<span style="mso-spacerun: yes;"> </span>What’s
happening here?” followed with controlled, intentional, low, slow language that
addresses the emotion and engages the left brain, “You are really upset.<span style="mso-spacerun: yes;"> </span>I would like us to sit down and talk about
this.<span style="mso-spacerun: yes;"> </span>Would you like to start or do you
need my help?”<span style="mso-spacerun: yes;"> </span>The parent or partner who
loses control focusing on blame or broken furniture adds fuel to the fire.<span style="mso-spacerun: yes;"> </span>It may take back up.<span style="mso-spacerun: yes;"> </span>In these extreme situations a safety plan is
necessary including early warning coping skills, supportive people to engage,
hotlines and other resources,
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
<tbody>
<tr>
<td><div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Emergency
Services</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Sometimes a parent simply cannot
keep the child, themselves, and others safe without engaging emergency
services including police, hospital, and residential care.<span style="mso-spacerun: yes;"> </span>But taking these extreme measures can be
risky for the future of the relationship.<span style="mso-spacerun: yes;">
</span>The way in which parents ask for and explain the assistance can make
all the difference.<span style="mso-spacerun: yes;"> </span>First, we do not
call the police, hospitalize a child, or place them in care because we
cannot handle them and have given up and need others to parent them or to punish
them for their behavior.<span style="mso-spacerun: yes;"> </span>That is a
cliff from which it is difficult to step back.<span style="mso-spacerun: yes;"> </span>We literally employ the services of law
enforcement, hospital staff, and residential caregivers to help us keep the
child and others safe.<span style="mso-spacerun: yes;"> </span>Second, it is
a mistake to believe that anything but first aid is being offered to
stabilize the situation and to offer parents respite and space to
regroup.<span style="mso-spacerun: yes;"> </span>Then, having separated the
child from the family <span style="mso-spacerun: yes;"> </span>it makes a
repeat more possible in the minds of the child and the parents thus
increasing traumatic stress while parents are attempting to repair the
rupture.</span></div>
<div align="center" class="MsoNormal" style="line-height: 150%; text-align: center;">
<br /></div>
</div>
</td>
</tr>
</tbody></table>
up to and including use of emergency services.<span style="mso-spacerun: yes;"> </span>
<br />
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
As aggravating and
frightening as lying, stealing, and aggression, behaviors that seem to be about
manipulation can be irritating and exasperating.<span style="mso-spacerun: yes;"> </span>Children and some adults may talk incessantly
to avoid the topic at hand, nag constantly until we give in, go slow or refuse
to complete tasks, pretend not to hear what people say to them, or play one
parent or sibling against another to find a way between them.<span style="mso-spacerun: yes;"> </span>It happens at home, and it happens in
therapy.<span style="mso-spacerun: yes;"> </span>It is important not to take it
personally because it is not personal.<span style="mso-spacerun: yes;">
</span>If we understand that anxiety and stress are at play, we can better
respond to the seeming manipulative behavior.<span style="mso-spacerun: yes;">
</span>Like the negative core belief system of traumatized people, their higher
baseline stress level never goes away.<span style="mso-spacerun: yes;">
</span>Both are likely to persist well into adulthood and, without adequate
treatment, lead to serious health consequences including heart attack, stroke,
and early death.<span style="mso-spacerun: yes;"> </span>Trauma and its
associated adrenaline and cortisol are serious stuff.<span style="mso-spacerun: yes;"> </span>It can be very difficult to accept that this
higher stress level is always present even when the child or adult seems calm
and relaxed.<span style="mso-spacerun: yes;"> </span>The hypervigilance is
always there.<span style="mso-spacerun: yes;"> </span>To cope, the person
attempts to take control of almost every situation.<span style="mso-spacerun: yes;"> </span>We know these people.<span style="mso-spacerun: yes;"> </span>We may be these people.<span style="mso-spacerun: yes;"> </span>The “control freak” who needs everything to
go their way and in perfect order is a very stressed-out person.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Accepting
this employs the empathy needed to address it.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>A
sense of humor helps.<span style="mso-spacerun: yes;"> </span>After all,
manipulation is just good sales, quite a skill.<span style="mso-spacerun: yes;">
</span>But we do not have to buy.<span style="mso-spacerun: yes;"> </span>As
with the persistent cookie seller outside the grocery store we can politely say
no or walk past with a smile until the person learns their pitch will not work
with us.<span style="mso-spacerun: yes;"> </span>It requires extreme patience
which is not always possible.<span style="mso-spacerun: yes;"> </span>However,
the opposite reaction simply invites more.<span style="mso-spacerun: yes;">
</span>That is, when we respond with repeated reminders, pleading, and anger,
we increase the anxiety level and the attempts at control continue.<span style="mso-spacerun: yes;"> </span>Having met basic needs, including affection
and play, and set reasonable expectations, we must have the courage of our
convictions.<span style="mso-spacerun: yes;"> </span>We still must be aware of
the person’s triggers; fear of bath and bed, hunger and pain, isolation and
abandonment.<span style="mso-spacerun: yes;"> </span>In session and out, this is
about silently soothing, lending the person our self-control, and remaining
consistent and safe.<span style="mso-spacerun: yes;"> </span>In therapy it means
sitting silently for 45 minutes with a child who is bouncing around the room
rather than listening to adults, not offering other alternatives to please the
child.<span style="mso-spacerun: yes;"> </span>At home it means pulling to the
side of the road immediately when a child begins to act out, not increasing the
danger by raising our voices. Children with trauma need adults who are safe and
in charge.<span style="mso-spacerun: yes;"> </span>This is powerful
parenting.<span style="mso-spacerun: yes;"> </span>When we “lose it”, we have
lost our power and contributed to the child’s already high stress level.<span style="mso-spacerun: yes;"> </span>We have fed the fire.<span style="mso-spacerun: yes;"> </span>It is not a battle, a test of wills, making
parents and children winners and losers.<span style="mso-spacerun: yes;">
</span>It is the difference between authoritarian, permissive, and
authoritative parenting styles.<span style="mso-spacerun: yes;"> </span>The
authoritarian rules by fear, increasing anxiety, impairing relationship. <span style="mso-spacerun: yes;"> </span>The permissive parent gives in early to avoid
an unhappy child only to wind up with an unhappy teenager who cannot be
satisfied by anything.<span style="mso-spacerun: yes;"> </span>Either situation
is out of control and can become downright dangerous. The authoritative parent
leads with confidence, able to admit mistakes and make mid-course corrections,
offering children consultation and experiences in which to learn and grow. </div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>As
Daniel Hughes (2007) suggests, when problem behaviors become the focus more
structure and supervision may be required.<span style="mso-spacerun: yes;">
</span>About the time we think we have all the routine and watchfulness we can
stand, we probably need more.<span style="mso-spacerun: yes;"> </span>At this
point, if not before, I offer parents my family chart (Appendix)<span style="mso-spacerun: yes;"> </span>with suggestions on how to organize the
family’s schedule, needs, expectations, privileges, and consequences.<span style="mso-spacerun: yes;"> </span>It may seem excessive to schedule every part
of a family’s day from sun up to bedtime but it provides the kind of
predictability that reduces anxiety and increases safety, just as it does in
the military and in residential treatment centers.<span style="mso-spacerun: yes;"> </span>Traumatized people do best with routine.<span style="mso-spacerun: yes;"> </span>Think about running a bed and breakfast or
cruise ship.<span style="mso-spacerun: yes;"> </span>Both vacations start with
clear orientations about the schedule, what is available to guests, what is off
limits, what will cost extra, when meals are served, what services are offered,
what to do in case of emergency.<span style="mso-spacerun: yes;"> </span>Can you
imagine what would happen if this information was not provided?<span style="mso-spacerun: yes;"> </span>This kind of clear instruction allows the
operation to run more smoothly.<span style="mso-spacerun: yes;"> </span>The
family chart makes for a good agenda item at regular family meetings.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
As to as schedule,
if one hour intervals leaves too much free unstructured time, then shorter timeframes
may be needed.<span style="mso-spacerun: yes;"> </span>Then, I place a major
focus on meeting the needs of the members of the family with affection and play
being at the top of the list followed by food, clothes, bed, hygiene, school,
doctor, dentist.<span style="mso-spacerun: yes;"> </span>Affection and play with
parents, hugs and high fives, tossing a ball and board games, are essential to
building attachment which provides the connection for parents to direct and
teach children.<span style="mso-spacerun: yes;"> </span>Basic needs do not
include bags of chips, dessert, telephones, television, sleepovers, and
shopping trips.<span style="mso-spacerun: yes;"> </span>Now the expectations are
meant for all members of the family, not just children.<span style="mso-spacerun: yes;"> </span>The list should be achievable, positive, and
short; everybody stays safe, do chores, return what you borrow, attend family
meetings, accept no for an answer.<span style="mso-spacerun: yes;"> </span>Avoid
words like respect and manners, they are subjective.<span style="mso-spacerun: yes;"> </span>Be specific, describe what you want to see,
“use please, thank you, excuse me, I’m sorry”; “knock before entering, dress
for dinner, hats are worn outside only”.<span style="mso-spacerun: yes;">
</span>As opposed to taking away privileges, every day starts with no
privileges and parents provide privileges as they see expectations met.<span style="mso-spacerun: yes;"> </span>Privileges include electronics, sleep overs,
shopping trips, and amusement parks.<span style="mso-spacerun: yes;">
</span>Children can live until adulthood with no privileges at all and receive
only what they can handle.<span style="mso-spacerun: yes;"> </span>To make this
work consistently, minimize reminders and the word no.<span style="mso-spacerun: yes;"> </span>The child asks, “May I watch TV?”<span style="mso-spacerun: yes;"> </span>The parent answers, “Yes, as soon as your
room is clean.”<span style="mso-spacerun: yes;"> </span>When handing out
privileges it is a big mistake to yes.<span style="mso-spacerun: yes;">
</span>Instead, “You may watch your show”, or “You may watch for 30
minutes.”<span style="mso-spacerun: yes;"> </span>If the child cannot turn off
the television, the parent does not remind but does not hand out the privilege
the next day.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Now
to consequences, discipline is about teaching not punishment.<span style="mso-spacerun: yes;"> </span>We expect children (and ourselves) to miss
the mark.<span style="mso-spacerun: yes;"> </span>The message needs to be,
“Mistakes are welcome here.”<span style="mso-spacerun: yes;"> </span>Teaching
takes the form of natural consequences, do overs, and making amends.<span style="mso-spacerun: yes;"> </span>Some mistakes or poor choices require empathy
and no consequences at all.<span style="mso-spacerun: yes;"> </span>If a child
breaks their toy by carelessness or on purpose say, “You must be sad about
that,” but do not blame or ridicule the child with, “That’s what happens when
you are reckless with your stuff.<span style="mso-spacerun: yes;"> </span>Do you
know how much that costs?”<span style="mso-spacerun: yes;"> </span>No, do not
replace it, let experience teach.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>There are a few choices, per Daniel Hughes
(2007), when a child does not meet expectations.<span style="mso-spacerun: yes;"> </span>1. Ignore it because the child has had a
bad day.<span style="mso-spacerun: yes;"> </span>2. Do it for them because you
love them. 3. Have the child pay someone else to do it.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>4.
Award privileges only when it is done.<span style="mso-spacerun: yes;">
</span>Finally, when a child has hurt someone by word or deed, help them make
it up to the person in a concrete way, and award privileges only when it is
done.<span style="mso-spacerun: yes;"> </span>You make brownies with the school
bully to give to his classmates.<span style="mso-spacerun: yes;"> </span>In
another example, a mother empathized with a boy whose trauma tantrums at bedtime
led to his kicking a hole in the closet door.<span style="mso-spacerun: yes;">
</span>She did not berate him.<span style="mso-spacerun: yes;"> </span>She gave
him the telephone to call the home store.<span style="mso-spacerun: yes;">
</span>He used adult language to order a new door and helped the handyman
install it.<span style="mso-spacerun: yes;"> </span>He did the math.<span style="mso-spacerun: yes;"> </span>It cost him 20 weeks allowance.<span style="mso-spacerun: yes;"> </span>He learned he could fix his problems and felt
great about it.<span style="mso-spacerun: yes;"> </span>His mother demonstrated
her commitment to him while not damaging the relationship.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>When
these behaviors<span style="mso-tab-count: 1;"> </span> persist despite parents’
commitment to non-traditional parenting, I pull out Daniel Hughes’ (2007)
hearts and walls exercise in session.<span style="mso-spacerun: yes;"> </span>I
deliberately draw a stick figure of the child as an infant as I tell their
story, “You were born with a perfect healthy heart, and then stuff started to
happen.”<span style="mso-spacerun: yes;"> </span>Then, I draw a figure of the
child at the age at which they were abused with a heart with some dark
marks.<span style="mso-spacerun: yes;"> </span>“Your parents were having
problems with mental illness and drugs, and they did not feed you, hug you, and
watch you.”<span style="mso-spacerun: yes;"> </span>Arrows pointing at the heart
indicate the abuse and neglect.<span style="mso-spacerun: yes;"> </span>Then, I draw
a figure of the child at the age at which they were adopted or when the
behaviors started to appear, this time with a box around the heart labeled
“yelling”, “tantrums”, “taking food”, “ignoring adults” and arrows pointing at
the heart labeled, “love”, “play”, “safety”, “hugs”.<span style="mso-spacerun: yes;"> </span>“You are a smart kid and you learned how to
protect your heart by putting up walls.<span style="mso-spacerun: yes;">
</span>Sometimes the walls keep out the good stuff.”<span style="mso-spacerun: yes;"> </span>Lastly, I draw a figure of the child as an
adult with a healed heart and question marks where the walls might be. Over
several sessions I bring these drawings back, next roleplaying the child
talking with themselves at different ages.<span style="mso-spacerun: yes;">
</span>One parent plays the child as an infant.<span style="mso-spacerun: yes;">
</span>Another parent portrays the child at the age they were hurt.<span style="mso-spacerun: yes;"> </span>The child plays themselves as an adult.<span style="mso-spacerun: yes;"> </span>Very importantly, I play the child with the
defensive behaviors defending them as necessary because “you cannot trust adult
to take care of you” and “you should keep the walls up when we’re grown
up.”<span style="mso-spacerun: yes;"> </span>The parents are able to identify
with the innocent infant and to empathize with the abused child.<span style="mso-spacerun: yes;"> </span>The child is also able to see themselves and
their parents from different perspectives.<span style="mso-spacerun: yes;">
</span>I end with a lingering question, “When do you think you’ll feel safe
enough to let down the walls and let the good stuff in?”<span style="mso-spacerun: yes;"> </span>Having taken time with this exercise, the
child will usually say something like, “When I’m 8”, or after their next
birthday.<span style="mso-spacerun: yes;"> </span>Sometimes they say they will
trust their parents when they are teenagers or as adults, but the seeds of
change are planted, a positive future is in view.</div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-92123168163811803802016-07-11T12:12:00.002-07:002016-07-11T12:12:27.047-07:00Self Esteem<!--[if gte mso 9]><xml>
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<b style="mso-bidi-font-weight: normal;">Chapter Ten</b></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b style="mso-bidi-font-weight: normal;">Self Esteem</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Persistent
mental illness, substance addiction, and trauma all negatively impact
self-esteem.<span style="mso-spacerun: yes;"> </span>Whether it is the struggle
of overcoming difficult symptoms that limit functioning or facing the
unfortunate stigma of a diagnosis, the view of self suffers.<span style="mso-spacerun: yes;"> </span>This issue ultimately comes up in the ninth
or tenth session if not before.<span style="mso-spacerun: yes;"> </span>Low
self-esteem is serious in that it can lead not only to depressed mood but at
worst to self-harm including suicide.<span style="mso-spacerun: yes;">
</span>People with low self-esteem often act in by withdrawing from social
interaction or act out by creating conflict with others.<span style="mso-spacerun: yes;"> </span>Targeting self-esteem starts with
assessment.<span style="mso-spacerun: yes;"> </span>Sometimes adults and
children will express how they feel about themselves, “I can’t do anything right,”
“I’m a bad kid.”<span style="mso-spacerun: yes;"> </span>More often the feelings
are expressed in behavior and demeanor such as slumping physical posture,
downcast eyes, and short stilted speech.<span style="mso-spacerun: yes;">
</span>One big sign of low self-esteem is the client’s inability or refusal to
talk about their situation or desire to change the subject.<span style="mso-spacerun: yes;"> </span>Whether the issue is mental illness or
trauma, one common symptom is self-blame thus low self-esteem.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Several
interventions can improve self-esteem.<span style="mso-spacerun: yes;">
</span>The first is naming it and normalizing it.<span style="mso-spacerun: yes;"> </span>Again, statements are more helpful than
questions: “You feel bad about yourself,” or “It sounds like you blame yourself
for your situation.”<span style="mso-spacerun: yes;"> </span>Because it is a
common feeling therapeutic joining is necessary.<span style="mso-spacerun: yes;"> </span>That means agreeing with the feelings and not
with the facts.<span style="mso-spacerun: yes;"> </span>A return to the initial
strengths-finding exercise can remind a client of their positive
characteristics.<span style="mso-spacerun: yes;"> </span>Once a therapeutic
relationship is established a continuing attitude of unconditional positive
regard and sincere pleasant human interaction set a tone from session to
session that helps the client see themselves in a different light.<span style="mso-spacerun: yes;"> </span>This is why, with families, I do not meet
with children alone and, in fact, put the parent in charge of changing in a way
that helps the child and the family.<span style="mso-spacerun: yes;"> </span>I
try not to make the child the subject of counseling or the target of
intervention in a direct confrontational way.<span style="mso-spacerun: yes;">
</span>Sometimes people with low self-esteem cannot tolerate hearing positive
things about themselves.<span style="mso-spacerun: yes;"> </span>A compliment or
positive remark is likely to be knocked down or dismissed by a person with low
self-esteem.<span style="mso-spacerun: yes;"> </span>The child client and even
adults can hear and take in more positive perspectives of themselves if they
are delivered indirectly.<span style="mso-spacerun: yes;"> </span>I encourage
parents and partners to focus on and tell positive stories about the
client.<span style="mso-spacerun: yes;"> </span>At home, a parent saying
something positive about the child to someone else within their earshot or in a
way they will hear indirectly has much more influence and staying power than a
compliment delivered directly to the child.<span style="mso-spacerun: yes;">
</span>The positive statement feels more valid.<span style="mso-spacerun: yes;">
</span>A good rule of thumb is 10 positive statements for every negative
one.<span style="mso-spacerun: yes;"> </span>This at least will reduce the
number of negative comments made about a client if positive statements are hard
to find.<span style="mso-spacerun: yes;"> </span>It does mean we ignore negative
behavior but balance the person’s experience.<span style="mso-spacerun: yes;">
</span>Using narrative therapy, parents may construct a “success narrative”, a
story putting the child in character with talents or “special powers”
overcoming obstacles to survive and win.<span style="mso-spacerun: yes;">
</span>I also use the book Don’t Feed the Monster on Tuesdays (Moser, 1991) and
role play the child client “talking down” the big monster who spouts negative
thoughts as a way of helping the child develop positive self-talk.<span style="mso-spacerun: yes;"> </span>In this case, it is important not to go
lightly but to state the child’s worst fears about themselves, “Your birth
parents left you because you are too much trouble to love.”<span style="mso-spacerun: yes;"> </span>When the child comes back with, “I am easy to
love because my parents do,” you have hit pay dirt.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>It
is imperative to distinguish between a person’s self-esteem and their core
belief system because they require different kinds of interventions.<span style="mso-spacerun: yes;"> </span>A person’s self-esteem is how they feel about
themselves.<span style="mso-spacerun: yes;"> </span>A person’s core belief
system is how they see the world.<span style="mso-spacerun: yes;">
</span>Negative self-esteem is serious but can be corrected.<span style="mso-spacerun: yes;"> </span>A negative core belief system is more
pernicious and less likely to change.<span style="mso-spacerun: yes;">
</span>For example, a child who is wanted, cared for and celebrated feels they
are important, adults are capable, and the world is safe.<span style="mso-spacerun: yes;"> </span>A child who is rejected, hurt, and shamed
feels they are bad, adults are scary, and the world is unsafe.<span style="mso-spacerun: yes;"> </span>The first child can tolerate failure.<span style="mso-spacerun: yes;"> </span>The second child expects it.<span style="mso-spacerun: yes;"> </span>The same goes for adults who have experienced
generally positive childhoods and those who have not.<span style="mso-spacerun: yes;"> </span>Because we behave in ways that confirm our
core belief systems, people with a positive view create, find, or interpret
situations to fit this picture and people with a negative view do the
same.<span style="mso-spacerun: yes;"> </span>Almost no amount of
strengths-finding, compliments, or positive self-talk will overcome a negative
core belief system.<span style="mso-spacerun: yes;"> </span>It requires a
paradox intervention.<span style="mso-spacerun: yes;"> </span>Confronting their
negative view of the world with our positive view is counterproductive and will
cause the person to dig in and feel unheard.<span style="mso-spacerun: yes;">
</span>It is like a person who comes home at the end of the day complaining
about their work and their spouse either tells them it is not so bad or how to
fix it.<span style="mso-spacerun: yes;"> </span>The person feels unheard,
dismissed, and disconnected.<span style="mso-spacerun: yes;"> </span>Instead, we
agree with them and join in their view of themselves and the world.<span style="mso-spacerun: yes;"> </span>This is very difficult for parents of
traumatized children who see as one of their primary roles to raise happy
children.<span style="mso-spacerun: yes;"> </span>What gets in the way is the
parents’ guilt and shame about the child’s trauma and their feelings of
responsibility for the child’s feelings and the honorable desire to make “the
bad stuff” go away or pretend it did not happen.<span style="mso-spacerun: yes;"> </span>It is not easy, and can be quite aggravating,
to be with a person who sees the world so darkly.<span style="mso-spacerun: yes;"> </span>This is not the same as depression, but can
feel like a bottomless pit of negativity.<span style="mso-spacerun: yes;">
</span>We have to get down in the muck with the person and not stand on the
edge of the hole calling down, “Pull yourself up!”</div>
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<span style="mso-tab-count: 1;"> </span>What
this looks like in practice is less talking and more experiencing.<span style="mso-spacerun: yes;"> </span>That means creating pleasant playful
experiences in session and out.<span style="mso-spacerun: yes;"> </span>Play
therapy and theraplay provide both.<span style="mso-spacerun: yes;"> </span>Taking
cues from the initial face mirroring and parallel drawing assessments in the
first session with the child, I teach, model, and coach parents to lead the
child into play and to follow the child through play.<span style="mso-spacerun: yes;"> </span>I use multi-colored feathers for parents and
children to blow off a table or to work together to keep one feather on the
table.<span style="mso-spacerun: yes;"> </span>I use play dough for a child to
create or for parents to “decorate” their child.<span style="mso-spacerun: yes;"> </span>Tin foil makes great hats, crowns, and bracelets.<span style="mso-spacerun: yes;"> </span>Lotion can be used to play “slippery hands”.<span style="mso-spacerun: yes;"> </span>Children and parents can create a mirror of
their own family or an imagined future using a doll house with figures and
furniture.<span style="mso-spacerun: yes;"> </span>A sand tray provides a
contained environment in which a child and parent may create a “world”
representing themes from their own lives.<span style="mso-spacerun: yes;">
</span>Blocks and Lego’s, crayons and paint, colored paper and pencils are all
media for creative play WITH children.<span style="mso-spacerun: yes;"> </span>A
child or person with a negative core belief system needs help experiencing themselves
and the people around them as protective and positive.<span style="mso-spacerun: yes;"> </span>It is important to know that success in this
area can be very fragile.<span style="mso-spacerun: yes;"> </span>One setback,
like a failing grade or the end of a relationship, can send a person back to what
seems like square one.<span style="mso-spacerun: yes;"> </span>Reversing a
negative core belief system requires patience and perseverance.</div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-38858555306487266462016-07-07T12:58:00.002-07:002016-07-07T15:45:51.540-07:00Coping Skills<!--[if !mso]>
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<div class="MsoNormal" style="line-height: 200%;">
<b style="mso-bidi-font-weight: normal;">Chapter Nine</b></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;">Coping Skills</b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
If stress is the
body’s normal reaction to challenges and changes, then behavior, whether
positive or negative, is the person’s way of coping with that energy.<span style="mso-spacerun: yes;"> </span>Sometimes that coping is adaptive, healthy,
and legal. Sometimes it is maladaptive, unhealthy, or illegal.<span style="mso-spacerun: yes;"> </span>Sometimes it is self care.<span style="mso-spacerun: yes;"> </span>Sometimes it is self harm.<span style="mso-spacerun: yes;"> </span>We know what is good for us and what is
not.<span style="mso-spacerun: yes;"> </span>The goals are reducing harm and
increasing functioning. Having faced those experiences head-on, it is time to
return to calm and a sense of safety.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>This is the pattern or rhythm I try to achieve
within a session or from one session to the next.<span style="mso-spacerun: yes;"> </span>I return to the client’s list of strengths
and achievements to highlight what is already working.<span style="mso-spacerun: yes;"> </span>Self-help books and the internet are full of
coping strategies; from healthy eating to exercise; journaling to meditation;
music to hot showers.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
With families and
children I introduce these ideas by drawing an “angry volcano”.<span style="mso-spacerun: yes;"> </span>I describe anger as a secondary or
superficial emotion that we see at the top outside the volcano but below inside,
the hot lava holds the primary or deeper emotions.<span style="mso-spacerun: yes;"> </span>“It looks like anger, but it’s really….”, and
the client, with support, lists frustration, confusion, sadness, illness,
embarrassment, and so forth.<span style="mso-spacerun: yes;"> </span>This is
part of developing emotional intelligence, figuring out what we really
feel.<span style="mso-spacerun: yes;"> </span>It also helps the parent or others
develop a different response to the client.<span style="mso-spacerun: yes;">
</span>Rather than reacting to the anger we think we see by misunderstanding,
judging, and rejecting, we can respond to the underlying feeling by accepting,
empathizing, and connecting.<span style="mso-spacerun: yes;"> </span>On the
sides of the volcano I draw “vents” and explain that while some volcanos “blow
their top” destroying people and property including the volcano itself, other
active older volcanos never blow their top because they have vents to “let off
some steam”.<span style="mso-spacerun: yes;"> </span>Then we list the things the
client likes to do to let off steam.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Healthy coping
means expressing not suppressing emotions.<span style="mso-spacerun: yes;">
</span>To that end, I demonstrate and guide children and parents through an
exercise designed to discharge emotion.<span style="mso-spacerun: yes;">
</span>I have used large wet sponges thrown against an outside wall of the
building or soft foam balls thrown at the door inside the office.<span style="mso-spacerun: yes;"> </span>I ask clients to verbalize what makes them
angry while throwing the sponge or ball.<span style="mso-spacerun: yes;">
</span>The physical release and the sound of the sponge hitting the wall are
satisfying.<span style="mso-spacerun: yes;"> </span>I encourage children to “let
the anger go” even if the anger seems directed at parents over petty
disputes.<span style="mso-spacerun: yes;"> </span>However, parents need some
limits.<span style="mso-spacerun: yes;"> </span>This is not the time for them to
express their anger at their children.<span style="mso-spacerun: yes;">
</span>Instead, like the role plays parents validate their child’s anger,
speaking for the child, using “I statements”.<span style="mso-spacerun: yes;">
</span>I connect the trauma history to current emotions by expressing anger for
the child about, “leaving my first Mom and Dad”, “getting hurt in foster care”,
“not seeing my brothers and sisters”.<span style="mso-spacerun: yes;"> </span>We
return to the activity often, sometimes with children saying they need it, and
suggesting it as a regular preventative routine before emotions become
overwhelming.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
If the goals are
building connections and co-regulation then theraplay is an effective
intervention.<span style="mso-spacerun: yes;"> </span>Because parents and
children communicate emotionally before they communicate intellectually,
theraplay emphasizes the experiential nature of this connection.<span style="mso-spacerun: yes;"> </span>Theraplay replicates the parent-child
relationship across all developmental dimensions; social, emotional, physical,
and cognitive.<span style="mso-spacerun: yes;"> </span>I introduce the four
styles of theraplay; structure, challenge, engagement, and nurture.<span style="mso-spacerun: yes;"> </span>Each allows the parent to introduce an
activity and interact with their child playfully in a way that may not be
routine in an average family focused on homework, chores, and bedtime.<span style="mso-spacerun: yes;"> </span>Structure addresses the parent’s ability to
set safe limits the child can accept.<span style="mso-spacerun: yes;"> </span>I
have the parent measure the child’s body; height, arms, legs, ears, and
smile.<span style="mso-spacerun: yes;"> </span>We play a version of “Mother may
I?” in which the child is encouraged to jump on one foot, pat their head and
rub their stomach, or do jumping jacks until the parent says to stop.<span style="mso-spacerun: yes;"> </span>Challenge allows the parent to set
expectations that stimulate the child’s development.<span style="mso-spacerun: yes;"> </span>Parent and child walk across the room holding
a pillow between them.<span style="mso-spacerun: yes;"> </span>The child
balances a pillow on their head and walks carefully to dump it on the parent’s
lap.<span style="mso-spacerun: yes;"> </span>Engagement fosters social
interaction.<span style="mso-spacerun: yes;"> </span>The parent applies band-aids
to the child’s bumps and bruises or the two create a special handshake.<span style="mso-spacerun: yes;"> </span>Nurture meets the child’s needs for
affection.<span style="mso-spacerun: yes;"> </span>The parent feeds the child a
bottle and applies lotion or decorates the child with tin foil.<span style="mso-spacerun: yes;"> </span>While talking about problems may become
overwhelming, theraplay returns the parent-child relationship to playfulness
and soothing.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Play and
relaxation provide great coping for all clients.<span style="mso-spacerun: yes;"> </span>For children play is not an escape from problems
but a way to make sense of them.<span style="mso-spacerun: yes;"> </span>Whether
they are drawing pictures or making crafts, children almost always reveal
themselves.<span style="mso-spacerun: yes;"> </span>If a parent can learn to
interpret the play as the child’s language communication and connection
happen.<span style="mso-spacerun: yes;"> </span>Returning to the example of the
parallel drawing I encourage parents to be both the leader with theraplay and
the follower with creative play by noticing and describing the child’s
activities as if they are a “play-by-play announcer” or “sports color
commentator”.<span style="mso-spacerun: yes;"> </span>Board games that include
“thinking, feeling, acting” cards or the terrific Ungame provide both the
safety of the structure of taking turns and the freedom to express concerns.<span style="mso-spacerun: yes;"> </span>The magic of The Ungame is that when the
session seems to stall the game takes a family back to the very concerns and
issues they have come to address, even if it is just the way they communicate
and work together.<span style="mso-spacerun: yes;"> </span>Parenting requires
both up regulating and down regulating.<span style="mso-spacerun: yes;">
</span>For movement I turn on the music and encourage parents and children to
dance or do yoga poses.<span style="mso-spacerun: yes;"> </span>The small
percussion instruments allow parents and children to express their emotions
from loud to soft and “speak” to one another with rhythm and sound.<span style="mso-spacerun: yes;"> </span>I lead parents and children in progressive
relaxation.<span style="mso-spacerun: yes;"> </span>“Stiffen each part of your
body starting with your toes and going to your head, making each one like a
piece of wood or stone, then go ‘soft and floppy’”<span style="mso-spacerun: yes;"> </span>Parents check the child’s body and we repeat.<span style="mso-spacerun: yes;"> </span>Both children and adults enjoy guided
meditation and relaxation breathing either led by me in session or using
applications and websites like Calm.com and Franticworld, com.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">The Power
of Silence</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">People and parents often feel the
need and responsibility to take charge, to lead, and to teach.<span style="mso-spacerun: yes;"> </span>We most often do so by giving directions
and explanations.<span style="mso-spacerun: yes;"> </span>Talking yields
diminishing returns.<span style="mso-spacerun: yes;"> </span>We help
children and partners self-regulate by lending them our self-control.<span style="mso-spacerun: yes;"> </span>In their anxiety they often draw us in to
an endless escalating discussion we feel we must win by repeating ourselves
with increasing determination. When we lose our self-control, the anxiety
level goes up.<span style="mso-spacerun: yes;"> </span>When we “lose it” we
lose our power.<span style="mso-spacerun: yes;"> </span>In these situations
silence seems weak, as if we are giving in or giving up.<span style="mso-spacerun: yes;"> </span>It is difficult to realize that doing
nothing is doing something; that saying nothing speaks volumes.<span style="mso-spacerun: yes;"> </span>Conscious use of silence is a powerful
intervention.<span style="mso-spacerun: yes;"> </span></span></div>
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<br /></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-30984964915550996352016-06-28T12:36:00.000-07:002016-06-28T12:36:23.360-07:00Trauma Therapy<!--[if !mso]>
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<div class="MsoNormal" style="line-height: 200%;">
<b style="mso-bidi-font-weight: normal;">Chapter Eight</b></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center; text-indent: .5in;">
<b style="mso-bidi-font-weight: normal;">Trauma Therapy</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>If
the purpose of therapy is to support the client in managing the effects of
changes and challenges on everyday life then identifying those specific events
is necessary.<span style="mso-spacerun: yes;"> </span>For many people and many
problems staying in the present and moving forward will work just fine.<span style="mso-spacerun: yes;"> </span>For others including children early life
experiences have an impact and we ignore this brain science at their
peril.<span style="mso-spacerun: yes;"> </span>Unplanned pregnancy, in utero
drug exposure, separation from birth mother, and removal from parents count as
much or more than multiple moves and physical or sexual abuse.<span style="mso-spacerun: yes;"> </span>A family history or other documentation can
supply information to construct genograms, timelines, and placement maps.<span style="mso-spacerun: yes;"> </span>A genogram, like a family tree, identifies
multiple generations of family members, the quality of their relationships, and
conditions like mental illness and substance abuse.<span style="mso-spacerun: yes;"> </span>A timeline lays out major developmental
milestones along with both major and minor positive and negative events in a
person’s life.<span style="mso-spacerun: yes;"> </span>A placement map shows
where and with whom a child may have moved and what happened in each home.<span style="mso-spacerun: yes;"> </span>The process of physically drawing out these
on paper is just as important as the finished products.<span style="mso-spacerun: yes;"> </span>It allows parents to really investigate
family life and to focus on details they may have forgotten or wish to
deny.<span style="mso-spacerun: yes;"> </span>In the hearing, the child is
educated about important events held in implicit or body memory and validated
for experiences held in explicit and verbal memory.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Many parents feel
uncomfortable sharing very scary information with children; if the child was a
product of rape, if a parent is in prison, if serious mental illness or
substance abuse is involved.<span style="mso-spacerun: yes;"> </span>They fear
hurting the child more, they fear dealing with the emotional consequences, they
fear the child will adopt the same behaviors, they feel ashamed of the behavior
or to be associated with people who make such decisions or hurt their
children.<span style="mso-spacerun: yes;"> </span>I acknowledge all of that to
parents.<span style="mso-spacerun: yes;"> </span>Yet, in most cases, the child
is the one associated with “those” people, “that” behavior.<span style="mso-spacerun: yes;"> </span>The nature of attachment trauma is that abuse
and neglect happen in the context of what is supposed to be a nurturing
relationship.<span style="mso-spacerun: yes;"> </span>Humans hurt each other,
sometimes on purpose, usually by accident.<span style="mso-spacerun: yes;">
</span>We are most often hurt by people we count on and love.<span style="mso-spacerun: yes;"> </span>That is the nature of the work.<span style="mso-spacerun: yes;"> </span>Parents may take themselves off the hook for
hurting the child but they must take responsibility for helping the child heal
because children cannot heal on their own.<span style="mso-spacerun: yes;">
</span>They are also self-centered and egotistical because they are supposed to
be.<span style="mso-spacerun: yes;"> </span>Everything is about them.<span style="mso-spacerun: yes;"> </span>That means what they don’t know, they make
up, what they make up is worse than the truth, and what they make up that is
worse than the truth is their fault.<span style="mso-spacerun: yes;">
</span>Children need to be taken off the hook for causing their own
trauma.<span style="mso-spacerun: yes;"> </span>So, children need to know the
truth as soon as they are able to handle it, and that is usually at a very
young age.<span style="mso-spacerun: yes;"> </span>Parents of infants and
toddlers can practice the story.<span style="mso-spacerun: yes;"> </span>“You
were a very beautiful baby when you were born.<span style="mso-spacerun: yes;">
</span>You have eyes likes your biological mother.<span style="mso-spacerun: yes;"> </span>We don’t know who your biological father is,
but he must have great hair, because you do.<span style="mso-spacerun: yes;">
</span>But your mother was taking methamphetamines which made her forget about
taking care of you.<span style="mso-spacerun: yes;"> </span>That’s why the child
welfare worker came and took you to a foster home because you needed bottles
and diapers just like every other baby.”<span style="mso-spacerun: yes;">
</span>It is not the details of the story a small child will grasp but the
parents’ tone in telling it.<span style="mso-spacerun: yes;"> </span>They may
not understand the details, but this story will be repeated for the rest of the
child’s life as they grow older and ask more questions requiring
elaboration.<span style="mso-spacerun: yes;"> </span>It is their story.<span style="mso-spacerun: yes;"> </span>It becomes the parents’ story as the family
grows and acceptance of these facts demonstrates acceptance of the child and
those connected to them.<span style="mso-spacerun: yes;"> </span>If we reject
biological parents, we reject the child.<span style="mso-spacerun: yes;">
</span>Talking about “something bad that happened”, “mistakes the parents
made”, or “they were smoking bad stuff” is a cop-out and damages the trust
parents want their children to have in them.<span style="mso-spacerun: yes;">
</span>Children deserve to hear the whole truth.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Again, a book like
The Little Flower (McAndrew, 1999) normalizes traumatic events and the emotions
that go with them.<span style="mso-spacerun: yes;"> </span>After the parent
reads the book I have the child draw a flower that represents themselves and
then we list the basic needs of flowers and children.<span style="mso-spacerun: yes;"> </span>It reinforces that the child deserves
care.<span style="mso-spacerun: yes;"> </span>Life events laid out on a timeline
provide a roadmap to healing.<span style="mso-spacerun: yes;"> </span>Both
positive and negative developments need to be included: “This is the house
where you learned to walk,” “this is the house where you ate dry Top Raman
because they did not feed you.”<span style="mso-spacerun: yes;"> </span>Sometimes
just seeing all of the events lined up on paper is enough to put the pain in
perspective; separations, divorces, deaths, moves, and more.<span style="mso-spacerun: yes;"> </span>Then we use colored pencils to highlight
happy, stressful, and neutral events.<span style="mso-spacerun: yes;"> </span>I
ask the client to scale the level of current stress associated with each
traumatic event and to prioritize the traumatic events for processing.<span style="mso-spacerun: yes;"> </span>I do the same for veterans and others with
Post-Traumatic Stress Disorder.<span style="mso-spacerun: yes;"> </span>When we
pick a triggering traumatic event we identify the thoughts, emotions, and
situations associated with each.<span style="mso-spacerun: yes;"> </span>We look
at the impact on the client’s life and what the client is doing to cope,
behaviors that are working or not working, normalizing the experience.<span style="mso-spacerun: yes;"> </span>For example, “if you heard adults fighting at
nighttime, no wonder you are scared to go to bed.”<span style="mso-spacerun: yes;"> </span>This is the format for trauma-focused
cognitive behavior therapy used with adults as well as children. The client is
supported in challenging automatic negative thoughts and cognitive distortions,
to learn and practice more effective coping skills, and to develop a narrative
of their life that focuses on surviving and thriving.<span style="mso-spacerun: yes;"> </span>For children it requires the active
participation of parents focusing on relational safety, co-regulation of emotion,
and intersubjectivity; the ideas that the parent provides acceptance and
commitment in the face of difficult experiences and behavior, can manage their
own emotions and lend the child support in managing theirs, and can accept the
child’s interpretation of events while guiding them to mastery of the material.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Role play is an
excellent way to bring events to life especially with children because of their
interest in fantasy and make believe and their visual learning styles.<span style="mso-spacerun: yes;"> </span>Role play can be very effective with adults
as well.<span style="mso-spacerun: yes;"> </span>I start by establishing a sense
of safety by emphasizing that role play is just that, play, we are playing
parts and we can make up the characters and script, which is often empowering
to the client.<span style="mso-spacerun: yes;"> </span>I give the client the
power to end the role play if it becomes overwhelming or uncomfortable by
practicing a hand signal like “time out” or simply saying, “Mike, can we please
stop.”<span style="mso-spacerun: yes;"> </span>For example, adopted children
will often like to revisit the court hearing at which the judge decided to
terminate parenting rights and order the child adopted.<span style="mso-spacerun: yes;"> </span>In this case, the child plays the judge, the
one in charge, and I take the roles of attorney, biological parent, or child
welfare worker, depending upon whom the child would like to hear from or “cross
examine”.<span style="mso-spacerun: yes;"> </span>The “bailiff” calls the
hearing to order, the judge pounds the “gavel”, and the witnesses take “the
oath” and “the stand”.<span style="mso-spacerun: yes;"> </span>The attorney asks
“biological mother or father” why their children were removed and whether they
have completed services to fix their problems.<span style="mso-spacerun: yes;">
</span>The child “judge” will often ask about their living situations and
whether they miss the child showing their deep concerns.<span style="mso-spacerun: yes;"> </span>When the real adoptive parents take “the
stand” the attorney asks about their preparation and commitment to adopt.<span style="mso-spacerun: yes;"> </span>The child “judge” most often asks about food
showing their interest in basic needs.<span style="mso-spacerun: yes;">
</span>The attorney gives a “closing argument” and the judge is asked to decide
whether the child will be “adopted”.<span style="mso-spacerun: yes;"> </span>The
child acting as judge signs the order along with the parents creating a
relationship agreement the child did not make the first time.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
The results are
sometimes as cathartic when the child wants to talk with a biological family
member or even their perpetrator who are not available or safe enough to see in
person.<span style="mso-spacerun: yes;"> </span>This comes after several
sessions in which we have developed a safe therapeutic relationship and a
practice of emotional expression and soothing coping skills to which to
return.<span style="mso-spacerun: yes;"> </span>Orlans and Levy, (2006)
demonstrate this in their trainings.<span style="mso-spacerun: yes;">
</span>Again, this requires some preparation and set-up, “Remember, you’ll
really have to use your imagination because I’m pretending to be your
bio-mother and I am Mike.”<span style="mso-spacerun: yes;"> </span>The other
preparation that makes this intervention more than mastering the trigger event
is the role of the parent in demonstrating intersubjectivity with the
child.<span style="mso-spacerun: yes;"> </span>The client is encouraged to ask
questions or talk with the “parent or perpetrator”.<span style="mso-spacerun: yes;"> </span>They might even prepare questions or a letter
to read.<span style="mso-spacerun: yes;"> </span>But if they cannot or do not speak,
the parent is encouraged to speak for them in “I statements” as the voice of
the child which demonstrates they share the child’s concerns and
interests.<span style="mso-spacerun: yes;"> </span>At the very least the
client’s experience is validated.<span style="mso-spacerun: yes;"> </span>At
most a moment of connection as when a “biological parent” suggests the child
“come to visit” and the child pulls back into the arms of the adoptive parents
whom he has seemed to reject.<span style="mso-spacerun: yes;"> </span>Another
time, a five year old boy faced his “uncle” who favored him over his jealous
siblings while molesting him.<span style="mso-spacerun: yes;"> </span>The
nonchalant “uncle” asked, “What do you want me to do?”<span style="mso-spacerun: yes;"> </span>The boy, who had scary tantrums daily in his
adoptive home said firmly, “I want you to apologize.”<span style="mso-spacerun: yes;"> </span>The nurturing mother pulled us both out of
that most real role play by having us play together again.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
When role play is
too intrusive and triggering to tolerate, narrative therapy helps people
process traumatic life events.<span style="mso-spacerun: yes;"> </span>Nichols,
Lacher, and May (2002) describe constructing narratives that review a child’s
developmental stages and traumatic experiences.<span style="mso-spacerun: yes;">
</span>Like bibliotherapy, third party story telling allows the person to take
a new perspective on events similar to their own in a way that reduces resistance
and dissociation.<span style="mso-spacerun: yes;"> </span>We heal by hearing
stories of people who have overcome problems like our own.<span style="mso-spacerun: yes;"> </span>With parents children can be engaged in
creating characters, plot, challenges, conflict, and resolution which can be
empowering and satisfying.<span style="mso-spacerun: yes;"> </span>I start with
a story of a prince or princess who leave their ill parents, the king and queen,
on a journey to find a family, going through a scary forest, meeting strange
animals, listening to magic birds, until they employ special powers to find a
home in which there are rules but also lots of love and care.<span style="mso-spacerun: yes;"> </span>I ask children with their parents to create
their own story in words and pictures.<span style="mso-spacerun: yes;"> </span>I
often provide an outline that includes chapters for the child’s birth, traumatic
events, moving, settling in, and growing up.<span style="mso-spacerun: yes;">
</span>Some children enjoy drawing pictures that represent events, others write
poems illustrated with drawings.<span style="mso-spacerun: yes;"> </span>Their
reading of their creation validates their experiences and reviewing it over
time helps them master their trauma.<span style="mso-spacerun: yes;"> </span>Similar
to the birth narrative I lead parents through telling the child’s developmental
and trauma narrative placing themselves at pivotal moments to support the
child’s growth; “and we would hold your hands as you begin to walk”, “and if we
saw you walking on the street in your diaper we would call the police and get
you some clothes and food.”<span style="mso-spacerun: yes;"> </span>Parents
often bring props like blankets, bottles, pictures, toys, food, and clothes
that bring the stories to life in a way that emphasizes nurturing and safety.</div>
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Trauma
Metaphors</span></div>
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Psychoeducation in the form of
examples, stories, and metaphors can be helpful for children, adolescents,
and adults.<span style="mso-spacerun: yes;"> </span>Two metaphors that may not
be scientifically based still help me conceptualize trauma and therapy.<span style="mso-spacerun: yes;"> </span>First, there is the analogy of airline
luggage.<span style="mso-spacerun: yes;"> </span>Sometimes we carry around a
lot of baggage that is heavy and expensive to check.<span style="mso-spacerun: yes;"> </span>Our whole lives are dumped into the
suitcase and it is not particularly organized.<span style="mso-spacerun: yes;"> </span>In therapy we unpack the big bag, take a
look at what is important, get rid of what we do not need, and organize it
in a smaller bag that is easier to wheel around and cheaper to carry
on.<span style="mso-spacerun: yes;"> </span>We put it up in the overhead
compartment or on the shelf in the closet and we can have access to it
whenever we need to recall, refresh, and update the contents.<span style="mso-spacerun: yes;"> </span>The second metaphor is about the brain as
computer.<span style="mso-spacerun: yes;"> </span>We are working along when
we get an error message or everything slows down or stops.<span style="mso-spacerun: yes;"> </span>Our computer has a virus and files may be
infected.<span style="mso-spacerun: yes;"> </span>The repair opens each
document saved on our hard drive, brings it up to the desktop, editing and
refreshing, resaving with a new name, organizing documents into the correct
file folders, deleting unwanted material, and emptying the recycle
bin.<span style="mso-spacerun: yes;"> </span>Each time we open and look at a
file we change it even if the content stays the same. Reviewing thoughts,
beliefs, and memories changes them.</span></div>
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<br /></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-36513871996868945612016-06-25T12:17:00.000-07:002016-07-06T14:17:27.981-07:00Emotional Intelligence<!--[if gte mso 9]><xml>
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<b style="mso-bidi-font-weight: normal;">Chapter Seven</b></div>
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<b style="mso-bidi-font-weight: normal;">Emotional Intelligence</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 2;"> </span>Having
established a framework for family therapy and done some initial assessment, it
is time to introduce, model, and practice a language of feelings to talk about
these issues.<span style="mso-spacerun: yes;"> </span>It is, after all, the
emotional content that distinguishes function from dysfunction, that drives
thought and behavior, and that disconnects or connects people in
relationship.<span style="mso-spacerun: yes;"> </span>Here I recall the
psycho-education material from the second session, often replaying my training
presentation for the child or adolescent to illustrate my point.<span style="mso-spacerun: yes;"> </span>Then, using Daniel Siegel’s hand/brain
demonstration (2003, p. 173) I ask parents and children to hold up a hand as I
describe the parts of the brain and their roles in physiological functioning,
storing pre-conscious emotional memories, and decision making. <span style="mso-spacerun: yes;"> </span>My hand up flat, pointing to the wrist I
start.</div>
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“The wrist represents the brainstem,
the earliest, oldest part of the brain, responsible for involuntary functions
like respiration and temperature, the part that sends our hearts racing and our
skin sweating when we are excited or scared.<span style="mso-spacerun: yes;">
</span>Now fold over your thumb like this.<span style="mso-spacerun: yes;">
</span>The thumb represents the emotional brain, the limbic brain, also
primitive in development, active before birth, and responsible for storing
memories of early experiences before our conscious awareness.<span style="mso-spacerun: yes;"> </span>This is the part that remembers the first
time we sat on our bottoms or how it felt to be held and fed, or how it felt
when Mom was stressed out about being pregnant, or how it felt to be left alone
and hungry.<span style="mso-spacerun: yes;"> </span>Next, fold your fingers over
your thumb.<span style="mso-spacerun: yes;"> </span>This represents the thinking
brain, the cortex, neo-cortex, and pre-frontal lobes that start forming in
utero but are not finished until about 25 years old.<span style="mso-spacerun: yes;"> </span>This is the part of the brain that remembers
experiences with words and stories, that learns math and science, that makes
decisions about what to do or not to do, most active after the age of
four.<span style="mso-spacerun: yes;"> </span>Now these three parts are
connected and communicate with each other, except when they don’t, for example
when we are excited or scared.<span style="mso-spacerun: yes;"> </span>That’s
when we sometimes ‘lose our minds’ and go into what’s called
fight/flight/freeze mode, when we need to fight back from attack, or run away,
or stay still because we are in danger or think we might be.<span style="mso-spacerun: yes;"> </span>This is a good thing.<span style="mso-spacerun: yes;"> </span>For example, if you are driving down the
highway and somebody almost hits your car, your brain tells you there’s a
threat to your life and your body needs to defend itself.<span style="mso-spacerun: yes;"> </span>The eyes widen to look around, the arms and
legs get tense to drive the car, and the heart and lungs start pumping blood
and oxygen to make everything work faster and stronger.<span style="mso-spacerun: yes;"> </span>You do not stop to think, ‘That guy probably
just had a bad day,’ no that part of your brain is not on, you need to save
your life.<span style="mso-spacerun: yes;"> </span>So, you hit the gas, or you
hit the brake, or you stay right where you are.<span style="mso-spacerun: yes;">
</span>Then, when the danger is over you begin to think about what to do,
whether you are hurt, whether the car is damaged, whether to call the insurance
company or the police.<span style="mso-spacerun: yes;"> </span>Your thinking brain
comes back on.<span style="mso-spacerun: yes;"> </span>The hard part is that for
some people who have experienced scary things, even things they can’t remember,
their brain disconnects and they go into fight/flight/freeze when they are
excited or scared even when they are not in any real danger, but think they
are.<span style="mso-spacerun: yes;"> </span>It can happen often all day long
like when a car cuts us off in traffic, or a teacher raises her voice, or when
Dad tells us to turn off the X-Box.<span style="mso-spacerun: yes;">
</span>Then, when someone talks to us we can’t hear them because that part of
our brain is not on, and it sounds like Charlie Brown’s teacher, ‘Wah, wah,
wah, wah, wah.’<span style="mso-spacerun: yes;"> </span>That’s what the teacher
means when he says, “Put your thinking caps on.” That’s why it’s important for
us to know and parents to know when it happens so we can help get our brains
back on.<span style="mso-spacerun: yes;"> </span>It’s also important to know
that sometimes we overreact because our baby brain remembers when we were alone
or hungry and as if we’re going to die.<span style="mso-spacerun: yes;"> </span>Because,
babies can die when they are alone or hungry.<span style="mso-spacerun: yes;">
</span>It takes our thinking brain to tell us we’re going to be OK.<span style="mso-spacerun: yes;"> </span>But first the thinking brain has to be
on.<span style="mso-spacerun: yes;"> </span>And, that’s what we’re going to work
on, getting back to calm, so the parts of our brain can work together.”</div>
<div class="MsoNormal" style="margin-left: .5in;">
<br /></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: .5in;">
This silent visual
then becomes a signal or sign language for when a child or parent</div>
<div class="MsoNormal" style="line-height: 200%;">
feels regulated and calm or
dysregulated and upset.<span style="mso-spacerun: yes;"> </span>Time and time
again throughout the process I will ask or the child will volunteer how they
are feeling using the hand gesture, sometimes with closed hand indicating they
are ready to delve deeper into distressing material, or slightly open hand
indicating they need to be nurtured and soothed and it is time to breathe and
play.<span style="mso-spacerun: yes;"> </span>Similarly, I put my closed hands
together to represent the left and right parts of the brain, how the left brain
is responsible for logical thought and the right brain is responsible for emotional
experiences, and how we are going to help the two sides of the brain work
together.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>The
next activity is about developing an emotional vocabulary.<span style="mso-spacerun: yes;"> </span>I like to start by having parents read their
child a book like Today I Feel Silly and Other Moods That Make My Day by the
actress Jamie Lee Curtis (1998).<span style="mso-spacerun: yes;"> </span>I
specifically ask the question, “Is it OK to be angry?”<span style="mso-spacerun: yes;"> </span>The reason is that some parents and people send
children and other adults the message, directly or indirectly, that anger is an
inappropriate or unacceptable emotion.<span style="mso-spacerun: yes;">
</span>Nothing could be less helpful.<span style="mso-spacerun: yes;"> </span>The
message of this children’s book and all other clinical work, reinforced by
therapeutic language and activities, is that all emotions are valid.<span style="mso-spacerun: yes;"> </span>Identifying, expressing, and managing specific
and multiple emotions are essential to healing.<span style="mso-spacerun: yes;">
</span>And, hearing and validating feelings are essential skills to strengthening
relationships including the parent-child relationship.<span style="mso-spacerun: yes;"> </span>Active or reflective listening does not come
automatically or naturally to some, especially those who have never been on the
receiving end.<span style="mso-spacerun: yes;"> </span>A game like Candyland can
be a simple start.<span style="mso-spacerun: yes;"> </span>I call it “Feelings
Candyland” and ask parents and children to play together and sometimes I join
in to normalize feelings and normalize the expression of emotions so that as we
move through difficult experiences we can focus on emotional content.<span style="mso-spacerun: yes;"> </span>For Feelings Candyland I use the gingerbread
men pieces, a die, but no colored cards.<span style="mso-spacerun: yes;">
</span>I ask the child to give a feeling word to each color on the board from
red to green to yellow to purple.<span style="mso-spacerun: yes;"> </span>I may
offer suggestions to make sure we cover the big ones; happy, sad, angry,
scared.<span style="mso-spacerun: yes;"> </span>Often adults are stuck with a
limited vocabulary for emotions.<span style="mso-spacerun: yes;"> </span>A side
benefit, although not the most important one, is that I can determine whether
the child can count and knows colors in addition to feelings.<span style="mso-spacerun: yes;"> </span>Then, each participant tosses the die, moves
that many spaces, and describes a time when they have that feeling or what
makes them have that feeling based on the assigned colors.<span style="mso-spacerun: yes;"> </span>We play for a few minutes.<span style="mso-spacerun: yes;"> </span>I sometimes suggest it for family
activities.<span style="mso-spacerun: yes;"> </span>Children often ask to return
to the game sometimes with creative sophisticated emotional language.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Another
fun theraplay game is Feelings Tic Tac Toe.<span style="mso-spacerun: yes;">
</span>The grid on plain paper has nine emojis each representing an
emotion.<span style="mso-spacerun: yes;"> </span>The child is encouraged to
place an M&M or fish cracker, or if you want to be healthy a carrot coin,
on each face and tell when they have that feeling or what makes them have that
feeling.<span style="mso-spacerun: yes;"> </span>The rules are, if they fill up
the card, they get to eat the “game pieces” but they may not feed
themselves.<span style="mso-spacerun: yes;"> </span>I take a beat here to wait
for the child, and parent, to figure out how this can happen.<span style="mso-spacerun: yes;"> </span>Often traumatized children feel the need to
take control of everything because they do not trust adults to do so, and
parents consider that an older child should feed themselves and that feeding an
older child seems like coddling them.<span style="mso-spacerun: yes;">
</span>However, just like the couple at a wedding who feed each other cake, the
parent feeding the child is not just an important symbol of their nurturing
role but a chance to recreate an early developmental experience.<span style="mso-spacerun: yes;"> </span>I encourage parents to do it often with food
and bottles, baby bottles, juice boxes, or sports drinks, even for much older
children, and to make it loving and playful.<span style="mso-spacerun: yes;">
</span>The same goes for other parent-child activities like reading books, lap
rocking, backrubs, combing hair, hide and seek, and wrapping in blankets, as
long as it does not trigger the child.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Aristotle
provided a good definition of emotional intelligence, “to be angry with the
right person and to the right degree and at the right time and for the right
purpose, and in the right way.”<span style="mso-spacerun: yes;"> </span>It is
difficult for adults let alone children.<span style="mso-spacerun: yes;">
</span>Scaling emotions is a start.<span style="mso-spacerun: yes;"> </span>I
start by laying out colored paper each with numbers one through five.<span style="mso-spacerun: yes;"> </span>Using angry and happy as an example, I act
out examples from the child’s life that would rate anger at level 1, like not
getting ice cream for dessert, to moderate anger, 3, like a friend saying
something mean, to the highest level 5, a family member getting hurt on
purpose.<span style="mso-spacerun: yes;"> </span>I start quiet with a
disappointed facial expression and no body movement, move up to words, “I’m
upset” with clenched fists, up to a full loud jumping tantrum, “That’s not
right!”<span style="mso-spacerun: yes;"> </span>Parents and children may
acknowledge that the child’s emotional scale has a default setting of
five.<span style="mso-spacerun: yes;"> </span>Then I ask the child to
demonstrate using the emotion happy.<span style="mso-spacerun: yes;">
</span>Children usually need some guidance from parents to rate the amount of
emotion to match the event.<span style="mso-spacerun: yes;"> </span>Sometimes
parents are not comfortable with the extreme levels of emotion children may
feel or express in relation to rather serious trauma events like being starved
or sexually abused.<span style="mso-spacerun: yes;"> </span>Often the level of
emotion children display over rather mundane issues is really about the
traumatic events.<span style="mso-spacerun: yes;"> </span>Sometimes parents are
not comfortable with any but the most urbane expression of emotion.<span style="mso-spacerun: yes;"> </span>Culture plays a role here, too, what is
acceptable in different families. This can keep parents disconnected from their
children because they are not able or willing to attune to the child’s emotions,
many times because they have difficulty acknowledging the depth of the child’s
trauma.<span style="mso-spacerun: yes;"> </span>Certainly, parents may display
extreme emotion when a child is misbehaving.<span style="mso-spacerun: yes;">
</span>It takes some coaching to help a parent display extreme emotion over
events that seem past for the parent but are very present for the child.<span style="mso-spacerun: yes;"> </span>This is what I attempt to model.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>This
activity can be used in two other ways.<span style="mso-spacerun: yes;">
</span>Having identified several typical life events and acted out the
associated feelings, we then talk about the various places in which emotions
happen.<span style="mso-spacerun: yes;"> </span>Then, using the 1-5 scale we
talk about in which places different emotional expressions would be acceptable
and safe.<span style="mso-spacerun: yes;"> </span>For example, “it’s probably
pretty important to stay on a 1 at a restaurant or church, but where would it be
OK to go all the way up to a 5?”<span style="mso-spacerun: yes;"> </span>The
child or parent may say, “Nowhere.”<span style="mso-spacerun: yes;"> </span>Most
often I suggest a tall mountain, the beach, or the backyard where others are
not around.<span style="mso-spacerun: yes;"> </span>Parents will often suggest
the child’s room.<span style="mso-spacerun: yes;"> </span>The point is there
must be a safe place, both emotionally and physically, for a child to express
extreme emotions, and most beneficially with their parents.<span style="mso-spacerun: yes;"> </span>Next, I ask the child to stand on the number
and color that represents the level of emotion their parents expect most of the
time, particularly at home.<span style="mso-spacerun: yes;"> </span>With back
turned toward parents the child will often stand on 1.<span style="mso-spacerun: yes;"> </span>I send a signal to parents to move the child
to 2 or 3 demonstrating that the parent does not expect the child to be perfect
and will accept high levels of emotion.<span style="mso-spacerun: yes;">
</span>The child is often surprised.<span style="mso-spacerun: yes;">
</span>Then, I ask the child to stand on the 5, and with some cheering from me
and parents to really get loud.<span style="mso-spacerun: yes;"> </span>This is
the exact opposite of what parents usually do in trying to shut down an exuberant
display.<span style="mso-spacerun: yes;"> </span>Sometimes predicting a tantrum
can take the steam right out of it.<span style="mso-spacerun: yes;"> </span>In
this case, I ask the child to “scale it down” as they continue with an emotion
but with reduced energy.<span style="mso-spacerun: yes;"> </span>It demonstrates
that with their brain fully engaged, which is usually not the case during tantrums,
and the support and understanding of their parents, a child may have the
capacity at least to regulate themselves.<span style="mso-spacerun: yes;">
</span>Parents are often surprised that a fun and exciting experience can lead
to a complete “meltdown” because the child cannot self-regulate. This is an
activity I either reference or return to throughout the therapeutic process.<br />
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"> Because emotional intelligence entails more than
verbal expression I often use a collection of small percussion instruments from
session to session.<span style="mso-spacerun: yes;"> </span>I demonstrate how
each instrument is played then allow family member to experiment with
several.<span style="mso-spacerun: yes;"> </span>In several different formats, I
lead with an instrument playing a specific rhythm and then ask each person in
the circle to match the rhythm.<span style="mso-spacerun: yes;"> </span>Each
person takes a turn leading.<span style="mso-spacerun: yes;"> </span>Then I ask
parents and children to play the major emotions; happy, sad, angry,
scared.<span style="mso-spacerun: yes;"> </span>No talking is necessary, the
emotion is communicated with rhythm, timing, and volume and heard and matched
by the others which is the very definition of attunement.<span style="mso-spacerun: yes;"> </span>We attune and empathize through the use of
non-verbal signals more than with language.<span style="mso-spacerun: yes;">
</span>To help parents and children communicate with each other without the
intrusion of language, I ask them to “speak” to one another using the
instruments alone.<span style="mso-spacerun: yes;"> </span>What results is a
back and forth “conversation” the theme of which is usually pretty easy to
follow.<span style="mso-spacerun: yes;"> </span>Then the pair explains what they
were “saying” to each other, and more often than not their words match their
communicated intentions.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Another important
emotion that is difficult for children and adults but which is at the core of
attachment trauma, especially adoption, is sadness.<span style="mso-spacerun: yes;"> </span>We must develop an understanding and skills
around grief and loss.<span style="mso-spacerun: yes;"> </span>For this I turn
to children’s books; Horace (Keller, 1991), Rosie’s Family (Rosove, 2001), or
other similar stories to open a conversation about sadness.<span style="mso-spacerun: yes;"> </span>Then I bring out the puppets to tell sad
stories.<span style="mso-spacerun: yes;"> </span>Using puppets takes the focus
away from the person and makes expressing sadness safer.<span style="mso-spacerun: yes;"> </span>Each person in the family chooses a puppet,
we go around and introduce them by made-up names, and I start with my puppet
telling a simple sad story about a classmate breaking my favorite pencil.<span style="mso-spacerun: yes;"> </span>By turn, each person uses their puppet to
tell a sad story.<span style="mso-spacerun: yes;"> </span>Almost inevitably, the
stories become sadder and sadder and much more real.<span style="mso-spacerun: yes;"> </span>If not, I go to my “born in a litter, raised
on a farm, sold to the city, living with strangers” farm animal story that
highlights the themes of separation from parents, siblings, and place of
birth.<span style="mso-spacerun: yes;"> </span>As parents and therapists, we are
“loss managers”, we have to have a comfort level around grief and loss as if we
are “running the funeral home” and know how to guide children through the process,
specifically by highlighting events and creating rituals that mark deaths and
other transitions.<span style="mso-spacerun: yes;"> </span>Rituals that include
letters to loved ones, poems, songs, pictures, candles, life books, flowers, food,
and other memorializing means are excellent in-session activities and homework
for families.<span style="mso-spacerun: yes;"> </span>Throughout therapy we must
be alert to sadness and not dismiss or overlook it.<span style="mso-spacerun: yes;"> </span>For example, a teenager whose biological
mother would not apologize for abandoning her fell silent.<span style="mso-spacerun: yes;"> </span>We could have moved on to school, sports, or
other subjects.<span style="mso-spacerun: yes;"> </span>But noticing the moment
and waiting in silence allowed for 45 minutes of comfort and connection between
child and parent with cathartic tears releasing years of sadness that had come
out in every other way than healing. It was a scene right out of the excellent
movie Inside Out (Disney Pixar, 2015) which illustrates the essential role of
sadness and all emotion in giving color and context to life.<span style="mso-spacerun: yes;"> </span>Without sadness we could not gauge happiness.<span style="mso-spacerun: yes;"> </span>Without emotion life would be rather grey and
boring.<span style="mso-spacerun: yes;"> </span>It is the rainbow of emotion,
both heat and light, that makes us human.<span style="mso-spacerun: yes;"> </span><span style="font-family: "times new roman" , "serif"; font-size: 12.0pt;">Emotions are individual and never wrong.<span style="mso-spacerun: yes;"> </span>Parents and partners can agree with the
feelings and not with the facts of a specific situation.</span></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-33557732116205533922016-06-20T13:49:00.001-07:002016-06-25T14:59:19.354-07:00Family Therapy<!--[if !mso]>
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<br />
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;">Chapter Six</b></div>
<div class="MsoNormal">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b style="mso-bidi-font-weight: normal;">Family Therapy</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Just
as with adults, the website can be a good way to orient a child to therapy and
the therapist.<span style="mso-spacerun: yes;"> </span>Pictures of the building,
the office, and the therapist give a client an idea of what to expect when they
arrive.<span style="mso-spacerun: yes;"> </span>Some children, particularly
adolescents, may feel more comfortable after reading the biography, frequently
asked questions, and even the client forms.<span style="mso-spacerun: yes;">
</span>I try to reinforce the parent role and defer to parents by asking them
to introduce their children to me.<span style="mso-spacerun: yes;"> </span>Then,
I welcome the child to my office and explain my expectations for their behavior
starting in the waiting room; sitting on the furniture or floor, using an
indoor voice, reading and waiting.<span style="mso-spacerun: yes;"> </span>I do
not expect all children to be able to meet my expectations, no more than they
can with their parents, but establish my role as an adult who cares for
children with an authoritative style.<span style="mso-spacerun: yes;"> </span>If
a child does not meet expectations, then therapy starts right there and then in
the waiting room with acceptance and understanding of the client’s abilities
for self-regulation and feelings about being in a strange place for the first
time about to enter into a sometimes intense experience with a stranger.<span style="mso-spacerun: yes;"> </span>This is not the time for behavior modification
or correction.<span style="mso-spacerun: yes;"> </span>It may also be the first
example for parents of the importance of timing interventions.<span style="mso-spacerun: yes;"> </span>This is not the time for discipline or consequences,
in part, because we have not established relationship safety.<span style="mso-spacerun: yes;"> </span>Instead, it is time to move the brain from emotion
to cognition by giving the child a choice, again reinforcing the parent role by
having parents practice giving a playful choice, “Do you want to walk in
sideways or backwards?”<span style="mso-spacerun: yes;"> </span>Sometimes, the
child cannot tolerate even that much stress, so therapy starts right there in
the waiting room as I did once with a smart four year old and her grandparents
sitting quietly and chatting for the whole session until she could make a
choice to come in.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Once
in the room I give the child a “tour” of the room, often giving them permission
to take a look at “my” books and toys.<span style="mso-spacerun: yes;"> </span>I
set expectations again about sitting or standing and staying away from my
office desk and computer.<span style="mso-spacerun: yes;"> </span>I demonstrate
using a slightly louder voice than the waiting room.<span style="mso-spacerun: yes;"> </span>And, “You may use my stuff if you ask
first.<span style="mso-spacerun: yes;"> </span>Sometimes the answer will be
yes.<span style="mso-spacerun: yes;"> </span>Sometimes the answer will be
no.”<span style="mso-spacerun: yes;"> </span>I ask the child why they have come
with their parents, but I do not expect an answer.<span style="mso-spacerun: yes;"> </span>Rather I want the parents to restate in front
of the child that they, the parents, have come for my aid in helping the child
or learning to be a happier family.<span style="mso-spacerun: yes;">
</span>Then, I repeat the same informed consent script I delivered to the
parents in the first session, this time showing the child the file I have
created with their name and the file cabinet in which I lock it until they are
28 years old.<span style="mso-spacerun: yes;"> </span>This has the effect of
demonstrating serious commitment over time. I check for the child’s
understanding and ask for questions.<span style="mso-spacerun: yes;">
</span>Some children have had previous experiences with therapists, both
positive and negative.<span style="mso-spacerun: yes;"> </span>The informed
consent talk often dovetails right into the statement of the problem.<span style="mso-spacerun: yes;"> </span>“I have worked with many families in which
the children were born to their first parents, and there were problems with
mental illness or drugs or fighting, and the children had to go into foster
care for their safety and sometimes get adopted.<span style="mso-spacerun: yes;"> </span>And the children are upset and angry and sad
about all this, and their feelings come out, like they have tantrums or take
food or refuse to do what their parents ask them to do, or break stuff or hurt
themselves or their friends.<span style="mso-spacerun: yes;"> </span>Those are
the kinds of kids and families I like to work with.”<span style="mso-spacerun: yes;"> </span>I often make direct reference to the child’s
specific story and concerning behaviors so that the child knows that their
parents and I have been talking about them and there will be no secrets.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Sometimes
the child is reluctant or downright refuses to “participate”.<span style="mso-spacerun: yes;"> </span>However, more often than not, if the parents
have been coming for several weeks on their own, or the child has been waiting
in the lobby while their parents consult with me, they cannot wait to get into
the room to see what is going on and to have their say.<span style="mso-spacerun: yes;"> </span>Sometimes a child is so afraid to stay alone
or so anxious to take control of the situation that they will not sit quietly
in the lobby.<span style="mso-spacerun: yes;"> </span>This too is diagnostic and
requires either support from another family member or friend to care for the
child at home or in the waiting area or frequent timely preventative check-ins
with the child.<span style="mso-spacerun: yes;"> </span>It is sometimes just as
concerning when a younger child can sit quietly in a strange waiting room and
seem not to be bothered.<span style="mso-spacerun: yes;"> </span>For this
reason, continuing the informed consent, I will check the child’s understanding
by asking if I am a friend or a stranger to them.<span style="mso-spacerun: yes;"> </span>More often than not the child will say
“friend”.<span style="mso-spacerun: yes;"> </span>Sometimes a child assumes that
is the more acceptable answer or they know their parents have been meeting with
me for several sessions.<span style="mso-spacerun: yes;"> </span>But it allows
me to clarify my role and our relationship by asking, “Have you ever seen me in
your whole life, or have I ever seen you in my whole life.”<span style="mso-spacerun: yes;"> </span>The answer is usually no, so I say, “So, we
are strangers today.<span style="mso-spacerun: yes;"> </span>Are we going to
stay strangers?”<span style="mso-spacerun: yes;"> </span>Again, the answer is
usually no.<span style="mso-spacerun: yes;"> </span>“Right, we are going to be
friendly but we are not going to be friends because friends are the ones who
come to your house for dinner or to play, and my office is the only place we
will be meeting.”<span style="mso-spacerun: yes;"> </span>This is in addition to
the informed consent script repeated with parents and children reinforcing
time-limited work.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Because
attachment therapy requires the commitment of the parent to caring for the
child I like to have the parents identify the child’s strengths.<span style="mso-spacerun: yes;"> </span>This is a powerful start that sets the stage
and provides a foundation to return to when we cover more difficult
material.<span style="mso-spacerun: yes;"> </span>I often have the parents draw
an outline of the child’s hand on paper or their whole body on large butcher
paper.<span style="mso-spacerun: yes;"> </span>Then I ask the parents to state
out loud their child’s positive characteristics as I write them inside the
outline.<span style="mso-spacerun: yes;"> </span>It may require clarifying that
strengths are not positive achievements or behaviors but qualities like
intelligence, humor, and kindness.<span style="mso-spacerun: yes;"> </span>This
allows the child to hear in their parents’ voice and see in colorful view what
makes them special.<span style="mso-spacerun: yes;"> </span>When there is hurt
and conflict at home, these words either do not get said or are easily
forgotten by both child and parent.<span style="mso-spacerun: yes;"> </span>In
fact, this strengths-finding activity is important for every client whether an
individual identifying their own strengths or a couple naming each
other’s.<span style="mso-spacerun: yes;"> </span>Outside the outline I write as
parents describe the child’s abilities, not what they do well, but what they
are attempting; learning to ride a bike, practicing an instrument, or drawing
pictures; the positive behaviors that we see on the outside that come from
feeling the strengths on the inside.<span style="mso-spacerun: yes;"> </span>Along
the same line, the book, I Love you Stinky Face by Lisa McCourt (1997)
emphasizes the parent’s commitment to the child which is the starting place for
family attachment therapy.<span style="mso-spacerun: yes;"> </span>After the
parent reads it to the child, and if the child is willing, I act out the
characters with them playfully; angry alligator, hungry dinosaur, sleepy
monster, giving the parent the chance to demonstrate acceptance of the child no
matter their behavior just like the parent in the book.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>An
important side note here is that in therapy I want the parent to read to the
child, no matter the age, to emphasize the caregiving role and facilitate
nurturing interactions that include sitting close together, use of an engaged and
soothing tone of voice, and to recall or redo an important developmental experience.<span style="mso-spacerun: yes;"> </span>Parents will often have the reflex to have
their child read to them, either because the role of teacher is more
comfortable or they want their child to learn something from the book by
reading it themselves.<span style="mso-spacerun: yes;"> </span>Sometimes the
child is also anxious to read to show that they can or to take charge of the
session to achieve safety.<span style="mso-spacerun: yes;"> </span>This defeats
the purpose of the intervention which is to engage the child’s emotional right
brain in experiencing the pleasure and relaxation of the interaction first so
that the information can then be processed by the logical left brain.<span style="mso-spacerun: yes;"> </span>Once again this mirrors how attachment forms
and sets a pattern of joining before teaching.<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"> </span><br />
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"> One intervention that is powerful for
traumatized children, particularly adopted children, is narrative therapy.<span style="mso-spacerun: yes;"> </span>Because story telling is so important both to
the relationship and to the parent’s and child’s understandings of their
experiences, I use it throughout the therapeutic process.<span style="mso-spacerun: yes;"> </span>Parenting with Stories (Nichols, Lacher, May
2002) provides guidance to parents and therapists in constructing stories based
on the family’s life; establishing a beginning, middle, and end, choosing characters
and content, and establishing an atmosphere and setting for telling the
story.<span style="mso-spacerun: yes;"> </span>When I want parents to
demonstrate their commitment to the child I start with the claiming
narrative.<span style="mso-spacerun: yes;"> </span>I ask even older children to
lie in their parents’ laps to listen.<span style="mso-spacerun: yes;"> </span>Here
the story starts before the child was born with the atmosphere and planning for
their birth.<span style="mso-spacerun: yes;"> </span>The parents express their
excitement at the pregnancy and preparation for this child.<span style="mso-spacerun: yes;"> </span>With subtle prompts, they describe the momentous
delivery, the celebration of all the family, and all the developmental
milestones from the care and feeding of an infant to the first birthday cake in
the face.<span style="mso-spacerun: yes;"> </span>The activity includes baby
bottles and blankets in my office.<span style="mso-spacerun: yes;"> </span>This
addresses the child’s inevitable curiosity about their beginnings, “Tell me
about the day I was born.”<span style="mso-spacerun: yes;"> </span>For adopted
and traumatized children the story may be in stark contrast to the actual
events surrounding their births, and opens the door to a discussion of their specific
facts of life.<span style="mso-spacerun: yes;"> </span>The storytelling
continues with the developmental, trauma, and successful child narratives which
often include source material from agency reports, props and other artifacts
from the child’s life, and the creation of a keepsake scrapbook, art project,
or memory box.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Next, I like to
emphasize the target of treatment in the relationship between parent and child
by having the parent read Patrice Karst’s The Invisible String (2000).<span style="mso-spacerun: yes;"> </span>The book then becomes a jumping off point for
activities.<span style="mso-spacerun: yes;"> </span>The Invisible String
explains attachment connections, so I often use a very visible rope extended
between parent and child, the ends tied to each, to illustrate attachment,
close in proximity and feeling when parent and children are together physically
during happy times, farther away when the pair is separated by distance or
disagreement.<span style="mso-spacerun: yes;"> </span>The parent and child can
“tug” on the rope as if to say, “I need you,” or “I’m still here.”<span style="mso-spacerun: yes;"> </span>The grown up version would say, “You’re
yanking my chain,” or “I feel the tug of your heart.”<span style="mso-spacerun: yes;"> </span>In moving parent and child together and apart
in the room, the rope “accidentally” comes loose, the child becomes “unattached”,
and the rope falls to the floor.<span style="mso-spacerun: yes;"> </span>I pick
it up in the middle, pitch my voice, and say, “See, this is what we’re here to
work on, to make sure the string is strong.”<span style="mso-spacerun: yes;">
</span>Then, I reinforce that the real “string” is invisible.<span style="mso-spacerun: yes;"> </span>The visual stays with children and
adults.<span style="mso-spacerun: yes;"> </span>It also leads to another
activity, identifying all of the child’s attachment relationships, strong or
weak, secure or disrupted.<span style="mso-spacerun: yes;"> </span>I either cut
lengths of string for the parent to tie around the child’s wrist or draw a
heart with rays extending out to include biological parents, siblings, aunt,
uncles, adoptive family members, friends, foster parents, grandparents, and
pets, whether living or dead, identified or unknown.<span style="mso-spacerun: yes;"> </span>The exercise illustrates that a child can
have many attachments of varying quality with no competition among them and
plenty of room for more.<span style="mso-spacerun: yes;"> </span>That hits at
the loyalty issues adults and children face between biological and adoptive
families.<span style="mso-spacerun: yes;"> </span>It begins to put to rest the
very harmful belief that an attachment to the first inhibits the attachment to
the second.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Another activity
that allows for a restatement of the trauma history and a commitment by the
parent to help the child heal is the “hurt heart”.<span style="mso-spacerun: yes;"> </span>I ask the child to draw and cut out a big
heart from red construction paper and write their name on it.<span style="mso-spacerun: yes;"> </span>Then, and this is very important, I hold the
heart and tell the story deliberately, “When you were born you had a perfect
heart.”<span style="mso-spacerun: yes;"> </span>I like to hold a doll to
represent the child as an infant and often explain that the heart is about the
size of our closed fist, holding my hand over my heart, the doll’s hand in the
same place.<span style="mso-spacerun: yes;"> </span>The heart, the hand, and the
doll are frequent tools.<span style="mso-spacerun: yes;"> </span>The story
continues, “And then stuff started to happen. Your parents started to take
methamphetamines and forget to take care of you, and you were hungry.”<span style="mso-spacerun: yes;"> </span>I make a tear in the red paper heart.<span style="mso-spacerun: yes;"> </span>The child’s eyes grow large.<span style="mso-spacerun: yes;"> </span>“Then, the social workers came and said it
wasn’t safe for you to stay, and so they took you to a foster home.”<span style="mso-spacerun: yes;"> </span>Another tear.<span style="mso-spacerun: yes;">
</span>“Then your parents did not come back and you had to meet your new
adoptive parents.”<span style="mso-spacerun: yes;"> </span>Rip.<span style="mso-spacerun: yes;"> </span>Depending on the number of multiple
placements and other traumatic events, the paper heart can have a lot of
rips.<span style="mso-spacerun: yes;"> </span>Then very slowly I ask, “Who…will
help…you heal…your heart?”<span style="mso-spacerun: yes;"> </span>And
wait.<span style="mso-spacerun: yes;"> </span>If things are going well, the
child may say, “my mom and dad.”<span style="mso-spacerun: yes;">
</span>Sometimes the child says, “I can do it.”<span style="mso-spacerun: yes;">
</span>Often the answer is a confused look.<span style="mso-spacerun: yes;">
</span>That is when I ask, “Would you consider trusting your parents to
help?”<span style="mso-spacerun: yes;"> </span>I give the torn heart to the
child and wait for them to hand it to their parent.<span style="mso-spacerun: yes;"> </span>Having prepared the parent for this activity
I prompt them to list warmly the things they have done, do, or will do to heal
the child’s heart.<span style="mso-spacerun: yes;"> </span>Here, it is about the
basics; feeding snacks, tucking in bed, taking the child to the doctor, helping
with school work, holding them while they cry, playing and laughing,
remembering biological and other family members. In the end, the paper heart
looks stronger but the hurts are still visible, a metaphor for healing
itself.<span style="mso-spacerun: yes;"> </span>I ask permission to keep the
heart in the child’s file so that I can pull it out in subsequent sessions to
remind us of our work or measure progress along the way.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
Sometimes in the
first or subsequent session with the child, and before anybody gets too
comfortable with the setting, I like to do two not-so-scientific assessment
exercises.<span style="mso-spacerun: yes;"> </span>In the first, I direct a
parent and child to face one another, “as if separated by a window” and with
mostly facial gestures, some hands, no words, to try to match each other’s expressions,
first with the parent leading and the child following then with the child
leading and the parent following.<span style="mso-spacerun: yes;"> </span>“Go!”<span style="mso-spacerun: yes;"> </span>I give them a few seconds to mirror each
other as I move around them at a distance observing the result.<span style="mso-spacerun: yes;"> </span>This can be a playful interaction, quite
intimate, sometimes terrifying.<span style="mso-spacerun: yes;"> </span>When a
pair are matching each other well and really enjoying the interaction I get a
sense of their comfort with one another, as if you are watching two sweethearts
making “goo-goo eyes” at each other.<span style="mso-spacerun: yes;"> </span>At
other times either the parent has difficulty acting so silly or the child finds
it so uncomfortable that they look away.<span style="mso-spacerun: yes;">
</span>If you try it with dyads in a classroom setting you will find how close
and comfortable people feel, whether they are friends or strangers.<span style="mso-spacerun: yes;"> </span>The most disturbing time I had was with a
small boy facing his adoptive father who turned and ran behind the curtains and
stayed their crying for most of the rest of the session.<span style="mso-spacerun: yes;"> </span>This kind of closeness felt quite unsafe to
that child.<span style="mso-spacerun: yes;"> </span>The exercise informs what we
do next which is usually working on relationship safety through play, starting
with teaching parents how to be playful.</div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
The second assessment
exercise is parallel drawing.<span style="mso-spacerun: yes;"> </span>Similar to
face mirroring, first the parent then the child leads.<span style="mso-spacerun: yes;"> </span>I put colored paper on the table, ask parent
and child each to choose a colored pencil, direct them to put their pencils on
the paper ready to draw next to one another, then say go and wait and watch. <span style="mso-spacerun: yes;"> </span>I do not give them any instructions about
what to draw, how to draw, or whether to talk.<span style="mso-spacerun: yes;">
</span>I turn the paper over, and with the same instructions, have the child
lead and the parent follow.<span style="mso-spacerun: yes;"> </span>Then,
usually silently, parent and child draw.<span style="mso-spacerun: yes;">
</span>Sometimes the parent will race ahead with a figure or object that is
quite well-developed and thought out, but not spoken, while the child struggles
to figure out what it is and match it.<span style="mso-spacerun: yes;">
</span>Sometimes, the child will race ahead etch-a-sketch style while the
parent deliberately attempts something more formal.<span style="mso-spacerun: yes;"> </span>Oftentimes, the drawings will be completely
separate matching perfect pictures.<span style="mso-spacerun: yes;"> </span>Other
times, the lines cross and intertwine together.<span style="mso-spacerun: yes;">
</span>Once in a while, parent and child will draw in the same direction, at
the same speed, with a product that flows organically from both, as if a dance
has been choreographed on paper.<span style="mso-spacerun: yes;"> </span>I am
looking not just for what the pair produces but how they work together, because
the exercise illustrates how they communicate, verbally and non-verbally.<span style="mso-spacerun: yes;"> </span>When there are two separate forms, it looks
like two toddlers doing their own thing side by side but not together.<span style="mso-spacerun: yes;"> </span>When either one races ahead it looks like one
wants to do their own thing but does not care much whether the other comes
along.<span style="mso-spacerun: yes;"> </span>When the result flows it looks like
the creation of a comfortable connection.<span style="mso-spacerun: yes;">
</span>I then take a pencil myself and draw with the child, this time with
voice and tone, first communicating what I am drawing slowly so the child can
follow along, then asking and waiting for directions so I can follow the child.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>“I am
modeling interactions you can have with your child that say, ‘I will go at your
speed because I want to be with you’, and ‘wherever you go I will follow’”.<span style="mso-spacerun: yes;"> </span>Both the face mirroring and the parallel
drawing can be good homework for parents to continue at home.</div>
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Self-Disclosure</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;"><span style="mso-tab-count: 1;"> </span>It
is quite normal for clients, both adults and children, to ask among other
personal questions: “Are you married?<span style="mso-spacerun: yes;">
</span>Do you have children?<span style="mso-spacerun: yes;"> </span>Are you
a Christian?<span style="mso-spacerun: yes;"> </span>Are you a veteran?”<span style="mso-spacerun: yes;"> </span>It is quite human to connect with people
through common experiences.<span style="mso-spacerun: yes;"> </span>And the
therapist-client relationship is a human one.<span style="mso-spacerun: yes;"> </span>However, the questions are professional
pitfalls and the answers have serious clinical significance.<span style="mso-spacerun: yes;"> </span>So, it pays to think through the personal
and professional consequences and prepare to answer them.<span style="mso-spacerun: yes;"> </span>Many in the profession and in the public
consider having similar qualities and conditions as clients to be prerequisite
to understanding and helping them.<span style="mso-spacerun: yes;">
</span>Substance abuse treatment and self-help groups like Alcoholics
Anonymous and others are contingent on it.<span style="mso-spacerun: yes;">
</span>It is nearly the first thing a friend or casual acquaintance will
offer, “Me too.”<span style="mso-spacerun: yes;"> </span>But for a
therapist, the ethical questions are: what are the benefits and risks of
self-disclosure and what other interventions could be more helpful and less
harmful.<span style="mso-spacerun: yes;"> </span>It is our responsibility and
not the client’s to consider this.<span style="mso-spacerun: yes;"> </span>The
answer for me is no self-disclosure beyond the professional education,
training, and experience and the perhaps obvious male of a certain age and
manner.<span style="mso-spacerun: yes;"> </span>That does not mean my answer
to the questions is, “None of your business.”<span style="mso-spacerun: yes;"> </span>Clients are asking because they want to
know if I understand their situation.<span style="mso-spacerun: yes;">
</span>This goes to the heart of treatment.<span style="mso-spacerun: yes;">
</span>My answers start with questions, “Why do you ask?<span style="mso-spacerun: yes;"> </span>(Wait for answer.)<span style="mso-spacerun: yes;"> </span>Is it important for you to know in order
for me to help you?”<span style="mso-spacerun: yes;"> </span>Then I continue
with statements, “These are very good questions.<span style="mso-spacerun: yes;"> </span>You want to know whether I can understand
your situation.<span style="mso-spacerun: yes;"> </span>The thing is,
whether I’m married, have children, etcetera, they are not your marriage or
children, and I want to spend our time understanding your unique experience
and not imposing my experiences on you.<span style="mso-spacerun: yes;">
</span>I want to understand things from your perspective.<span style="mso-spacerun: yes;"> </span>Like all people, we have each experienced
some highs and lows in our families, so we have that in common.<span style="mso-spacerun: yes;"> </span>I know it might seem unfair that I know
more about you than you know about me, but I want to learn what your
marriage, your children, your faith, etcetera, mean for you.<span style="mso-spacerun: yes;"> </span>Is that OK?”<span style="mso-spacerun: yes;"> </span>The fact is we cannot have had all the possible
experiences our potential clients have had, and neither should we have to
limit our client base to those who have had our similar experiences.<span style="mso-spacerun: yes;"> </span>Many clients have difficulty setting
boundaries; with children, spouses, family members, employers, and
friends.<span style="mso-spacerun: yes;"> </span>Setting this boundary not
only reinforces the therapist-client relationship but models for the client
how they might do the same for themselves while stopping at the top of the
slippery slope to self-aggrandizement.</span></div>
</div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<br /></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-10471557999536387482016-06-15T14:11:00.003-07:002016-06-27T10:35:06.347-07:00Treatment Planning<!--[if !mso]>
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<br />
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;">Chapter Five</b></div>
<div class="MsoNormal">
<br /></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b style="mso-bidi-font-weight: normal;">Treatment Planning</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Depending
on the time it takes to provide informed consent, psychoeducation, and
assessment, treatment planning may follow in the third or fourth session.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
</div>
<table cellpadding="0" cellspacing="0" style="width: 100%px;">
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<i><span style="font-family: "cambria" , "serif"; font-size: 14.0pt; line-height: 150%;"><span style="mso-tab-count: 1;"> </span></span></i><span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Attachment
Trauma Treatment Plan</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Increase secure attachment to
parent as evidenced by help seeking and cooperation using attachment
therapy, narrative therapy, and play therapy.</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Increase emotional intelligence
as evidenced by the ability to identify, express, and manage emotions with
parent help using play therapy and cognitive behavioral therapy.</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">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.</span></div>
</div>
</td>
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<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>First,
I like to set parents’ expectations for their child’s behavior in session.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The funny part
is, most children with attachment trauma can “hold it together” and present
themselves well for a while.<span style="mso-spacerun: yes;"> </span>This
ability bothers parents to no end.<span style="mso-spacerun: yes;"> </span>“Why
can’t s/he behave like this at home?”<span style="mso-spacerun: yes;">
</span>“You’re not seeing the ‘real” child.”<span style="mso-spacerun: yes;">
</span>“He doesn’t act this nice at home.”<span style="mso-spacerun: yes;">
</span>“Why don’t you come home with us?”<span style="mso-spacerun: yes;">
</span>The reason is not that the therapist has any extraordinary skill but the
therapist is not trying to get close to the child.<span style="mso-spacerun: yes;"> </span>The therapist is not the parent who loves and
cares for them.<span style="mso-spacerun: yes;"> </span>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.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>That
is why I will not work with a child alone while a parent waits in the
lobby.<span style="mso-spacerun: yes;"> </span>What does it say to a child to be
dropped off by a parent and to go into a room with a therapist?<span style="mso-spacerun: yes;"> </span>It says, “You’re the problem.”<span style="mso-spacerun: yes;"> </span>And, as Malcolm X asked, “How does it feel to
be the problem?”<span style="mso-spacerun: yes;"> </span>Child trauma is not a
child’s fault and they should not be expected to fix it themselves.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The parent is present for those
moments and needs the knowledge and skills to recognize and respond to them.<span style="mso-spacerun: yes;"> </span>For children who do not have a parent who can
provide safety, the therapist may be one of the few who does.<span style="mso-spacerun: yes;"> </span>But the parent who is unable or unwilling to
learn to provide safety is the exception, so I attempt to teach them
first.<span style="mso-spacerun: yes;"> </span>I tell the parent I believe them
when they report that the child was “out of control” at home.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>And hurt
themselves, which they think they deserve.<span style="mso-spacerun: yes;">
</span>So, helping a child starts with accepting who they are, what they have
experienced, and their behavior as an expression of that pain.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>I
let parents know that when I am interacting with their child I am modeling
skills for them to adopt.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>But I specifically ask parents not to have expectations for their
child’s behavior in the therapy room.<span style="mso-spacerun: yes;"> </span>I
do not expect children to sit quietly and listen and answer questions.<span style="mso-spacerun: yes;"> </span>I do not expect children to like coming to therapy
or to show me respect.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>I have had children sit like stone unwilling
to talk.<span style="mso-spacerun: yes;"> </span>I have had children hide behind
the furniture.<span style="mso-spacerun: yes;"> </span>I have had children lash
out and throw things at me.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The therapy room needs to
be a discipline-free zone.<span style="mso-spacerun: yes;"> </span>Parents will
often “bribe” their child to behave and cooperate in therapy, “a treat if you
behave”.<span style="mso-spacerun: yes;"> </span>Nothing could be more counterproductive.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
That is not to say I will do
nothing if a child or parent behaves in a dangerous or hurtful way.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Those are therapeutic encounters, too,
requiring everything from de-escalation skills to police back-up.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>I model asking for help.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>I
set a few more boundaries to reinforce the parent-child relationship.<span style="mso-spacerun: yes;"> </span>I do not hug children or adults or touch them
in affectionate ways.<span style="mso-spacerun: yes;"> </span>Children do need
comfort and hugs in my office but I redirect them to their parent, and that is
not me.<span style="mso-spacerun: yes;"> </span>Handshakes and high-fives are
just fine.<span style="mso-spacerun: yes;"> </span>Traumatized children and
adults have often been touched in sexual and violent ways, and I do not want to
trigger them.<span style="mso-spacerun: yes;"> </span>And, while I may be a
stranger to start, I will not become their friend.<span style="mso-spacerun: yes;"> </span>Although I try to be friendly, this is a
professional relationship.<span style="mso-spacerun: yes;"> </span>I am not
coming to their home like a friend, giving or receiving gifts, or celebrating
birthdays and holidays.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>I
consider the parent to be a co-therapist for their child.<span style="mso-spacerun: yes;"> </span>To that end psychoeducation, coaching, and
modeling is about helping parents be therapeutic, in my office and in their
homes.<span style="mso-spacerun: yes;"> </span>I use Daniel Hughes’ acronym PACE
or PLACE (Hughes, 2007, p.61) as a guide.<span style="mso-spacerun: yes;">
</span>PACE stands for playfulness, acceptance, curiosity, and empathy.<span style="mso-spacerun: yes;"> </span>Playfulness means an attitude of lightness
and pleasure in the presence of the child, even in the face of difficult
behavior and material.<span style="mso-spacerun: yes;"> </span>This is not easy
to pull off without seeming condescending or cruel but is essential to
recapture the innocence of childhood.<span style="mso-spacerun: yes;">
</span>Acceptance means staying present with the child, behavior and emotions
and thoughts all at once, without rushing to correct or judge.<span style="mso-spacerun: yes;"> </span>We can agree with the feelings and not with
the facts, which makes the whole difference.<span style="mso-spacerun: yes;">
</span>Curiosity requires keeping an open mind, questioning messages and
meanings, willing to test theories through trial and error, an interested
investigative parent.<span style="mso-spacerun: yes;"> </span>Empathy means
seeing the issue from the child’s perspective and joining in their
interpretation of their experiences, not imposing our ideas or sympathies.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Of
course, therapy entails talking but even then, as Daniel Siegel (2003) makes
clear, rhythm, timing, tone, and volume are more important than words.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Then,
I set a pace for therapy.<span style="mso-spacerun: yes;"> </span>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. <span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>Parents may bring food, blankets, books, and toys that sooth and
support.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>I also use drawing, games, role play, and
storytelling.<span style="mso-spacerun: yes;"> </span>I often consult with
parents alone while the child waits, or check in with parents before bringing
in the child.<span style="mso-spacerun: yes;"> </span>Even this demonstrates
that parents are working to change, not the child.<span style="mso-spacerun: yes;"> </span>Sometimes, parents feel the need to leave the
child at home and spend the session on their own concerns.<span style="mso-spacerun: yes;"> </span>The child benefits here, too.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Two
techniques I teach parents and use myself I take from the work of Orlans and
Levy (2006).<span style="mso-spacerun: yes;"> </span>First, using statements
instead of questions with children and often with adult clients as well.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Instead, statements do not require an answer,
but allow the client to make a choice; say nothing, agree or disagree with what
is said.<span style="mso-spacerun: yes;"> </span>“Why do you have tantrums when
your mother asks you to turn off the television?” does not get you
anywhere.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>One four year old who tore up my notes and
threw adoption books on the floor hid behind the couch.<span style="mso-spacerun: yes;"> </span>I asked her parents, “Why do you think the
mother gave birth then left the baby at the hospital?”<span style="mso-spacerun: yes;"> </span>A small voice answered, “I think the baby
cried too much.”<span style="mso-spacerun: yes;"> </span>Her statement said
everything about her behavior.</div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-tab-count: 1;"> </span>Which
leads to the second technique, making a statement of the trauma story.<span style="mso-spacerun: yes;"> </span>Parents and therapists alike want to “start
where the client is” and “do no harm”.<span style="mso-spacerun: yes;">
</span>So we work on developing a trusting relationship waiting for the child
to reveal their innermost concerns and questions.<span style="mso-spacerun: yes;"> </span>We wait for the child to be “ready to
talk”.<span style="mso-spacerun: yes;"> </span>Most of the time parents take a
child’s silence about trauma, including adoption, as a sign that they do not
think about it.<span style="mso-spacerun: yes;"> </span>This is usually because
the parents do not want to think about it.<span style="mso-spacerun: yes;">
</span>It does not mean the child does not.<span style="mso-spacerun: yes;">
</span>And so children and families go for years without addressing major
issues while the resulting behaviors and emotions persist.<span style="mso-spacerun: yes;"> </span>We forget that people, particularly children,
do not necessarily talk about their feelings, they act them out.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>We acquiesce to this arrangement with our silence.<span style="mso-spacerun: yes;"> </span>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.”<span style="mso-spacerun: yes;"> </span>Loneliness and shame
increase.<span style="mso-spacerun: yes;"> </span>We want to send the opposite
message, “We can handle it,” and we will not wait and let you to suffer in
silence.<span style="mso-spacerun: yes;"> </span>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.”<span style="mso-spacerun: yes;"> </span>This also helps parents
introduce therapy to their child.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span>We want you to come with us so
we can practice what we have learned.”<span style="mso-spacerun: yes;"> </span>And
so it begins.<br />
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">Diagnosis</span></div>
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">While accurate diagnosis is an
ethical responsibility, many clients see a label as an end in itself as if a
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children and adults, some diagnoses are rather clear cut. <span style="mso-spacerun: yes;"> </span>Anxiety, attention deficit hyperactivity
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what?<span style="mso-spacerun: yes;"> </span>Defiant to whom? <span style="mso-spacerun: yes;"> </span>Reactive to whom?<span style="mso-spacerun: yes;"> </span>These are individual diagnoses for relational
problems that require looking at the whole family.<span style="mso-spacerun: yes;"> </span>More accurate names for these might be
relational traumatic stress or dyadic developmental disorder.<span style="mso-spacerun: yes;"> </span>You would never diagnosis a couple with
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Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-40252275960323286672016-06-06T13:59:00.000-07:002016-06-06T13:59:01.106-07:00Adult Attachment Assessment<!--[if gte mso 9]><xml>
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<div class="MsoNormal" style="line-height: 200%;">
<b>Chapter Four</b><span style="mso-bidi-font-weight: bold;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b>Adult
Attachment Assessment</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>If the intention of
therapy is to change parent behavior in order to increase the child’s sense of
safety and security, to help them attune to their child and demonstrate it, then
understanding what drives the parent is essential to treatment.<span style="mso-spacerun: yes;"> </span>Identifying the parent’s attachment style,
understanding their trauma history, and joining in their parenting journey are
the keys for me in helping parents help their children heal and grow.<span style="mso-spacerun: yes;"> </span>Reviewing clients’ trauma history and
attachment styles also provides context for helping couples and individuals in
their relationships whether the issues are communication, finances, and
intimacy or grief, mental illness, and substance use.<span style="mso-spacerun: yes;"> </span>Certainly some issues are best and most
quickly addressed with present focused cognitive-behavioral and future focused
solution focused treatment.<span style="mso-spacerun: yes;"> </span>But when
working with children no one can ignore the impact of early attachment,
developmental history, and parenting style to their overall health and functioning.<span style="mso-spacerun: yes;"> </span>And when working with parents no one can
ignore the impact of the way they were parented and their ideas about
parenting.<span style="mso-spacerun: yes;"> </span>Every time I have ignored by
better judgment and moved ahead with parent-child treatment without
investigating the parents’ history and relationship style, the issues have
stalled any progress.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>Using Mary Main’s Adult
Attachment Interview as a guide, while certainly not trained or following the
protocol, I use a brief set of structured questions that help reveal for me and
the client some of the roots of the challenges they have in parenting and
relationships in general.<span style="mso-spacerun: yes;"> </span>The format,
order, and tempo of the interview are important.<span style="mso-spacerun: yes;"> </span>They allow the answers to come unfiltered and
unprocessed revealing often unconscious beliefs, feelings, and thoughts that
drive present behavior.<span style="mso-spacerun: yes;"> </span>I say slowly
with no additional explanation, “Please give me three adjectives that describe
your childhood.”<span style="mso-spacerun: yes;"> </span>Then, I ask for an
experience that goes with each of those adjectives, and I wait.<span style="mso-spacerun: yes;"> </span>I do not explain the question or give
examples.<span style="mso-spacerun: yes;"> </span>Then, I ask the client to
describe how their relationship with, first, their mother, and then their
father developed from infancy to adulthood and how it may have changed along
the way.<span style="mso-spacerun: yes;"> </span>The follow up question here is,
“Did you ever feel separate or rejected by your parent?”<span style="mso-spacerun: yes;"> </span>Then, “Was there anyone else to whom you felt
close; an older sibling, aunt, uncle, grandparent or family friend?”<span style="mso-spacerun: yes;"> </span>After these questions, I ask about the
person’s journey to parenthood with some set-up.<span style="mso-spacerun: yes;"> </span>“From an early age, and for both boy and
girls, we usually have ideas about if, when, how we might become parents and
what kind of parent we will be.”<span style="mso-spacerun: yes;"> </span>Then I
acknowledge that the reality of parenting rarely matches our ideal and ask,
“What are your parenting challenges?<span style="mso-spacerun: yes;">
</span>What do you find most difficult about parenting, or parenting this
specific child?”<span style="mso-spacerun: yes;"> </span>Finally, I ask how the
client parent best learns, that is, how I may coach or support them.<span style="mso-spacerun: yes;"> </span>This has to do with the parent’s learning style;
audio, visual, or kinetic.<span style="mso-spacerun: yes;"> </span>“Some people
like to read and do, watch and do, or learn by doing.”<span style="mso-spacerun: yes;"> </span>This exchange usually takes 10 to 15 minutes
per parent.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">I conduct the interview with clients in
individual sessions and with couples together.<span style="mso-spacerun: yes;">
</span>Sometimes couples may be hearing this material for the first time in
this way, and sometimes one partner will prompt the other with an example.<span style="mso-spacerun: yes;"> </span>While it may be more accurate to do this
interview individually with each member of a couple, the interview is so brief that
it does not seem to make much difference.<span style="mso-spacerun: yes;">
</span>Neither does it seem to make much difference if one or the other partner
goes first, giving the other a head start thinking about their answers.<span style="mso-spacerun: yes;"> </span>It feels more valuable if the client answers,
“off the top of their head”, or “what comes to mind first”, but it is also
helpful for partners to hear the other’s answers.<span style="mso-spacerun: yes;"> </span>This self-disclosure and self-reflection often
leads to some surprising insights and the beginning of empathy and
understanding, which is the whole point.<span style="mso-spacerun: yes;">
</span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>In terms of interpreting
the information from this brief interview, I am listening as much to the depth
and tone as to the content and coherence of the answers.<span style="mso-spacerun: yes;"> </span>The first answer adjectives may include
happy, fun, adventurous or sad, lonely, and poor.<span style="mso-spacerun: yes;"> </span>Based on the adult attachment styles
identified by Mary Main, these descriptors are not as important as what comes
next.<span style="mso-spacerun: yes;"> </span>If the examples of childhood
experiences are consistent with the adjectives it demonstrates some coherence
in the person’s understanding of their life story.<span style="mso-spacerun: yes;"> </span>For example, a lonely childhood in which
parents were divorced or absent makes sense, describing it as happy with no further
detail does not.<span style="mso-spacerun: yes;"> </span>I have heard parents
describe a painful childhood in which parents were clearly abusive.<span style="mso-spacerun: yes;"> </span>This does not necessarily predict adult
relationship problems.<span style="mso-spacerun: yes;"> </span>One client reported
a happy childhood but with no memories before the age of six.<span style="mso-spacerun: yes;"> </span>The partner reminded the client that they
were ill as a child spending a lot of time in the hospital.<span style="mso-spacerun: yes;"> </span>The parent seemed disconnected from their own
suffering.<span style="mso-spacerun: yes;"> </span>The couple was asked to care
for a boy with anxious attachment, the result of inconsistent care by parents
with drug addiction, and a teenage girl with avoidant attachment, the result of
multiple foster care placements.<span style="mso-spacerun: yes;"> </span>The boy
was very needy and demanding.<span style="mso-spacerun: yes;"> </span>The girl
seemed independent and wanted nothing to do with adults.<span style="mso-spacerun: yes;"> </span>One can see that the mother with the
dismissive adult attachment style, who could not feel empathy for herself, would
have difficulty feeling for these children.<span style="mso-spacerun: yes;">
</span>You might predict that the mother would find the boy annoying and
needing of medication or another placement.<span style="mso-spacerun: yes;">
</span>On the other hand, she would be unlikely to see the need to reach out to
the teenager until it was too late.<span style="mso-spacerun: yes;"> </span>In
the first session, she was most concerned about how to decorate their rooms
before their arrival.<span style="mso-spacerun: yes;"> </span>In contrast
another parent reported a sad childhood in which his parents were addicted to
alcohol nearly causing a divorce and lots of conflict in the family.<span style="mso-spacerun: yes;"> </span>The parents subsequently achieved sobriety,
the parents and children became closer in adolescence, and the client used
therapy to process his childhood. <span style="mso-spacerun: yes;"> </span>This
earned security gave him the ability to be reflective about his own experiences,
and his wife’s, and thus more likely to be able to be responsive to their
children’s feelings.<span style="mso-spacerun: yes;"> </span>Next, the questions
about relationships with parents and times of rejection reveal whether the
parent experienced acceptance and empathy from their parents, and thus have the
ability to provide it to their children.<span style="mso-spacerun: yes;">
</span>If the parent experienced repair of a disconnection with their parent
they are more capable of repairing the inevitable disconnections with their
children.<span style="mso-spacerun: yes;"> </span>A parent once described an
abusive childhood at the hands of her father who she had cut out of her
life.<span style="mso-spacerun: yes;"> </span>It was not the fact that the
breach had not be repaired but that the wounds were still very raw, a
preoccupied adult attachment style, that made it difficult for this parent to
tolerate a child with a disorganized attachment style, his neediness and anger,
without taking it personally.<span style="mso-spacerun: yes;"> </span>To be sure
developing secure attachment requires both the anxiety of need and satisfying
the need, the rupture and repair of relationship.<span style="mso-spacerun: yes;"> </span>This is what Daniel Siegel (2013) describes
as “the dance of attunement”.<span style="mso-spacerun: yes;"> </span>In the
parent-child relationship, the parent leads the dance and has the
responsibility to correct the missteps; disconnections can lead to stronger
connections if parents have the self-awareness and self-control to make the
necessary adjustments.<span style="mso-spacerun: yes;"> </span>Parents do it all
the time when they hear a baby cry and through trial and error find what sooths
the infant.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">The idea here is that no one gets through
life unscathed, without experiences of separation, pain, or trauma.<span style="mso-spacerun: yes;"> </span>A secure adult attachment style does not mean
the parent had a perfect childhood but that they have made sense if not peace
with it and so is better able to take responsibility for their triggers when
they arise with their children.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Children will “push our buttons”, but they did
not put them there, our parents did.<span style="mso-spacerun: yes;">
</span>Knowing where our buttons are, and taking care to heal them on our own
and take care of ourselves, is essential to mindful parenting.<span style="mso-spacerun: yes;"> </span>Also, especially in adoption, children have
attachment styles that are the result of previous caregivers and experiences,
with strange coping behaviors like lying, stealing, and aggression.<span style="mso-spacerun: yes;"> </span>Adoptive parents can “take themselves off the
hook” for creating some of the behaviors, but make the commitment to care for
the child.<span style="mso-spacerun: yes;"> </span>Healing is in their
hands.<span style="mso-spacerun: yes;"> </span>Children do not choose to be
abused, and they do not choose to be adopted.<span style="mso-spacerun: yes;">
</span>Their misbehaviors, intentional as they may seem, are not choices but
their attempts to cope with their own triggers.<span style="mso-spacerun: yes;">
</span>Often the child’s trigger is the parent themselves, especially the safe,
nurturing parent.<span style="mso-spacerun: yes;"> </span>This is what Bruce
Perry describes as “relational PTSD”.<span style="mso-spacerun: yes;"> </span>The
child has difficulty accepting and believing in loving parenting.<span style="mso-spacerun: yes;"> </span>So, understanding the parents’ triggers is as
important as understanding the child’s.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">I do not use this interview to determine the
parents’ adult attachment styles.<span style="mso-spacerun: yes;"> </span>That
would be unethical, unnecessary, and not particularly helpful.<span style="mso-spacerun: yes;"> </span>Instead, what is helpful is identifying the
parents’ triggers so I can notice them and help them manage them in present-day
interactions with their children.<span style="mso-spacerun: yes;"> </span>Is it
any wonder that a parent raised by a father with an alcohol problem finds his
son’s impulsive behavior so difficult to deal with?<span style="mso-spacerun: yes;"> </span>The father’s automatic response is to raise
his voice or leave like he did to avoid conflict with his father, both of which
disconnect him from his child who needs him close and calm.<span style="mso-spacerun: yes;"> </span>Knowing this helps him change his reaction to
a more effective response.<span style="mso-spacerun: yes;"> </span>One mother
whose adopted son was so anxious that he would not let her go to the bathroom
without banging on the door and who once drove away leaving her child at home
realized that she used to run away and hide anytime her critical father
demanded she do more work on the farm.<span style="mso-spacerun: yes;">
</span>Knowing this helped her stay and tolerate her discomfort until her son
was comfortable that she would not leave him.<span style="mso-spacerun: yes;">
</span><span style="mso-spacerun: yes;"> </span>I keep and refer back to this
information often throughout the therapeutic process. <span style="mso-spacerun: yes;"> </span>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, in addition to a class
based on it.</span></div>
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<span style="mso-bidi-font-weight: bold;">Parents’ hopes and dreams about having
children, their motivations and reasons for becoming parents, often explain
their actions and emotions in facing current challenges.<span style="mso-spacerun: yes;"> </span>Again, whether we decide to have children or
not, to give birth or adopt, and there is huge social pressure do so, each of
us has fantasized about the kind of child we would have.<span style="mso-spacerun: yes;"> </span>Even if for a fleeting moment, we have
considered “our” child.<span style="mso-spacerun: yes;"> </span>Sometimes, that
fantasy is fully developed.<span style="mso-spacerun: yes;"> </span>We decide
the gender, we picture hair color, we pick the clothes, the school, the career.<span style="mso-spacerun: yes;"> </span>Nobody dreams of having a child with
challenges.<span style="mso-spacerun: yes;"> </span>Sometimes, we choose not to
parent and a child with challenges shows up anyway.<span style="mso-spacerun: yes;"> </span>Unplanned pregnancies and grandparents
raising grandchildren are two examples.<span style="mso-spacerun: yes;"> </span>And,
the contrast between our expectations and reality often cause conflict, grief
and loss.<span style="mso-spacerun: yes;"> </span>We experience pain and sadness
when our children are in pain and we cannot help them, or what we are doing
does not seem to be working the way we want.<span style="mso-spacerun: yes;">
</span>As Kubler-Ross taught us, grief and loss is part of life, a process to
be identified and addressed.<span style="mso-spacerun: yes;"> </span>The last
stage she identified, acceptance, is better stated as readjustment.<span style="mso-spacerun: yes;"> </span>We do not get over loss, we get used to
it.<span style="mso-spacerun: yes;"> </span>We incorporate it into the story of
our lives.<span style="mso-spacerun: yes;"> </span>Grief and loss is a central
issue in adoption.<span style="mso-spacerun: yes;"> </span>Particularly, in
adoption, if parents have spent years trying to give birth or considering adoption,
they have also spent more time developing a picture of their “ideal
child”.<span style="mso-spacerun: yes;"> </span>Usually, adoptive parents are
even asked their preferences as to gender, age, and ethnicity, as if ordering
at a drive-through restaurant.<span style="mso-spacerun: yes;"> </span>Even if
their “real” child matches their preferences, he or she is not, cannot be, that
“ideal child”. <span style="mso-spacerun: yes;"> </span>Not even birth children
match up.<span style="mso-spacerun: yes;"> </span>Each child surprises their
parent with their uniqueness, their collection of abilities, personality, and
temperament.<span style="mso-spacerun: yes;"> </span>It is the discrepancy
between the ideal and the real that causes the pain.<span style="mso-spacerun: yes;"> </span>The real child exists.<span style="mso-spacerun: yes;"> </span>The ideal child never did, except in our
minds.<span style="mso-spacerun: yes;"> </span>Until we grieve, yes bury, the
ideal child, it is very difficult to accept the real one.<span style="mso-spacerun: yes;"> </span>And acceptance is the beginning of attachment
and healing.<span style="mso-spacerun: yes;"> </span>As therapists we are loss
managers, we run the funeral home.<span style="mso-spacerun: yes;">
</span>Acknowledging this and guiding clients through it is part of the
treatment plan.<span style="mso-spacerun: yes;"> </span>Creating rituals can be
helpful as an intervention.</span></div>
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<span style="mso-bidi-font-weight: bold;">In terms of choosing interventions it is very
helpful to know the client’s learning style.<span style="mso-spacerun: yes;">
</span>As therapists our shelves are full of books explaining symptoms and
diagnoses, exercises and interventions.<span style="mso-spacerun: yes;">
</span>We learn in different ways, too.<span style="mso-spacerun: yes;">
</span>A client who can read about their situation brings so much knowledge and
understanding into the session for work.<span style="mso-spacerun: yes;">
</span>There may be little teaching or psycho-education that needs to be
done.<span style="mso-spacerun: yes;"> </span>Some clients take in everything we
say and benefit from our explanations and examples.<span style="mso-spacerun: yes;"> </span>Others really need not just our demonstration
of a technique but our coaching in trying it themselves, whether it is using “I
statements”, tone of voice, or playing with their children.<span style="mso-spacerun: yes;"> </span>A favorite time was when two beautiful,
smart, funny twin boys decided they did not want to follow their mother’s
instructions to shake my hand and walk out of my office.<span style="mso-spacerun: yes;"> </span>A loud tantrum ensued, two hours of
overturning chairs, dumping the contents of an ottoman, taking the wheels off a
table.<span style="mso-spacerun: yes;"> </span>When their mother pleaded or
placated, they cried louder, “You’re ruining my life!<span style="mso-spacerun: yes;"> </span>Let us leave.”<span style="mso-spacerun: yes;"> </span>They could have walked out at any time, they
never did.<span style="mso-spacerun: yes;"> </span>When I got quiet, and coached
the mother to stay calm, the chairs went upright, the puppets went back in the
box, and the wheels went back on the table with perfect cooperation and
skill.<span style="mso-spacerun: yes;"> </span>Stress created the tantrum, they
were testing whether they could trust their mother to hold her ground.<span style="mso-spacerun: yes;"> </span>Quiet calm created the safety they needed to
put their thinking caps back on, and a friendly handshake sealed the deal.</span></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-65974179431153097892016-06-01T11:36:00.002-07:002016-06-01T11:36:45.907-07:00Psychoeducation<!--[if gte mso 9]><xml>
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<div class="MsoNormal" style="line-height: 200%;">
<b>Chapter Three</b></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b>Psychoeducation</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>It helps to clarify any miscommunication or misunderstandings.<span style="mso-spacerun: yes;"> </span>Something a client may have felt
uncomfortable sharing the first session might be easier to broach in subsequent
sessions.<span style="mso-spacerun: yes;"> </span>Clients may also come to the
conclusion that they are not ready and willing to participate in therapy at the
time.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span>They often return with increased motivation
and confidence and willingness to accept coaching and feedback.<span style="mso-spacerun: yes;"> </span>This client/therapist decision is central to
contracting for service.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>Because many of my clients are adoptive families, attachment, trauma,
grief and loss are the issues.<span style="mso-spacerun: yes;"> </span>For
blended, military, and single-parent families this can also be the case.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>It is the impact of trauma on relationships
that is the target of my work.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Trauma affects physiological,
psychological, and neurological functioning.<span style="mso-spacerun: yes;">
</span>It can lead to emotional, cognitive, physical, and social impairment.<span style="mso-spacerun: yes;"> </span>This often results in maladaptive coping
behaviors with potential long term consequences for mental and physical health,
interpersonal and social problems, even early death.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>This is a big change in my thinking since
graduate school when I railed against a professor who taught “relationship is
everything”.<span style="mso-spacerun: yes;"> </span>Like many people I saw
changing behavior as the point of therapy.<span style="mso-spacerun: yes;">
</span>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.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>So, I teach about the
brain showing diagrams of the brainstem, limbic system, and cortex.<span style="mso-spacerun: yes;"> </span>I talk about how the brain reacts to trauma
by releasing the stress hormones adrenaline and cortisol with the classic
fight/flight/freeze response.<span style="mso-spacerun: yes;"> </span>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<span style="mso-spacerun: yes;"> </span>(Perry and Szalavitz, 2006, p. 21-25).<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>We grow from the inside out.<span style="mso-spacerun: yes;"> </span>Because trauma like child abuse, domestic
violence, and death most often happens in the context of relationships, attachment
and trauma are linked.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Ainsworth
(1978) and Bowlby (1988) defined four specific child attachment styles: secure,
anxious, avoidant, and disorganized.<span style="mso-spacerun: yes;">
</span>Secure attachment is the result of consistent parenting and results in a
child who can self-regulate and has stable self-esteem.<span style="mso-spacerun: yes;"> </span>Anxious attachment is the result of
inconsistent parenting and results in a child who cannot self-regulate and has
shaky self-esteem.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>Disorganized attachment is the result of
frightening parenting and results in a child with unpredictable behavior who
sees the world as dangerous.<span style="mso-spacerun: yes;"> </span>Securely
attached children are easier to love and teach.<span style="mso-spacerun: yes;">
</span>Children with anxious, avoidant, or disorganized attachment require more
patience and are harder to parent.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The goal is to develop
safety within the relationship.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>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).<span style="mso-spacerun: yes;"> </span>The adult attachment style influences the way
we relate to others particularly partners and children.<span style="mso-spacerun: yes;"> </span>Mary Main defines four adult attachment
styles; secure, dismissive, preoccupied, and disorganized.<span style="mso-spacerun: yes;"> </span>She has developed an interview protocol to
determine attachment style.<span style="mso-spacerun: yes;"> </span>While I am
not trained to conduct the protocol I do ask a series of questions that suggest
the adult attachment style of parents.<span style="mso-spacerun: yes;">
</span>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.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;">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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>The person with preoccupied
attachment lives in their childhood pain and feels others’ behavior including
their children’s behavior as hurtful.<span style="mso-spacerun: yes;"> </span>They
cannot stay present with someone else’s pain without making it personal.<span style="mso-spacerun: yes;"> </span>The person with disorganized attachment lives
in a state of constant anger and fear that makes helping others’ with strong
feelings very difficult.<span style="mso-spacerun: yes;"> </span>To be certain
the attitudes and behaviors of adults with less than secure attachment are
about coping, even if they are dysfunctional or maladaptive.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>It is essential in helping children toward
more secure attachment.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>Whether working with
adults or children, two other topics besides attachment and trauma are
important to investigate, developmental history and grief and loss.<span style="mso-spacerun: yes;"> </span>Conditions like depression, anxiety, trauma,
autism, and learning disabilities sometimes result from or lead to missed developmental
milestones and loss.<span style="mso-spacerun: yes;"> </span>Maslow (1943)
theorized that survival and safety needs are prerequisite for feelings of love
and belonging.<span style="mso-spacerun: yes;"> </span>A person in survival mode
is not free to learn and connect with others.<span style="mso-spacerun: yes;">
</span>Brain-based conditions like Post Traumatic Stress Disorder and Attention
Deficit Hyperactivity Disorder impact the ability to read social and emotional
cues.<span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span>A person who was not able to develop basic
trust in a primary caregiver may have difficulty forming intimate relationships
as an adult.<span style="mso-spacerun: yes;"> </span>Whether the condition is
organic or the result of experience, it leads to loss.<span style="mso-spacerun: yes;"> </span>Losses include readily identifiable events
like the death of a parent, illness and injury, or more ambiguous less
recognized losses like infertility and divorce.<span style="mso-spacerun: yes;">
</span></span>Kubler-Ross (1969) calls attention to the specific stages of
grieving that are accepted as natural.<span style="mso-spacerun: yes;">
</span>Identifying unmet basic needs, missed developmental milestones, and unresolved
stages of grief help target interventions.<span style="mso-bidi-font-weight: bold;"></span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>Developing awareness and
understanding of attachment and trauma leads to a sometimes uncomfortable realization;
traditional parenting and therapy will not help and often hurt.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>If behavior is need-driven, then identifying
and meeting the need is the answer not rewarding or punishing behavior.<span style="mso-spacerun: yes;"> </span>Points and prizes, charts and stars, tokens
and timeouts, lecturing and spanking will not work to build or repair a
relationship.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;"> </span>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.<span style="mso-spacerun: yes;">
</span>Interventions are counterintuitive and subject to scorn from others who
do not understand the specific situation.<span style="mso-spacerun: yes;">
</span>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. <span style="mso-spacerun: yes;"> </span>(Cue rolling eyes and gaping mouth.)<span style="mso-spacerun: yes;"> </span>This is where treatment planning begins.</span></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-47747175352483103492016-05-24T19:09:00.001-07:002016-07-21T15:48:12.828-07:00Practice Model<!--[if !mso]>
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<div class="MsoNormal" style="line-height: 200%; tab-stops: 9.0pt;">
<b>Chapter Two</b></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b>Practice
Model</b></div>
<div class="MsoNormal" style="line-height: 200%;">
<b><span style="mso-tab-count: 1;"> </span></b><span style="mso-bidi-font-weight: bold;">Having established a professional identity,
the next step is articulating and operationalizing a practice model, the
structure of each session supported by your theoretical orientation in a way
that can be explained and documented.<span style="mso-spacerun: yes;"> </span>It
starts with education, training, and practice in the different therapeutic
modalities; individual, couple, family, and group, and experience with the
multitude of psychotherapy theories.<span style="mso-spacerun: yes;"> </span>We
watch and learn the different intervention strategies; attachment-focused therapy,
cognitive-behavioral therapy, motivational interviewing, narrative therapy,
play therapy, solution-focused brief treatment, etcetera. We may describe our
theoretical orientation as eclectic.<span style="mso-spacerun: yes;">
</span>However, developing this orientation entails both adopting
evidenced-based practices shown to be effective with specific issues and
carrying them out with fidelity and embracing practices that feel comfortable
in our delivery.<span style="mso-spacerun: yes;"> </span>This is where your
personal learning style comes into play.<span style="mso-spacerun: yes;">
</span>I do best reading about interventions and putting them into
practice.<span style="mso-spacerun: yes;"> </span>Others are visual learners who
like to see the practice modeled.<span style="mso-spacerun: yes;">
</span>Certification in the delivery of several practice models like Dialectical
Behavioral Therapy and Eye Movement Desensitization and Reprocessing require
hours of training and supervised practice.<span style="mso-spacerun: yes;">
</span>This still may not provide a road map for each session.<span style="mso-spacerun: yes;"> </span>Rather than feeling “eclectic” I choose to
pick interventions appropriate for the situation with a framework to support
the art and science, use of self and personal style that has become my practice
model.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>Having set the first
appointment by telephone or e-mail, and that is the only purpose for which I
use either, and directing the client to my website for directions and to
complete, print, and bring the initial paperwork, I greet the client in my
waiting room with, “Are you here to see Mike?”<span style="mso-spacerun: yes;">
</span>I learned this from another therapist as a way to protect the client’s
confidentiality.<span style="mso-spacerun: yes;"> </span>Similarly, besides
being unprotected or un-encrypted, telephone and e-mail messages are prone to
misinterpretation which I learned the hard way.<span style="mso-spacerun: yes;">
</span>Clients may find it convenient to let me know what is going on with them
and the family which can be very helpful. <span style="mso-spacerun: yes;"> </span>But my attempts to provide feedback or
guidance in a quick written response are too easily misunderstood and instead
require the clarification and processing possible only in face-to-face
communication.<span style="mso-spacerun: yes;"> </span>The welcome is followed
by an invitation to be seated and a casual conversation about directions, the
parking, and restrooms and any other needs like disability access and comfortable
seating.<span style="mso-spacerun: yes;"> </span>For children, in the presence
of parents to model, I provide my expectations of their behavior; where they
may sit, the volume of their voice, books they may use or not use in the
waiting room.<span style="mso-spacerun: yes;"> </span>I repeat my expectations for
their behavior in my office; where they may sit, their tone of voice, what they
may use if they ask, and I invite them to take a tour of the office to increase
their comfort.<span style="mso-spacerun: yes;"> </span>This is after I have
prepared parents to include their children in subsequent sessions.</span></div>
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<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>The first session allows
the client to explain their reasons for seeking service often repeating some of
the information they have shared in the initial telephone call scheduling the
appointment.<span style="mso-spacerun: yes;"> </span>I acknowledge the concerns
but do not pursue them much further before I have established informed consent
and because I do not want the client to disclose sensitive personal concerns before
we can establish a safe professional therapeutic relationship, which can lead
the client to end therapy before it starts because of strong feelings of
vulnerability.<span style="mso-spacerun: yes;"> </span>Informed consent includes
the education, training, experience, and licensure of the provider, an
explanation of theoretical orientation, the benefits and risks of therapy, how
the client’s confidentiality will be protected or breached in the case of
mandated reporting and safety risks or limited in the cases of lawsuits against
the therapist and collection of fees, how the client may schedule, cancel, and pay
for services, and how services may be terminated professionally.<span style="mso-spacerun: yes;"> </span>The document and the conversation include who
may provide consent, how the client may communicate with the therapist, other
services that could be adjunct or alternatives to therapy, and grievance and
appeal procedures for dealing with complaints and disagreements.<span style="mso-spacerun: yes;"> </span>Those are the basics.</span></div>
<div class="MsoNormal" style="line-height: 200%;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>Articulating these
policies takes some thought.<span style="mso-spacerun: yes;"> </span>For
example, I specifically started asking parents whether they are parenting with
a partner, and for families of adoption and divorce, who has legal custody of
the child client.<span style="mso-spacerun: yes;"> </span>I ask parents to
produce proof of these legal arrangements and for both parents to sign the
consent for treatment.<span style="mso-spacerun: yes;"> </span>Without it I have
had to terminate services with a parent and child whose non-custodial parent with
legal rights did not consent to the child continuing therapy.<span style="mso-spacerun: yes;"> </span>Children 12 and older may consent to their
own treatment for substance and sexual issues but there are limits to
confidentiality here, too.<span style="mso-spacerun: yes;"> </span>It also saves
time to ask clients to determine what kind of mental health benefits they have
and whether I am on their specific insurance panel.<span style="mso-spacerun: yes;"> </span>I have spent too much time on the telephone
determining whom to bill or dealing with the denial of claims which calls into
question professional and therapeutic boundaries. <span style="mso-spacerun: yes;"> </span>Putting it in the hands of the client to seek
the authorization for treatment and following up on billing is a clinical
decision literally requiring clients to buy in to the process.<span style="mso-spacerun: yes;"> </span>Just like making the initial telephone call,
keeping appointments, and showing up on time these are measures of client capabilities
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<![endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-ansi-language: EN-US; mso-bidi-font-weight: bold; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;">Clients also make a
statement when they fail to show up for appointments, sometimes a statement
they are not able or willing to deliver to the therapist in person;<span style="mso-spacerun: yes;"> </span>the issue is something they can address on
their own, the problem is not severe enough to disrupt a busy life, the
therapist is not a good fit, another form of help is better.</span></div>
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<span style="font-size: 10.0pt; line-height: 150%; mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;">“I’ve been a social worker for 17
years, licensed since 2004, in private practice 10 years.<span style="mso-spacerun: yes;"> </span>I work with individuals, couples, and
families, many adopted families since my background is in child welfare.<span style="mso-spacerun: yes;"> </span>With families I work with parents and
children together. <span style="mso-spacerun: yes;"> </span>And, I focus on
relationship, not behavior, except perhaps parent behavior.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>I
consider the parent to be the co-therapist and I coach parents in
addressing concerns with their children.<span style="mso-spacerun: yes;">
</span>Because of this I do not keep secrets between parties, that is, if a
parent or child shares something with me I will use my best professional
judgment in determining whether, when, and how to share it with the other
people.<span style="mso-spacerun: yes;"> </span>Specifically, I do not meet
with children alone, and children do not have a right to confidentiality
separate from their parents.<span style="mso-spacerun: yes;"> </span>I will
tell your child I do not give hugs, we are not friends. <span style="mso-spacerun: yes;"> </span>I represent this as a professional
relationship.<span style="mso-spacerun: yes;"> </span>They get their hugs
from their parents, so handshakes and high-fives with me will do.<span style="mso-spacerun: yes;"> </span>I do not give or receive gifts.<span style="mso-spacerun: yes;"> </span>I am not a friend.<span style="mso-spacerun: yes;"> </span>Friends are the ones who come to your
house for dinner.<span style="mso-spacerun: yes;"> </span>I will not come
to your home or school without your consent.<span style="mso-spacerun: yes;"> </span>If we see each other out in public I will
not acknowledge you unless you notice me first.<span style="mso-spacerun: yes;"> </span>That is to protect your
confidentiality.<span style="mso-spacerun: yes;"> </span>You are welcome to
leave me a voicemail or e-mail sharing events or concerns but I will
address those questions in session so we can make sure we understand each
other.<span style="mso-spacerun: yes;"> </span>If someone other than you
calls me about you I will not acknowledge you as a client.<span style="mso-spacerun: yes;"> </span>What we talk about in the room stays in
the room.<span style="mso-spacerun: yes;"> </span>I document our sessions to
remember what we have done.<span style="mso-spacerun: yes;"> </span>Some
things cannot stay secret.<span style="mso-spacerun: yes;"> </span>If a
child or older person or disabled person or animal is hurt, I have to tell.<span style="mso-spacerun: yes;"> </span>If someone is going to hurt themselves or
someone else, I have to do something about it.<span style="mso-spacerun: yes;"> </span>I will explain this again with your
child.<span style="mso-spacerun: yes;"> </span>You are welcome to bring
other family members into session if you think it will help.<span style="mso-spacerun: yes;"> </span>If there are others you think it would be
helpful for me to talk with such as a psychiatrist or teacher or another
therapist, I will ask you to sign a release of information for me to do
so.<span style="mso-spacerun: yes;"> </span>I may consult with other
therapists about our work, but I will preserve your confidentiality when I
do so.<span style="mso-spacerun: yes;"> </span>I keep client files for 10
years after we finish our work together then I destroy them.<span style="mso-spacerun: yes;"> </span>I keep then locked and encrypted.<span style="mso-spacerun: yes;"> </span>I consider therapy has a beginning,
middle, and end.<span style="mso-spacerun: yes;"> </span>I meet with parents
three to four times before bringing the child in and often without the
child after we start.<span style="mso-spacerun: yes;"> </span>It is
important to understand the work adults do will benefit the child.<span style="mso-spacerun: yes;"> </span>You may even decide to spend the session
for you.<span style="mso-spacerun: yes;"> </span>I am not the parent and
children are not dry cleaning that can be brought into an office for 45
minutes to have their behavior “cleaned up”.<span style="mso-spacerun: yes;"> </span>I expect to have a friendly relationship
with the child but it is OK if they don’t like me.<span style="mso-spacerun: yes;"> </span>I intend to strengthen and reinforce the
parent-child relationship so I try to put myself alongside or behind the
parent in those interactions.<span style="mso-spacerun: yes;"> </span>My
appointments are 45-minutes long.<span style="mso-spacerun: yes;">
</span>You may reschedule or cancel with 24-hours’ notice. There’s a rhythm
to therapy.<span style="mso-spacerun: yes;"> </span>We will work and play in
session understanding that play is the work of children.<span style="mso-spacerun: yes;"> </span>This first meeting allows you to decide
whether you feel comfortable enough to continue with me, and I get to
decide whether I think I know enough to help.<span style="mso-spacerun: yes;"> </span>Once we decide we can develop a
plan.<span style="mso-spacerun: yes;"> </span>Sometimes, it takes just a few
sessions, sometimes months.<span style="mso-spacerun: yes;"> </span>I have also
worked with families off and on for years as children grow and challenges present
themselves.”</span><span style="mso-bidi-font-style: italic; mso-fareast-font-family: "Times New Roman"; mso-fareast-theme-font: major-fareast;"></span></div>
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<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>The rest of the first
session is devoted to engagement, assessment, risk assessment, mental status
examination, and suggestions for adjunct resources like books, classes, and
support groups.<span style="mso-spacerun: yes;"> </span>Engagement happens as I
listen and restate the major concerns of the client, empathizing with
challenges and appreciating areas of strength.<span style="mso-spacerun: yes;">
</span>I take this initial assessment directly from my intake forms which the
client has either reviewed or completed.<span style="mso-spacerun: yes;">
</span>Here I have included questions about pertinent medical and mental health
history, previous counseling and psychotropic medications, and developmental
and family history.<span style="mso-spacerun: yes;"> </span>I use a checklist
that includes symptoms of depression, anxiety, and other conditions and
specific risk assessment questions including substance use, self-harm and
aggression toward others, relationship safety, and child, elder, disabled, and
animal abuse.<span style="mso-spacerun: yes;"> </span>I included parent
behavioral concerns like stealing, lying, aggression, and manipulation and added
a severity scale of 0-10 so the intake assessment also becomes an evaluation
tool that can be reviewed as treatment progresses.<span style="mso-spacerun: yes;"> </span>Having started with an open conversation I
use these forms as a tool to cover these specific questions which makes asking
them more comfortable and normalizes them as part of the therapeutic process.</span></div>
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<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>Payment is also part of
the discussion in the first session.<span style="mso-spacerun: yes;">
</span>After all, making a living is the point of private practice.<span style="mso-spacerun: yes;"> </span>Discussing money feels uncomfortable to many,
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training and experience has value.<span style="mso-spacerun: yes;"> </span>The
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identity to say, “I charge $120 for a 45-minute session and I have also agreed
to receive insurance payments if you choose to use your benefits.”<span style="mso-spacerun: yes;"> </span>It takes some confidence to provide a bill,
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same time with a client who uses Medicare as one who pays cash?<span style="mso-spacerun: yes;"> </span></span><span style="mso-bidi-font-weight: bold;"><span style="mso-spacerun: yes;"><!--[if gte mso 9]><xml>
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<![endif]--><span style="font-family: "times new roman" , "serif"; font-size: 12.0pt;">The same goes for
ethically billing insurance companies by providing accurate dates, times,
procedure codes, and diagnoses, and collecting co-pays and no show fees from
clients.<span style="mso-spacerun: yes;"> </span>This continues to take practice
as I set boundaries and expectations around payment for services.<span style="mso-spacerun: yes;"> </span>I will discuss questions and challenges
around joining insurance panels in a later chapter.</span></span></span></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-76165856062522383892016-05-20T14:59:00.002-07:002016-05-20T14:59:38.682-07:00Professional Identity<!--[if !mso]>
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<div class="MsoNormal" style="line-height: 200%;">
<b>Chapter One</b><span style="mso-bidi-font-weight: bold;"></span></div>
<div align="center" class="MsoNormal" style="line-height: 200%; text-align: center;">
<b>Professional
Identity</b></div>
<div class="MsoNormal" style="line-height: 200%; tab-stops: 9.0pt;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>The
more than century-old discipline of social work offers a specific identity embodied
in the National Association of Social Workers Code of Ethics which includes the
values of service, human dignity, and integrity.<span style="mso-spacerun: yes;"> </span>Social work training articulates skills
including reflective listening, open-ended questions, and non-verbal
communication.<span style="mso-spacerun: yes;"> </span>Psychotherapy theorists
define interventions like identifying specific behaviors, solutions, and
relationship styles.<span style="mso-spacerun: yes;"> </span>Laws and court
decisions require steps like risk assessment, mandated reporting, and
documentation.<span style="mso-spacerun: yes;"> </span>Insurance means
diagnosis, informed consent, and billing.<span style="mso-spacerun: yes;">
</span>These are among the questions to be answered in developing a
professional identity.<span style="mso-spacerun: yes;"> </span>When you decide
to “hang out your own shingle”, how does all that fit on the sign?<span style="mso-spacerun: yes;"> </span>Of course, the business sign these days is
not a sign at all.<span style="mso-spacerun: yes;"> </span>And, business is
generally not generated by drop-in or drive-by customers.<span style="mso-spacerun: yes;"> </span>In ten years, despite investing in print
advertising, memberships in therapy directories, and direct mail and e-mail
marketing, most of my referrals still come by word of mouth from clients
themselves.</span></div>
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<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span><span style="mso-spacerun: yes;"> </span>There are a variety of platforms that serve as
the modern day business sign, among them websites, Facebook, Linkedin, and
Plaxo, and I use them all.<span style="mso-spacerun: yes;"> </span>But the one
that has been most useful, flexible, and personal is my website: </span><a href="http://www.michaelajoneslcsw.com/"><span style="mso-bidi-font-weight: bold;">www.michaelajoneslcsw.com</span></a><span style="mso-bidi-font-weight: bold;">.<span style="mso-spacerun: yes;">
</span>However, it is not having the website that defines my professional
identity but the process of developing it.<span style="mso-spacerun: yes;">
</span>It requires answering and continuing to reflect on the big questions:
Who are you?<span style="mso-spacerun: yes;"> </span>What do you believe?<span style="mso-spacerun: yes;"> </span>What do you have to offer?<span style="mso-spacerun: yes;"> </span>How do you think about people and their
challenges? How do you work?<span style="mso-spacerun: yes;"> </span>On what
education, knowledge, and experience is your work based?<span style="mso-spacerun: yes;"> </span>With whom will you work?<span style="mso-spacerun: yes;"> </span>What will you do or not do?<span style="mso-spacerun: yes;"> </span>Who are your colleagues and connections?<span style="mso-spacerun: yes;"> </span>Because this business sign exists in the
ether and not at a specific physical address or even on paper it can represent
me where ever I work and whatever I do.<span style="mso-spacerun: yes;"> </span>It
holds a space for my professional identity and ideas whether I am in private
practice or working for another organization or not at all.<span style="mso-spacerun: yes;"> </span>It can be changed and updated and refreshed
whenever I am.</span></div>
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<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>The
process started by reviewing a lot of websites, both those of other therapists
and those of other businesses.<span style="mso-spacerun: yes;"> </span>Then I
had to determine the necessary content, like contact information, and nice
content, like intake forms and other resources.<span style="mso-spacerun: yes;">
</span>Most importantly it may be a client’s first introduction to me and my
services.<span style="mso-spacerun: yes;"> </span>In that way it provides a
first impression and first informed consent, the legal and ethical information required
to be provided to clients.<span style="mso-spacerun: yes;"> </span>This is
included in a professional biography, philosophy, and frequently asked
questions also contained in the forms clients sign to provide informed consent
for treatment and notice of privacy practices.<span style="mso-spacerun: yes;">
</span>The latter leads to thinking and planning how client information and
files, both paper and electronic, will be stored and secured for retrieval
until they can legally be destroyed.<span style="mso-spacerun: yes;"> </span>In
my case, it is a locked filing cabinet inside a locked office and password protected
software and computer.<span style="mso-spacerun: yes;"> </span>The first intake
forms I used I borrowed directly from the more experienced therapists with whom
I worked, changing and updating them to meet my needs as my own experience and
training progressed.<span style="mso-spacerun: yes;"> </span>The forms are
therapeutic tools after all, including important background information,
symptom checklists, and risk assessments that contribute to treatment.
Providing them online was a practical way to save printing costs but also to
allow clients to begin to consider the kinds of topics that might be covered in
session.<span style="mso-spacerun: yes;"> </span>Developing a list of resources
required me to make connections and to consider what referrals my clients might
need from emergency to supportive services.<span style="mso-spacerun: yes;">
</span>A bibliography suggests options for biblio-therapy.</span></div>
<div class="MsoNormal" style="line-height: 200%; tab-stops: 9.0pt;">
<span style="mso-bidi-font-weight: bold;"><span style="mso-tab-count: 1;"> </span>These
days websites are simple to create and maintain by registering a domain name
and hiring a hosting company, even designing the site yourself as one of my
colleagues did with a Microsoft program.<span style="mso-spacerun: yes;">
</span>I paid a web designer to pull my ideas together into a cohesive
presentation.<span style="mso-spacerun: yes;"> </span>First, I had to figure out
what to call my website.<span style="mso-spacerun: yes;"> </span>My television
handle, Mike Jones, fit nicely on the screen but a quick Google search showed
it was already taken by hundreds of others and my business would be difficult
to find on the internet.<span style="mso-spacerun: yes;"> </span>Having my face
in the public eye made it easy to put it on my website and business cards.<span style="mso-spacerun: yes;"> </span>Most of my colleagues do not do this either
because they see it as undignified, as if we are selling real estate, or they
are simply not as vain as I.<span style="mso-spacerun: yes;"> </span>But there
is a clinical reason I plaster my picture all over my media.<span style="mso-spacerun: yes;"> </span>Going to therapy, like the doctor and the
dentist, it not always easy or comfortable.<span style="mso-spacerun: yes;">
</span>Many clients are in crisis or distress.<span style="mso-spacerun: yes;">
</span>In line with trauma-informed care, showing a client who they will meet,
where they will meet, and what they can expect reduces anticipatory anxiety.<span style="mso-spacerun: yes;"> </span>It is really the beginning of the therapeutic
process, contemplating change.<span style="mso-spacerun: yes;"> </span>An
explanation of services explains your practice model and socializes a client to
the therapeutic process.<span style="mso-spacerun: yes;"> </span>Answering
frequently-asked-questions helps to define professional boundaries.<span style="mso-spacerun: yes;"> </span>The same rationale applies to including maps,
directions, and pictures of the office and building along with parking
information and amenities.<span style="mso-spacerun: yes;"> </span>Including
links to blog, Facebook, and Twitter, if not LinkedIn and Plaxo, too, are other
ways to extend the reach of a professional identity.<span style="mso-spacerun: yes;"> </span>These are the mission and vision of a private practice. </span></div>
<b></b>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-86713367718363939682016-05-19T13:54:00.004-07:002016-05-24T12:26:03.616-07:00TEN YEARS PRACTICE<!--[if gte mso 9]><xml>
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<div class="MsoNormal" style="line-height: 200%;">
<b>Introduction</b></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">Private Practice.<span style="mso-spacerun: yes;"> </span>That was the pinnacle of success I saw when I
decided to change careers and become a social worker.<span style="mso-spacerun: yes;"> </span>Private, because it was something that would
belong to me, my own creation I would pursue without interference after years
of working for media companies and at the whim of whatever news director was in
charge at the time.<span style="mso-spacerun: yes;"> </span>This kind of
independence runs in the family.<span style="mso-spacerun: yes;"> </span>My family
was farmers used to planting their own crops, butchering their own animals,
building their own homes.<span style="mso-spacerun: yes;"> </span>Only after
farming failed and World War II ended did my grandfathers go to work for the
railroad and an ordinance plant to bring home union paychecks.<span style="mso-spacerun: yes;"> </span>My father tried all that but chafed under the
supervision of corporate bosses and union chiefs.<span style="mso-spacerun: yes;"> </span>So, he went from pool hall owner to repo man
to delivering propane to heating and air conditioning with independent efforts
at running a hardware store and real estate scattered in between.<span style="mso-spacerun: yes;"> </span>He liked making his own decisions and making
his own hours.<span style="mso-spacerun: yes;"> </span>It’s not a surprise then
that all five of his children are either in business for ourselves or have
carved out unique and independent roles in service to others just like our mother, a registered nurse.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">Private also means, to some extent,
solitary.<span style="mso-spacerun: yes;"> </span>Certainly, private practice
can include working in a group, with other therapists and disciplines, or for a
company providing mental health services.<span style="mso-spacerun: yes;">
</span>But for me private practice meant owning my own business as a sole
proprietor or limited liability corporation.<span style="mso-spacerun: yes;">
</span>Which means that decisions from advertising to office space, client referrals
to specialized training, to risk assessment, mandated reporting, treatment
planning, and intervention strategies are mine to make.<span style="mso-spacerun: yes;"> </span>With this privilege comes power, and with
this power comes liability, and with this liability comes a certain amount of
stress, separate from the stress of managing finances, which is often an inside
joke among social workers, but rather serious business when your living depends
on the literal ebb and flow of income and expenses.<span style="mso-spacerun: yes;"> </span>Which is why a saying sticks with me from
business books to military training to a law and ethics training by Gerry
Grossman: “Never worry alone.”</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">Maya Angelou describes standing on the
shoulders of those who have gone before and of feeling backed by those who have
supported us on our way.<span style="mso-spacerun: yes;"> </span>I have been
lucky to have had many of those mentors starting with my own parents and
teachers.<span style="mso-spacerun: yes;"> </span>In television as in other
industries the moto is “fake it ‘til you make it.”<span style="mso-spacerun: yes;"> </span>So, when I started reporting the news I would
“channel” Barbara Walters asking serious questions of those in authority or my
journalism professor at the University of Missouri, Columbia, Dan Dugan, in
writing and Walter Cronkite in pacing my delivery.<span style="mso-spacerun: yes;"> </span>During my master of social work studies at
Our Lady of the Lake University in San Antonio, Texas, I had the excellent
examples of my field instructors.<span style="mso-spacerun: yes;"> </span>Ed
Cardenas at J.T. Brackenridge Elementary School could calm a group of
hyperactive boys just by walking in the room.<span style="mso-spacerun: yes;">
</span>At Catholic Charities of San Antonio Arlis Schmidt took me for a Coke after
a particularly triggering run-in with a nun.<span style="mso-spacerun: yes;">
</span>At Child Welfare Services in San Diego my LCSW supervisor Becki DeBont
would simply say, “And the mirror appears”, emphasizing the need for
self-reflection.<span style="mso-spacerun: yes;"> </span>Supervisor Laurie Adam
would back me to the hilt when I disagreed with management about adoption
recommendations.<span style="mso-spacerun: yes;"> </span>Also at Child Welfare
Services, first Renee Smylie then Karen Martin turned me loose to create an
internship program that taught me more than anything I had to offer
students.<span style="mso-spacerun: yes;"> </span>When I did put my foot in the
water of private practice after earning my license Nancy North, LCSW was there
to hold my hand.<span style="mso-spacerun: yes;"> </span>Then I landed in an
office with exceptional therapists who had already made the leap from
Children’s Hospital.<span style="mso-spacerun: yes;"> </span>Chris Diani, LCSW,
Laurie Hall, LCSW, and Deborah Holmes, LCSW shared everything from a practice
philosophy to the forms and paperwork to get started on my own.<span style="mso-spacerun: yes;"> </span>To this day there is a safety net of
colleagues with whom to consult and complain.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">The practice part puts you at the party with
doctors, lawyers, and other professionals who have degrees, licenses, offices,
billing, and malpractice insurance.<span style="mso-spacerun: yes;"> </span>“My
practice,” sounds like you have arrived.<span style="mso-spacerun: yes;">
</span>It sounds trite to say that practice is not an end but a beginning and
just as trite to say that practice makes perfect.<span style="mso-spacerun: yes;"> </span>There can be no end to learning about the nature
of humans, our strengths and challenges and what works to apply one to the
other.<span style="mso-spacerun: yes;"> </span>And there can be no perfection in
the joining of unique individuals except in the joy of doing so.<span style="mso-spacerun: yes;"> </span>Practice, then, is not a noun but a verb that
indicates the act of applying knowledge and experience from our education and
training with consultation and supervision to the life experiences and personal
wisdom of clients with the intention to help as much as necessary while hurting
as little as possible.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>It is also cliché to say that these human
services, from customer care to nursing, from sales to psychotherapy, are as
much art as science.<span style="mso-spacerun: yes;"> </span>But despite the
efforts of industrial science to quantify human interaction and research into
human behavior to develop evidenced-based practice, there is qualitative
research to indicate it takes some time to achieve mastery.<span style="mso-spacerun: yes;"> </span>Popular media quote 10-thousand hours to
achieve mastery in one’s field, approximately five years at 40-hours a week
with two weeks off for vacation.<span style="mso-spacerun: yes;"> </span>If that
is true, I achieved mastery in 2011.<span style="mso-spacerun: yes;"> </span>But
I and most of my colleagues would say we have achieved some level of competence
but nowhere near perfection.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">Why, you may ask, did you switch from a
lucrative career in television reporting to a completely different career in
the profitable field of social work?<span style="mso-spacerun: yes;">
</span>(Tongue planted firmly in cheek.)<span style="mso-spacerun: yes;">
</span>My answer is that they are essentially the same job.<span style="mso-spacerun: yes;"> </span>As a reporter I was expected to respond to
crisis situations; fires, floods, tornadoes, murders, political disputes both
major and mundane.<span style="mso-spacerun: yes;"> </span>I had to find the
source; the victim, the perpetrator, the authority.<span style="mso-spacerun: yes;"> </span>And, with nothing but a pad and pen, and oh
yes, a camera and a microphone, convince them to tell me their story.<span style="mso-spacerun: yes;"> </span>I had to ask very personal questions of
complete strangers in a way that would reveal the truth of their
circumstances.<span style="mso-spacerun: yes;"> </span>Then, under deadline
pressure, turn this raw data into an assessment of sorts, a compelling
narrative with a beginning, middle, and end in the space of a minute and thirty
seconds.<span style="mso-spacerun: yes;"> </span>Those stories aired on the
evening 6:00 p.m. or late night 11 p.m. newscast could entertain, educate, and
sometimes challenge people and organizations to change.<span style="mso-spacerun: yes;"> </span>Not all of them in 15 years were
Emmy-winning, in fact none were, but they did get some attention, some a
lot.<span style="mso-spacerun: yes;"> </span>For some reason, after a time, I
was either assigned or volunteered to find and interview the victims and family
members of the disaster of the day.<span style="mso-spacerun: yes;"> </span>In
April 1992, it was the family of one of four young people lined up inside a
walk-in cooler and shot in the back of the head execution style at a Lee’s
Famous Recipe Chicken restaurant in Tulsa, Oklahoma.<span style="mso-spacerun: yes;"> </span>The mother of the 15-year-old boy let me in
the front door.<span style="mso-spacerun: yes;"> </span>The very top of the
living room walls was lined with pen and ink and watercolor drawings.<span style="mso-spacerun: yes;"> </span>It was the work of her son.<span style="mso-spacerun: yes;"> </span>It was his story I told that night on the
news.<span style="mso-spacerun: yes;"> </span>I sat with her and the other
family members as the suspects were put on trial and convicted, then I went on
to cover the election of President Bill Clinton, lots of 4<sup>th</sup> of July
parades, and the bombing of the Alfred P. Murrah Federal Building in Oklahoma
City.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">In 1998, as I was starting my graduate
education in social work I was sitting at the assignment desk one Saturday
morning at KSAT-TV, the ABC affiliate in San Antonio, Texas where I was working
part time.<span style="mso-spacerun: yes;"> </span>In the morning mail, there
was an envelope addressed to me personally.<span style="mso-spacerun: yes;">
</span>I opened the envelope and out fell two letters, each written two years
apart, and a picture of a woman with long brown hair standing in front of a
bright orange Corvette.<span style="mso-spacerun: yes;"> </span>I had no clue
who the woman was or how she found me.<span style="mso-spacerun: yes;">
</span>This was before Google searches and Facebook.<span style="mso-spacerun: yes;"> </span>The woman was writing to thank me for my work
in showing compassion and telling the story of her son who was one of the
victims of the chicken shop shooting.<span style="mso-spacerun: yes;">
</span>And then I remembered.<span style="mso-spacerun: yes;"> </span>She had shown
me the shell of a vehicle in the garage that day that was to be her son’s first
car.<span style="mso-spacerun: yes;"> </span>But he did not live to be 16 and
get his driver’s license, and so she and her husband completed the project and
toured car shows with the restored Corvette in his honor.<span style="mso-spacerun: yes;"> </span>My lesson: people can survive tragedy and
grow and you play a part.<span style="mso-spacerun: yes;"> </span>On April 19,
1995, the newsroom secretary interrupted the morning meeting with a report of
an explosion in Oklahoma City.<span style="mso-spacerun: yes;"> </span>A
photographer and I immediately jumped in a car and headed west on the
interstate.<span style="mso-spacerun: yes;"> </span>We thought we would be back
by lunch.<span style="mso-spacerun: yes;"> </span>But the state troopers
speeding past us signaled something serious was happening.<span style="mso-spacerun: yes;"> </span>The city looked like it had been hit by a
more familiar tornado and we carefully drove down side streets avoiding broken
glass and moving debris.<span style="mso-spacerun: yes;"> </span>We made it to
a parking lot and saw the federal building two blocks away, its façade sheared
off and a pile of rubble where the entrance use to be as the 13 floors
“pancaked” during the explosion caused by the fuel bomb in the Ryder truck
driven by Timothy McVeigh.<span style="mso-spacerun: yes;"> </span>For 10 days,
wearing the same blue suit, I broadcast live morning, noon, and night as survivors were pulled from the
pile and the body count ticked up to 168 dead including 19 children in the day
care.<span style="mso-spacerun: yes;"> </span>At one point rescue workers found
a tattooed severed leg.<span style="mso-spacerun: yes;"> </span>It was gruesome
and sad.<span style="mso-spacerun: yes;"> </span>However, it was also
inspiring.<span style="mso-spacerun: yes;"> </span>The workers needed more
gloves, more masks, more batteries.<span style="mso-spacerun: yes;"> </span>The
line of reporters bathed in floodlights would turn to our cameras and tell
viewers and trucks of gloves and masks and batteries and more would
arrive.<span style="mso-spacerun: yes;"> </span>It was my first experience in
direct social work practice.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">Then we went into the Red Cross tents and the
hospital wards and began telling the survivors’ stories, administrators,
clerks, and secretaries in wheelchairs and bandages.<span style="mso-spacerun: yes;"> </span>As the search went on first for a “middle eastern”
suspect then the quick capture of McVeigh, parents and grandparents, husbands
and wives put flowers and pictures on a makeshift memorial fence and waited for
their love ones to be identified.<span style="mso-spacerun: yes;"> </span>The
question remained, why would someone do something like this?<span style="mso-spacerun: yes;"> </span>And the broader question for me, why do
people think what they think, feel what they feel, and do what they do?<span style="mso-spacerun: yes;"> </span>It was the beginning of my social work
education and my journey to private practice.<span style="mso-spacerun: yes;">
</span>It would take another four years to leave my first dream job and earn my
graduate degree.<span style="mso-spacerun: yes;"> </span>I would return to the
Oklahoma City site a year later where the federal building had been levelled
and a memorial park planned.<span style="mso-spacerun: yes;"> </span>But my
heart and mind were in a different place with hopes of preventing such
tragedies or helping those who survived them.</span></div>
<div class="MsoNormal" style="line-height: 200%; text-indent: .5in;">
<span style="mso-bidi-font-weight: bold;">So my intention here is to explain my thought
process and the steps I took in establishing my “practice”.<span style="mso-spacerun: yes;"> </span>After deciding that social work with its
broad person-in-environment view was the best fit for me, I had to put on the
mantle of social worker, develop a professional identity, and carve out a niche
for myself.<span style="mso-spacerun: yes;"> </span>First, there was the role of
social worker in “public” practice as a child welfare worker, and then came
trainer, supervisor, therapist, and teacher, the jobs that would pay the
bills.<span style="mso-spacerun: yes;"> </span>In the meantime, in order to run
a business, I had to define my product, how to sell it, and what to charge for
it.<span style="mso-spacerun: yes;"> </span>Marketing a service as nebulous as
human interaction is like selling space on the internet.<span style="mso-spacerun: yes;"> </span>Others, like Murray Bowen, Virginia Satir, and
Aaron Beck, and more recently Insoo Kim Berg, Daniel Hughes, and Susan Johnson
have quantified their interventions.<span style="mso-spacerun: yes;"> </span>Yet
in setting your bicycle apart from bicycles sold by other manufactures, it’s
necessary to go beyond the fact that yours has two wheels, handle bars, and a
seat to distinguishing what sets it apart from other models and why someone
should buy and take a ride on yours.<span style="mso-spacerun: yes;"> </span>To
take the metaphor further, are you going to teach them to ride or repair the
thing if it breaks down?<span style="mso-spacerun: yes;"> </span>Most
importantly, how will it feel to ride the bike you make?<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>These
are all questions that go into developing your unique brand, the professional
identity that is you.</span></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-15690628038657861102016-03-21T12:09:00.001-07:002017-01-03T13:47:32.330-08:00Grandparents Raising Grandchildren<!--[if gte mso 9]><xml>
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<div class="MsoNormal" style="text-align: justify;">
<span style="font-size: small; line-height: 115%;">As of July 2015, there were more than 54,000 children in
foster care in California, nearly 3,000 of those in San Diego County.<span style="mso-spacerun: yes;"> </span>Those numbers have gone down substantially
over the last 10 years.<span style="mso-spacerun: yes;"> </span>Of those
children, just more than 35% were placed with relatives in October 2015, the
largest placement type.<span style="mso-spacerun: yes;"> </span>The goal is that
100% of children who cannot stay with their parents are placed with relatives
because it causes less stress than placements with strangers, children move
less and stay longer with relatives, and reunification with parents is more
likely when children are placed with relatives. <span style="mso-spacerun: yes;"> </span>The 35% of relative caregivers represents
sustained effort on the part of child welfare to place children in the least
restrict and least traumatic environments.<span style="mso-spacerun: yes;">
</span>Since more children are being placed with relatives including
grandparents, case managers have had to learn how to work with relative
caregivers.<span style="mso-spacerun: yes;"> </span>Since more children are
being placed with grandparents, more children are being adopted by their
relatives or grandparents if they cannot be reunited with their parents.<span style="mso-spacerun: yes;"> </span>We can say that grandparents have been
raising their grandkids formally and informally since forever, with or without
the child welfare system. You may be the largest number of caregivers.<span style="mso-spacerun: yes;"> </span>But that does not keep you from feeling
isolated or separated from the rest of society, even from other foster parents
who may be younger or adopting for different reasons.<span style="mso-spacerun: yes;"> </span>That’s why developing and maintaining your
connections to each other and this community is so important for you and the
children you are parenting. The central issues we face on this journey include
grief and loss, stage of life, parenting traumatized children, and developing a
positive view of the future. </span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><b style="mso-bidi-font-weight: normal;"><span style="line-height: 115%;">Grief and Loss</span></b></span></div>
<div class="MsoNormal">
<span style="font-size: small; line-height: 115%;">Grief and
loss comes in many forms and from many places in raising our relatives. It is a
subject that is difficult to discuss for many but one that we must
address.<span style="mso-spacerun: yes;"> </span>No one is immune from grief and
loss in this process; not you as a grandparent or relative caregiver taking in
a child or children not born to you, not your children or the biological parents
from whom the child was removed because of abuse, and certainly not your child
who has lost both parents and homes but, like you, faces the adjustment to a
different life with different parents.<span style="mso-spacerun: yes;">
</span>Starting with you, there’s the shock and sometimes denial of having the
children you raised sidelined by mental illness, substance abuse, or domestic
violence to the point that their children are injured and need to be removed
for their protection.<span style="mso-spacerun: yes;"> </span>There’s the anger
and guilt of having investigators and case managers asking questions about your
family, challenging your parenting, and sometimes placing your grandchildren
with strange foster parents in a system that is scary and confusing.<span style="mso-spacerun: yes;"> </span>There’s the sadness and even depression of
parenting children who have had so much disruption and are not ready to
appreciate you.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span style="font-size: small; line-height: 115%;">Then, there’s
the denial and bargaining that biological parents experience in the removal of
their children, the intervention of the court, and the guilt and shame of
having to ask or allow or accept their parents caring for their children.<span style="mso-spacerun: yes;"> </span>That includes the anger and the grief of the
conflict between you and your children.<span style="mso-spacerun: yes;">
</span>It’s a painful transition when you go from being parent and grandparent
to a relative caregiver approved and supervised by the county and ultimately an
adoptive parent to whom the court gives parental rights removed from your own
child.<span style="mso-spacerun: yes;"> </span>That’s not a happy
celebration.<span style="mso-spacerun: yes;"> </span>That’s an unhappy unplanned
outcome.<span style="mso-spacerun: yes;"> </span>And we ignore this big sad fact
at our own peril.<span style="mso-spacerun: yes;"> </span>Of all the issues that
hit adoptive families, and especially grandparents adopting their
grandchildren, grief and loss is the one that goes most unaddressed and results
in the most conflict and pain.<span style="mso-spacerun: yes;"> </span>So, how
do we face grief and loss head on?<span style="mso-spacerun: yes;">
</span>First, by acknowledging it, naming it, and talking about it.<span style="mso-spacerun: yes;"> </span>We need to address it just like a death in
the family, because it is, the death of dreams.<span style="mso-spacerun: yes;">
</span>It’s so uncomfortable to admit, so we don’t.<span style="mso-spacerun: yes;"> </span>We need to mourn the loss of desired futures,
of expected family roles, of changed relationships.<span style="mso-spacerun: yes;"> </span>It’s like a divorce and remarriage.<span style="mso-spacerun: yes;"> </span>We need a funeral, time to mark the
transition, rituals to remember what we lost, and anniversaries of the same.<span style="mso-spacerun: yes;"> </span>There are any number of resources available
to guide us through this process, books about grief and loss associated with
adoption, ideas about celebrations and rituals to memorialize the events, and,
of course, professional help and groups like this one.<span style="mso-spacerun: yes;"> </span></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-size: small;"><b style="mso-bidi-font-weight: normal;"><span style="line-height: 115%;">Lifestage</span></b></span></div>
<div class="MsoNormal">
<span style="font-size: small; line-height: 115%;">Speaking of
grief and loss, how about the loss of life plans?<span style="mso-spacerun: yes;"> </span>At the very time when you see the light at
the end of the tunnel, when your dreams of sailing into the sunset of life are
almost in site, when you are looking forward to more ME or WE time full of
adventure and fun, you are yanked by the heartstrings, sometimes kicking and
screaming, back to a previous stage of family life from which you had thought
you graduated: raising children.<span style="mso-spacerun: yes;"> </span>Just
when you thought you would have your home, your car, your TIME to yourself, you
have to share them with these new people, the ones you used to visit on weekends
or holidays then send back home.<span style="mso-spacerun: yes;"> </span>They’re
staying and they won’t leave.<span style="mso-spacerun: yes;"> </span>And they
bring stuff and people with them, clothes and shoes, teachers and social
workers, laptops and I-phones, strange friends, awful music, pornography and
video games.<span style="mso-spacerun: yes;"> </span>You did not sign up for
this.<span style="mso-spacerun: yes;"> </span>But then you did, or felt you had
to, out of a sense of commitment, guilt, love, responsibility, family.<span style="mso-spacerun: yes;"> </span>This brings its own shock or reality check. Your
golden years may be filled with tennis shoes instead of cruises.<span style="mso-spacerun: yes;"> </span>Retirement may come with diapers, report
cards, and skateboards.<span style="mso-spacerun: yes;"> </span>Or there may be
no retirement at all as you continue to work to put food on the table or pay
sports team fees.<span style="mso-spacerun: yes;"> </span>These off-time changes
are financially and physically draining.<span style="mso-spacerun: yes;">
</span>Your body may be begging for rest, but the laundry and the carpool
call.<span style="mso-spacerun: yes;"> </span>It can be exhausting and lonely
and the last thing you may want to do is go out for wine with your
girlfriends.<span style="mso-spacerun: yes;"> </span>First, because your bed is
calling and second, because they like to talk about their gardening and
needlepoint while you need someone to listen to your tails of ADHD and
medication madness.<span style="mso-spacerun: yes;"> </span>You’ve done this
already, raised children.<span style="mso-spacerun: yes;"> </span>But then
again, the guilt, “if I did such a good job, why can’t my child raise his or
her own kids.”<span style="mso-spacerun: yes;"> </span>And, “if they think I
messed them up so bad that my kids turned to drugs and crime, what makes them
think I can do any better with their children?”<span style="mso-spacerun: yes;">
</span>It also takes a toll on marriages and other relationships.<span style="mso-spacerun: yes;"> </span>You may not be on the same page with your
spouse; about finances, about parenting, even about this new chapter in your
life.<span style="mso-spacerun: yes;"> </span>This strange new life stage brings
more complicated worries.<span style="mso-spacerun: yes;"> </span>“What if I get
sick?<span style="mso-spacerun: yes;"> </span>What if I need care?<span style="mso-spacerun: yes;"> </span>What if I die before my children are
grown?<span style="mso-spacerun: yes;"> </span>Who will raise them?<span style="mso-spacerun: yes;"> </span>I was already the last option before
strangers.”<span style="mso-spacerun: yes;"> </span>Speaking of the bargaining
phase of grief and loss, we may hope or want this to be a temporary
situation.<span style="mso-spacerun: yes;"> </span>Our children will get their
act together, come get their kids, and let me move on with my life.<span style="mso-spacerun: yes;"> </span>The kid hopes the same thing.<span style="mso-spacerun: yes;"> </span>It’s a dangerous dream.<span style="mso-spacerun: yes;"> </span>It keeps us from adjusting to reality.<span style="mso-spacerun: yes;"> </span>The role of grandparent is a real reward and
losing that role while re-taking the role of parent is a real loss.<span style="mso-spacerun: yes;"> </span>What wisdom can you bring to this
endeavor?<span style="mso-spacerun: yes;"> </span>At this age, you have
developed some definite ideas about what’s right and wrong, what works and what
doesn’t, what you like and what you don’t.<span style="mso-spacerun: yes;">
</span>I’ll talk in a minute about why that’s a slippery slope to conflict and
unhappiness.<span style="mso-spacerun: yes;"> </span>But what you do have is
life experience; dealing with difficult circumstances, diligently gathering
necessary information, solving prickly problems, and most important, letting
go.<span style="mso-spacerun: yes;"> </span>Letting go of perfection, letting go
of total responsibility, letting go of people who are not supportive.<span style="mso-spacerun: yes;"> </span>A young strong body is not a prerequisite for
good parenting.<span style="mso-spacerun: yes;"> </span>Patience,
self-awareness, and a good sense of humor will take you much farther.</span></div>
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<span style="font-size: small;"><b style="mso-bidi-font-weight: normal;"><span style="line-height: 115%;">The Child</span></b></span></div>
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<span style="font-size: small; line-height: 115%;">Parenting a hurt child can be challenging and sad.<span style="mso-spacerun: yes;"> </span>Abuse and neglect and moving from home to
home does real damage.<span style="mso-spacerun: yes;"> </span>In addition to
this trauma, our children may have other problems; learning disabilities,
medical conditions, social issues.<span style="mso-spacerun: yes;"> </span>We
may know our grandchildren very well.<span style="mso-spacerun: yes;"> </span>We
were there when they were born.<span style="mso-spacerun: yes;"> </span>We took
care of them or even parented them from time to time.<span style="mso-spacerun: yes;"> </span>Or, we don’t know them at all.<span style="mso-spacerun: yes;"> </span>Sometimes we weren’t even aware they were
born, let alone taken into custody until we get the call from child welfare
services asking us to take care of them.<span style="mso-spacerun: yes;">
</span>We think we know them.<span style="mso-spacerun: yes;"> </span>They share
our genetics.<span style="mso-spacerun: yes;"> </span>They look like our
kids.<span style="mso-spacerun: yes;"> </span>They remind us of our
children.<span style="mso-spacerun: yes;"> </span>They may share personality
characteristics that are familiar to us.<span style="mso-spacerun: yes;">
</span>Being with them is like a flashback to earlier times, either good or
bad.<span style="mso-spacerun: yes;"> </span>If those earlier experiences were
positive, it is a shock to find out the child is very angry with us, does not
trust us, and is very willing to let us know.<span style="mso-spacerun: yes;">
</span>If those earlier times were negative, the child’s demanding, defiant,
rejecting behaviors trigger us resulting in some very unpleasant
interactions.<span style="mso-spacerun: yes;"> </span>We have the idea that
since these children are our kin, they should love us, respect us, and trust
us.<span style="mso-spacerun: yes;"> </span>But their experiences with their
parents and other adults have shown them that adults are not safe and trusting
them is a bad idea.<span style="mso-spacerun: yes;"> </span>That leaves
grandparents trying to justify their existence to their grandchild, defending
their role, proving their love, and responding to the extreme anger the child
cannot possibly express directly to the people who hurt them the most.<span style="mso-spacerun: yes;"> </span>In response to guilt and sadness,
grandparents may spend a lot of time trying to make up for lost time, going
above and beyond to please the child, extra clothes, toys, trips, doing the
grandparent thing when the child needs a parent the most.<span style="mso-spacerun: yes;"> </span>Parents have to be strong and structured, the
one who says no, while most grandparents look forward to saying yes and letting
the parents deal with the consequences.<span style="mso-spacerun: yes;">
</span>The child’s very pain makes us angry, a reminder of what went wrong,
what was lost.<span style="mso-spacerun: yes;"> </span>And then in the teenage
years, adolescence, when conflict is the order of the day this gap of not one
but two generations really stands out.<span style="mso-spacerun: yes;">
</span>Younger parents may have the stamina to face the daily challenges to
authority.<span style="mso-spacerun: yes;"> </span>The temptation for older
parents may be to dig in, or give in, or give up.<span style="mso-spacerun: yes;"> </span>Is there hope?<span style="mso-spacerun: yes;"> </span>The first task is acknowledging that this is
not the child we thought we knew, then carefully going back to the beginning to
get to know the real child, to focus on the relationship from the very
start.<span style="mso-spacerun: yes;"> </span>It really does require starting
all over again.</span></div>
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<span style="font-size: small;"><b style="mso-bidi-font-weight: normal;"><span style="line-height: 115%;">Family Story</span></b></span></div>
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<span style="font-size: small; line-height: 115%;">Grandparents raising grandchildren stand out, raise eyebrows,
raise questions that both grandparents and their children need to answer for
themselves first. “What happened to us?” The interesting part of grandparents
raising grandchildren is that elders are at that stage of life when making
sense out of life and telling stories is the main focus and just what their
children need. <span style="mso-spacerun: yes;"> </span>Raising grandchildren adds
extra interesting chapters to this life narrative that only grandparents have
the perspective to tell.<span style="mso-spacerun: yes;"> </span>Grandparents
carry the culture and history of the family for generations, important parts of
the child’s identity often lost in the foster care system. Grandparents are at
the stage when the meaning of life comes into sharper focus and raising
grandchildren redefines that meaning in a profound way.<span style="mso-spacerun: yes;"> </span>While writing the final chapters of their
lives, grandparents are also creating lasting memories and passing those
lessons onto the next generation.<span style="mso-spacerun: yes;"> </span>On the
balance sheet of life, grandparents are an asset.</span></div>
Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-26782016783515476462016-01-06T12:02:00.000-08:002016-01-07T10:23:25.074-08:00Stop Giving Stuff to Foster Kids We have just passed the biggest giving time of the year. The gifts piled up and the returns are on their way. Charities are counting their donations and we are counting our tax deductions. And, the organizations that help poor families, homeless people, and underprivileged children are taking a deep breath after distributing the food, clothes, and toys dropped off during the holiday season. Now the commercials appear with beautiful faces representing foster children manipulating us into sending them coats for the winter. You're not helping a foster child, you're hurting one. Don't do it.<br />
Not only are direct gifts of goods the least efficient and effective way of helping foster youth, it is demeaning and damaging to their development and relationships. First, it is important to specify that foster children do not belong to the categories of homeless or poor. They are dependents of the court which is responsible for their care having removed custody from parents because of abuse or neglect. Child Welfare Services, funded by local, state, and federal taxes, reimburses foster parents and group homes for the care of children. These payments range from about $450 to $9000 per month depending on the age of the child and particularly the level of supervision required for the child. Some of these payments are recouped from the parents. The money is meant to cover the cost of caring for the child which includes food, clothes, and shelter. So, if the reimbursement rate accurately reflects the cost of caring for a child, no foster child should be going without necessities. The fact that they might should be of concern for auditors and taxpayers.<br />
Yet for-profit companies and non-profit agencies continue spending time and money asking the public for donations of winter coats, pajamas, school supplies, and toys. It makes us feel better and salves our consciences to spend the time to buy that Transformer figure or those Frozen pajamas to drop in the bin at the store. As if we can decided what a stranger's child needs or wants. We have warm thoughts and even experiences of handing those gifts to those poor children represented in the commercials. We can walk away feeling a lot better about ourselves. We are not thinking about the damage we are doing. The company or agency will report its huge charitable effort and how much it is needed and appreciated. It's a big public relations boon to see smiling children shopping with famous football players on television. And, yes, foster parents and those representing children sign up for the gifts and accept them with glee. This is the "give a man a fish" kind of metaphor. When we give the kid a coat, we take away the experience of shopping for the coat of their choice. The regular kid down the block goes with their parent not a social worker or celebrity.<br />
Having been removed from their parents' care through no fault of their own, foster children have the right to have their needs met. They are not charity cases who should be expected to appreciate their care or to be grateful to strangers for giving them stuff. We want foster children to have as normal a life as possible given their less than normal circumstances. No regular child receives gifts from strangers for which they are expected to be thankful. Would you force your child to unwrap a gift from a stranger "just for you" and expect them to write a thank you note? That's what we do to foster children. Regular children receive gifts from their parents and family members. Regular children are not expected to accept the Ninja Turtle backpack or the Hello Kitty blanket that a stranger dropped in a bin at a mattress store. Regular children are given an allowance or a budget by their parents to shop and buy the necessities of their or their parents' choice, whether the allowance or budget covers Macy's or Target or the local thrift shop or Goodwill. This conveys the respect of their personal choices and teaches that stuff does not come from people with whom they have no connection. Who can forgive a foster child whose belongings have been moved in trash bags or lost entirely between homes if they seem to have no appreciation for their belongings and expect stuff to just appear on demand.<br />
In the meantime, businesses that specialize in managing inventory feel they have the expertise to do social services and agencies that specialize in social services feel forced to manage inventory. Sometimes that inventory includes that sweatshirt you outgrew, the blanket frayed at the corner, or the half-used soap on a rope. Yes, foster child, be grateful for someone else's trash because you are a treasure. There is everything good about reusing and recycling, but let it be a choice. The homeless person on the street has every right to accept or reject your offering. A foster child may gladly take free stuff without realizing the respect stolen from them in the process. The responsible adults are complicit in this further victimization. So, what to do instead? It feels good to give. First, leave the stuff at the store where they know how to handle it. Second, if you must give, give cash to foster parents to reinforce their central role as provider for the child. Third, give through your taxes by supporting increases in the reimbursement rates for foster parents. Finally, consider either supporting a foster parent by giving them a night out or a day off or becoming a foster parent yourself.<br />
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<br />Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-9867398297887280492015-07-13T15:11:00.000-07:002015-07-13T15:11:28.031-07:00Parenting Adolescents For many parents the adolescent years are a roller coaster fueled by hormones, a white knuckle ride best survived with their eyes closed. However, recent brain science shows it to be a period of great potential if parents can hang in there with their teenagers. This is especially true in the areas of cognitive functioning, relationships, and identity development. It is a time of tremendous brain growth, as important as the toddler years, when thinking becomes faster and more streamlined. Two processes make this happen, pruning and myelinization. Pruning is when the brain discards cells and connections it no longer needs. Myelinization is when the nerve cells are insulated in a way that aides in quicker, smoother transfer of data. These result in more advanced cognitive competence.<br />
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Sometimes. What most parents know is that this faster thinking is not always better thinking. "The price of everything, the value of nothing." There are a couple of reasons for this. First, brain volume increases one to four years earlier in females than in males. Second, the emotional brain grows faster than the thinking brain. Then, late maturation of the prefrontal cortex means conscience and judgment are delayed until the twenties. Teenagers tend to give more weight to the reward over the risk even when they overestimate the risk. However, adolescents are capable of more abstract and critical thinking, applying memory and meaning to problem solving. What teenagers require to make this successful is context, more thorough explanations, concrete examples, practice and positive feedback. They are also motivated by self interest, "What's in it for me?" So appeals to standing out, fitting in, measuring up, and personal goals are likely to work better than, "Because I said so."<br />
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Relationships also undergo considerable strain during this time. Teenagers' efforts to achieve independence from parents often result in conflict. Good peer and sibling relationships can modulate the anxiety of separation from parents, but a good parent-child relationship can rebound in the late teen years. Peers and siblings can be both positive and negative models with young teens most susceptible. Female siblings often experience distancing from each other in middle adolescence and then come back together while male siblings stay close during middle adolescence then exhibit less emotional closeness later. Romantic relationships contribute to identity, status, affection, and conflict resolution. Social media creates opportunities for self expression and social interactions but also leads to pseudo-intimacy and anxiety. Life satisfaction decreases for most early to middle teens, but parental admiration and family values are buffers.<br />
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As adolescents negotiate their ethnic, gender, sexual, and social identities through challenges like sex, drugs, and mental illness some parenting techniques are protective and others increase risk. Protective factors include monitoring, warmth, tolerating conflict, encouragement, communication, consistent discipline, and family closeness. Factors that leave a teenager at risk are low monitoring, negative criticism, chronic conflict, poor communication, coercion and shaming, inconsistent discipline, and family conflict. Close relationships are protective. Teenagers need authoritative, consultative not authoritarian, parents. They learn best through vicarious experience, story telling, parent modeling, positive feedback, reasonable expectations, and warmth. Perhaps the most interesting finding confirmed by the brain research leads to rethinking treatment of boys and girls. Traditional parenting focuses on protecting females and encouraging independence in males. What works is more independence for girls and more emotional support and adult interaction for boys.<br />
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Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-70152709736665717952015-06-25T16:26:00.001-07:002015-06-25T16:26:16.613-07:00Celebrating Success On a daily basis, parents are working hard to provide for their children and help them grow up to be productive citizens. Among them are parents of foster and adoptive children who face additional challenges. The trauma of abuse, neglect, and abandonment has left them wounded and unable to trust. The six-year-old girl hits her grandmother and refuses to sleep in her own bed. The five-year-old boy runs into the street and gets kicked out of preschool. The 10-year-old girl cries when asked to do chores or when her parents welcome guests. These tired parents ask, "Why is this happening?" "What can I do?" "How long will it last?" "Will this child ever be 'normal'?"<br />
It is helpful and heartening, then, to witness success stories. An angry, demanding, bossy little three year old with a mentally ill biological mother and four failed adoptive placements graduates from high school with a full scholarship to a major university. Her whole family including her bio-mom watch her receive her diploma. A once quiet, sly twin removed in diapers first from a substance using mother then older sister is reunited with siblings and completes high school with lots of friends and family. Brothers abandoned by immigrant parents are excited to have their own rooms and a big back yard since they are moving, for the first time, with their adoptive parents. A teenager dropped off at ten by her mother at the shelter is turning her story into performance art. Another teenager adopted from a group home once tore up the house is now building homes for the poor on mission with his father.<br />
These success stories have several things in common in addition to the children's once strange behavior. Their parents have worked hard to develop several characteristics that are essential for helping their children heal and grow.<br />
<ul>
<li>Each has an openness to learning, changing, asking for help, and receiving support.</li>
</ul>
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<li>Each has an interest in the child as a unique individual separate from their personal concerns.</li>
</ul>
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<li>They have an appreciation for the child's biological family and honor those relationships. </li>
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<li>These parents have tolerance for conflict, emotional and otherwise, and stand up for their kids.</li>
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<li>Each has learned to keep perspective, to take the long view, and know that growth takes time.</li>
</ul>
Parents still in the middle of the mess ask, "Will it get better?" "Will it get easier?" The simple answer is probably. The honest question is, what are you willing to change if it does not? Children, particularly those suffering from trauma, are counting on parents who are willing to learn how to help them. Nothing is more satisfying than celebrating a child's successes, both large and small, and knowing the things you did, both large and small, made all the difference in the world.Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-27936689534809071662014-05-23T15:20:00.000-07:002015-06-23T15:07:53.452-07:00What's in a Name?One of the highlights of becoming a parent is naming the child. People, both men and women, start at a very young age, about the time they get a new pet or learn where babies come from, thinking about names they might give their children. And when expecting and prospective parents approach the event, naming the child usually becomes an exciting and serious part of the preparation. Names are important, signaling belonging and identity, and having lifelong impact and meaning.<br />
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However, this ritual part of parenting is complicated when the child is adopted either by strangers or family, in the case of child welfare, international, and private adoptions or step-parent and grandparent adoptions. When adoptive parents are identified before the birth they are often allowed by the biological parents to choose the baby's name or participate in naming the child. That is not the case when the named child is adopted after birth, except in some situations, both foreign and domestic when the infant has not been named at all. Generally, the older adopted child has a name and a birth certificate identifying the names of the child and the biological parents.<br />
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That means, whether the child was intended for adoptive placement or the court has determined that the child will be adopted, the biological parents and not the adoptive parents have chosen the child's name. Like so much else in the adoption process this is sometimes a source of conflict and sadness. The biological parent, whether intending to place the child for adoption or later having parental rights terminated due to abuse and neglect, took the first important step of claiming the child by its name. The adoptive parent(s) who wants to make this child his/her own, misses this monumental privilege.<br />
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Sometimes adoptive parents try to take this privilege back for themselves by re-naming the child. This can have detrimental and sometimes devastating consequences for their relationship with the child and the child's own development and mental health. Last names are a little less tricky. Adding a last name, as in John Doe Smith, says to the child and the world that John Doe belongs to the Smith clan. But by changing John Doe to George Smith, the adoptive parents are sending a strong message that they wanted George, whoever "George" is, and "John" is simply not acceptable. How John becomes George after identifying himself as John is cause for years of identify confusion. You cannot make John and his biology go away by calling him George. That just adds to the trauma. <br />
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It didn't seem to bother President Gerald Rudolph Ford, Jr. who was re-named after his adoptive stepfather from Leslie Lynch King, Jr. after his biological father. But that was in the early 1900's before we understood much about identify development in children. Through the 1950's the shame of unwed pregnancy led to "illegitimate" births (as if a child is not real) and secret adoptions with closed records. Reaction to the stigma continues to this day with the state re-issuing new birth certificates replacing the biological parents names with the adoptive parents names pretending the original event did not happen. How is that supposed to make an adopted person feel? California and other states are beginning to make adoption records and original birth certificates available to adopted people.<br />
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To be sure, some names are quite unique and require explanation and pronunciation. One biological mother named her girls Chevy and Corvette. Another Johnny Walker. There's a story there. Early last century Beverly, Gay, and Adolphe were acceptable boys names. These days North West seems to work. Hollywood stars used to change their names to hide who they were. Now we can celebrate the work of Chiwetel Ejiofor and Charlize Theron and learn to pronounce their names. When a Chinese girl named Chan-juan is renamed Mary Rose she loses her country and her culture, graceful moon, but is expected to live up to her new identity. Something says, "You are not who you are supposed to be." Adoption is about addition, not subtraction. Gerry Ford's legal name could easily have been Leslie Gerald Rudolph Lynch King Ford, Jr. It wouldn't fit on a bumper sticker, but it would fit on a legal document. No need for a new birth certificate. His story is part of history.<br />
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In the teenage years, youth begin to explore their identities. John becomes Johnny becomes Jack becomes J.R. Or, a youth begins to live her/his gender identity and asks to be called Chelsea instead of Charles. Generally, we do not get to pick our names. Parents have that responsibility. Adoptive parents have the additional responsibility of managing their own grief and loss over not giving birth and having naming rights. They also have the responsibility of celebrating their chosen child for who they are and not the "ideal" child they had in mind. That includes accepting from whom they were born and for whom they were named. There is no shame in making another person's child your own. <br />
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<br />Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0tag:blogger.com,1999:blog-911920320806464736.post-47783758473595281862014-04-07T12:19:00.002-07:002014-04-07T12:19:53.968-07:00Paying Attention to What HurtsA four year old, asked why her drug addicted mother left her at the hospital, says, "I think I cried too much." A fourteen year old, also born exposed to methamphetamine, says, "I think it was because I was a boy." That is the case for eight girls left behind by a mother who fled to Mexico with a son. To the last one, the adopted children with whom I work feel there is something deeply wrong with them. And their sometimes strange and dangerous behaviors often have their parents believing it is true.<br />
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Attachment and trauma-informed care asks us to think about it in a different way. These young survivors of physical, emotional, and sexual abuse; neglect, abandonment, and multiple placements have developed some interesting coping skills to deal with painful emotions and fear of closeness. Their parents are also coping with these difficult behaviors; lying, stealing, aggression, manipulation, defiance, tantrums, and control battles. The parents and children are both saying, "Make it stop!"<br />
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In her article for the March/April 2014 edition of Social Work Today, "Mindfulness, Women, and Child Abuse: Turning Toward What's Difficult", Char Wilkins, LCSW, faculty member at the University of California San Diego Center for Mindfulness writes about techniques for adults. It dovetails nicely with the principles of Acceptance and Commitment Therapy promoted by Russ Harris, M.D. The focus is on accepting and being present with unwanted feelings without resistance.<br />
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It is very difficult for parents to watch their children suffer. In my experience it is even more difficult for parents to experience sadness, anxiety, and shame with their children. Like their children, parents (like all people) avoid, deny, and distance themselves from troublesome thoughts, feelings, and sensations. Yet these are the fears that drive the unwanted behaviors. If a parent cannot tolerate these feelings, what is a child to do on her own? Parent and child are running, from each other.<br />
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Yet, while it is not the entire treatment, focus on these unpleasant feelings can make them less powerful. Without pushing or pulling, they can be regulated. "Fear is here," as Wilkins writes. As in Post Traumatic Stress Disorder it turns on the fight/flight response and releases the stress hormones cortisol and adrenaline. But with practice, the chemicals dissipate, the extreme reactions slow, the brain's emotional amygdala is quieted and the thinking cortex begins to make decisions toward self care. The keys here are presence and silence. I have participated and watched as parents have demonstrated with their breathing, posture, and touch that they can be trusted with their child's heavy burdens. The bodies relax, the expressions soften, safety returns, and the relationship grows stronger.Michael A. Jones, LCSWhttp://www.blogger.com/profile/10943069504535177199noreply@blogger.com0