Monday, June 20, 2016

Family Therapy

Chapter Six

Family Therapy
            Just as with adults, the website can be a good way to orient a child to therapy and the therapist.  Pictures of the building, the office, and the therapist give a client an idea of what to expect when they arrive.  Some children, particularly adolescents, may feel more comfortable after reading the biography, frequently asked questions, and even the client forms.  I try to reinforce the parent role and defer to parents by asking them to introduce their children to me.  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.  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.  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.  This is not the time for behavior modification or correction.  It may also be the first example for parents of the importance of timing interventions.  This is not the time for discipline or consequences, in part, because we have not established relationship safety.  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?”  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.
            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.  I set expectations again about sitting or standing and staying away from my office desk and computer.  I demonstrate using a slightly louder voice than the waiting room.  And, “You may use my stuff if you ask first.  Sometimes the answer will be yes.  Sometimes the answer will be no.”  I ask the child why they have come with their parents, but I do not expect an answer.  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.  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.  This has the effect of demonstrating serious commitment over time. I check for the child’s understanding and ask for questions.  Some children have had previous experiences with therapists, both positive and negative.  The informed consent talk often dovetails right into the statement of the problem.  “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.  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.  Those are the kinds of kids and families I like to work with.”  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.
            Sometimes the child is reluctant or downright refuses to “participate”.  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.  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.  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.  It is sometimes just as concerning when a younger child can sit quietly in a strange waiting room and seem not to be bothered.  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.  More often than not the child will say “friend”.  Sometimes a child assumes that is the more acceptable answer or they know their parents have been meeting with me for several sessions.  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.”  The answer is usually no, so I say, “So, we are strangers today.  Are we going to stay strangers?”  Again, the answer is usually no.  “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.”  This is in addition to the informed consent script repeated with parents and children reinforcing time-limited work.
            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.  This is a powerful start that sets the stage and provides a foundation to return to when we cover more difficult material.  I often have the parents draw an outline of the child’s hand on paper or their whole body on large butcher paper.  Then I ask the parents to state out loud their child’s positive characteristics as I write them inside the outline.  It may require clarifying that strengths are not positive achievements or behaviors but qualities like intelligence, humor, and kindness.  This allows the child to hear in their parents’ voice and see in colorful view what makes them special.  When there is hurt and conflict at home, these words either do not get said or are easily forgotten by both child and parent.  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.  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.   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.  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.
            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.  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.  Sometimes the child is also anxious to read to show that they can or to take charge of the session to achieve safety.  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.  Once again this mirrors how attachment forms and sets a pattern of joining before teaching. 
     One intervention that is powerful for traumatized children, particularly adopted children, is narrative therapy.  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.  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.  When I want parents to demonstrate their commitment to the child I start with the claiming narrative.  I ask even older children to lie in their parents’ laps to listen.  Here the story starts before the child was born with the atmosphere and planning for their birth.  The parents express their excitement at the pregnancy and preparation for this child.  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.  The activity includes baby bottles and blankets in my office.  This addresses the child’s inevitable curiosity about their beginnings, “Tell me about the day I was born.”  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.  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. 
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).  The book then becomes a jumping off point for activities.  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.  The parent and child can “tug” on the rope as if to say, “I need you,” or “I’m still here.”  The grown up version would say, “You’re yanking my chain,” or “I feel the tug of your heart.”  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.  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.”  Then, I reinforce that the real “string” is invisible.  The visual stays with children and adults.  It also leads to another activity, identifying all of the child’s attachment relationships, strong or weak, secure or disrupted.  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.  The exercise illustrates that a child can have many attachments of varying quality with no competition among them and plenty of room for more.  That hits at the loyalty issues adults and children face between biological and adoptive families.  It begins to put to rest the very harmful belief that an attachment to the first inhibits the attachment to the second. 
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”.  I ask the child to draw and cut out a big heart from red construction paper and write their name on it.  Then, and this is very important, I hold the heart and tell the story deliberately, “When you were born you had a perfect heart.”  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.  The heart, the hand, and the doll are frequent tools.  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.”  I make a tear in the red paper heart.  The child’s eyes grow large.  “Then, the social workers came and said it wasn’t safe for you to stay, and so they took you to a foster home.”  Another tear.  “Then your parents did not come back and you had to meet your new adoptive parents.”  Rip.   Depending on the number of multiple placements and other traumatic events, the paper heart can have a lot of rips.  Then very slowly I ask, “Who…will help…you heal…your heart?”  And wait.  If things are going well, the child may say, “my mom and dad.”  Sometimes the child says, “I can do it.”  Often the answer is a confused look.  That is when I ask, “Would you consider trusting your parents to help?”   I give the torn heart to the child and wait for them to hand it to their parent.  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.  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.  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.
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.  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.  “Go!”  I give them a few seconds to mirror each other as I move around them at a distance observing the result.  This can be a playful interaction, quite intimate, sometimes terrifying.  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.  At other times either the parent has difficulty acting so silly or the child finds it so uncomfortable that they look away.  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.  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.  This kind of closeness felt quite unsafe to that child.  The exercise informs what we do next which is usually working on relationship safety through play, starting with teaching parents how to be playful.
The second assessment exercise is parallel drawing.  Similar to face mirroring, first the parent then the child leads.  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.   I do not give them any instructions about what to draw, how to draw, or whether to talk.  I turn the paper over, and with the same instructions, have the child lead and the parent follow.  Then, usually silently, parent and child draw.  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.  Sometimes, the child will race ahead etch-a-sketch style while the parent deliberately attempts something more formal.  Oftentimes, the drawings will be completely separate matching perfect pictures.  Other times, the lines cross and intertwine together.  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.  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.  When there are two separate forms, it looks like two toddlers doing their own thing side by side but not together.  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.  When the result flows it looks like the creation of a comfortable connection.  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.   “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’”.  Both the face mirroring and the parallel drawing can be good homework for parents to continue at home.
                It is quite normal for clients, both adults and children, to ask among other personal questions: “Are you married?  Do you have children?  Are you a Christian?  Are you a veteran?”  It is quite human to connect with people through common experiences.  And the therapist-client relationship is a human one.  However, the questions are professional pitfalls and the answers have serious clinical significance.  So, it pays to think through the personal and professional consequences and prepare to answer them.  Many in the profession and in the public consider having similar qualities and conditions as clients to be prerequisite to understanding and helping them.  Substance abuse treatment and self-help groups like Alcoholics Anonymous and others are contingent on it.  It is nearly the first thing a friend or casual acquaintance will offer, “Me too.”  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.  It is our responsibility and not the client’s to consider this.  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.  That does not mean my answer to the questions is, “None of your business.”  Clients are asking because they want to know if I understand their situation.  This goes to the heart of treatment.  My answers start with questions, “Why do you ask?  (Wait for answer.)  Is it important for you to know in order for me to help you?”  Then I continue with statements, “These are very good questions.  You want to know whether I can understand your situation.  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.  I want to understand things from your perspective.  Like all people, we have each experienced some highs and lows in our families, so we have that in common.  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.  Is that OK?”  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.  Many clients have difficulty setting boundaries; with children, spouses, family members, employers, and friends.  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.

No comments: