Wednesday, June 1, 2016


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