Wednesday, June 15, 2016

Treatment Planning

Chapter Five

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

While accurate diagnosis is an ethical responsibility, many clients see a label as an end in itself as if a pill or other quick fix will cure it.  For children and adults, some diagnoses are rather clear cut.  Anxiety, attention deficit hyperactivity disorder, autism spectrum disorder, bi-polar disorder, depression, obsessive compulsive disorder, post-traumatic stress disorder, and schizophrenia, while complicated especially if co-occurring, have pretty straight forward treatment protocols or evidence-based interventions.  Other diagnoses like oppositional defiant disorder, conduct disorder, and reactive attachment disorder are more difficult to identify because their “symptoms” are more subjective.  Oppositional to what?  Defiant to whom?  Reactive to whom?  These are individual diagnoses for relational problems that require looking at the whole family.  More accurate names for these might be relational traumatic stress or dyadic developmental disorder.  You would never diagnosis a couple with oppositional defiant disorder.  The individual diagnosis puts the onus on the person to change when the target of intervention needs to be on the interpersonal dynamics and interactions between individuals.