Chapter Eleven
Problem Solving
Sometimes the therapeutic process seems to
stall. The client sees no progress, and
the therapist feels frustrated. The
therapist begins to feel the client’s hopelessness in facing nagging persistent
problems. We feel like blaming the
client for not trying. The client feels
like blaming us for not helping. We feel
stuck together. Sometimes it is about
goodness of fit. I may have reached the
limits of my knowledge and skills. Another
therapist may bring a new perspective, a new start, and new skills to meet the
challenge. If, however, we can work
through this period together the results can be quite satisfying.
After assessment, psychoeducation, and
treatment planning, after identifying trauma, expressing emotions, and
practicing coping skills and sometime between the first and tenth session
specific problem behaviors come to light that require individual attention. 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. These issues are of central concern and
deserve to be the focus of work. Some
further investigation is in order: What comes before the behavior? What do people do during the behavior? What is the result of the behavior? What has been tried to resolve the
behavior? What seems to have worked to
reduce the behavior or its impact? What
does the client believe about the cause of the behavior? What is the client willing to do to resolve
the behavior?Some
attention needs to be given to the understanding of problem behaviors. First, some problem behaviors are symptoms of
the condition itself. Problems with
functioning; sleeping, eating, elimination, sex, energy, mood, pain, conflict,
thinking, socializing are symptoms of diagnoses like depression, anxiety, and traumatic
stress. Second, other problem behaviors
are attempts at coping with the condition; alcohol, drugs, fighting, isolation,
poor hygiene, spending, stealing, and self-harm. Third, other problems are the result of
either the condition or attempts to cope with it; employment, financial, social
and legal issues. Understanding behavior
goes back to beliefs about humans themselves.
Interpretations of behavior as good or bad, positive or negative,
appropriate or inappropriate, are meant for punishment not for healing. Behavior is need driven. It is either helpful or unhelpful. Behavior is purposeful, but not always for
the purpose we think. We do things to
increase our pleasure and decrease our pain.
The underlying needs according to Maslow (1943) are, and the order is
important, survival, safety, love, and belonging. The more sophisticated attachment needs
described by Johnson (2008) are safety, attention, value, validation, respect,
and love. To these I would add sovereignty,
the individual right to one’s own body, mind, and spirit. Given this understanding, trying to stop,
start, or replace a behavior without looking at underlying needs will have
limited success. We must be proactive in
meeting the need not reactive in focusing on behavior. The big four behaviors that parents are most
concerned about are lying, stealing, aggression, and manipulation. I will take them one at a time.
Lying is a
developmental defense that we all use as we grow. 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.” Lying is also a socially acceptable way to
avoid hurting people’s feelings as when we are asked, “Do I look fat in
this?” Or, “How do you like my
dinner?” For people with attachment
trauma lying is not so much a learned behavior as a defense. Lying to an abusive parent may be a moral
imperative. So, telling the truth is about
safety. A child, or an adult, tells a
lie because it does not feel safe to tell the truth. Their subjective sense of safety in the
place, with the person, in the relationship is about perspective. Punishing a traumatized child increases
anxiety and jeopardizes safety. The onus
is not on the child to tell the truth but on the adult to make themselves safe
enough to hear the truth. It starts with
not setting up the child to lie by asking questions. 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. This is not
focusing on safety, the first of human needs.
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. We can be sad about
that. We will not be able to believe
them. We can practice, “trust but
verified.” But, we must be ready to hear
sometimes harsh “truths” without reacting and rejecting. It does not mean ignoring the facts. If the room is dirty, it needs to be
cleaned. When the partner says, “No, I
do not like your cooking,” the response needs to be, “Thanks for your honesty.” Focusing on compliance over connection leads
only to more stress for both parties.
Prioritizing relationship over power leads to healing.
In the same way,
stealing or “taking” is best viewed as a survival skill. 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. 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. In order to address this problem we must take
the person’s perspective. For an infant
or small child, abandonment, hunger, and violence are life-threatening
experiences. This trauma is stored in
the pre-verbal, pre-conscious amygdala or limbic brain and drives these
fight/flight/freeze responses. That is
why traumatized children seem to take issues around bathroom habits, eating,
and sleeping to the extremes. The person
with a negative core belief system simply does not believe that their needs
will be met. They are on their own in
the world.
Tackling stealing starts with
making sure basic needs are met and doing so in a very dramatic nurturing
way. 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. No locks on refrigerators and cabinets. If it is not meant to be eaten, do not buy
it. The same goes for items that are not
basic needs. 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. 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? Expecting a person
with sticky fingers to make it through a store without taking something is an
unrealistic expectation. 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? Can a traumatized child or adult
stop stealing? Yes, if they feel that
their basic needs will be met, if they feel safe in their home. 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. A parent may need to help the child return,
replace, or repair the stolen items as restitution using allowance or extra
chores. Ultimately, the community may
weigh in with arrest, charges, and sentencing the parent needs to support
without rescuing the child from the consequences.
The
same may be true for aggression especially if it goes beyond verbal assaults
and tantrums. We have to acknowledge
that our society has a strange attitude toward aggression. We condone it in many areas; in physical
discipline, in sports, and in war. Similar
to lying and stealing there are times when aggression may be morally necessary
to save our lives. This again is often
the perspective of traumatized people who have faced truly life-threatening attack
in the form of rape and other violence.
So, again, while we wish for everyone in the family to feel safe, it is
the person who uses aggression who does not.
Often, what starts as a minor irritation escalates to complete
dysregulation, the person is out of control, they have “lost their mind”. 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. 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. We recall the “vents” of the “angry
volcano”. These are coping skills. They cannot be assigned to the child but need
to be lead and shared by the parent. The
parent or another adult lends the dysregulated person their self-control. In session, this means teaching, modeling,
coaching, and role playing de-escalation skills through the use of reflective
listening and therapeutic joining. In
practice, it means administering large doses of empathy, to the aggressive
person. We check in briefly with the
injured party and move quickly to attend to the aggressive child. It does not mean keeping a calm voice. Two year old tantrums require soothing. You take the child out of the situation and
sit with them until they settle. The
initial non-violent intervention with aggression needs to match the intensity
of the situation, “Stop! What’s
happening here?” followed with controlled, intentional, low, slow language that
addresses the emotion and engages the left brain, “You are really upset. I would like us to sit down and talk about
this. Would you like to start or do you
need my help?” The parent or partner who
loses control focusing on blame or broken furniture adds fuel to the fire. It may take back up. In these extreme situations a safety plan is
necessary including early warning coping skills, supportive people to engage,
hotlines and other resources,
Emergency
Services
Sometimes a parent simply cannot
keep the child, themselves, and others safe without engaging emergency
services including police, hospital, and residential care. But taking these extreme measures can be
risky for the future of the relationship.
The way in which parents ask for and explain the assistance can make
all the difference. 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. That is a
cliff from which it is difficult to step back. We literally employ the services of law
enforcement, hospital staff, and residential caregivers to help us keep the
child and others safe. 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. Then, having separated the
child from the family 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.
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up to and including use of emergency services.
As aggravating and
frightening as lying, stealing, and aggression, behaviors that seem to be about
manipulation can be irritating and exasperating. 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. It happens at home, and it happens in
therapy. It is important not to take it
personally because it is not personal.
If we understand that anxiety and stress are at play, we can better
respond to the seeming manipulative behavior.
Like the negative core belief system of traumatized people, their higher
baseline stress level never goes away.
Both are likely to persist well into adulthood and, without adequate
treatment, lead to serious health consequences including heart attack, stroke,
and early death. Trauma and its
associated adrenaline and cortisol are serious stuff. 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. The hypervigilance is
always there. To cope, the person
attempts to take control of almost every situation. We know these people. We may be these people. The “control freak” who needs everything to
go their way and in perfect order is a very stressed-out person. Accepting
this employs the empathy needed to address it.
A
sense of humor helps. After all,
manipulation is just good sales, quite a skill.
But we do not have to buy. 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. It requires extreme patience
which is not always possible. However,
the opposite reaction simply invites more.
That is, when we respond with repeated reminders, pleading, and anger,
we increase the anxiety level and the attempts at control continue. Having met basic needs, including affection
and play, and set reasonable expectations, we must have the courage of our
convictions. We still must be aware of
the person’s triggers; fear of bath and bed, hunger and pain, isolation and
abandonment. In session and out, this is
about silently soothing, lending the person our self-control, and remaining
consistent and safe. 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. 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. This is powerful
parenting. When we “lose it”, we have
lost our power and contributed to the child’s already high stress level. We have fed the fire. It is not a battle, a test of wills, making
parents and children winners and losers.
It is the difference between authoritarian, permissive, and
authoritative parenting styles. The
authoritarian rules by fear, increasing anxiety, impairing relationship. 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. 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.
As
Daniel Hughes (2007) suggests, when problem behaviors become the focus more
structure and supervision may be required.
About the time we think we have all the routine and watchfulness we can
stand, we probably need more. At this
point, if not before, I offer parents my family chart (Appendix) with suggestions on how to organize the
family’s schedule, needs, expectations, privileges, and consequences. 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. Traumatized people do best with routine. Think about running a bed and breakfast or
cruise ship. 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. Can you
imagine what would happen if this information was not provided? This kind of clear instruction allows the
operation to run more smoothly. The
family chart makes for a good agenda item at regular family meetings.
As to as schedule,
if one hour intervals leaves too much free unstructured time, then shorter timeframes
may be needed. 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. 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. Basic needs do not
include bags of chips, dessert, telephones, television, sleepovers, and
shopping trips. Now the expectations are
meant for all members of the family, not just children. 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. Avoid
words like respect and manners, they are subjective. 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”.
As opposed to taking away privileges, every day starts with no
privileges and parents provide privileges as they see expectations met. Privileges include electronics, sleep overs,
shopping trips, and amusement parks.
Children can live until adulthood with no privileges at all and receive
only what they can handle. To make this
work consistently, minimize reminders and the word no. The child asks, “May I watch TV?” The parent answers, “Yes, as soon as your
room is clean.” When handing out
privileges it is a big mistake to yes.
Instead, “You may watch your show”, or “You may watch for 30
minutes.” If the child cannot turn off
the television, the parent does not remind but does not hand out the privilege
the next day.
Now
to consequences, discipline is about teaching not punishment. We expect children (and ourselves) to miss
the mark. The message needs to be,
“Mistakes are welcome here.” Teaching
takes the form of natural consequences, do overs, and making amends. Some mistakes or poor choices require empathy
and no consequences at all. 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. Do you
know how much that costs?” No, do not
replace it, let experience teach. There are a few choices, per Daniel Hughes
(2007), when a child does not meet expectations. 1. Ignore it because the child has had a
bad day. 2. Do it for them because you
love them. 3. Have the child pay someone else to do it. 4.
Award privileges only when it is done.
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. You make brownies with the school
bully to give to his classmates. In
another example, a mother empathized with a boy whose trauma tantrums at bedtime
led to his kicking a hole in the closet door.
She did not berate him. She gave
him the telephone to call the home store.
He used adult language to order a new door and helped the handyman
install it. He did the math. It cost him 20 weeks allowance. He learned he could fix his problems and felt
great about it. His mother demonstrated
her commitment to him while not damaging the relationship.
When
these behaviors persist despite parents’
commitment to non-traditional parenting, I pull out Daniel Hughes’ (2007)
hearts and walls exercise in session. 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.” Then, I draw a figure of the
child at the age at which they were abused with a heart with some dark
marks. “Your parents were having
problems with mental illness and drugs, and they did not feed you, hug you, and
watch you.” Arrows pointing at the heart
indicate the abuse and neglect. 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”. “You are a smart kid and you learned how to
protect your heart by putting up walls.
Sometimes the walls keep out the good stuff.” 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.
One parent plays the child as an infant.
Another parent portrays the child at the age they were hurt. The child plays themselves as an adult. 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.” The parents are able to identify
with the innocent infant and to empathize with the abused child. The child is also able to see themselves and
their parents from different perspectives.
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?” Having taken time with this exercise, the
child will usually say something like, “When I’m 8”, or after their next
birthday. 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.