Thursday, July 21, 2016

Evaluation and Termination

Chapter Twelve
Evaluation and Termination
Sticking Points


Wednesday, July 20, 2016

Problem Solving

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.

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.