Tag Archives: therapy

Rookie therapists, rookie family support

June 26th, 2019

“Thank you for the opportunity to work with your son,” the therapist said at our last appointment.  “I’ve learned so much.”  He had been a good therapist but a very inexperienced one.  The old therapist had moved out of state and my son needed an appointment with no lag time, so we traded off waiting for someone experienced with having someone quickly.  I knew from the beginning that he was a rookie, but the advantages outweighed that, or so I thought.  He had grown in his understanding of us and the next person would reap that benefit.  Just not us.

My complicated son was a challenge to even the most experienced therapists.  His laundry list of diagnoses and symptoms didn’t fit neatly into any slot.  But inexperienced therapists mistook his anxiety for ADHD and his meltdowns for conduct he could be enticed to control with star charts.  Both were untrue. We had to wade through these tentative, by-the-book steps each time we had someone who was a rookie.

Complicated kids with significant mental health problems get matched to newbie therapists every day.  Veteran parents talk online or in support groups about ways to speed up their learning curve.  We share our hard won knowledge with them and try to temper their faith in the system with our practicality.  Sometimes it works.

The very best match is for a complicated child to see an experienced therapist.  That therapist draws on their book learning, just like rookies do, and knows when to throw some of it out the door.  They pull strongly on their own hard won knowledge and have a really good idea of when to stay the course or try something new.  They often see parents as allies, bolstering our belief in ourselves.  They get it.

Many years ago, I heard Robert Brooks, a child psychologist, speak about children and building resilience.  Although I was fascinated by the topic, what I still remember was that he said he should probably go back and apologize to the patients he treated early on in his career, which was an unexpected thing for a psychologist to say.  There was so much he didn’t know, he had realized.  He gave his then-best in those early days, but lacked the wisdom, experience and empathy he gained over time.  Those are precious components in the work of therapy, ingredients that are built steadily and slowly, which make an enormous difference.

Recently, I had a chance to co-author a chapter on family advocacy in a handbook for the American Psychological Association with Kathleen Ferreira.  We wrote about the work of family partners and family support specialists and how their impact is unparalleled.  We were enthusiastic about promoting the importance of family advocacy in a volume that will probably be used to educate new psychologists.  We paused midway through and talked about the mismatch we both see between complicated kids and inexperienced therapists.  “It happens with family advocates, too,” I said and we immediately saw the parallels and went on to toss that idea about several times.

Most professions recognize that the beginner, the one who has the initial required qualifications, still has a long way to go.  In sports and law enforcement, the newbies are called rookies.  Other professions, like social work, have different levels of licensure, which indicates both experience and education.  In other occupations, such as being an electrician or plumber, there are well-defined levels of expertise.  This is also true in professions as diverse as musicians and carpenters.  A light bulb went off for both of us and we decided to apply this to family advocates.

At the novice level, we wrote, there is a great deal of enthusiasm, but also “well meaning mistakes.”  Next, at the apprentice level, the family support person has greater skills and is beginning to understand how tough the system can be to navigate.  At this stage, people often realize that while they did everything right, they didn’t get the results they intended.  Third, at the journeyman level, the family advocate has more good days, better results, has seen more and is becoming adept.  Finally, at the master level, we wrote, the family support person or family advocate “does not guess, but rather knows what to do. The advocate has skills that often make the work look effortless to others, and that is reflected in the results.” This is the ladder to mastery – from novice to expert.

Family advocacy or family support work is still pretty new and we are all still trying to find ways to talk about it.  When my son was young and we were trying to educate a rookie therapist, I noticed that my fellow family support specialists were all over the map in terms of expertise.  Some had it all together with mountains of knowledge and skills.  They were comfortable helping families whose children had significant mental health needs navigate through special education, call their insurer or make their case to state agencies.  Others knew some of that, but not all.  Still others were rookies, enthusiastic, knowing their own experiences could help the families going down the same road.  But they had a lot to learn like any newbie does. When this work was new, we were quiet about our learning curve.  We were working toward acceptance, endorsement and validation of our work.  It was the right thing to focus on then.

That was then.  I’ve been the novice, apprentice, journeyman and master.  I’ve faked it, hoping no one saw my skill gaps and I’ve said, “Let’s figure it out together.”  Like that rookie therapist my son had, I’ve learned from every parent who was gracious enough to teach me what they knew.  In the end though, complicated kids and families do better when there is expertise.  Rookies, please learn quickly.

Tags: Children's Mental Health, expertise, family advocacy, family support, Kathleen Ferreira, therapy

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Therapeutic relationships and 4 therapeutic pearls of wisdom

May 7th, 2019

“He shares things with you,” the therapist groused, “that he should be talking about in therapy.”  It was true.  My young son often told me things that were on his mind or that caused him pain or fear when we were alone in the car, sometimes on the drive to therapy.  There was something about the combination of road noise, looking straight ahead and knowing the trip would soon end that worked for him.  Sometimes things would spill out and shortly after, we’d reach our destination.  He’d be done and would have no desire to bring up whatever it was again, in therapy or elsewhere.  I described this to the therapist then added, “Maybe you should get two parallel car seats in here. It seems to be a key ingredient.”

What I couldn’t explain was that my son was simply unable to form a therapeutic relationship with anyone.  He would like them and talk about ordinary things, like a television show or favorite food, but that was all.  It wasn’t just that I was his mom and he already had a relationship with me — though that helped — but he didn’t have the bandwidth. He was so overwhelmed with jagged emotions and racing thoughts that he couldn’t process much and was only able to share things in short spurts.  Any longer and he was uncomfortable at best and feeling pained at worst.  He had no fertile space inside to grow a relationship.

Sure, I had lots of little “tricks” up my sleeve. I knew just how to touch his shoulder to redirect him when he was obsessing.  I knew how far to move into his space and what words he could hear in a neutral way.  But what the therapist wasn’t seeing was my son’s inability to form that relationship on anything but a superficial level.  It wasn’t until years later, when someone explained what a therapeutic relationship was to me that I could help nudge my son in that direction.  Just like I encouraged other relationships he had trouble navigating.

That’s how I learned what a therapeutic relationship was and how my son could benefit from it.

There were other pearls of wisdom that his therapists gifted to me over the years that helped enormously.  I’d like to share four of them.

Pearl #1.  When my son was about 8 or 9 and couldn’t explain how his meltdowns happened or how he felt afterward, his therapist told me that at about age 14, children develop the ability to observe themselves and the things around them in a new way, sort of like young journalists.  They can describe and report as if they are watching themselves.  I waited for that day, believing it would make a difference.  It didn’t come in a flash rather, more gradually, but it was there.  What’s more, I could actually see it happen.  This new ability didn’t calm or make sense of his feelings but gave us all a much-needed window on them.

Pearl #2. During another period, when he was in middle school, he became more explosive each week.  One day, his 10-year old brother had had enough of the safety plan where he removed himself, getting out of the path of the storm.  Instead, he provoked the confrontation he knew was coming and it got physical before I could get between them.  In family therapy that week, I despaired, “I don’t think they will ever be able to simply be in the same room with each other.”  The therapist commiserated then offered this: “Your son does pretty well with adults and not as well with children.  When his brother is an adult, they will probably be able to restart their relationship on a positive note.”  Part of me was disbelieving – she didn’t see the horrible fight! – but part of me held on to that idea with both hands.  It turned out to be true.

Pearl #3. A couple of years later, still during middle school, we went through a tough period of medication trials, dosage changes, weaning off and still more trials.  My son had never been on a medication combination that worked well, but until then he’d had periods where his symptoms had lessened, his sleep or focus or moods had improved.  I filled out charts, trying to track whether his mood swings had slowed or his suicidal thoughts had abated.  I concentrated on the medications wondering about their direct impact.  As his medication trials seemed to offer hope, then withdraw it, my hopes soared and crashed as well.

Of course, I kept his therapist in the loop.  One day she remarked, “Medication is intended to be an adjunct to therapy.  In the best of worlds, it calms the mind, sharpens the focus, evens out the mood and helps people be more available to therapy.  So that therapy can be successful.”  I looked at her, light bulbs turning on above my head.  Until that moment, I had measured the success of medication by the relief of my son’s symptoms and hadn’t given this much thought.  Now I did.  When I explained it to him, he got it, too.  I changed my thinking about medication that day and it stayed changed.

Pearl #4.  My son was a little boy, a first grader, when he first blurted out that he wanted to die.  I was horrified and hoped never to hear it again.  But I heard  it again a couple of weeks later.  Soon he said it almost every day and also developed crying jags, meltdowns, nightmares and phobias.  I longed for a day, just one, when he wasn’t sad, scared, angry or unpredictable.  “How do we cure him?” I asked his therapist.  “How do we make him better?”  “It works like this,” she told me.  “We find treatments and things to do that make the outbursts less intense.  We give him care that makes the sad or angry times farther apart.”  I had a difficult time letting go of the idea of a cure.  I wanted to see him not just better, but all better.  But I learned to be glad to see the time between meltdowns grow – even if at other times it collapsed again.  I watched for days when he was less sad and less fearful of a million different things.  I adjusted my idea of what progress looked like.

It wasn’t until he was older and experienced less emotional chaos that my son could form a therapeutic relationship.  But I did.  Sometimes it was his therapists who guided my thinking and coached my approach to him.  Maybe that was just as important.

 

Tags: Children's Mental Health, therapeutic relationship, therapy

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Giving trust, losing trust. Does it make a difference?

January 28th, 2019

I remember that moment when I realized that there was no way I could do this without help. I had tried every technique I knew, been patient, yelled some, loved my son with all my heart and absolutely nothing got better.  He was only six, I thought.  Maybe there is one more thing, something overlooked, that I can try?  But there wasn’t.  I had exhausted what I knew and needed help.

I took him to our pediatrician who said it was time to try therapy and maybe medications.  I made an appointment and waited. And while I waited, my son got worse.  He was anxious at school; now he hid under the desk for hours.  He was sad; now he cried often and was inconsolable, sometimes saying he wanted to die.  He was going to school intermittently; now he stopped going altogether.  That first appointment couldn’t come too soon.

Like many parents, I walked into that first therapy appointment with vague but powerful hopes.  I hoped the therapist would know exactly what was going on with my son.  I hoped he would have smart and effective things for me to try.  I fervently hoped there was a path to wellness that would be short and have regular signposts so I would know I was on the right track. I hoped I could trust the therapist, trust the steps we were taking and trust the safety net I was hearing about.

There is a bargain parents enter into when they use mental health services and it’s simply this.  You give over some decision making and in return, you are expected to trust.

For the most part, we are happy to make that bargain at first.  We long for others to “get us” and define what our children need.  We long to trust that therapists, teachers and doctors have great intentions, a mountain of relevant knowledge and a strong base of experience.  We often begin with an uncritical kind of trust.

There are many kinds of trust ranging from blind trust to a “trust but verify” stance. While some of us find it easy to give our trust, many of us find it much harder. “What are we trusting?” we wonder. Expertise, good will, an attitude of “do no harm” or a commitment to our child’s mental health?   These can vary widely.  My son has had therapists, doctors and teachers who were experienced or newbies, skilled or blundering and some had a kind of humility while others were wrapped in arrogance.  I know I’m not the only parent who has been told a certain program, medication or approach is a perfect fit only later to hear that “we’ve never met a child quite like your son before.”

I read that Suzanne Massie, an American writer, met with President Ronald Reagan and taught him the Russian proverb “Doveryai, no proveryai” or “Trust, but verify.” She advised him that the Russians like to talk in proverbs so he should know a few.  He used the phrase often during important negotiations over treaties.  It’s also a phrase I wish I’d learned far earlier.

We think that the bargain we make, giving trust in exchange for help with decisions, access and healing, will be short term.  We learn that the next set of services, the next program, the next relationship asks for the same kind of trust.  Trust is defined as the belief in the reliability, truth, ability, or strength of someone or something. Sometimes that reliability or strength comes through for us.  Other times, not so much.  That makes it harder to keep trusting.

Doubt creeps in and it stays.  And it shows in our demeanor, our attitude and our body language.  I know it did in mine.

The unexpected can happen, too.  One therapist apologized to me when staff handled my son’s very rigid obsessive eating patterns with discipline, instead of understanding at his therapeutic school.  She then made changes so it didn’t happen again.  Another time a psychiatrist told me he regretted not listening to me about a medication choice.  I’d told him that we’d tried it before and it had been useless.  He insisted and had the same results.  Saying he chose wrongly made up a lot of lost ground.

It’s also awkward that therapists and other mental health professionals know so much about our lives from the trivial to the awkward to the things that make us feel vulnerable.  Yet, we often don’t know much about theirs.  When they share something, it can help our trust return.  The psychiatrist my son had in his teens (maybe the 6^th one by then) had pictures of her children and dog on her desk.  I knew she was a parent and she let me know one day that her child had ADHD.  I already liked her but I could feel a part of me relax and trust a little more.

Part of parent’s job is to make decisions for their child as well as their family.  You might consult others, but in the end you decide, adjust and live with the results.  When your child has mental health problems, you are faced with a different paradigm.  Instead of consulting, you share or give over decision making.  Instead of adjusting, you rely on others to make changes.  You still live with the results.  Most of us want to believe and trust.  Sometimes we are glad we did.  But other times, it’s hard.

Tags: Children's Mental Health, family involvement, parenting, therapy, trust

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Including parents should be part of effective trauma therapy

August 2nd, 2017

Some mornings as I drive to work, my mind wanders through my family memories.  I often wonder if my life is at all like other people’s lives.  I always think about my children first and then think of the many families and young people I have supported as they needed it. At times I think about all the kinds of therapy, services, supports and various medications that I have tried out. I think of the binders filled with IEPs, treatment plans, timelines and photos that I have taken to remember it all, and wonder if I remember all the facts. It can be hard with three children.  They are all unique and different but share one  thing – trauma.

Trauma is now looked at more and more with children (and adults) and there are lots of conversations about new supports, new research and new ideas. I have tried the Trauma-Focused Cognitive Behavioral Therapy approach, Eye Movement Desensitization and Reprocessing, sensory diet , Attachment Regulation and Competency and therapy after therapy. And you know how it works best? Including the family, especially the parent.

My child has received therapy in the residential setting and the community but when I have not been taught and included in the treatment, it really hasn’t worked most effectively.  Many therapists told me to focus on my trauma and they would focus on my child . The reality has always been that my trauma has already been worked on and the PTSD that I have incurred from going through the ongoing issues with my children has been just as hard.  The reality is that the one therapy where I was included resulted in both my son’s greatest gains and his ability to maintain his skills and improve in his journey.

Trauma has turned out to be so common that it is something more and more systems are identifying and seeking better outcomes. Is anyone noticing that when you include the parent, the treatment improves? Are we making sure the skills are taught to the parent so that the approach can be done during home time, day trips, holidays at home and more? Do people see the parent as an investment or a problem?  I would love to see more outcomes that look at how including parents helps the child. I absolutely know that improvement for the child is very much tied to the connection to the parent.

An underlying piece of the onion that no one sees and no one wants to understand continues to be the things many parents and caregivers do to make it feel safe for their child. It takes patience, understanding, empathy and sometimes just someone to show that they hear the parent and see them as the expert.  It has been the one area in my children’s life that has been a mystery to figure out.

As the brain develops things change, memories change, and behaviors to deal with it change too. My oldest son and I talk now about what memories we have and how we continue to feel lucky to be able to talk about it and how we are going to deal with it. Trauma comes up when you least expect it.

For us the biggest trigger is fire.  We remember a house fire that we were in. We are triggered by seeing the burnt house we drive by, a candle burning in a house, smell of smoke, a fire alarm and at times just people lighting a grill. It comes up and each of us deal with it differently. I approach it with a mindful approach, my middle son using the Attachment Regulation and Competency approach and my oldest using the Trauma-Focused Cognitive Behavioral Therapy approach. They are all correct and all okay- but without my understanding and embracing what works for them it would not work.

I appreciate being asked about trauma and talking to people about their approaches. It doesn’t go away. It is not the last peel of the onion for us– it is actually near the outside.

My last suggestions are the following:

1. Include parents in your treatment model- teach them and include them
2. Ask the parent what has worked and not worked
3. If a parent asks for assistance to get outside support for trauma, help connect them
4. Talk about positives that are possible so that parents know it gets better
5. Remember that it doesn’t matter how large or small – if people use the word trauma LISTEN

Let’s change trauma to something we talk about and help.

Meri Viano is our guest blogger.  She is the parent of two sons and a daughter who continue to inspire her blog posts.

 

Tags: Children's Mental Health, family involvement, parenting, therapy, trauma

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