Sunday, August 25, 2013

My Feelings Monster

Externalizing a problem is a well known therapy technique. It fits well with my constant emphasis on exploring behaviors rather than trying to change them. The trick is to do this work when the child is in a good, calm place or as my co-worker Steve Brown would say, when the iron is cold. Work on these thngs with a light touch, and with a lot of emphasis on how the behavior has been a friend to the child, has helped them out.

I am going to make a workbook for this out of these questions, and more I may think of:

Exploring Me 

My Name is:
I am ___ years old. 
Some of my favorite things are:
Color:
Music group:
Activity:
Food:
Outfit:
People:
Smell:
Book:
Movie:
School subject:
Some things I can’t stand are:
Some things that are gross are:
Some things that scare me are:
Some things that comfort me are:
I can’t wait until….           

What I want for my future:
Job:
Live:
Relationships:
Enjoy:
Learn:
Be sure to do:
However I have this problem that is getting between me and what I want.  The problem is:

I call it:
Here is a picture of it:


 

I am going to learn more about ___________
__________ has been my friend in the past. Here are some ways ________ has helped me:
However recently ________ has gotten a little too big and is getting in the way of what I want. So I plan to study him, learn all about him, and make friends with him again. That way I can use the best part of him, but he won’t get in my way.
The times ________ is strongest are:
The times he takes a nap and leaves me alone are:
The times I am glad he is there are:
The times I wish he would go away are:
 Here’s what I can do that feed _____ ‘s energy:
Here’s what I can do that makes him a little easier to get along with:
I am going to make some charts about me and _____.

I think I will start by rating how much energy he had this week. I’ll call 1 when he was sleeping or being cooperative. I’ll call 5 when he really took over my life and was bossing me around. I’ll make a note about anything I notice. 

 
Monday
Tuesday
Wed
Thursday
Friday
Saturday
Sunday
Morning
 
 
 
 
 
 
 
Afternoon
 
 
 
 
 
 
 
Notes
 
 
 
 
 
 
 
 
 
 
 

 Then I think I will track ways that _______ helped me.

 
Monday
Tuesday
Wed
Thursday
Friday
Saturday
Sunday
Morning
 
 
 
 
 
 
 
Afternoon
 
 
 
 
 
 
 
Notes
 
 
 
 
 
 
 
 
 
 
 

 Now I’m going to track things I did that bad him quieter and friendlier or louder and madder.   I’ll put an up arrow   when I make him madder and a down arrow   when I help him relax.

 
Monday
Tuesday
Wed
Thursday
Friday
Saturday
Sunday
Morning
 
 
 
 
 
 
 
 
 
Afternoon
 
 
 
 
 
 
 
 
 
Notes
 
 
 
 
 
 
 
 
 
 
 

 Other things I have learned about ________.

You know if I am kind to ____ he is kinder to me.  Now he is some times helping me get what I want instead of getting in my way so much.

So what do you think? Can you think of anything else I should add? Click on "comment" and let me know.

Sunday, August 11, 2013

Understanding a Child

Here are some basic questions to use as guidelines when trying to respond to problem behaviors in a child or youth: 

         What has happened to him?

         What has he learned about other people?

         What biological changes has he experienced?

         What skills has he learned to survive?

         What skills does he need to learn?  

When supporting parents or treaters in understanding behavior and responding to crisis:

         Ask how we understand the behavior using our formulation

         Relate to experiences in the child’s past

         Look for patterns

         Look for problem child is solving

         Consider fear and confusion

         Consider feeling overwhelmed

How can we help the child solve his problems in more positive ways?  

In responding to a crisis:

         Validate both adult and child

         If possible connect the child’s behavior to behaviors the adult has experienced in  their own life

         Look for ways to make amends and reconnect

 

Sunday, August 04, 2013

How To Create a Person

Terri is one of those kids who seems empty. She does not have an internal solid self that is continuous between moments. If she is with Sonia, she develops an accent. If she is with Janaia, she likes hip hop music; if she is with Courtney she likes Justin Beiber. She tells swears at her team mate Vanessa and tells her that she hates her one moment, and the next she says she loves Vanessa and wants a hug. She is at the mercy of her emotions. A small disappointment occurs and the feelings sweep over her, getting bigger and more extreme by the moment. She has no ability to modulate her feelings, instead the tide rises and swells until, suddenly, it breaks and Terri is completely fine. She has goals- in fact many, contradictory goals- but she has absolutely no ability to hang onto them or use them in the face of any obstacles. 

Terri has had many people in and out of her life and many changing circumstances. Her mother has been her one constant, and her mother has gone through a lot of hardship throughout Terri’s childhood years. Somehow Terri missed whatever it takes to consolidate a sense of who you are. 

Furthermore, Terri is caught in the dilemma that is so familiar within our population. She has learned that the infallible way to engage with others is to have problems. She has trouble figuring out how to be a good friend. She misses cues and doesn’t quite know when to get closer or when to move away. But, she can always get someone’s attention by baiting them, saying whatever will most upset them. She feels lost and empty inside, and has no ability to remember that people care about her when they are not physically present. So when adults are not with her or even are paying attention to someone else, she feel bereft. That’s okay- she has a surefire way of getting them back. Scream. Cut herself. Become agitated. Stand in the middle of a busy road. Adults tend to drift away and become less available, but they always have to engage when you become unsafe. 

So you have someone with no central core and a longstanding pattern of engaging people through problems. At this time Terri is so vulnerable to people in the world that would take advantage of her desperate need for love. What do you do? How can treaters help to build a person? 

Two overlapping fairly difficult treatment activities will be helpful. The first is to concentrate a lot of effort on helping Terri create who she is. This involves activities such as:
  • Create a Me Book with all sorts of categories, such as my favorite color, favorite TV show, singers I like, singers I do not like, etc. etc. Terri could use cut outs from magazines or drawings, some words (less emphasis on words).
  • Every day staff should ask Terri what she liked in her day, what she didn’t. What did she have for lunch? How was it? This should largely replace any questions about how her behavior was.
  •  Every time anyone does something with Terri, they can discuss it with her. At a movie, which character did she like? Why did they do what they did? Would she have done the same thing? If she is reading a book, relate it to what she thinks, feels, would do. Terri will not have much patience for these discussions but in short bursts she could be engaged in them.
  • Whenever possible give Terri choices and comment on her choices.” So, you chose these clothes, you like bright colors.”
  • Comment on any strengths or skills you see. Not just or even particularly coping skills- more things like “you bake good cupcakes”.
  • Engage Terri in helping staff to do work. Coach her to persist despite minor obstacles that arise.
  • Coach and support Terri to sustain her effort when something is hard, and point out the positive results.
  • Have posters in her room of “Things Terri Likes” and “Things Terri Does Not Like” and have her keep adding pictures from magazines.
The theme of this series is to help Terri move her self-definition away from a girl with severe psychiatric problems and define herself as an ordinary girl.  

The second part of the approach is to tell Terri that we understand she has learned that the best way to connect with people is to have problems, but that this is not true. We are going to help her learn other ways to connect that are more fun. So to do this we are going to be less interested in her problems and more interested in the rest of her life. 

How do we carry this out? When Terri goes into her emotional escalations, staff and her family of course have to interact with her and keep her safe. However, they should do so in as non-emotional, uninvolved, and routine way as they possibly can. The trick here is not to be punitive, judgmental or mean. You have to try to come from a stance that: we understand you have to do this, you are doing the best you can right now, we hope you can learn better ways but meanwhile we will keep you safe and look forward to when you are calm and we can have fun together.

It is essential that this non-involved, non-emotional approach to problems be paired with an extremely involved, very attached availability when Terri is not having problems. If Terri is available to play a game, have fun, do work, just talk, go for a walk, talk about her day, that is when staff and her family should be very interested, connected and involved. If the talk turns to psychiatric problems, the adults should be more distant and try to change the subject. The adult should be very interested and available to discuss normal teen age problems, like how do you know if a boy likes you? Or how much make up should I wear? The adult should encourage talk about Terri’s experiences and her reactions to them. 

It will also be helpful if Terri engages in rhythmic activities with an engaged adult. Dr. Bruce Perry’s work has shown us that these sort of activities help organize the brain and its ability to manage the body. These could include walking with someone, dance, music, drumming, petting animals, throwing a ball back and forth, jump rope, hand clapping games, etc. Doing fun physical activities with a connected adult will also be the best way to change Terri’s deepest assumptions about adults, that they are not there. 

This work is hard, and the adults doing it need a lot of sustenance and support. Yet Terri will only have a chance of a life worth living if she develops a sense of who she is. With time and repetition the adults who care about her can help her strengthen her inner core.