Saturday, October 3, 2009

The Emotional Connections of Family Therapy

Yesterday Richard Schwartz presented an incredible model of therapy. His Internal Family Systems utilize the viewpoints of systemic family therapy to address the inner conflicts within our minds. It was interesting to hear his perspective that he has not always felt welcome at AAMFT because of his model’s emphasis on the ‘inner mind’ struggles and because there is intense emotion experienced with this type of therapy. He suggested that the early days anticipation of success has not been met and has caused some newer models to abandon true ‘systemic thinking’ such as narrative therapy and solution focus therapy, where neither one offers transformative change. The inner ‘deep’ work of IFS taps into the deeper emotions of fear and anger and allows one to truly change how they related to others. He further suggested there was much in common with Susan Johnson Emotionally Focused Couples Therapy.

Today Susan Johnson began with “there is an exquisite logic to our deepest emotions” and that family therapy has missed the boat by not addressing issues of love. She immediately challenged MFTs to expand their understanding of therapy to realize reducing conflict and lowering reactive is not ‘good enough’ therapy. Small emotional signals from our partner such as a lift of an eyebrow can turn a marriage into a tornado. Flexible joyful connection can bring deep fulfillment to our families. Are there basic mechanisms of change that cut across models of therapy…couples that move into to deeper emotions in therapy will move into deeper sense of personal fulfillment and more meaningful relationships. We need to know the core issues of love and bonding. As systems theorists we need to know the inner loop of the interplay of emotions and inner cognitions as well as the outer loop of how people related to each other in their interpersonal world. Set our sights higher as therapists…instead of just reducing conflicts and lower reactivity to creating nurturance and love. The founding fathers of our field had no understanding of love and nurturance.

Some take home thoughts: We are attaching peoples and there is much of the tissue in our brains is dedicated to detecting the emotional signals of those we are close to. We need a special connection with others…lovers regulate each other physiology. Connection with an attachment figure anesthetizes the shocks of the world. There is only effective or ineffective dependency. We do not grow out of dependency. If we are securely attached we will be more confident and resilient in the stresses of life.

Love relationships are defined by emotional responsiveness and the question or all questions, “Are you there for me?” If you have this sense of felt security all other problems can be managed safely. How you handle security and disconnection enables us to handle all other issues in life. Sue also challenged the present status of MFT by stating “we don’t need magic questions” (a gentle poke at Solution Focus Therapy?) but we much engage in the understanding of love. She also took Minuchin and Nichol’s to task by challenging their ‘we must understand the limits of relationships’ and stating as therapists we must help couples create ‘safe haven connections’ so they can explore the limitless possibilities of human relationships.

Friday, October 2, 2009

Families with Autism Spectrum Disorders…stuff that works...

1 in 150 eight year old children in the U.S. has an Autism Spectrum Disorder and this spectrum has a wide range from high functioning to profoundly impaired. Of course for parents who have a child diagnosed with an ASD has the potential for: Added stress, greater social isolation, more marital discord, greater caregiving burdens, increase sense of meaning and purpose, greater family solidarity and unity, and opportunities for growth and skill development. If you look at this short list of potentialities you will see some are positive and some are negative.

It is exciting to see Marriage and Family Therapists doing research in the area. Julie Ramisch, Robert Hock, and Tina Timm, found that parents with an ASD child wanted to improve their relationship with their child (41%), wanted to improve their relationship with each other (32%), wanted to discuss individual concerns such as depression or anxiety (32%), wanted parenting advice (20%), and wanted parenting tools to use in the future (18%). Family therapist can offer assistance and coaching is all of these areas.

The take home message for MFT is even though research points to stressful family situations, good things can and do happen for families with a child with an ASD. The need for competent professionals who deal with the whole family is great and thorough assessment and effective intervention can help families adapt and succeed.

One family stated: “I suppose if it doesn’t – destroy is a pretty harsh word – but disabilities can really strain a marriage unlike anything’s else, I think a child’s disabilities, and you either become stronger, I think, in a relationship or it probably disintegrates. So if you survive all those things there is not a lot that can come between you in life that would really cause strain on a marriage.”

Difficult Kids and Difficult Parents…Promoting working together…

I attended a six hour workshop with James Keim yesterday and the subject was Oppositional Defiant Disorder in Children. The basic presentation was taken from his chapter written several years ago but still the information was useful and meaningful to my work.

When working with ODD Children there are two main therapeutic GOALS: Help them become more age appropriate in their interactional style and help to disempower them in a healthy ways. A couple of caveats are worth noting here:

1. YOU CAN DO MORE HARM THAN GOOD: if you take a kid that is weak in authority and take away even more authority

2. YOU CAN DO MORE HARM THAN GOOD: if you take a kid that is powerful and give them more power.

With both of those caveats in mind and with the overall therapeutic GOALS I will discuss what is ODD and how it looks in within the family structure. The American Psychiatric Association defines ODD as

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults' requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful or vindictive
AND only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level AND the disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning AND the behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder AND (almost done with this long definition) if child is not diagnosed with a Conduct Disorder, AND, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder. (Reprinted in part from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition 1994 American Psychiatric Association).

Whee…now with that in mind we need to add three more components and it is in these THREE ADDITIONAL PIECES where the helpful information comes from:

1. ODD Children are process oriented, that is, during confrontation they are more focused on the process rather than on the outcome of the confrontation. Process orientation is different from outcome orientation…it is not more or less healthy but it is about what gets communicated in the process of the confrontation. There is a MISMATCH between the process oriented kids and the outcome oriented parents. Now as you think about a confrontation between an ODD CHILD and her parents ask yourself three questions:
a. Who determines the timing…that is who controls when the discussion/conflict/confrontation takes place?
b. Who determines the content and direction during the confrontation...that is who determines what is discussed and the direction the discussion goes during the confrontation.
c. Who determines the mood during the confrontation…ah, yes, who controls the emotional atmosphere in which the confrontation occurs.
You can see that ODD children, who are process oriented, determine the timing, content, direction and the mood of the confrontation and the parent is totally derailed, disempowered, disheveled, disheartened, discouraged, etc.
Let’s look a bit more at the differences between outcome orientation versus process orientation. I think this illustration will serve to distinguish one orientation from the other. If you were to visit the IRS and the goal of your visit is to be sure you owe no more money then during that visit you were outcome oriented. However, if your goal in visiting the IRS was to push the emotional buttons of the IRS agent and to tell him how mean and unfair he is, then your visit would be characterized as being process oriented.

2. ODD children have a strong win/lose perspective…or they have a win/lose orientation…the ODD kid is expecting to win. The ODD kid approaches confrontational situations with a win/lose perspective! It is not about determining the outcome of the confrontation but about determining the PROCESS of the confrontation. ODD children have the MYTH of WINNING that drives most of their confrontational energy…it is the MYTH they are they are winning if they control the process! The “common sense” of the ODD teenager is that because I have pushed your buttons, you emotionally reacted, I have gotten my way and therefore I have won! The ODD kids have bought into the notion there must be a winner and a loser…when you apply this to emotional relationships, of course, it does not work.

It is very important for adults to recognize the fact that they may have this same perspective when they have conflicts between themselves! The ‘common sense’ notion that adults often have is seen in “IF you just had enough insight/if you just understood my point of view then we would be OK (or at least I would be OK) I would win!”

3. ODD children have a HIGH Hierarchy…that is they argue like emotionally immature adults...they believe and act like they are in charge! In fact when you witness a live confrontation between ODD teenagers and their parents it is very difficult to determine who the ADULTS are and who are the CHILDREN!

When ODD children get better (whether with family therapy or by themselves) then both the child and the parents begin to act more age appropriate in their interactional style…it feels more age appropriate!

Some things to remember:
ODD kids have a basic distrust of the adult system…they are unsure of the motivations of adults and there are a lot of different ways young people can come to that basic distrust.

The best special education teachers have lots of facial expression, lots of warmth, and there is no question of about their benevolent intent.

OPPOSITIONAL BEHAVIOR occurs within interactions with authority figures, therefore individual therapy is not beneficial for ODD kids. ODD happens between people…these ODD interactions don't happen in the imagination of the kid.

Many time it is MORE EFFECTIVE to coach adults rather than coaching the kids.
KIDS view yelling different than ADULTS do…ADULTS see yelling as raising the voice while KIDS view yelling as saying anything critical of them…

ODD BEHAVIOR is statistically associated with ADD/ADHD, with problems of SELF SOOTHING at an early age, and COLIC at an early age.

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