What Kind of Therapy Should We Use?

One of the questions I often hear is, “What KIND of therapy should we use to help our child?”  My answer is always, “I don’t know.”  (Real helpful, huh?)  The thing is, I don’t believe any ONE therapy will help.  Our kids’ “stuff” starts at different places and different ages.  Trauma that happens early (and often) is often much more difficult to treat therapeutically than trauma which happens when a child is older. 

When I started trying to sort through all the therapy options 4.5 years ago, it seemed everyone I knew was singing the praises of Beyond Consequences, Logic and Control (BCLC).  This method was started by Bryan Post (who calls himself “Dr.” but does not hold a doctoral degree from any accredited institution -- only an online and now defunct diploma mill, and who was disciplined by the state of Oklahoma in 2007) and Heather Forbes, LCSWC (who has distanced herself from Post and now runs BCLC without him).  I read all the BCLC books.  I read articles on Forbe’s website.  I learned techniques from other parents who’d attended her trainings.  However, some of the BCLC stuff was easily manipulated by my very smart kids.  Besides, my kids NEEDED to feel as though someone was in “control.”  They’d had to control too much in their lives, too early.  They needed the direction of an authoritative parent.  (Notice I did not use the word, “authoritarian.”  Authoritarian parenting results in rebellion and steps backward in the healing process.  Authoritative parenting lets the child know who is in charge, and gives them a sense of safety, consistency, and protection.  My kids need that.)  In short, BCLC had some things that worked, and some things that didn’t.

We have used a lot of play therapy and family therapy (and play therapy as family therapy).  These methods have helped a lot with attachment.  It is SO important to find a therapist who really knows about attachment and trauma.  Activities such as playing games and using sand trays have helped us find breakthroughs for both The Princess and Youngest Son.  For example, our therapist uses the game “Sorry” and adds some rules of her own.  If we get a “1,” we get out onto the board, but only if we say something good that’s happened since our last session.  If we get a “2,” we have to say something that concerns us.  If we get a “3” we have to say something that our family does together that we like, etc.  These games almost always never go on very long before our kids are working, without ever feeling (terribly) pressured to “go there.”  This method helps us deal with specific issues, using Interpersonal Therapy (IPT) methods.  It is the method by which I’ve learned the most in how to BE a therapeutic parent for my kids.

Cognitive Behavior Therapy is a very traditional therapy.  We use it a little bit, but only when things are going well.  When things hurt, and when a kid is dealing with trauma stored in the emotional part of their brain (amygdala), it’s nearly impossible to process things in the front part of their brain where cognition happens.  Still, it’s a therapy that has helped my kids feel as though they have some control over their lives -- when things are going well.

As I’ve written in earlier posts, for Youngest Son, Dialectical Behavioral Therapy (DBT) is the therapy that has changed his world (and ours).  However, this type of therapy would not have been possible with him even a year ago.  It is really just this school year that he’s matured enough, and has become stable enough on his medications, that he WANTS to change the way he responds to things.  Because DBT emphasizes responsibility for one’s own “stuff,” it was able to move him into a place where he could work cognitively and truly “own” his response to the things that trigger him.  It is only in recognizing that he DOES have PTSD, and that there ARE things that trigger him, that he is able to grasp hold of those triggers and change his behavior.

There are a lot of other things we’ve tried, as well, including “out-crazying the crazy.”  (Which is fun!)  We’ve even used (gasp!) traditional parenting methods in our therapeutic approach.  Like any of the above, sometimes it works and sometimes it doesn’t.  In my experience, raising hurt kids is a very fluid enterprise.

I found a PDF which may be helpful to some.  It describes various therapy methods in very basic terms and is a good introduction to the world of therapy.  You can find it HERE.  It might serve as a conversation starter when talking to a potential therapist for your family.  There are also lists of questions to ask available on various blogs and websites.  One good list is HERE.

Please feel free to share other ideas in the comments section.

More About DBT (Dialectical Behavior Therapy) and Ch-ch-changes

We are making choices for change in our household.  Some of those changes are forced upon us and we don’t like them.  They hurt.  Some of those changes are a result of getting ourselves into situations where we could hurt someone else, as well as be hurt.  Most of the changes have come from a sweet surrender, very connected to our faith, and our belief about the way God heals our family – how he refines gold.  If you’re just coming to the blog for the first time, this is an on-going theme for me these last several days.  The unexplainable JOY that has settled upon my soul in this full release cannot be explained in words.  There is relief, but it is not simply relief.  There is release, though it is not just release.  There is forgiveness from the One who matters most and there is unimaginable love for those who’ve harmed us, and continue to harm us, but those circumstances do not matter.  Again, it’s hard to explain.  Truth remains and some of that truth is uncomfortable.  Bitterness is gone in this household, at least.  The only word I have for it is “joy.”

As I wrote last time, Youngest Son has been doing very well these last several months.  Last year at this time, things were hard.  We were just getting into what would be a very difficult time of him going through a period of stealing, lying, shutting down, and being hateful.  At the time, a friend said some hard things to me, and I wasn’t ready to hear them.  Over time, God worked on my heart to understand the hurt that my son had endured and how it had changed his brain – for life.  No praying, pleading or begging to God was going to change that.  God had another plan.  It was not that He COULDN’T change it, but He doesn’t work that way, and I was slow to learn it.  The damage done to my son was not going to heal in the way I wanted it to heal.  Instead, God would lead us both to an acceptance of what is, what happened to him, and that he wasn’t the “same,” nor would he ever BE “the same” as my typical children.  Still, Youngest Son was his own unique, awesome, amazing kid.  He was a survivor.  He’s a smart kid and he’d learned to survive.  Since he was so smart, he could also learn to thrive.  He could heal THIS way – because God was in the business of refining gold!

We did more than two years of attachment therapy, and therapy that combined techniques from well-known adoption therapists such as Heather Forbes (Beyond Consequences, Logic, and Control), Daniel Hughes, Becky Bailey, and others.  We used what worked for us.  Not everything from every well-known clinician did work, but we used the things that helped us develop a connection.  Physical punishment never made a connection.  Time in (even if I was tired and didn’t want to do it), made the connection.  (That’s not to say that time outs did not have their place, too.  They still do.  I’m the one who needs them most often, so I don’t end up letting ALL my buttons get pushed and wind up doing something ineffective or harmful).  Validating my kids’ feelings worked.  Telling them to just “stop,” or just “obey,” or just “get over it,” only aggravated the situation.  They couldn’t JUST stop or obey, they had to have their feelings validated – even named for them because they could not name them alone.  They were too developmentally delayed emotionally to do so.  Natural consequences worked (still do).  Restitution worked, though it was hard.  Punishment only made matters worse.  It did not mean the same to my hurt children that it meant to my older, well-attached, biological children.  It felt like rejection.  Rejection meant using survival skills.  Survival skills were meant to build walls and stop more pain for the child, but they ended up causing more pain for all of us.  We still don’t have all this figured out or completely mastered, but after nearly four years in therapy, we’ve gotten a pretty good handle on a lot of it, most of the time.  I wish I’d had it more figured out at one year, or even two years home.  We could have been that much further along. – Ah, but I guess we’ve all learned at the rate we CAN learn.

After Youngest Son went through all those things, we decided it was time to be more directive with him in therapy and in our parenting.  Our therapist was using Dialectical Behavior Therapy (DBT) with teens and adults, and we decided to give it a go with Youngest Son, even though it would be flexible when/if his needs changed.  This therapy technique was originally developed by Dr. Marsha Linehan, Ph.D. (1993) and was initially used to help people with borderline personality disorder.  People with BPD usually struggle with other problems, not unlike the challenges our older adoptive kids face including complex trauma, anxiety, hyper-vigilance, depression, self-harm behaviors, out-of-control emotions (“big feelings” like rages), even substance abuse and suicide attempts.

When the brain is changed by trauma (read more about childhood trauma and the young brain HERE), it becomes hard-wired in a way that it processes emotions and events differently than the typical brain.  When something happens that triggers the brain back to that traumatic event, whether it is conscious or not in the person experiencing the trauma, the individual responds in reflex.  It is truly a reflex reaction.  DBT helps the person and his caregivers validate that reflex and those big feelings, and accept them.  When the person and his caregivers have learned to accept that past trauma, and that there is a profound difference in the way that person’s brain will always process triggers, then the healing can begin – the gold can be refined.  The older child can begin to use cognition of the triggers to gain control over behavior – even learning to be happy!

Our son has worked this year on being mindful of the things that trigger him.  He is working on interpersonal effectiveness by learning to respectfully and properly ask for the things he wants, accept when the answer is no (without TOO much begging and bargaining – he is, after all, still 16), and even accept correction when his behavior warrants it!  For example, yesterday after church, the kids were in the back seat of the car, bickering and just being plain nasty to one another.  Exasperated, I said, “Can’t you guys take ONE 10 minute car ride and THINK about treating the other person they way you’d like to be treated?  Can’t you TRY to be kind?”  Youngest son said, “Yes Ma’am.  Sorry.”  (I nearly had a heart attack.)  The Princess said, “But he started it!”  (Yeah, we’ll keep working with her.)  This example shows that Youngest Son has made great strides in regulating his emotions so that a trigger does not turn into a full-blown shut down (or rage).  By being more aware of the triggers, and accepting of an awareness of who he is, he is increasing his tolerance of the things that stress him.

In DBT therapy, the therapist is “in charge.”  It is more directive.  It is not so open-ended. 

The three fundamentals of DBT are 1) Cognitive Behavioral Therapy where the teen learns NEW behaviors – behaviors that show him that life is WORTH living; 2) Validation (Acceptance) where the teen is taught by the therapist to accept their differences, to use cognitive behavioral strategies and also to accept and validate new skills and behaviors learned.  [Note: this is a VERY simplified explanation.  For more detail, see the links posted below.]; and 3) Dialectics which teaches us that everything is connected to everything else (everyone is connected to everyone else), change is constant and inevitable, and with work, we can take even opposite thoughts, feelings, and perceptions and form a closer approximation to what is true and move forward.

A big challenge for hurt kids is getting “unstuck” from the age, stage, and developmental process the child was in when the trauma occurred.  When triggered, a child will revert to that age and stage and be unaware he’s done so.  This is why our kids will behave much younger than their chronological age when they are triggered.  DBT helps get them “unstuck” from those rigid ways of thinking, because it accepts those rigid thoughts, and allows for another arrow to shoot off into a more healthy direction.  It is accepting that life gave you lemons and trading those lemons for limes to make limeade.

The goals of DBT are to instill a closely-held belief that life is worth living, and that a good life now is not dependent upon having had a good life all along.  To do this, DBT organizes treatment into four stages:

1.      Gaining control of one’s behavior by reducing and then eliminating life-threatening thoughts and behaviors, and by eliminating behaviors that interfere with treatment.  (For Youngest Son, this was “controlled” by him with shutting down and refusing to participate in treatment.  When we because very firm and directive with him, he complied.)

2.      Moving from being shut down to being able to experience and express emotions.  By shutting down, they may think they have control, but they are taught instead that their traumatized brain has them in a state of “quiet desperation.”  Here the therapist and his caregivers become very directive so that the client experiences all of his emotions and is able to label them without shutting down.  This is the hard part.  In letting the emotion out, the client also then needs to learn to not allow those emotions to take over.

3.      Making it through ordinary life – working on ordinary life problems, rehearsing how to behave, what to say, how to do it.  THIS is what enabled my son to say, “Yes, Ma’am” on Sunday.  He had to be taught – firmly – how to do that.  Eventually, just yesterday, he was able to do it on his own.

4.      Moving from feeling incomplete and like something is missing to connection and completeness is something we are still in process for with Youngest Son.  For him, that connection began last summer when he made a real commitment to a Christian faith.  For other teens, it may be something different.  I happen to believe God makes the biggest difference in a refined gold healing.

Just as therapists are directive in DBT, parents must be keenly involved.  As parents, we must experience this therapy for ourselves.  As our kids go through these stages, we can, too – if we’re willing – if we’re not afraid to let go. 

Personally, I’ve equated it to being like Jonah.  I was called to Ninevah, but went running my own way and ended up in the belly of a stinky ol’ fish.  I’ve been spit out.  We’re heading to Ninevah where we belonged in the first place.  Our gold is being refined.  (Okay, so that’s not a mixed metaphor, but is there such thing as a mixed “biblephor?”  Eh, it works, don’t you think?)

Marsha Linehan, Ph.D.'s website

What is DBT?

DBT Self Help (Non-professional website)

Standing in the Gap

The following post is very much focused on my faith and prayer life in regards to healing hurt kids.  If this is not your belief, I respect that.  I am simply dealing with some things as a real person who happens to be a Christian, working with and loving on other real people who happen to be Christians, too.  I promise I'll get back to writing about therapeutic parenting ideas soon.  This post contains the story of Youngest Son's turn around and how he's been doing better.  So, if you're interested in that, you may want to continue reading.  If not, that's okay.  See you tomorrow!

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A friend asked me about a post I wrote the other day.  In it, I expressed my frustration with folks who do not parent traumatized kids telling me I should be praying for my children’s healing.  I said I wished people would understand that the traumatized brain is changed for life.  In another post, I explained the brain science behind this and the development of a child’s brain at birth, at age five, and at age 12+.  I explained a different kind of healing – one in which we, as parents, join in work God is ALREADY DOING in refining gold (I Peter 1:7).  I expressed my wish that people would not plead their own will, begging God for healing as they believe it should be, asking God to make their child typical (my new word for normal).

This friend (not an adoptive parent) asked what I would say to another adoptive parent that DID want everyone to just see their child as typical, not treating him or her any differently than another other kid, even as they do plead with God to heal their child into their own image.  He is working with a couple of kids who clearly need support that is different than support he gives to typical kids.  I replied that I would still stand with that parent in respect of their wishes -- that I would stand in the gap in prayer for them.  Their child is not my child.  Their calling is not my calling – even if we walk in similarly styled shoes.  I would not impose my beliefs upon them for their child, even as I would hope they would respect the work we are doing.  However, an adopted child IS different.  The child knows it even if the parents do not want to do anything differently to parent them, or to test them and get them additional support.  Ask any adult that was adopted.  They'll tell you they wished their parents had a better clue.  

I told my friend I would stand in prayer for these parents and for their child, asking God’s will for healing -- in the way He chose to bring healing into that family.  My friend asked if I thought that might upset some people that I wasn’t praying for healing with them?  I smiled and said, “Ah, but I am doing just that, my understanding just looks a little different. Besides, I wouldn't lord over them with prayer.  I'd pray in my private place.  If I had the opportunity to pray with them, I would verbally pray for God's edification and support.  I pray for people much more on my own, alone with God than I ever pray publicly with them.  It's just who I am.

I’ve simply learned God’s complete healing often looks different than I wish it would look sometimes.  When, I look back over the last 50+ years, I see God’s hand of healing happened in many ways that were different than I ever would have orchestrated myself.  So what if it didn’t look the way I wanted it to look sometimes, it all worked for the good to those who knew, and loved Him, and were called according to His purpose (Rom. 8:28).  If praying according to the Word upsets someone, or if praying along the lines I have seen in the bible that God teaches His people to pray upsets someone, then I would be sorry those parents are upset, but I will continue to pray to God on God’s terms.

He asked more questions and we got to a discussion of how my understanding of healing had changed last year, when I gave up my dreams for Youngest Son, and surrendered myself to whatever God’s dreams might be for him.  My friend  said I should tell that story, so here goes:

About a year or so ago, Youngest Son was stealing some pretty expensive electronics from classmates, youth group members, and his family.  He may have also taken things from other places.  We will likely never know the complete story.  What we do know, we’re pretty sure is 50% true and 50% lies.  I struggled with this boy since the day I picked him up at the orphanage in 2007.  He always challenged me.  He was always surly to me.  He always was sneaky and did whatever he wanted to behind my back, especially if I told him not to do it.  He was always “innocent.”  He always “didn’t know” what, why, how, or when something happened – or who did it.  We knew.  We’re not new.

He treated me like dirt.  He was always angry at me, no matter what I did or said.  We fought.  I didn’t always parent him the way I knew I had to.  He pushed my buttons and I yelled and said things I shouldn’t have.  He said lots more.  It hurt.  I wondered if I’d ever really love this kid.  I wondered if he would ever show ANY signs of attachment to us.  I wondered if he would end up in jail.  I told him I would report him to the police if I ever caught him stealing again and that I would press charges if he ever stole from us again.  I mean it.  I also told him I would NEVER bail him out of jail if he got arrested.  I mean that, too.

We talked.  We fought some more.  He fantasized about his life in Eastern Europe and how everything would have been just fine if he’d been left there.  He said he’d have a job, an apartment, a car, and a girlfriend by now.  He was delusional.  He couldn’t remember that at age 12, he’d had about the equivalent of a third grade education.  How he thought he’d be ready to be on his own at 16 is just plain – well, ‘don’t want to use that word. 

We had him tested with a battery of good neuropsychological and developmental/educational tests at a reputable mental health facility.  We increased meds and he went into a directive type of therapy called DBT (Dialectical Behavioral Therapy).  It was a gamble.  It wasn’t really anything like BCLC (Beyond Consequences, Logic, and Control) by Heather Forbes.  It was more than responsibility parenting by Dr. Michael Popkin.  It was much more task oriented cognitively and it FORCED him to think, to talk, to draw, to write, and to play games like Trouble and Sorry with therapeutic rules that made him talk and think even more.  The reason all this was a gamble is because everything we’d learned about dealing with hurt, older adopted kids from a post-institutionalized background told us this approach was a recipe for either total shut down or off-the-wall rage.  Surprisingly, and very happily, we got neither.

I remembered something another adoptive mom told me long before we brought The Princess and Youngest Son home.  She adopted three girls from foster care as older kids.  I had them in my AWANA group.  She said, “The biggest thing I want to teach my girls is to stop being the victim.  I want them to deal with the hurt and heal, but I don’t want them to use it as an excuse to stay messed up and perpetuate this victim crud into the next generation.” 

I don’t want my kids to be the victim either, but I had a hard time letting go of my pleas to God for healing of my son in my own image.  So, I continued to pray, and ask for prayer to this end.  I BEGGED.  I cried.  I moaned and groaned to trauma mamas I trust.  Most of them commiserated with me.  I’m glad for that.  I needed it so I didn’t feel so alone.  I still need it.  We trauma mamas need that from one another.  Sometimes, though, we need something else.  That’s what happened when one friend said to me, “Mama T, what if this is the child you have?  What if this IS Youngest Son?  What if he’s never going to be the dream you have?  What if God has a different dream for him?  A different kind of healing?”

I didn’t want to hear it.  I was hurting.  I wanted MY hurt acknowledged. 

She was spot on.

It took me a few weeks, but I realized my friend was correct, and God had used her to speak truth to me.  He placed these kids into our family for His reasons.  He was at work long before they ever got home.  I had to surrender my selfish dreams for healing for my kids in my own image to His much more effective plan for refined gold healing.  Youngest Son’s brain was not going to change.  Trauma creates a neuropsychological process in the brain that does not change.  It is a reflex like any other reflex.  His healing is coming by learning to process those reflexes.  For Youngest Son, it was in being VERY directive and giving CLEAR instructions, with only a couple of things to work on at a time, that started to make a difference as we prayed for support to THAT end.

Last summer, Youngest Son apologized to his brothers for the lying and stealing.  He worked to make restitution.  He worked to restore relationships.  He wanted an honest relationship with God – a real one, not a holier-than-thou showy one.  He told other people he was glad he’d been adopted into our family.  (We have yet to hear it – baby steps.)

Being very directive with Youngest Son has made him feel more in control, even though it would appear to most that his therapist and his parents are the ones in control.  Since he never got that kind of guidance as a young child, he never had the opportunity to learn to make good decisions.  Like a younger child, he needs to be told what to do and how to do it.  It is only then that he can begin to THINK about HOW the things he’s doing make a difference in how he feels and how he navigates the world.  He has goals in his treatment plan and his caseworker reminds him of those goals every two weeks.  He’s working.  He is very consciously working.  He gets very direct instruction on HOW to do that.  He feels successful because he’s doing well.  We still have work to do, and I’m still always waiting for a shoe to drop, but he’s making it.  He’s come such a long way.  I am so proud of him.  We are attaching.  He is MY boy!  He is healing because we gave up on asking for our vision of what his healing should look like, and gave into God refining gold.

I am confident The Princess will get back on track.  We just have to figure out a strategy that works for her.  Prayers are appreciated as we go through adjustments.  She’s changing meds and there is just so much going on with her.  I have figured out that part of the gold that’s being refined is my patience with her.  I hate that.  Frick (as Christine would say.)