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A Series of Writings for Clinicians on Common Factors Research and What Promotes Change in Couple and Family Therapy, Part 1

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By Jason Briggs, MA

What motivates a client to change and what are the processes therapists can use to help?

If you’re like me, most therapists have a period in their learning curve where they have spent countless hours being ahead of their clients’ abilities to promote effective change because we aren’t seeing what stage of change our clients are in, and aren’t sure what processes could help motivate our clients in therapy. We (therapists) can also be less skillful about being transparent with each other about our own work with clients and how we promote change and challenges to this process we call psycho (mind/soul) therapy (treatment used to treat issues, problems and symptoms one feels conflicted about). This series is  an homage to Common factors research (CFR), that points to common factors which underlie all therapy models that work together to promote change in therapy. The three Common factors researchers work I will be summarizing are authored by Douglas H. Spenkle PhD, Sean Davis PhD and (last but not least) Jay L. Lebow, PhD, which can be found in their book Common Factors in Couple and Family Therapy, The Overlooked Foundation for Effective Practice. Sean Davis is in private practice, a supervisor in the Roseville, CA area, and a local Professor at Alliant International University, Sacramento Campus. Dr. Davis was my past academic advisor and admittedly an “at a distance” self-selected role model.

In the age of having many models of therapy to choose from its helpful to know two Common Factors (CF) that help promote effective change in Common factors research (CFR), that being the ‘client factor’ and ‘therapist factor’ both, in connection with each other. What is it specifically about the client that lends itself to change and what is the role of the therapist in supporting this change, that both the therapist and client might have an effective therapy outcome?  Many therapists and clients assume it is what the therapist does that is the most important aspect of therapy, but Common Factors Research asserts that it’s not only what the client does in therapy, but what the client does in response to the therapist, or how a client uses and focuses on the information the therapist presents. Ultimately it’s a collaborative venture.

As is often the case, I will invite my clients to share in what is called a “here and now” time, at the end of our sessions to explore our shared experiences in the session. In the “here and now”, I invite my clients to share what they found was helpful, worked or what didn’t work, or just to relate their experience in our session and in particular, with me; their answers never cease to amaze me, often citing something I felt was just a passing comment, experience or interaction or some other very important aspect of their experience. Using this “here and now” time, it is a both/and way of interacting, the focus is on the client but the therapist is wise to find ways to work with clients’ perceptions, being curious about them, and helping them identify what works for them. This should include what they struggle with in sharing their own experiences, cultivating a focus on what a client may feel is “ok” in therapy according to their worldview, and then seek ways that help promote a motivation to expand their worldview and promote change.

The Common Factors researchers do note that an extreme view of Common Factors research may engender a therapist to say “even a poor therapist can do therapy” but in their book they actually say quite the opposite and tend to place great value and importance in their role, but not by placing their own role above the clients’ role. They note, that the therapist who places such extreme value on client factors, to the exclusion of the therapists’ own involvement and development, may run the risk of discouraging themselves to think they have nothing to offer to help the client change and a thus engender a “why try” attitude that could encourage therapist laziness and a lack of a sense of accountability to clients.” The Common Factors research discusses the nature of clients’ and therapists’ factors as being reciprocal (giving and receiving in balance) and further discusses how the therapist can motivate a client to change also asserting that a client motivated to change can then impact the therapist’s motivation and behavior! That’s reciprocity! So, it is clear that their emphasis is on the value and importance of matching our own behaviors as therapists with the client’s motivation to change, and what processes will help them engage in such a change.

It seems all humans pass through Stages of Change (SOC-a common behavioral health model) and have various levels of motivation. Known by therapists as Motivational Interviewing (MI), MI has typically been thought to be helpful to only substance abusers, but it has been used successfully with individuals, couples, and families with other issues as well. Motivation is always present according to the researchers, but that it looks differently depending on each stage, and that each client is motivated by different things. There are 6 stages of change (SOC) and they are Pre-Contemplation, Contemplation, Preparation, Action, Maintenance, and Termination. There are 9 processes of change which are Consciousness Raising, Dramatic Relief, Environmental Re-evaluation, Self-Re-evaluation, Self-Liberation, Contingency Management , Helping Relationships and Counter-Conditioning and finally Stimulus Control.

This will only focus on clients in the SOC called Pre-contemplation, the helpful process and interventions that Common Factors research has shown will help clients at this particular motivation level in their process of change. These clients it would seem are not intending to change anytime in ‘the next 6 months’ and they are either unaware of or uninformed about the severity of their problems. Clients who wish to successfully move from this stage to the next, Contemplation, “need to increase the number of pros (versus cons) they see in a life without the problem.” The Common Factors researchers suggest helping clients focus on increasing insight, suggesting that using the Consciousness Raising processes are ideal during this (SOC). A couple of Consciousness Raising processes offered that I find effective in my practice are, bibliotherapy (book therapy) and psychoeducation (education of the psyche, and how it becomes rigid and flexible in its structures). Another is making a list of what the positive effects of living life without the problem and envisioning a life without the problem.  Another I enjoy is helping clients experience guided imagery that focuses on adaptive information they may need to make a shift or change.

Another process of change that may prove helpful during the Pre contemplation SOC is Dramatic Relief, which much like guided imagery, it activates emotions that are felt during the problem. Interventions using this process could be role plays, guided imagery that focuses on a life with the problem in the future, and experiential interventions, such as empty chair/Gestalt, sculpting, inner dialog, etc.

The last process of change Common Factors researchers note that is helpful during this SOC is Environmental Re-evaluation. These interventions include helping the client to accept the perceptions of their family members by carefully exploring each person’s readiness to give and receive feedback, and when ready (can manage emotions), preparing the client to lean into the perceptions of their family, and helping the client experience understanding (not necessarily agreement). Another process is to use any experiential technique that will allow the client to cultivate empathy for those impacted by their behaviors, how it affects the system’s environment, and to see how those behaviors are experienced by others in the system.

Being willing to explore, understand, and apply Common Factors research can help therapists and clients move through change in life in a much more empathic way. There is always motivation to be found and it is the clinician’s role to see what motivates our clients so they can bring about effective change in their lives.

Coming soon,  my next writing in this Common Factors blog series is on Contemplation, the next stage of change following Pre-contemplation and helpful processes for the therapist to help clients embrace their own limitless potential for healing and growth.


References

Douglas H. Sprenkle,Sean D. Davis, Jay L. Lebow. Common Factors in Couple and Family Therapy, Guilford Press, Aug 10, 2009

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The Components of Trustworthy Relationships

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By Cassandra Vogeli, Psy.D. Candidate, M.A.

“Life isn’t fair. But Relationships can be.” – Janet Hibbs (2010)

In her book, Try to See it My Way: Being Fair in Love and Marriage, Janet Hibbs outlines the importance of fair give and take within relationships. We each come into life from families with various ideas about what is fair, what we are entitled to (constructive and destructive), and how to go about getting such needs met. Unfortunately, sometimes these ideas about fairness and the ways we go about meeting our own needs can end up working against our closest relationships and us.  Nagy & Krasner (1986) suggest that in order to create healthy and balanced relationships as well as get our needs met in a way that is constructive within our relationships; we need to understand our own fairness model. Hibbs (2010) outlines four very useful and practical elements in the process of being fair within relationships; first I will outline them below and then use them in an everyday example so that you can see what they look like in action.

  • The first is a concept called, reciprocity. Reciprocity as defined by Hibbs is, “The balance of mutual care and consideration.” Reciprocity is the act of giving to a partner or relationship with trust that they will reasonably give back in some way at some time. Be aware not to mistake this with tit-for-tat giving, where one might say, “I will do this for you (ONLY) if you do this for me”; this type of giving erodes trust.
  • The second concept is acknowledgment. Acknowledgement, although often undervalued and overlooked, is kind of a one-two punch for constructively giving in a relationship. It serves to give credit to your partner, affirm their good intentions, as well as validate their reality. This means putting yourself in your partner’s shoes and recognizing their effort or positive intentions.
  • Next there are (fair) claims. Fair claims are part of an earned entitlement based on past giving within the relationship, to ask for one’s needs to be met, or to request certain destructive behaviors to end. In order for a claim to be “fair” it should: (1) be realistic (2) not take advantage of your partner’s trust and (3) it must be earned between the two relating individuals.
  • The last element outlined by Hibbs is trust. Trust is created through each of the aforementioned: reciprocity, mutual acknowledgement of efforts and intentions, as well as fair claims. Trust can be built or depleted through different acts of reciprocity, acknowledgment, and fair claims. Trust grows when needs are considered, even if they are not met, this is important to remember. The more trust that exists within a relationship, the more a healthy “closeness” can exist between the couple (Hargrave & Pfitzer, 2003). Hibbs’ summarizes trust beautifully: “In a healthy relationship, you’re able to give freely and trust that you’ll receive care in return.”

Now let’s see these four elements of fairness in action. In the first example I will outline a situation in which reciprocity, acknowledgement, fair claims, and trust are not utilized:

Consider the couple James and Sara, who have been married for 12 years.  One evening Sara is working late, so James decides to cook dinner and have it ready when Sara arrives home. Sara enters and is so pleased to find dinner on the table for her.  After the couple finishes eating, Sara enters the kitchen and James sits down on the couch to wind down from the day. Upon entering the kitchen Sara sees a gigantic mess awaiting her, dishes everywhere, food all over the floor and counter tops, pans coated with a layer of sticky residue, and all she can think is, ‘why does he always make such a mess when he cooks!’ Trying to hold it together, Sara begins to clean the kitchen silently hoping that James will join in to help her. By the time she wades through the mess by herself, she is fuming, and her attempts to curb her aggression are futile. Unable to ignore the bubbling aggression, she explodes at James. “You always make a huge mess when you cook! You never clean up after yourself!” Triggered by her aggressive outburst James retorts, “You never appreciate anything I do, nothing is ever good enough! I tried to make dinner for you as a favor and this is the thanks I get?” Sara, still fuming, shoots back, “I didn’t ask for this! I would have rather picked up a pizza on the way home then have to clean up this mess!” The fight escalates and the emotional “bank account” within the couple system is eroded.

Now let’s look at how this situation may have gone using the four elements of fairness Hibbs outlines:

This time when Sara enters the kitchen she decides to handle things a bit differently.  Using acknowledgement, she states, “I appreciate you making dinner for me, I know you did it as a favor because I had a long day.” Not disregarding her own feelings, she makes a fair claim, “I am exhausted after today. Could you clean the kitchen for me?” James tired as well, acknowledges Sara and also makes a claim, “I bet you’re tired, I apologize for making such a big mess. I’m really beat as well, would it be okay with you if we left the dishes tonight and did them in the morning?” Sara acknowledges his effort and agrees while she also makes a claim for James to be more conscious of making a mess when he cooks and the couple leaves the situation having built trust and reciprocity, instead of putting more stress on their relationship. Following these guidelines may help to ensure that we grow from mistakes and shortcomings, rather than depleting our relationships unintentionally.

If you are interested in learning more about fairness within relationships, or about your own fairness model, I recommend checking out “Try to See it My Way” by Janet Hibbs. It is a wonderful book full of great resources and hands on exercises to really help your self-awareness and your relationship with your partner grow. Happy reading!


References

Boszormenyi-Nagy, I., & Krasner, B. R. (1986). Between give and take: A clinical guide to contextual therapy. New York: Brunner/Mazel.

Hargrave, T. D., & Pfitzer, F. (2003). The new contextual therapy: Guiding power of give and take. New York: Routledge.

Hibbs, J. B., Getzen, K. J. (2010). Try to see it my way: Being fair in love and marriage.

Penguin Group, New York, NY.

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Enhancing Resilience

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By Dr. Jennie Lorena Thomas

Most of us may not like to be reminded of this, as being human means we will face pain at some points during our journey through this world. Unfortunately, we cannot avoid this life’s truth no matter who we are. Fortunately, we now know that the sooner you internalize this truth and grieve your losses, the happier, less stressed, and healthier you will feel and live.

Thus, while you journey towards this truth, let me reinforce the truth of the strength our resilient spirit is capable. This spirit or energy essence can allow us to stand up to, and breathe through any adversity; it allows us to shine both inside and out. In fact, Change Basics (Russell and Russel, 2006) contains resiliency tips that solidify this point.

  • Proactive people actively engage change and shape their own vision, keep their locus of control focused internally, preserve their self-efficacy, have a strong self-confidence and self- assurance, and are aware that their choices influence their response to challenges
  • Develop a personal meaning and vision so they have a clear belief and vision of what they want to create. They allow that purpose to propel them forward, so when adversity approaches, they can see it through hopeful eyes as a possible opportunity and stay focused on the larger more realistic view of life beyond it
  • They nurture interpersonal competence, our ability to truly empathize with others, thus magnifying their social awareness and interpersonal efficacy
  • They remain flexible and adaptable by staying aware of what’s happening around them so they can then make sensible adjustments in response.
  • They take a moment to think before acting. The more you practice the skill of organizing your thoughts and feelings; the result tends to yield an inner focus and outward stability. (Prioritizing to-do lists, and then following that prioritization, will enable you to manage your time effectively)
  • Strive to problem solve by analyzing and breaking down complex challenges to discover and explore their root causes. Recognize and clearly define the interdependence of these challenges within the larger system, and then set manageable goals.
  • Connection with community is important in attracting healthy caring and supportive relationships that create love and trust, provide effective mentors, and offer encouragement and reassurance. This is a foundation for continued personal efficacy.

 

Ways to Strengthen Resilience

After reading through these examples, perhaps select one tip a day and work with it a bit. For example, take the flexibility concept and consciously work on growing your awareness of your surroundings for a day. See the ways you’re less flexible and perhaps choose to let that some of that rigidity go. Alternatively, be that problem-solver for a day by taking a problem and breaking it into its constituent parts, then analyze how the parts fit together, and see how your various responses can be part of the problem and solution. Just observe how things can become more manageable. And add an extra kick of self-confidence to your day. Speak from your belly, look people in the eye, straighten your spine and put your shoulders back a bit. Feel yourself grow taller.

What everyone needs to know is that we actually have access to everything we need for a balanced life: awareness, determination, vision, creativity, love, passion, faith, and intuition. These human endowments begin to be realized when we focus on them, and they come into full bloom when we let them ripple through us, further building our innate resilience.

Admittedly, the journey as life students is sometimes arduous, often working full-time, and/or going to school while taking care of our families, maintaining ourselves, working to complete our degrees, get that position, that promotion, or that bonus. Let me now acknowledge each of you—great job for your hard work and continued effort. Keep smiling and know you are not alone.

 


References

Mary K. Alvord, PhD, Director, Group Therapy Center at Alvord, Baker, and Associates, LLC, Silver Spring, MD

Robin Gurwitch, PhD, University of Oklahoma Health Sciences Center

Russell and Russel, (2006) Measuring Employee Resilience, Published in the 2006 Pfeiffer Annual Training

Jana Martin, PhD, private practice, Long Beach, CA; (2003) President of the California Psychological Association

Ronald S. Palomares, PhD, Assistant Executive Director, Practice, American Psychological Association

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Self Compassion

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By Christine Brady, MA

When was the last time you recall hearing something like the following; “I can’t believe that you did that, what an idiot, you are so stupid, you always mess everything up.” Would you be surprised to know that many people speak to themselves like this on a daily basis?

While most of us would never dream of saying something so toxic to others we may have no problem speaking to ourselves this way. It may seem natural to respond with compassion and empathy to others that may be struggling while at the same time we may choose not to extend that same consideration to ourselves. It’s as if we believe that by coming down hard on ourselves we will somehow improve our performance.

Life naturally includes challenges and setbacks. We can add to the impact of intense events in our lives by colluding with an internalized bully. Constantly ruminating about past mistakes, current errors, and potential future gaffs keeps you out of the present moment and can exacerbate feelings of depression, anxiety, low self-esteem, relationship problems, and difficulty in recovering from setbacks.

Developing a sense of self-compassion isn’t merely positive thinking or repeating mantras in an attempt to quiet your internal bully, it is based in the relationship that we have with ourselves. Self-compassion is the willingness to treat ourselves with the same caring support that we extend to others.

Self-compassion balances the truth of a situation such as “I made a mistake” with the ability to realize that making a mistake does not diminish your worth and value. This allows you to both acknowledge what happened directly while avoiding the feelings of shame that can lead to feelings of hopelessness, thereby increasing the level of difficulty in finding solutions.

Self-compassion is a skill that allows us to navigate our humanness with objectivity, empathy, understanding, and kindness. It is a way in which we can relate to ourselves both when we’re struggling and when things are going well. This compassionate view of ourselves brings light to the dark places, soothes the soul, and provides a safe space for imagining creative solutions to everyday problems.

The following is adapted from KimFredrickson.com (2015) We All Need Kindness, Identifying Self-Compassionate Ways that we can relate to Ourselves.

Truths We Can Share with Ourselves

    • You are valuable and precious, no matter what is happening
    • Even in the suffering you are going through, you are valuable and of great worth
    • Most people do the best they can with what they have. It is true that we want to live as healthy lives as possible, and it is also true that there are deep reasons why we make choices that can cause us harm
    • It is ok, and normal to be angry, confused, sad, and all jumbled up inside. These feelings are a normal and necessary part of the process of adjusting to what you are going through
    • Allow yourself to have and express your feelings if possible, because this expression cleanses and will subside
    • No matter what is happening, you can be a good friend to yourself
    • Take this time to allow your body/mind/spirit to heal. This is just as important as other things you need to do. Make sure care of yourself is in your schedule
    • Listen to yourself (your heart, feelings, thoughts, body, and spirit). What do you need right now? What would a really good friend do for you right now? You can be that friend
    • You are going through such a difficult time. What would the kindest person you know say to you right now?
    • Give yourself time to have a good cry and sleep. This may be just what you need
    • Breathe….and Rest…and be Kind…to You!

References

Fredrickson, K. (2015, November 19). We all need kindness. [web log post] Retrieved December 4, 2015 from http://www.kimfredrickson.com/we-all-need-kindness/

Fredrickson, K. (2015). Give yourself a break turning your inner critic into a compassionate friend. Grand Rapids, MI: Revell.

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‘Thinking in Pictures’ Helps Us Understand Life on the Spectrum

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Temple Grandin, Ph.D. at a TED Conference in 2010 (Photo Credit: Red Maxwell)

By Nicolina Santoro, MA, IMF 77972

As I read Thinking in Pictures: My Life with Autism by Temple Grandin, Ph.D., a pang of jealousy pervades my thoughts. Having the ability to engineer intricate machinery, memorize volumes of information, or create art that inspires us to new levels of emotional ecstasy, would seem to be an amazing gift.

However, on the autism spectrum, it is not without deficit to other areas of functioning. Thinking in Pictures also highlights the discrimination people with disabilities endure. Temple Grandin describes her visual memory skills as similar to the way Pinterest can group thoughts visually. Any information she needs for her task can be called up at will in a series of picture associations. These pictures are the road map she continuously develops to bring her to the next door of personal evolution, and how she copes with the lack of sensitivity to social cues and abstract conceptual understanding that most of us take for granted.

Thinking in Pictures is not just a story of the author’s life with autism, it is a comprehensive overview of the symptoms of autism, past and current research, and treatments now widely used.

Grandin is extremely high functioning on the autistic spectrum. Most people envision the autistic as mute, unresponsive and unreachable, like trying to interact with someone through opaque plate glass. For so long the autistic mind has been shrouded in mystery, its intricacies and strength misconstrued by the strange behaviors autistic people sometimes exhibit. It’s easy for most of us to relate to one another. Social situations are, for the most part, pleasurable and enlightening to the normal mind. Due to difficulties with these types of abstract concepts, a person on the autistic spectrum usually lacks the ability to easily comprehend social cues for etiquette and relationships.

Grandin recounts her difficulties in school when trying to form relationships with her fellow students, but relating to animals, and seeing as they do was her inherent passion and gift. Her visual memory enabled her to engineer significant contributions to this world in how animals are humanely treated and slaughtered. Grandin also furthered research around the concept of squeezing a person in midst of a meltdown to abate the symptoms of anxiety that accompany sensory overload.

Thinking in Pictures allows us to imagine many of the challenges that people on the spectrum have to contend with, including sensory hyper-arousal, difficulties with verbal expression, and motor tics. Grandin has made many significant contributions to the study of autism. Her ability to describe life with autism has enabled to her to create systems for dealing with various symptoms. The author’s own hyper-arousal experiences coupled with seeing cattle in distress before their slaughter, enabled the creation of a device that can bring the user down from a hyper-aroused state using a squeezing machine. The user crawls into a box in which the sides can be manipulated to cause the amount of pressure that would produce the desired state of calm. In Grandin’s research of others who suffer from autism, pressure seems to be an effective manner of coping with the hyper-arousal anxiety component of the disorder.

Grandin emphasizes that people on the spectrum need to be encouraged to explore what they are good at from an early age, so they are not depriving the brain of much needed sensory experiences. As high functioning adults, jobs and hobbies are also important.

Science has advanced our knowledge of autism greatly, and the high functioning have given the world a view of life on the autism spectrum, and several ways they use to cope with a highly sensitive arousal response. Thinking in Pictures emphasizes that inside the seemingly closed world of the autistic person lives enormous potential for contribution and growth, while science has helped to make Grandin’s journey accessible to everyone.

accept_understand_love_autism

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World Sickness and the Thirst for God

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By Nicolina Santoro, MA, IMF 77972

Once upon a time, in the vast kingdom of the helping professions, there lived a therapist whose thirst for knowledge and desire to aid in the process of personal and interpersonal change was unrivaled in all the land. This therapist had taken it upon herself to rewrite the story of her own history in a manner that changes the context of painful past experiences from blockages into tools that create a larger understanding and empathy for those she has chosen to serve in her work.

This constantly evolving therapist became immersed in theory and work of great minds such as Carl Rogers and William James. Realizing that human potential is vast, she wanted to understand how important stories and fairy tales were to constructing the memories that colored the landscape of reality, a reality that seemed to have the power to dictate how people see themselves and live their lives.

These dominant fairy tales permeate the fabric of our perceptions which also bump up against the lives of others we come into contact with out in the world. Personal narratives or “life styles” are filled with characters that are archetypal in nature, influencing us to play out repetitive sequences in life. These characters tend to take on the personas of stereotypical themes that are reinforced by learning them at a young age, or by the social referencing effect of our dominant culture.

William James calls the mental fatigue effect of living in an environment laden with unrealistic scenarios or fairy tales “world sickness.” It appears as though living in a world dominated by stereotypes and fairy tales could be implicated in the aggravation of many types of mental health issues.

How can we address the fatigue, depression, anxiety, and thought distortions that world sickness creates and impacts?

Let’s start with being gentle with ourselves. When we imagine a supreme spiritual being, the embodiment of certain characteristics seems to be present across many cultures. Some of these characteristics include unconditional love (a love that exists beyond judgment), a superconscious presence that never dissipates or abandons, and the ability to create out of seemingly thin air. For the scientists who have a different path, god could also be described as the picture of what we theorize as the highest human potential. We have the potential to express this in our own reality by living our lives in accordance to our deepest and strongest values while moving away from comparing ourselves to the unrealistic standards or “fairy tales” woven into the fabric of our society, loving ourselves and others through the lens of acceptance and vulnerability, a gentler version of happily ever after.


References

James. W. (1902). The Varieties of Religious Experience: A Study on Human Nature. Longmans, Green & Co. London, UK.

Miller, W.R. (2006). Integrating Spirituality into Treatment: Resources for Practitioners. Washington: American Psychological Association.

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School Refusal Solutions for Parents and Teachers

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By Christine Brady, M.A.,
Intern of Marriage & Family Therapy

What parent among us has not experienced the plaintive pleas of little ones, their little voices crying out, “I don’t want to go to school!” Sometimes these requests are due to vague physical complaints such as, “I don’t feel good”, or “My tummy hurts”. Other times, the range of reasons can vary from mean teachers to lack of friends, or perhaps an exam is scheduled for that day. For a lot of children these occurrences are few and far between. For others, this is a pattern which seems to happen almost daily, increasing family stress, and causing harried parents to count down the days until graduation (a daunting task if your child is in elementary school).  School refusal, if left unchecked, this pattern can escalate lead to chronic lateness, repeated absences, and consequences from truancy officials at school.

Consistently truant children often attempt to conceal their absence from parents and spend their day away from home while children typically termed as school refusers tend to stay home during all or part of the day with parental knowledge. School refusing children commonly become upset at the prospect of going to school and may show signs of fearfulness, crying, temper tantrums, unexplained physical symptoms, or other behaviors, such as stalling, missing the bus, or oversleeping. Children who are refusing to attend school may be attempting to avoid a fearful experience. Being bullied, the structure and discipline of the school setting are common reasons for avoidance. Another motivation for school refusal could be pursuing a positive experience like staying at home with access to video games, access to the internet, or gaining parental concern or attention.

School refusers can have anxiety around specific situations such as the bus ride, cafeteria, restrooms, or locker rooms thereby increasing the desire to avoid school. A child may or may not be able to identify their specific fear, only knowing that they don’t want to be at school because it makes them feel awful. Another group of school refusers may find the social or performance aspects of school such as interactions with peers, writing on the board, being called on in class, tests, or performance classes such as PE make the prospect of attending school frighteningly unbearable. Some children experience school as a place where they are constantly reminded that they are not good enough to achieve at a normal level, let alone, excel.

Dr. Haarman further relates in his book, School Refusal Behaviors, that the most important factor in increasing the likelihood of success with children who can’t or won’t go to school is to return to school as soon as possible. The longer the child avoids a normal school day routine, the more difficult and traumatic it will be to return to school.  A viable starting point for the effective exposure therapy of the child returning to regular school attendance may be to build tolerance to the anxiety provoking activity by attending some portion of the school day whether attending particular classes for a limited time period, or certain days until the child’s anxiety returns to near normal levels. This may require cooperation of school administration, such as a modified schedule change, a teacher change, or allowing the child to arrive late or leave early.

Treatment of School Refusal

This chart is adapted from research conducted by Kearney and Albano, identifies a number of possible intervention strategies most suited for each of the four types of school refusers.
Function Treatment Components
(crying, nausea, distress, sadness, and various phobias, i.e. bathrooms, cafeteria, teachers, bullies, etc.) Somatic control exercises such as breathing retraining and muscle relaxation

Gradual re-exposure to school

Reduce physical symptoms and anticipatory anxiety

Self-reinforcement, self-talk, self-esteem

To escape aversive social and evaluative situations (social phobia, test anxiety, shyness, lack of social skills) Role play restructuring of negative self-talk

Gradual exposure to real life situations

Social skills training and reduction of social anxiety

Coping strategy templates

To get attention  (tantrums, crying, clinging, separation anxiety) Parent training in contingency management

Clear parental messages

Evening and morning routines

Use of consequences for compliance/noncompliance

For positive tangible reinforcement  (lack of structure or rules, free access to reinforcement, avoidance of limits) Family contingency contracting to increase rewards for attending school and decrease the rewards for missing school

Curtail social and other activities for nonattendance

Alternative problem solving


References and Further Reading:

Albano, A.M., Chorpita, B.F., & Barlow, D.H. (2003). Childhood anxiety disorders. In E. Marsh and R. Barkley (Eds.), Child psychopathology (279-330).New York, NY: The Guilford Press.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Washington, DC, American Psychiatric Association, 2013.

Berg, I. (1996). School avoidance, school phobia, and truancy. In: M. Lewis (ed.), Child and Adolescent Psychiatry.  Baltimore, MD: Williams and Wilkins.

Berg, I. (1997). School refusal and truancy. Archives of Disease in Childhood, 76, 90-91

Bernstein, G.A., Helter, J.M., Burckhardt  C.M., & McMillan, M.H. (2001). Treatment of school refusal: one-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 206–213.

Broadwin, I.T. (1932). A contribution to the study of Truancy. American Journal of Orthopsychiatry, 2, 253-259.

Coolidge, J.C., Hahn, P.B., & Peck, A.L. (1957). School Phobia: Neurotic crisis or way of life? American Journal of Orthopsychiatry, 27,296-306.

Dube, S.R. & Orpinas, P. (2009). Understanding excessive school absenteeism as school refusal behavior. Children and Schools, 31(2) 87-95.

Duckworth, K. & deBug, J. (1989). Inhibiting class cutting among high school students. High School Journal, 72, 188-195.

Evans, L.D. (2000). Functional School Refusal Subtypes: Anxiety, avoidance, and malingering. Psychology in the Schools, Vol. 37(2), 183-191.

Fremont, W. P. (2003). School refusal in children and adolescents. American Family Physician, 68, 8, 1555-1560.

Haarman, G.B. (2012). School Refusal: Children who Can’t or Won’t go to School, Foundations: Education and Consultation Press. Louiseville, KY.

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Four Principles of Ecologically Sound Parenting in the New Age

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(Photo Credit: SUDIO 1ONE)

By Nicolina Santoro, M.A., MFTI #77792

Our modern society does not appear to be slowing down, and uncensored information is readily available, even among young children. But as technology continues to expand, so has a focus on parenting practices aimed at helping families navigate the use of digital devices in a mindful and balanced way.

More and more research reveals how family and social environments, whether in person or virtual, heavily impact the way children learn to understand the world. According to Modern Psychology and Ancient Wisdom by Sharon G. Mijares, PhD., moderating access to technology, while remaining connected to children through active participation, can positively influence the developing psychological health of youth today.

With this aim in mind, here are four principles of ecologically sound parenting in the new age that can create a more compassionate humanity in generations to come.

1. Attachment

In psychology and development theories, attachment is described as a central component of parenting because of its impact on positive pro-social behaviors in children. Secure attachment has shown to be an important aspect of a child’s developing personality and intrinsic security. Attachment-fostering activities are fairly global, such as breastfeeding, physical contact, talking, singing, playing, and attending promptly to a child’s needs. The concept of, “it takes a village,” adds to a sense of belonging and worthiness that children develop early. Fostering secure attachment in children inspires them to view the world as generally safe and to become more autonomous with less hindrance from fear.

2. Autonomy

As children begin to branch out and initiate new experiences on their own, the child benefits from his or her parent’s support in this endeavor. The encouragement of a child’s autonomy enhances creativity, imagination and wonder. In later adulthood, a child whose autonomy is nurtured will tend to feel more creative and solution oriented when presented with life on their own or with added familial responsibilities. An autonomous child is also more likely to explore the world outside of the family for a greater understanding of context.

3. Exploration

By fostering and supporting the explorative nature of a child’s experience, parents can bring new information into the family system. Children whose natural desire to explore is supported by primary caregivers and the larger family system have a natural advantage in the experience of expanding their awareness into many ways of viewing the world. The culminating experience of a truly diversified and differentiated individual that thinks beyond culture and color is the next evolution into the globalized human.

4. Globalization

A person that is globally minded has cultivated an aptitude for assimilating new information, promoting awareness, social androgyny, resource-based contribution, and creative solutions to global issues. A globalized family may creatively adopt spiritual rituals and practices from many cultures. Some tribal traditions and philosophies on family system and structures may come from many indigenous peoples and times in history with no distinction that any one way is superior to another. A globalized family may exhibit qualities that are collectivistic and individualistic depending on what would work most advantageously for the health and wellbeing of not only the family, but the larger context in which the family exists, spanning all the way out to the family’s footprint on the culture of their continent and the world.


References and Further Reading:

McGoldrick. M., Pearson, J. & Giordano, J. (2005). Ethnicity and family therapy. New York: Guilford Press. ISBN:9781593850203

Mijares, S. (2003). Modern Psychology and Ancient Wisdom. New York: Haworth Healing. Integrative Press. ISBN:0789017520

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Sacramento Earth Day 2015

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The Annual Sacramento Earth Day Celebration is held every April at Southside Park, downtown

4/21/15 @ 7th Street and T Street. 11am - 4pm

Healing Pathways Psychological Services is excited to join the celebration of Sacramento Earth Day 2015. Our contribution to the event not only educates people about what we’re up to in our city, but we will be putting smiles on their faces with fun activities and prizes. We are so delighted to share these festivities with all of you and look forward to sharing this rare opportunity to spend the day together.

As always, the Sacramento Earth Day Celebration is FREE!

Parking:
During the event, parking meter spaces adjacent to the park may be available, but the meters are limited to two hours.  The two hour parking limits at sites that do not have meters, on nearby neighborhoods streets, are not applicable on weekends.

Food and beverages will be available for sale at the park during the event.  Sacramento Earth Day 2015 will be hosting six vegan food vendors in the northwest corner of the park during the event.  Compostable waste, recyclable waste, and landfill waste containers will be stationed in triads throughout the event venue.  Containers at each station will be marked by printed labels and event volunteers will be present at most stations to advise attendees, vendors, and other volunteers on waste separation requirements.

The Annual Sacramento Earth Day Celebration is filled with wonderful food, entertainment, interactive activities and business, non-profit, cultural and government organizations with invaluable and practical information, goods and services for saving money, living healthier, and protecting and celebrating the environment and the Sacramento region.

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Stop and Smell the Roses: What is Mindfulness, Anyway?

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(Photo Credit: Gromovataya)

By Melanie Ernould, Psy.D.

Have you ever driven somewhere and arrived at your destination thinking that you have no recollection of the actual drive? Have you ever realized the amount of time you spend on your mobile phone to the exclusion of the world around you? Or perhaps you’ve realized you’ve lost touch with important people in your life because you’ve gotten caught up in the tasks of your everyday life? What about spending time doing something to realize that you’ve spent most of that time worrying about something else, like your to-do list or your messy house? These are all common ways that we miss out on being in the moment in front of us.

You may have heard the term “mindfulness” being tossed around in conversations about staying in the present moment, but have you wondered exactly what this means or how to apply the concept to your life?

Mindfulness was once an obscure Buddhist concept but has become a wildly popular psychotherapeutic intervention in the past 10 years. This is due to the popularity of successful mindfulness-based stress reduction (MBSR) programs and the mindfulness component of dialectical behavior therapy. The term mindfulness can mean a “moment-by-moment awareness”  or a “state of psychological freedom that occurs when attention remains quiet and limber, without attachment to any particular point of view,” according to Jeffery R. Martin, Ph.D.

In the article What are the benefits of mindfulness? (from the July/August APA Monitor on Psychology), the authors Daphne M. Davis, Ph.D. and Jeffrey A. Hayes, Ph.D. define mindfulness as a “moment-to-moment awareness of one’s experience without judgment,” and claim that this is the definition that is most often used in the research. Jon Kabat-Zinn, Ph.D. was the first to develop a modern definition of mindfulness, and defined it as “paying attention in a particular way, on purpose, in the present moment, and non-judgmentally.”

The application of mindfulness meditation in the field of psychology was not a huge leap. According to Mindfulness-based Approaches: are they all the same? (from the 2011 Journal of Clinical Psychology) by Alberto Chiesa, M.D. and Peter Malinowski, Ph.D., the goals of mindfulness meditation and psychological health are related: both Buddhist philosophy and psychology discourage behaviors that bring on and maintain negative emotions, and encourage positive emotions. Mindfulness is considered an acceptance-based therapy, where there is not an attempt to change thoughts or emotions no matter how unpleasant they may be. Well, how does it work then, you might ask?

Perhaps paradoxically, it is through acceptance that change is brought about. In other words, the less you try to change how you think, the more you are able to then change how you think. You focus on being rather than always trying to do. This works because you are not trying to force change; you are accepting yourself as you are and creating a freedom in your thoughts in the process. It takes practice to be truly mindful but this practice has helped treat and prevent people with problems, such as anxiety and depression. Below I outline a few exercises to aid in your mindfulness practice.

Paying Attention

To start the practice of paying attention mindfully, try this practice next time you are eating something that you would normally take for granted or not think about, a chocolate or M&M candy for example:

  1. Before you put the food in your mouth, bring your attention to seeing the food as if with new eyes. What do you see? What color is it? What is the shape? What texture do you notice?
  2. Now feel the food with your fingers. What does it feel like? Is the surface smooth or bumpy?
  3. Notice whether you have any thoughts that might be coming up for you about the candy, food, or eating in general.
  4. Now smell the food and pay attention to what you notice about the experience of smelling it.
  5. Bring the food item to your lips, noticing how your hand is holding the item and moving it toward your mouth. How does your body respond to the food moving toward your mouth?
  6. Now put the food in your mouth and leave it in your mouth for a while, noticing how it tastes and what happens to it as you suck on it.
  7. Pay attention to the impulse to swallow. Imagine the food item entering your body, like you are one M&M or ____ heavier.
  8. Finally, what are your reactions and observations about this experience? How did this compare to how you usually eat?

We tend to eat mechanically and for emotional comfort without paying attention. However, if we can slow things down, we start to notice and enjoy our experiences, and act with purpose. This is what meditation is: paying attention to your experience from moment to moment.

Stop and Smell the Roses

Pay attention to one pleasant event each day as it is happening. Write in a journal the answers to these questions:

  1. What was the experience?
  2. Were you aware of any pleasant feelings while the event was happening or only later?
  3. How did your body feel during the experience? Describe this in detail.
  4. What moods, feelings, and thoughts were present as the event was actually happening?
  5. What thoughts are in your mind now as you write this down?

I’m Stressed!

When you notice that you are feeling stressed about something, start by bringing your attention to your breathing. In… and out… In… and out… Then, ask yourself these questions:

  1. How does my body feel?
  2. How fast is my heart beating?
  3. Am I tense? Where am I holding my tension?
  4. What am I thinking about?
  5. What am I feeling? How do I know I’m feeling this?

References and Further Reading:

Allen, M., Bromley, A., Kuyken, W., & Sonnenberg, S. J. (2009). Participants’ experience of mindfulness-based cognitive therapy: “It changed me in just about every way possible.” Behavioural and Cognitive Psychotherapy, 37, 413-430.

Chiesa, A. & Malinowski, P. (2011). Mindfulness-based approaches: Are they all the same? Journal of Clinical Psychology, 67, 404-424.

Davis, D. M. & Hayes, J.M. (2011). What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy, 48, 198-208.

Ernould, M. (2012). Addressing lesbian, gay, and bisexual bullying: A mindfulness-based intervention manual. Retrieved from aura.antioch.edu

Germer, C.K., Siegel, R.D., & Fulton, P.R. (2005). Mindfulness and psychotherapy. New York: Guilford Press.

Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research, 57, 35-43.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness. New York: Dell Publishing.

Martin, J.R. (1997). Mindfulness: A proposed common factor. Journal of Psychotherapy Integration, 7, 291-312.

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