Successful Anger Management Therapy

Anger management is a considerably frequent topic in therapy, both in our work with individuals and couples. Some people seek therapy on their own to get help, whereas others are court ordered to address anger management. Anger can cause toxic divisions between people, have partners lacking senses of safety or predictability in relationships, and induce powerful shame and embarrassment in the one who struggles to regulate emotion. Fortunately, people can make significant strides in their relationship to their anger in a relatively short time.

The first key element of working through anger is to openly and earnestly explore what functions it serves in one’s life. It can in fact be an adaptive mechanism at times, and recognizing this normalizes and validates it, undermining some of the resultant shame which can occur when one has problematized their anger. Speaking broadly, there are two general functions it serves with people. First, it serves as a communicator when one feels they are not being listened to (albeit a less-than-skillful communicator). Exasperation in not being heard can lead to a person, purposefully or unconsciously, choosing to increase the volume and vitriol. Second, as Sue Johnson explains in Emotionally Focused Therapy (EFT), it can serve to obscure the more tender, intimate feelings, such as loneliness, fear or hurt. If one contacts and communicates these primary feelings, the protection of anger isn’t as needed in one’s life. Successful working through anger requires a skilled and intentional replacing of these functions.

The next key in approaching anger is simply to allow oneself the space to intervene with it. Buddhist psychologist and meditation teacher Jack Kornfield refers to this as taking the “Sacred Pause.” The hormones associated with anger, testosterone, adrenaline and cortisol, lead to racing thoughts and a sense of needing to declare one’s truth (loudly and forcefully) as it occurs. Taking a moment to reflect, calm oneself into a place of internal stillness, and respond rather than react is critical in this work. Many people are never taught this skill and can make great strides at this when taught in therapy. Once that space has opened up, a gentle breathing exercise such as deep diaphragmatic breathing can be a way to soothe the physiological impacts of the stress hormones. Another way to allow ourselves the opportunity to monitor our feelings and ensure they aren’t hurling us around the room is to be sure to listen with openness and repeat back what we are hearing prior to responding. This can slow down the conversation in a way that we may gain some distance from our habitual triggers.

Cognitive therapy can assist with another important part of managing one anger, which is learning respect for others and for opinions that differ from one’s own. Once a person gains insight into what purpose their anger serves, learns to manage the hormonal rush associated with anger, and becomes a better listener, the next challenge is to not get riled up if what one hears or experiences is not what they want. Mutual respect for others’ right to have a different way of thinking, even if you disagree with it, assists a great deal with staying calm.

Having learned to remain calm and listen, the next step is being able to communicate one’s thoughts and feelings effectively. Building communication skills is thus also important to emotion regulation, because it is easier to avoid becoming angry when you feel confident in your ability to clearly express yourself.

Finally, it can be instructive to inquire into what exactly our triggers really are. A common theme is a lack of control leading to frustration or rage. For these people, there can exist a vicious cycle in which they feel powerless or out of control, become frustrated, and then their emotions themselves dictate their words and choices, which reconfirms this feeling of being out of control (only now it’s their own feelings controlling them!), and an instantaneous negative feedback loop is born.

Through a deeper understanding of anger’s place in one’s life, its birth and how it perpetuates, along with some simple emotional regulation and communication skills, people are able to make significant strides. While people on the other end of someone’s anger feel hurt by it, the anger also takes a toll on the person who is angry… it does not feel good to be consumed with anger. Thus these strides in new anger management skills benefit both the individual and those around the person…everyone benefits!

Transitioning to College for Students with a SLD or ADHD

How to Plan a Successful Transition to College for Students with
Learning Disability or Attention-Deficit/Hyperactivity Disorder

Here are some practical tips for high school students who have been identified with a Specific Learning Disability (SLD) and/or Attention-Deficit/Hyperactivity Disorder (ADHD) who are transitioning to a postsecondary institution.

Contact the Disability Services Office of the university to determine the necessary requirements for academic accommodation application available under Section 504 of the Federal Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990 and the ADA Amendments Act (ADAAA) of 2008. Each institution may have a slightly different name for that office. For example, the University of North Carolina (UNC) is listed as Accessibility Resources & Services, Duke University is the Student Disability Access Office and Wake Technical Community College (Wake Tech) is Disability Support Services.

Collect and review your existing educational reports from your high school and other documentation, which may include previous standardized testing such as the Scholastic Aptitude Test (SAT) and/or the American College Test (ACT), high school transcripts, report cards, Individualized Education Plans (IEP) or End of Grade/Course test scores.

Obtain a current psycho-educational evaluation, and check with your college to find out what they consider recent enough. Often you will need to do new updated testing, which would be at the student’s own expense. This assessment must be conducted by a qualified psychologist and include background information (IEPs are helpful, but are not sufficient documentation by themselves), a clear interpretation of the test data, a specific diagnosis, an explanation of how the diagnosed disability substantially limits a student’s major life activity (learning), and recommendations for academic accommodations.

After gathering all relevant data, schedule a meeting with the appropriate disability services personnel, who have the authority to determine eligibility for accommodations. Submit the documentation prior to the meeting so personnel have a chance to review it and be prepared to discuss options. Basic accommodations include time and one-half on exams and rest breaks. Other accommodations may include double time, reader, scribe or keyboard entry aid, separate testing room, calculator, American Sign Language substitute for Foreign Language, access to class notes, taped textbooks, use of a text reader, use of a computer, priority registration, note-taker, reduced course load, course substitution.

The student may be expected to meet with a disability counselor at the beginning of each semester to discuss the disability and its relationship to accommodations for the upcoming courses or the disability services office may send a letter to the instructor. Be prepared to explain in a simple and concise manner why specific academic accommodations are being requested. LD and ADHD are lifelong conditions, but severity and manifestations may change over time, so be able to discuss your current experience and related needs.

Seek any additional support offered through the disability services office such as tutorial services, study skills and learning strategies training, writing tutorials, and stress management. Many of these offerings may be at no cost.

It is important to note there are differences in the laws that govern accommodations in K-12 education and those that apply to postsecondary education. Due to these differences, the same accommodations that were available in past educational settings may not be available in postsecondary settings. Common standards for accommodations in many postsecondary institutions are based on criteria established by the Association on Higher Education and Disability (AHEAD) or the Educational Testing Service (ETS).

Be proactive — the student needs to advocate for himself/herself! The intent of accommodations in a postsecondary setting is to provide equal access to educational opportunities to individuals diagnosed with disabilities. It is the student’s responsibility to establish and manage his/her own academic support system. To be most effective, this assistance needs to be in place BEFORE academic difficulties are experienced.

Cooperative Parenting Part V: Managing Your Anger

The previous article in this series provides guidelines for developing a business partnership with your parenting partner. That is, a relationship that is based mostly on logic rather than emotion. In this article, we’ll explore perhaps the biggest obstacle to this: anger.

There are many levels of anger: annoyance, irritability, anger, fury, rage, etc. It’s important to notice when you are getting increasingly angry and you are headed towards a rage explosion (whatever that looks like for you) because there is collateral damage that happens along the way – most importantly, to our children. So, the earlier we notice we are on this trajectory the sooner we can stop ourselves and not only keep from doing something unhealthy that will hurt our children, but choose to do something healthy which will help them.

Red flags are signs and symptoms that let us know we are creeping up that anger scale. A red flag is one that is typically there when we’re escalating and doesn’t tend to be there at other times when we’re feeling other things. There are four types of red flags:

  1. Behavioral: things you do that others can see you are getting angry
    Examples: clenched fists, pacing, rolling eyes, yelling, slamming doors, etc.
  2. Physiological: symptoms that your body creates
    Examples: face turning red, racing heart, muscular tension, etc.
  3. Cognitive: your thoughts
    Examples: “This is so unfair!” “Why do they always do this?!”
  4. Emotional: other feelings that precede angry ones
    Examples: frustration, anxiety, embarrassment, guilt, shame, hurt, etc.

Click image to enlarge

That curved line after the big blow up (“punch wall”) is when you suddenly figure out you’re angry and need to de-escalate. It’s good to realize that at any time, but imagine if you thought of it sooner? All the stuff that came before wouldn’t have happened and done damage. What if you began to de-escalate as soon as you noticed yourself thinking “unfair!”? You could take a time-out and cool down before you waste more time in anger and lose it in front of your parenting partner and kids. Win-win-win.

Just as important as knowing when you’re getting angry is knowing what triggers your anger. Then you can anticipate when either to avoid certain situations or be prepared with skills.

When you notice yourself getting angry, take a time-out and cool down (if it’s good enough for our kids, it’s good enough for us, right?). If you are talking with the other parent, say, “I need a break from this discussion. I’ll contact you later today/tomorrow so we can finish talking about this.” And then contact them when you promised. While you are taking your break, distract yourself first to get some distance from the event, thoughts, and emotions, and then consider where they might be coming from. When you’ve been able to empathize or at least get better control of yourself, return to the discussion as promised and ask if they would like to start or would like for you to start. That can help decrease the anxiety and anger on their part.

Now, about anxiety and anger… have you ever noticed they often go hand-in-hand? That’s because anger is often a secondary emotion to more vulnerable emotions, like anxiety, guilt, shame, fear, embarrassment, sadness, or hurt. People, especially men, are taught in this culture that anger is more acceptable than a vulnerable emotion because it is perceived as strong. So, we learn to show anger rather than a “softer” and more authentic emotion. But imagine how a conversation might go differently if both parents were willing to show their genuine, vulnerable emotions with each other rather than just show the anger? It not only decreases the reaction of fear and defensiveness but it allows us to express and understand the actual problem (“I’m worried she won’t get a good education in that school system”) rather than just issue an attack (“She’ll go to that school over my dead body!”).

The point here is to be authentic, not to be passive. Passive communication is where you don’t stand up for your rights and so you don’t tend to get your needs met (e.g., letting the other parent choose the babysitter against your better judgment). Assertive communication is where you stand up for your rights while respecting the rights of others (“Because of (x reason) I’m concerned this babysitter isn’t very responsible and I want to find a new one”). Aggressive communication is where you stand up for your rights while disrespecting others (“You are a big idiot if you think I’m going to let that imbecile take care of my child!”). Passive-aggressive communication is where you are indirectly aggressive (“The babysitter you chose is indeed very attractive but I believe other qualities are more important when it comes to taking good care of our child so I’ll pick the next one”). Assertiveness is the only direct form of communication; the rest are indirect and leave a lot to the interpretation of the other person. When passive communication is relied upon, a blow-up of some sort will happen later; either aggressive, passive-aggressive, or a “blow-in” of depression.

The next article will deal with how to express anger, how to use it to your advantage, and the relationship between beliefs, thoughts, and anger.

Nature and Health

Anyone who has spent time in nature knows how peaceful and calming it is. Even if you don’t consider yourself an outdoorsy person and prefer living or vacationing in a city, you surely have come across a park and have enjoyed sitting on a bench admiring the landscaped flowers and trees. What is it about natural environments that make it so good for our mental health? Why are spiritual and health retreats typically held in the mountains, by an ocean, or deep in a forest? Psychologists call it Attention Restoration Theory (ART). The theory says that we have two attentional systems. The first type of attention allows us to have intense prolonged focus where we can ignore distractions long enough to solve a problem at work or to study for an exam. This type of attention is prone to mental fatigue – anyone who has studied for a big exam or needed to meet a deadline for a work project knows this mental fatigue! The second attentional system does not require such intense focus, but rather involves effortless reflection and observation. ART says that it is this second attentional system that gets activated when in nature, and which allows for recovery from mental fatigue. Mountains, oceans, lakes, streams, and forests demand very little from us, yet they still engage us in a way that does not drain our energy. Unlike cities and social media which are constantly vying for our attention to “look here! look there!” and “pay attention to this before it becomes irrelevant!” – nature allows us to pay attention in our own time. When in nature, we can think as much or as little as we’d like.

Our ancestors used to spend the majority of their lives outside and it’s only relatively recent in our evolution that we spend so much time indoors. The average American now spends 93 percent of their life inside (this includes time spent in a vehicle). It’s no wonder our alienation from nature has coincided with higher rates of illness, attention difficulties, and has diminished use of our senses (living on autopilot).

The Japanese culture has something called Shinrin-yoku, which translates to “forest bathing.” How cleansing does that sound! Forest bathing is the act of spending a few hours in a forest only engaging your five senses. Studies from Korea had patients with depression engage in psychotherapy outdoors and they found those patients had reduced cortisol (stress) levels, improved heart rate variability, and reduced overall depressive symptoms. The benefits are so great the Japanese government have officially designated certain lands for “forest therapy.” People can go to different areas based on the types of trees they particularly enjoy for their visual appeal and scents. Another lesser known benefit of being in nature? There is a harmless bacteria in soil that can decrease inflammation in your immune system, alleviating a variety of health issues. The bacteria also acts as a natural antidepressant by increasing the release and metabolism of serotonin in parts of the brain that control cognitive functions and mood. This could be why gardening has been considered a great stress reliever.

We need to start prioritizing the importance of nature on our health. Remember, one size does not fit all. Find what you like! Not down with rolling around in the dirt? Take a stroll through a public garden. Find a nature retreat for your next vacation, even ‘glamping’ is better than nothing! Play outside with your children. Whatever it is, find a place to engage your secondary attentional system on a regular basis.

Should You Have Your Client Re-Tested, or Have a Previous Evaluation Reviewed?

Exploring the Benefits of Re-Evaluation and Review

You have previous psychological testing on your client, yet your instincts tell you something isn’t quite right. Instincts, or “gut feelings” as they are called, exist in humans for a reason. They are a combination of experience and intellect as well as our own emotional memory giving us a signal. So while instincts can clearly be incorrect, they also should not necessarily be ignored. Here are some varied cases in which re-testing and/or reviews of previous testing revealed and provided information very important to the outcome of the cases. (All identifying information has been changed to protect client confidentiality.)

  1. Bias in evaluations can occur. Evaluators are human, and can be unconsciously swayed by a client’s presentation. This can result in them viewing test results more negatively or positively, and unfortunately can even affect what they include in their report and their conclusions and recommendations. Thankfully most forensic evaluators are well trained in and skilled at avoiding bias, and we do not believe it happens often. But it does happen. A few years ago we were asked to review a custody evaluation for a family with three teenage boys, where one party felt vastly misrepresented in the report. The attorney explained in hiring us that since it was common for a party in a custody case who did not like the recommendations to take issue with the report, he did not necessarily really expect us to find anything. His client, however, was insistent about a professional review of the data. We found the father’s data had been fairly accurately noted in the report, and his test results, interviews, and collateral contacts mostly matched what was written. His test results that elevated into the clinical range, showing anxiety several standard deviations above the mean, however, were minimized as ‘mild,’ and some possible anger issues were ignored. In contrast, the mother’s test data was exaggerated as problematic even when none of her scores elevated into the clinical range, and a large amount of highly relevant positive information provided by collateral contacts was omitted from the report; these two things taken together resulted in a much more negative picture of the mother than test and collateral data would suggest was accurate. (Bias can generally be avoided all-together when psychologists work as a team versus as a sole evaluator.)
  2. We were asked to provide a third opinion/evaluation for a fitness for duty case, as the first evaluation had resulted in a ‘not fit’ recommendation and the second in a ‘fit’ recommendation. The client, a firefighter, had experienced post-traumatic anxiety after he had witnessed a very difficult scene. The first evaluator interviewed the client and utilized two psychological tests. In reading the report, we were uncertain if the results of one test were included; tests have certain lingo associated with their interpretation, which is how we noticed. We requested test data be sent, and received the scores for that test but no interpretive report. That is unusual but it is possible the evaluator used a manual versus the computerized method. We had the client’s answer sheet so we ran an interpretive report. What we found was the results of that test contradicted the results of the other test. Thus rather than report that and perhaps have to say the evaluation results were inconclusive, the data that contradicted the ‘not fit’ conclusion was left out of the final report. Or, it is also possible it was a mistake and the test was never interpreted, thus not included. In addition, a one-interview format was used, which is common in evaluations, however, a person describing a traumatic event will often present as much more agitated when recounting that event than they appear typically. Lastly, time is an important factor in return to work evaluations. It may very well be he was still too highly anxious to function safely on the job so soon after the event, when the first evaluation was done. Time can help dissipate anxiety, particularly when the anxiety is situational and not chronic. Thus sometimes simply due to time it can be beneficial to have your client re-tested, even if the previous testing was top-notch.
  3. Sometimes even if an evaluation is recent, if done for clinical purposes it does not serve a forensic need well. When a client presents for a clinical psychological evaluation, he/she is seeking to determine an accurate diagnosis for effective treatment planning, and when psychologists perform these evaluations, we generally believe what we are told by the client and by others. In forensic evaluations, however, our role is also to question what we hear, and gather collateral information so that information is supported in many ways.A client self-referred for a psychological evaluation to use in court. She had received two diagnoses from two other mental health professionals based on testing and interviews with her and her husband. She believed her husband would use these diagnoses against her in their custody negotiations. Though she described having been ‘evaluated’ because she took tests, review of her records revealed no prior comprehensive psychological evaluation other than a few assessment tools used at various times to help determine medication and/or treatment. One test was used by their marriage therapist, as well as collateral information from the husband (who had been the therapist’s individual client previous to marriage therapy). She elevated a scale on which people with bi-polar typically elevate, and that can also be elevated when a client is highly stressed, such as when in a high conflict marriage. This therapist diagnosed bi-polar and referred to a MD for medication. The psychiatrist then also diagnosed her with bipolar based again on potentially biased collateral information from the husband who had a highly conflictual relationship with her at the time. In addition, the psychiatrist gave two tests, a mood disorder test and an AD/HD test. The doctor did not adhere to the actual scoring guidelines on the mood disorder assessment, and she administered an AD/HD rating scale meant for individuals under the age of 18 when the patient was clearly well above that age. Thus in this case, re-evaluation allowed the party to contest the original diagnoses she believed were inaccurate and based on faulty data.
  4. In clinically complex cases, time can be an evaluator’s friend, allowing a wealth of data to accumulate and providing the new evaluator a better opportunity for clinical clarity. This was the case in a disability re-testing we provided. In addition, there are cases in which the evaluation needs to be extremely in-depth and specialized for accurate results. The client had been evaluated numerous times over the past 25 years, beginning with a psychotic episode at age 22. She was diagnosed with bi-polar disorder and medicated. The medication was considered effective in that psychotic symptoms did not reoccur, nor did she experience deep depressions or mania. She had extreme difficulty holding a job, had been through many over the years, and was still financially supported by her parents at age 46. Her parents explained it seemed likely she could not hold a job due to her inability to interact comfortably with others, and noted she was quite socially odd. She wanted to work and was upset by the many job losses.Social difficulty is not necessarily a problem associated with bi-polar, nor is inability to hold a job when depression and mania are controlled. Rather than too easily attach these as related to the bi-polar, we considered whether alternate diagnoses were possible, and included cognitive testing, in case neurological problems were impacting her ability to work. (Too often, cognitive issues are not assessed when a person has a mental illness and thus their difficulties are ascribed to that.) A comprehensive assessment was conducted that included: clinical interview; observations; cognitive and intellectual testing; emotional and personality testing; collateral interviews; and document review of the past 25 years. Our diagnosis was schizoaffective disorder, bi-polar type, which much better described her. In addition, cognitive testing found deficits in executive functioning, and in particular in areas of cognitive functioning that would directly impact the type of career she had endeavored on. Thus in addition to her bi-polar medication, she had always also needed social skills therapy for her schizoaffective symptoms, and needed to determine if any skill building could allow her to remain in her current field or whether she should seek career counseling to find a field that better matched her strengths.

In summary, as evaluators we would like to point out that most evaluations performed by well trained clinical and forensic psychologists are very good pieces of work. We are certainly fans of the team approach such as we utilize here at the group practice, in which peer review is built into our evaluation process to protect against human error or unconscious bias. (Generally forensic reports here are reviewed by a minimum of three psychologists before finalized.) However, as you can see, it is not only mistakes or bias that can taint a report, but things like the passage of time, the intent of the original report, and the complexity of the case all play a part as well.

You (and Your Therapist) Can Change Your Personality!

You (and Your Therapist) Can Change Your Personality!
(Synopsis of the New York Times Article)

There is much controversy about how our personality is formed. Some psychologists believe it is formed in early childhood and remains stable through adulthood. Others would argue it is prone to change over time. Recently, personality psychologists have taken a more middle-of-the-road view…if personality traits change, it is slowly and somewhat limited. However, an article published in the Psychological Bulletin disputes those old ideas!

A team of six researchers analyzed 207 studies on personality-trait changes and discovered that, with a therapist’s help, personality can and does change, a lot and usually within the first month of therapy! The trait identified through this research to be the most effected by therapy is neuroticism. Individuals with this trait are more likely to be moody and to experience such feelings as anxiety, anger, envy, guild, depressed mood and loneliness. Interestingly, a person’s gender or age or type of therapy did not seem to affect the outcome.

Researchers continue to question as to whether real changes actually occur in the personality trait, i.e. neuroticism, or if therapists are able to help clients return to their “normal” before conditions such as depression or anxiety became an issue. But regardless of the underlying mechanism or process, the good news is there seems to be research to support the idea that, with the help of a therapist, personality change is possible!

How to Talk to Your Partner with Different Political Views

Every couple experiences differences in some aspect of their relationship: differences in daily routines, food preferences, personality traits, etc. Most couples find their way to work around or accept these issues, but what about when it comes to politics? Given the polarization our country has seen with this past election, it is likely that there are folks out there experiencing the same polarization of political views within their marriage. Here is a list of suggestions on how to effectively communicate with your partner when you disagree on politics. These strategies are also helpful when talking to friends and family who have different political views.

  • If you are going to talk about politics, know the difference between “fact” and “opinion.” An opinion is “a view or judgment formed about something, not necessarily based on fact or knowledge.” A fact is “something known to have happened or to exist.” For example, “Millard Fillmore was the 13th President of the United States” is a fact, while “Millard Fillmore was the best president in the history of the United States” is an opinion. People often state opinions as if they are facts and usually this is harmless (i.e., “It is a fact that my grandmother bakes the BEST apple pies in the world!”); however when we move into the complex and impactful world of politics, it is especially important that we see the difference. Stick to provable facts when you are talking to your partner about politics, or graciously offer your opinion by noting it is only an opinion and not fact. Keep in mind much of what we hear and accept as ‘fact’ from the news can be misinformation and/or laden with opinion. When in doubt, do not argue over if something is a fact or not, just accept you disagree on a point.
  • If you or your partner do not share personal opinions, don’t ridicule them; respect each other’s perspectives, and do not be passive-aggressive.
  • Use your listening skills. This does not mean staying quiet and waiting for your partner to stop talking so you can respond with your own facts or opinion. Actively listen to what they are stating and try reflecting back what she or he is saying to ensure you truly understand what they are talking about. After all, conversation can serve to increase a sense of connection, love and respect when the goal is to connect with and better know the other human being you are talking with, versus conversation being to make your own point, be ‘right’ or win the debate.
  • Do not focus on trying to change your partner’s political views. Rather, focus on trying to understand where they are coming from. It could be helpful to think about the socioeconomic status of their family of origin, their culture, their other life values and life experiences they have had that contribute to why they believe in the political views they do. Couples do not have to agree on everything, but it is healthier for the relationship when you can understand where each person is coming from.
  • Look for commonalities in your political views. Perhaps you both agree more funding needs to go to education but disagree on renewable energy. Focusing discussions on the issue you agree with and how you can support it together can be a connecting experience as a couple.
  • If politics are extremely important to you, talk about them early in the relationship. Politics often reflect values, and having shared values are important for long term relationships. If politics are not a key part of your identity, then differing views may not matter at all. If they are, it is best to know early own if your views are a good match.

In summary, many a happy marriage has survived staunchly differing political views! This is possible when your goal in conversation is to learn more about the other person, hear them out, be interested in their thinking, and explain your own thinking so they can better connect to you. Crushing your partner in conversation to prove you are right will not fare so well. Conversing with regard for dignity and respect can still result in an invigorating political debate!

Trauma Focused Cognitive Behavioral Therapy For Children

As an attorney, you may come in contact with cases where a child has been traumatized. Effective treatment is important otherwise the trauma can impede normal development. Understanding TF-CBT can help you make appropriate referrals when you learn a child has experienced trauma. People can experience many types of trauma including sexual abuse, domestic violence, natural disasters, terrorism, community violence, and traumatic loss throughout their lifetime, to name a few.

Symptoms related to trauma include:
An inability or unwillingness to recall details of the trauma
Intrusive thoughts about the trauma
Emotional and physical numbing
Recalling physical sensations that occurred during the trauma
Difficulty staying still or fidgeting
Disturbed sleep routines
Rapid changes in mood
Difficulty concentrating
Irritability or depression
Low self-esteem
Inability to trust others
Drug use
A desire to hurt oneself or others

In children, symptoms can lead to problems at school, isolation, and conflicts with parents and peers. If symptoms are not addressed, they can impede a child’s normal development. Thus it is vital a child get treatment for their trauma.

Trauma focused cognitive behavioral therapy has been widely researched and there are proven results! Studies have shown TF-CBT to be more effective than other therapeutic interventions in addressing trauma symptoms. Over 80% of children show significant improvement within 12-16 weeks of weekly treatment. Improvements are seen in PTSD symptoms along with depression, anxiety, behavior problems, trauma related shame, interpersonal trust, and social competence.

TF-CBT is a treatment model targeting children ages 3-18 who have developed significant emotional or behavioral difficulties following exposure to trauma. Treatment includes individual sessions with the child, individual sessions with a non-offending parent/caregiver, and joint parent-child sessions to maximize progress. It integrates cognitive and behavioral interventions with traditional child abuse therapies to teach children how to examine their thoughts, feelings, and behaviors and how to change these in order to feel better. Treatment is guided by assessment measures that are completed by both the child and caregiver to provide the most individualized care. Therapy incorporates gradual exposure to trauma details to build the child’s confidence and competence. The best part of this treatment for children is that sessions are designed to be fun!

The child will learn others have survived similar experiences and the trauma was not their fault. They will have the opportunity to discuss details about their trauma in a supportive and nurturing environment.

Children will learn to:
Use adaptive skills to handle stress
Identify feelings and learn how to manage them
Relax and tolerate trauma reminders
Identify negative thoughts and replace them with more helpful ones
Resolve problems
Implement safety skills

Parents/caregivers will have the opportunity to explore their own thoughts and feelings about their child’s experience and resolve their own distress. Parents will learn many of the same skills being introduced to their child in addition to learning effective parenting skills and ways to provide optimal support to their child.

Forensic considerations when recommending TF-CBT:
1) TF-CBT is NOT a form of evaluation. Referrals should be made only following an identifiable trauma and when the child is displaying symptoms. For a child to be a candidate for TF-CBT they need to be in a safe living situation, having no contact with the alleged perpetrator. There also needs to be a stable, supportive caregiver able to engage in treatment with the child regularly.

2) It should also be noted the trauma narrative is not a forensic tool. The narrative should not be used or viewed by others outside of the therapy setting. The purpose of the trauma narrative is for the child to be able to address maladaptive thoughts contributing to ongoing symptoms. The goal is for the child to make meaning out of their experiences, identify times where they took action to keep themself safe, and be able to talk about their trauma without becoming overwhelmed with anxiety or other intrusive symptoms.

For more information about TF-CBT and whether it could be right for a child, you can:

– Call Dr. Tina Lepage for more general information/case consult, 919-572-0000.
– Contact Dr. Colleen Hamilton at Diverse Family Services (serving children with Medicaid), 919-572-8833.
– Contact Jordan Motta, Mental Health Clinician and Intake Coordinator at Duke Center for Child and Family Health, 919-385-0710.

Helping Children Become Everyday Heroes

Do your little bit of good where you are; it’s those little bits of good put together that overwhelm the world. –Desmond Tutu

What is a hero? By definition, a hero is “a person who is admired or idealized for courage, outstanding achievements, or noble qualities.” How many heroes are there in the world? How many people demonstrate idealized courage, outstanding achievements, and noble qualities? However many, I think we need more. We need Everyday Heroes – people whose courage, achievements, and noble qualities shine through in their everyday interactions with others. For example, there are social phenomena, such as the bystander effect – i.e., the probability of help is inversely related to the number of bystanders – that take courage and thoughtfulness to overcome.

To be an Everyday Hero, a child needs to be able to identify their own emotional state, the emotional state of others, and take on the perspective of another individual’s emotional state… AND they must possess a sense of courage and morality that will drive them to act on their empathy skills. This is where the idea of social phenomena comes in. As previously mentioned, there are phenomena such as the bystander effect that prevents people from coming to the aid of others. Additionally, there are other studies such as the Milgram studies and Stanford Prison Experiment that demonstrate how social influences can override an individual’s moral code and promote conformity to perceived social expectations, even when those social expectations compromise the well-being of others.

How do we create Everyday Heroes? Parents, teachers, coaches, care providers, etc. can help foster these qualities at a young age and encourage children to begin expressing them on a daily basis.

Acknowledge and address your child’s needs.

When children’s emotional states are identified and their needs met, they are more likely to develop a sense of empathy. Additionally, having their needs met promotes a secure attachment in the parent-child relationship, which in turn provides stability and support, and allows children to show empathy to other children who may be suffering.

Be mindful of your child’s physical needs. Responding to physical needs sets the stage for a secure attachment and promotes a sense of safety for the child.

When interacting with your child, reflect their emotional state back to them, beginning at a young age. For example, if your child is laughing, reflect back, “You are happy playing with that teddy bear.” If you child is frustrated, “You are feeling frustrated because you are having a hard time finishing this puzzle.”

Teach your child the facial expressions and body language that accompany different emotional states. While reading, you can ask your child how he or she knows a particular character is happy, sad, or mad. You can also ask you child to demonstrate with his or her own facial expression and body language different emotional states. Children learn through play, so incorporating emotional identification into play will aid in learning.

Model the empathic, courageous, noble behavior you want your child to demonstrate.

Just as children learn behaviors such as household chores and playing games from watching and modeling their parent’s behavior, they learn empathy from watching their parents and other adults demonstrate empathy for others, including for the child. Children observe how the adults they are around treat others.

Be mindful of how you are treating not only your child and family members, but also others in the community such as a store clerk, police officer, or fellow pedestrian.

Find ways to teach your child about empathy. For example, if you are reading a book or watching a television show where a character has been compromised or victimized, engage your child in discussion about what feelings the character may be experiencing. For example, “Joey is all alone today because he wasn’t invited to the baseball game with all of his other friends. How do you think Joey feels?”

Have your child imagine a character who is experiencing a particular emotional state, and have him or her act out, especially in facial expressions and body language, how that character might be feeling. Research shows that engaging in behaviors that emulate a particular emotional state allows the individual to more accurately experience the emotion. This will help your child take on the possible emotional perspective of another individual and thus enhance their ability for developing empathy.

Promote moral development.

A child’s moral development is fostered by witnessing behavior modeled by adults and by learning the necessity of rules.

Promote a sense of internal self-control when it comes to responding to the needs of others. Children should not be rewarded for helping or caring for others. Research suggests children are less likely to help others in future situations when their behavior has been previously materially rewarded. Instead, praise helping behaviors verbally.

Discuss the importance of rules and how individuals are impacted when they, and others, do and do not follow rules.

When your child witnesses or is involved in an event where another person’s wellbeing is compromised, address the needs, physical and emotional, of the compromised individual first to highlight the importance of ensuring someone’s safety and wellbeing.

Teaching children about feelings and promoting development of empathy and morality will prepare future generations to stand up for and identify the physical and emotional needs of others, despite social phenomena that may normally stifle someone’s internal drive to do so. Your child will experience pride, self-esteem, and connection to community by learning the skills to be an Everyday Hero.

Cooperative Parenting Part IV: Creating a Business Relationship

The first three articles in this series emphasize how intense emotions can make co-parenting and moving on with the next stage of your life very difficult. To get your children through this life transition as positively as possible you need to be able to offer support and stability. And to do that, you need to have a functioning relationship with their other parent.

Of course, it would be ideal to have a friendly functioning relationship with them but divorce doesn’t always happen that way. The next best thing is to have a healthy and effective business relationship, since you are in the business of raising your children together. Having a working business relationship models for children that you can get along with someone you had a falling out with, allows them to feel free to love both parents, and lets you transform the negative energy you were wasting on the other parent into positive energy towards your children and creating your new life. Easier said than done, as anyone involved in a contentious divorce would say. It helps to know the characteristics of a good business relationship. Let’s take the example of two business partners who don’t have a personal relationship together and are trying to build, let’s say, a furniture moving company. What are the critical relationship components that would help their business succeed?

  1. A common goal. To get their business off the ground the two partners need to be on the same page about the goal of their company. If one person’s business goal is to develop a furniture moving empire by targeting affluent companies, and the other person’s goal is to provide moving services for the indigent and underserved for free, it seems obvious they’re not going to move forward. So just as two business partners need to agree upon the goal for their company, two parents need to agree on the goal for their children. (Good news! The general goal of parenting is always the same: to raise children who are physically and emotionally healthy.)
  2. Win-win. Imagine the furniture moving business partners are not committed to the “partnership” idea and each keeps trying to win every disagreement. They might even start undermining each other to the customers. The company will fail because they won’t be able to effectively work with each other anymore as things get more hostile. Not a huge deal when there’s just a moving company at risk. But when it’s your own child there’s even more reason to have a win-win mindset, because ultimately the child wins when you get along.
  3. Compromise and other conflict skills. Our two-person moving company should expect change and disagreement in the course of building and maintaining a business together. They might have different ideas on how to handle inclement weather or the influx of customers in the spring. Calm and respectful communication and strong conflict skills are critical to keeping the partners effectively engaged and doing what they need to do for the good of the company. So it is with parenting – kids will have new activities and school demands and responsibilities and privileges that necessitate good communication and compromise on the part of the parents.
  4. Business courtesies. Even if they don’t like each other, our furniture moving partners can have a thriving business if they do what works: share a calendar about events affecting the business, keep each other apprised of business expenses, discuss important changes you make at your end of the business, communicate at reasonable times and with a reasonable frequency, make requests instead of demands, and keep communication brief, pleasant, and about the topic at hand. All of these business practices work for co-parenting.
  5. Facts, not feelings. It might be easier for business partners than parents, but strive to carve out emotions that might interfere with your ability to make effective decisions. As described in previous posts, intense emotions can interfere with the ability to make logical decisions and can lead to communicating in ways that will hurt the partnership and ultimately your child. Remember that your parenting partner is not (right now) an emotional support. They are there to problem-solve with you for the good of your child.

It will be impossible to engage in a neutral, practical business relationship if you are stuck in an emotional, adversarial mindset. There are a few types of adversarial mindsets that interfere with businesslike neutrality: victim mindset, control mindset, and revenge mindset. Victim mindset sounds like, “I gave up my career for him and he does this! He ruined my life, this isn’t fair.” A control mindset would sound like this: “I don’t have to let her know about the parent-teacher conference. It’s not my fault if she doesn’t think to ask.” A revenge mindset might be: “At the last exchange he made me wait for 15 minutes; now he can wait while I take my sweet time.” One of these ways of thinking might sound more familiar than the others, or all three might sound familiar to you. They are not abnormal mindsets to have after a divorce but as soon as possible you want to move away from this type of thinking and into partnership mindset, because that is the best way to help your child through this life transition.

Another strategy to jumpstart operating in a business fashion with your parenting partner is STP-A: Stop, Think, Pause, Act. Stop yourself from reacting immediately (which is usually out of emotion) when a situation comes up. Take a breath and stay calm. Think about the long-term goal for your child, not the short-term goal or what you want, and get clear on what is best for your child in this issue. Pause even longer to ensure you are about to enter this issue in a business mindset, as though you’re going to weigh in during a business meeting. Act out of logic, considering long-term goals, and with a business mindset.

This article has used the word “partner” twelve times. The word “ex-spouse” was used zero times. The language you use affects how you believe, think, feel and behave. It affects your self-concept, how you see the world, and colors your interpretations of what you experience. So start making positive change right now by substituting “parenting partner” for whatever word you use for your child’s other parent. Your child will thank you for it.


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