Sunday, April 15, 2012

Building Hope

Last week I attended and presented at the MASOC/ Massachusetts Association for the Treatment of Sexual Abusers 14th Annual Conference on The Assessment, Treatment and Safe Management of Sexually Abusing Children, Adolescents and Adults. I particularly enjoyed being part of a gathering of NEARI Press authors, and celebrating my soon-to-be-released book. It is in the NEARI press catalog and is expected to come out in June. Steve Brown also presented, his workshop was entitled: “I Can’t Get that Picture Out of My Head” – Vicarious Trauma in Work with Sexual Abusers – What It Is and What We (and Our Agencies) Can Do About It? My presentation was entitled: How to Use the New Brain Science to Provide More Effective Treatment- and to Have More Fun at Work. I guess you are doing okay as a presenter when the only improvement suggestions you get are to make the presentation longer. I was very moved when later in the day a woman I did not know came up to me and said: “that was the most helpful presentation I have ever been to”. If you are reading this in CT, I will be presenting on the same subject at the NASW Annual conference this Friday.
I attended a workshop entitled Parenting with Love and Limits (PLL): A Promising Practice for Sexually Aggressive Youth by Paul Castaldi, MSW. The presenter referred to a meta-analysis of the amount of improvement in treatment (I did not get the citation). He stated that the one variable that consistently correlates with improvement is the creation of hope.

So this made me start thinking: how do we actually create or enhance hope? Many of our clients have good reason to feel hopeless. We serve children who have no adult connections, children who have been hurt and betrayed repeatedly. We serve adults whose own early trauma histories have never been attended to and who feel despair about the ways in which their symptoms have interfered with their parenting. The system we work within is certainly not always responsive or able to give people what they need. Where then do we find the hope?

I think we often assume that we have to give clients concrete facts in order to create hope. We talk about pointing out their strengths, and remarking on instances of improvement. We try to create opportunities for clients to learn and grow, and to experience success. All this is of course extremely important.

But I think we underestimate the hope that is created by forming an attuned, mutually respectful relationship. In such a relationship the client feels seen and heard. They feel a sense of belonging, of being part of something. Early templates about relationships always being associated with hurt and loss are challenged. The client gradually builds a secure base, a place he can return with triumphs or with pain. The client also builds an inner connection: he takes the treater into his mind, creating a caring voice that can soothe him in times of stress.

The very participation in a respectful relationship creates hope that there may be other relationships like this in the future. Maybe there are some people that can be trusted. Maybe love is a possibility after all. The opportunities in life expand.

As the relationship experiences difficulties (the child hits the staff member for example) and these are worked through and the relationship persists, new hopeful possibilities emerge. What if it is not true that whenever you do something wrong the other disappears? What if it is possible to get through hard times and reconnect?

One profound way that enduring relationships increase hope is through their effect on shame. Shame is the sense that deep within me I am no good, that I have a rotten center, and that anyone who gets to know me will turn from me in horror. But what if in fact this doesn’t happen? The antidote to shame is to be known, to share the secret self, and to have the other person not be repulsed. This is so hard to accomplish, because the person who experiences shame is so reluctant to share his true self, which he feels is so horrible. But if we are able to create a relationship that is strong and safe enough, and the client does share with us the parts they hide, we have a precious opportunity. By validating and not turning away, we begin to heal the shame. Consider how much hope flows into a person’s life as shame decreases, and the possibility of being a normal human emerges.

So, here are more reasons why we must emphasize the relationship as the vehicle of healing. This means providing time and space to build relationships, and creating policies and procedures that promote and honor them. It also means taking good care of our staff so that they have the stamina to stay open-hearted in these difficult relationships, and attending to the vicarious traumatization that is created by doing so.

And it also means paying attention to the personal transformation that can occur for us as treaters through increasing hope. Our own personal hope grows when we watch hope blossom in a child or a parent that has been wounded by life through no fault of their own, and who now is open to the possibility of love in their world.

Sunday, April 01, 2012

Doing Dialectical Behavior Therapy

As I have mentioned, we use Dialectical Behavioral Therapy in several of our programs. I have attended an intensive training, read Marcia Linehan’s books, and attended many other trainings. I highly recommend th new book by Kelly Koerner, Doing Dialectical Behavior Therapy.  (Doing Dialectical Behavior Therapy: A Practical Guide (Guides to Individualized Evidence-Based Treatment)  Kelly Koerner PhD Guilford Press; 1 edition, December 2, 2011). Dr. Koerner uses many case examples to describe what  the therapist actually does in this complex therapy. In true dialectical spirit, Dr. Koerner demonstrates both the complexity and difficulty of the therapy and the use of the theory and structure to provide guidance in what to do. Dr. Koerner starts with an overview of the bio-social origins of Borderline Personality disorder. She identifies the core problem, emotional dysregulation. She then describes the key DBT strategies.
Dr. Koerner uses straightforward language, humor and case examples to create a road map to follow in difficult, complex cases through a formulation and a treatment plan. She shows how to use the specific DBT hierarchies to plan the case interventions. She demonstrates the use of the chain analysis to provide direction for the therapist and client. At all times Dr. Koerner respects the difficulty of the change process for both the client and the therapist. She demonstrates deep respect for the client and operates from the assumption that the client is doing the best she can and still must do better. In the lengthy transcriptions of sessions, she demonstrates how the therapist avoids being distracted from the change task while respecting the client’s pain and lack of skills.

 One interesting section is the one in which Ms. Koerner examines the use of relationship contingencies in shaping behavior. This is an area that we do not use deliberately enough. Another refreshing aspect is that Dr. Koerner is always aware that it may be the therapist, not the client, who is creating the problem.

 Validation strategies are the key to successful therapy. The client cannot respond to change strategies without extensive validation. And Dr. Koerner states and demonstrates how accurate, precise validation is the most powerful, and describes what, when and how to validate.

 Dr. Koerner teaches us how to hold a dialectical stance toward the therapy itself, and use dialectics to help us decide what to do next. She ends with a description of the role of the Consultation Team in supporting the therapist.

I think that anyone who is doing DBT will be greatly enriched by reading this book.