A transformative therapy model helps parents and children heal

Breaking the cycle to create a new story

Imagine that you are the foster parent of two toddlers who were born drug-exposed and who exhibit such challenging behaviors that you have been asked to remove them from two day care centers. You and your spouse, who are hoping to provide a nurturing and stable environment for these children, have to work to support your household and are nearing your wits’ end.

An excerpt from an actual note written to the director of a third center explaining the situation illustrates the difficulty that children with challenging behaviors and their caregivers face. “Foster children often come with behavioral and developmental challenges, and ours are no exception,” this foster parent wrote.

“Even as toddlers, many are hyper-vigilant and have learned to always be on guard and not trust the adults in their lives. They act out because the wiring in their little brains has changed as a result of their trauma and/or drug exposure. They act out because they are desperate for consistency and security.”

As you can imagine, you’d hope the center would accept your children. But you’d know you need more than an understanding daycare staff to truly help your kids.

The inability to regulate behavior and “acting out” at a young age can put a child on a very difficult path. The world often begins to label young children who exhibit behaviors that may range from forms of aggression (defiance, anger, hurting others) to anxiety (fear, crying, separation anxiety) as “bad kids.”

Because they are often subject to punishment, criticism, or tagged as being problems, children with challenging behaviors also begin to self-identify as bad kids. It’s the story they begin to tell themselves.

What’s below the surface, however, is that these children often have been through scary or painful events such as loss of a loved person, separation, serious medical procedures, abuse, or violence at home or in the community. These are known as Adverse Childhood Experiences.

Unfortunately, very young children who are unable to regulate their emotions and continue to act out have great difficulty not only in conforming to behavioral norms at school, but frequently later in life at work, or in intimate relationships.

Research has found a correlation between Adverse Childhood Experiences and negative health effects in adulthood, addiction and involvement with the legal system.

How can we help these kids?

There are several therapy models in use to work with children to overcome behavioral challenges. One model, Child-Parent Psychotherapy (CPP), works specifically with caregivers and children up to age five, and is supported by the New Hampshire Children’s Health Foundation, which has funded the training of practitioners in its use in New Hampshire.

Child-Parent Psychotherapy is family therapy for young children and their parents or caregivers. It’s a nationally recognized, evidence-based intervention model for children who have experienced at least one traumatic event. What separates it from other family or behavioral therapies is that it requires significant involvement by parents or caregivers.

Rather than seeking to simply modify behavior through rewards or other modification techniques, CPP first works a caregiver to understand the “story” behind the child’s behavior. Once this occurs the caregiver can work with the child to also understand that story and to begin healing by establishing safety and creating a new one.

What a parent or caregiver often discovers in working with a CPP therapist is that the “story” did not begin with their child. It’s often a story that they experienced themselves. One which may have been repeated cyclically in their family for generations, and one from which they can also heal.

A “transformative” treatment model

Beth Ketaineck, Psy.D. is a licensed clinical psychologist with the Children’s Intervention Program at Riverbend Community Mental Health in Concord. She is trained and rostered as a CPP provider and says, “When I reflect on what Child-Parent Psychotherapy has meant to my practice as a psychologist, the word transformative is always the first to emerge.”

“Not only has this treatment model transformed my understanding of healing and the way I provide treatment – to families and children of all ages – it also transforms parent-child relationships as a means to heal from adversity, improve the developmental trajectory, and reduce dysregulated emotions and behaviors – which are often the reason for the referral,” she says.

Dr. Ketaineck notes that her favorite thing about Child-Parent Psychotherapy is that the nonjudgmental stance taken by the clinician allows for a deep exploration into intergenerational patterns of (often toxic) relationships, and begins a shared journey to understand, address, and change those patterns.

“The vast majority of these are cyclical,” she says. “Our goal is to break these patterns and start something new.”

According to Dr. Ketaineck, unlike other therapy models, Child-Parent Psychotherapy shifts the focus away from “changing” behavior to “understanding” behavior. The goal is to look beneath the behavior to understand what the child is communicating through it.

“Parents – and the world – often respond to children who can’t self-regulate with punishment, instead of empathy, and this builds an internal story in the child, that ‘I’m a bad kid,’” Dr. Ketaineck says. “Parents of ‘bad kids’ are often told by the world – and begin to see themselves – as a ‘bad parent.’”

Child-Parent Psychotherapy works to break this cycle of shame and blame. It delves into what it terms “The Triangle of Explanations” working with children to help them understand:

1. These are the experiences that you’ve had.
2. This is how they affect you.
3. This is what we’re going to do about it.

Using understanding instead of stickers

A typical referral that CCP providers get for young children is as a result of massive behavioral outbursts. “They can’t control their behaviors,” Dr. Ketaineck says. “They are angry. They’re hitting. They’re kicking. They’re stomping.”

One approach a clinician might employ would be to set up a behavior plan with the child and the parent that might involve giving the child a sticker every time he or she uses an alternative coping skill instead of kicking or biting.

In the Child-Parent Psychotherapy model, “Before even thinking about addressing this behavior, we really dive in with the caregiver to understand this particular child’s history, experiences, exposure to trauma and adversity and make sense of the behavior in light of those experiences,” Dr. Ketaineck notes. The emphasis on caregiver-only work is unique to Child-Parent Psychotherapy.

Initial exploration with a caregiver, for example, may uncover a story about exposure to domestic violence in the home, or frequent name calling or shaming.

As this exploration progresses, Dr. Ketaineck says it’s common to see the caregiver experience “aha” moments as they begin to understand why their child might cope with anxiety or perceived threats by acting out.

“It’s a common myth that kids just ‘get over things,’” Dr. Ketaineck notes. “These aha moments help caregivers make important connections.”

The next leg of the journey

Understanding and empathy begin the next phase of the journey as Child-Parent Psychotherapy providers guide parents to a stronger, more secure attachment with their child.

Once a CPP provider and the caregiver understand and talk about the child’s “story,” together they begin a series of play-based therapy sessions with the caregiver and the child to look for themes and to help the child understand his or her own story and learn to be safe with their caregiver.

“What’s incredibly transformative about this is to watch a child develop some context to understand the big feelings and big behaviors that they’ve been experiencing,” Dr. Ketaineck says. “It can free them from the blame or the negative narrative that they’ve developed about themselves, namely, ‘I’m just a bad kid.’”

Dr. Ketaineck says that unfortunately that’s how the world often responds to children with challenging behaviors. It tells them, “You can’t be in a regular classroom. You can’t come to my school. You will be excluded from fun activities, because you are not good enough, or regulated enough, to do these things.”

By looking beneath their behavior, a child begins to understand, “This isn’t my fault. This is what’s happening to me.” They discover that these are actually normal responses to abnormal experiences.

“And we want both the child and the caregiver to understand that,” Dr. Ketaineck says.

You’re not doing it right

During Child-Parent Psychotherapy it is also common for a caregiver to recognize they have also been experiencing negative emotions, hostility, or a really hot temper because of the things that they went through. This gives them the opportunity to free themselves from the shame and the blame that they have been experiencing for so long.

“Often these parents have been told time and time again, ‘You’re not doing a good enough job of parenting. You’re not doing this right. You’re not doing that right.’ So they’re getting all of those same messages,” Dr. Ketaineck says.

The opportunity that Child-Parent Psychotherapy presents is for the therapist and the caregiver to explore, in a nonjudgmental space, what is causing challenges in their family system or in their relationship with this particular child, according to Dr. Ketaineck.

“They have never had the opportunity to reflect on that before, they’ve only been told, ‘You’re not doing it right as a parent, you need to do it better.’ Which in turn, causes them to want to only address the behavior of their child, because other people have only addressed their behavior,” Dr. Ketaineck says.

That leads to parents saying to their child, “You’re not doing it right. You need to do it better. You can’t have these tantrums anymore.”

And unfortunately, the way that many parents cope with this or try to change behavior is through punishment.

That’s counterproductive. “Punishment erodes a relationship,” Dr. Ketaineck states. “It’s about me asserting my power over you.”

“When we look at the child we see there’s a really understandable reason why the child is behaving this way,” she notes. “And we can also look at the caregiver and say, ‘Actually, there’s a very understandable reason why you’ve been behaving this way.’ It translates from the caregiver to the child.”

“It has truly been a gift to observe this and hear about ongoing improvements in development, relationships, and capacity for co-regulation,” says Dr. Ketaineck. “We’re giving the caregivers what they need in order to give that to the child.”

Giving children a safer world

Because Child-Parent Psychotherapy involves both the caregiver and the child and addresses issues that may have been ingrained in a family structure for generations, the therapy model does take time. It typically encompasses 50 sessions. The first five or six with the caregiver alone. Then 30 or more play-based sessions with the caregiver and child. The final 10 sessions focus on summing up and transitioning from therapy.

The effort is worth the investment. “When parents and children are free to “speak the unspeakable” by telling their stories and exploring the negative impacts of their experiences on their well-being, they can feel empowered to release themselves from blame and write new stories,” says Beth Ketaineck.

Making sense of their experiences jump-starts the process of healing together. Children begin to look to their caregivers for safety, love, security, attunement and coregulation.

“The safer children feel with their caregiver,” Dr. Ketaineck says, “the safer they feel in the world.”

 

 

 

Published NH Children’s Health Foundation – 2021