Tuesday, December 31, 2019

2019 Hiatus & Update

You might be in your final year of graduate school if. . .

You have only written four blog posts IN ONE YEAR!

Yep, I’m still here.  I’ve just taken a brief hiatus as I focus on balancing my graduate studies with my family life and working part-time.  I’ve been made painfully aware that it’s impossible to be “perfect” in all areas of one’s life- something’s got to give and be put on the back burner.  And this blog has definitely been put on the back burner over the past couple of years.

The good news is that I am starting to see the proverbial “Light at the End of the Tunnel” as this Spring I will be finishing up my graduate studies and required hours of supervised internship experience to receive my Masters in Social Work.   Eventually, after 4,000 MORE supervised hours and passing the licensing exam I will be an LCSW (Licensed Clinical Social Worker).

          I am currently working in my second internship placement and I am quite satisfied with both the population I serve and the work I am involved with.  I felt a loss last year, as well as a bit of guilt, when we came to the decision to close our foster care license after 12 years of fostering.  Then in 2019 I was presented with a job opportunity (at my current internship) which seemed to fill that particular “void” of helping children in the foster care system without necessarily being a foster parent.  

        At my current practicum placement I not only get to work with children and adolescents in the foster care system, but with their caseworkers, their foster parents, their biological parents (in some cases), as well as a few Guardians ad Liteums and judges on occasion.  More specifically, I have been trained to conduct mental health assessments and provide in-home therapy to these children and their families.  To learn more about the type of modality I’ve been trained in and use, which is both trauma-informed and attachment-based refer to this post.  Other modalities I draw from in my work with clients are Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Parent-Child Interaction Therapy (PCIT), and Trust-Based Relational Intervention (TBRI).
          Although I can’t and won’t give details about my experiences for obvious reasons, I’d like to provide some general observations (not necessarily in any particular order) of things I’ve learned over the past year in my therapeutic role to children and families impacted by being placed in state custody.  I feel like I could honestly write an individual post for each one of these observations, but for the sake of space and time these summaries will do for now:

-      Caseworkers have a tough job- witnessing a lot of emotional pain and having high caseloads.  It's challenging to work with clients who are court-ordered and don't believe they need any services.   It’s not surprising that child welfare workers have a heavy turnover rate.

-    I appreciate relatives who are able to step up and open their homes to becoming Kinship Placements- especially grandmas, who forfeit their role as grandparent to that of “parent” to their grandchildren in what could be their years of retirement.  In some cases, these grandmas are the bedrock and/or savior of their family

-      Parentification isn’t just about taking care of younger sibling’s physical needs: (getting them dressed or to school on time, and making sure they have enough to eat), but there’s an emotional aspect a well where the child feels responsible for their parent’s emotional needs.

-   Regarding parentification and patterns I’ve seen, many children from early to middle childhood (grade school) continue to worry about and feel false responsibility for their parents who are or have been absent from their lives due to substance abuse struggles and/or mental illness, and readily excuse and overlook any dysfunction on the part of their parents.  However, by the time these same children reach adolescence or young adulthood they are more prone to be filled with resentment for caring for younger siblings for so long and/or they become tired of having the roles reversed after constantly worrying about or covering for their parents for so long.

-      Attachment is everything.  Children can become hurt, broken, and damaged in relationships (especially in family relationships) but healing can take place with the proper interventions and resources, including supportive relationships.

-     So many disorders can be preventable because of early traumas and one’s family life.  One semester when I had a class delving into the DSM, I would find myself immediately jumping ahead to the section of “Risk Factors” for disorders to find just how many disorders are influenced or precipitated by neglect and abuse, including Oppositional Defiant Disorder, Conduct Disorder, Borderline Personality Disorder, Reactive Attachment Disorder (which is probably the most obvious) but trauma and stressor-related disorders and Depressive and Anxiety Disorders.  
 I believe it’s more important to treat a person than a diagnosis.  And although diagnoses are helpful in formulating a Treatment Plan or understanding which symptoms to focus on (and are necessary for Medicaid reimbursement), a person is much more than their diagnosis.

-   I wish Developmental Trauma were an officially recognized DSM-V Disorder because although it has similarities with other traumas the attachment and trust component require such specialized care and a unique approach.

-      It is essential to understand that someone’s developmental age may be vastly different than their chronological age.  It was very insightful to me to read a very comprehensive neuropsychological evaluation of one of my clients from a developmental psychologist who measured different aspects of one’s IQ.  I realized that I needed to approach this client in a different way based on his developmental age.

-      Symptoms of ADHD and Trauma can look a lot alike.  Sometimes it’s hard to unravel the two- especially if both exist.

         (I got this graphic off of Pinterest- don't know where exact credit should go)

-      Just like “It takes a village to raise a child” , it takes a team to work together for children in foster care.  I’ve been able to attend Child and Family Team Meetings in a new role this past year- as a therapist versus a foster parent- but my observations are the same:  There are so many facets of support to a youth in state custody: physical health, mental health, schooling, other opportunities- that the more professionals and caregivers can step forward and come together in behalf of a child, the more hope and resources there are for the child.  

    I was touched to be able to attend one CFTM where not only the teacher and after-school coordinator of a client were present, but the principal of the school as well.  In a different meeting, a Transition to Adult Living Coordinator was there to help the youth who was preparing to age out of the system.  In other meetings nurses are ready to make sure all appointments or physical concerns are followed through with.  I even discovered that my state has a specific nurse assigned to oversee any youth who are prescribed psychotropic medications.

-      School is children’s work- where they spend most of their day.  Because of that, I’m grateful for trauma-informed classrooms and sensitive teachers.

-      Because I’m a social worker, I try to get the “big picture” of what’s going on in a client’s life: not just their mental health, but their physical health, their social environment, their school, etc.  Having said that, I would like to learn to incorporate more physically-based interventions (besides just deep breathing and meditation- maybe somatic experiencing or sensorimotor techniques) with my clients who have sleep problems- particularly insomnia, or who have a lot of muscle tension as a result of past traumas or whatever reasons.  I feel so frustrated for children and adolescents who can’t relax because muscle aches and insomnia seem like “old person problems”.  Many of these kids have tried melatonin which may help them get to sleep but they cannot sustain restful sleep.  And then they're expected to go to work (school) the next day and perform like nothing is wrong!

-      I use various assessment measures when conducting Mental Health Assessments with clients for the first time, but I recently started using the ACEs- not necessarily because it will give me a diagnosis, but because it helps me to gather a more complete social history of the client.  After one session this year, I was both amazed and saddened that I came across one client who had an ACES score of 9 (out of 10). He had experienced all but one of the adverse childhood experiences.  As I was driving home from work that night and the enormity of what my client had been through sunk in with me I wanted to cry.
    On a more hopeful note, here are some protective factors to help mitigate a high ACES score:

Using Attachment, Regulation, and Competency Modality with Foster Children

This is a summary/review of an assignment I did last semester.

Background:  This year I am doing my internship with an agency that contracts with DCFS to provide Mental Health Assessments and Individual and Family Therapy to children and adolescents who are currently in the foster care system or who have been adopted (in many instances) from foster care. 

Employees at my work are required to read the book Treating Traumatic Stress in Children and Adolescents: How to Foster Resilience and through Attachment, Self-Regulation, and Competency written by two clinicians, Margaret Blaustein and Kristine Kinniburgh.  Blaustein and Kinniburgh are a clinical psychologist and a clinical social worker who both specialize in treating complex childhood trauma and/or in incorporating trauma-informed practices into a range of settings.  These two women were influenced by the work of Dr. Bessell Van der Kolk, among other clinicians, who work with clients impacted by trauma and they have developed a specific treatment framework called the ARC Modality which is used to treat developmental trauma and accompanying problems in youth.   

Before I explain the ARC Modality, I will summarize what Treating Traumatic Stress in Children and Adolescents teaches about developmental trauma and how that fits into my internship:  The population that I work with would never have come into state custody in the first place if they hadn’t suffered from abuse, neglect, or abandonment.  Although the symptoms and diagnoses of my clients vary, all of these children are suffering in some degree from the affects of developmental trauma which can be defined as chronic trauma caused by a child’s caregivers early in life which greatly affects, among other areas, their ability to form safe and healthy attachments with others.  There are many other traumas such as a car accident, natural disaster, or sexual assault which can result in the victim developing acute stress disorder, adjustment disorder, or PTSD.  The difference between a traumatic event such as a car accident or fire, for example, versus parental neglect and child abuse is that they are not usually caused by an individual’s caretaker who has the responsibility to care for them so the child’s ability to trust and form safe and healthy attachments is greatly impacted, sometimes resulting in attachment disorders such as Reactive Attachment Disorder or Disinhibited Social Engagement Disorder.  Many children suffering from early trauma at the hands of their caregivers also have trouble regulating their emotions since so much of their energy and brain is stuck in “fight, flight, or freeze” mode or they are triggered easily.

ARC stands for Attachment,Regulation, and Competency which are the three different domains of their treatment.  When I develop treatment plans and therapy goals with my clients at work I am required to use the ARC Modality.  

 Attachment refers to being able to connect with people in a safe way which is hard for a lot of kids if they never had the opportunity for their parents or first families to meet their needs and model what a healthy, nurturing parent-child securely attached relationship looks like for them.  Regulation simply refers to not only being able to identify emotions in oneself and others but being able to express those emotions in healthy ways (not kicking or hitting other people when you’re angry, etc).  or, on the other extreme, not ignoring or dissociating from unpleasant emotions and sensations.  Competency refers to being able to function executively and follow through with basic tasks of everyday living. 

The majority of my sessions with clients focus on the simple goal of affect identification and regulation- or simply put, being aware of one’s emotions and keeping them in check.  This book not only gives an overview of attachment theory and developmental trauma, but also contains some assessment questions and suggested interventions for treating each of the domains in the ARC Modality- Attachment, Regulation, and Competency.  It’s been especially helpful to get ideas for interventions for attachment because I’ve recently started doing family therapy with a few clients either between parent and child or siblings together and attachment is almost always primarily what we work on in those sessions.  In addition, some of the attachment interventions are ones I can use to increase attunement with my own children in my own home.

If you currently work with or have an interest in working with clients or families who have suffered attachment injuries or developmental trauma I recommend reading the book Treating Traumatic Stress in Children and Adolescents.