Transcript Clinical Issues in Providing Therapeutic Services:

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Handout #4.6
Joanne: Clinical Interventions with a Birth Mother
How did Joanne’s experience with adoption factor
into the presenting issues?
What background factors are particularly relevant in
relation to the presenting issues surrounding the
involuntary termination of her parental rights?
Do you agree with the assessment conclusions
reached by the therapist? Why or why not?
How would you describe the key treatment strategies
used by the therapist?
How important was the therapist’s adoption
competence in this case?
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Specific Clinical Interventions
Written role play
 Therapeutic writing
 Bibliotherapy
 Therapeutic rituals
 Group work
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Strategy for facilitating the birth parent’s
exploration of hopes, fears, beliefs, and
expectations in relation to the child and adoptive
family
Client chooses who to write to – it is not intended
that the letter will ever be sent
Therapist asks the client to:
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“Correspondence with the self.”
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◦ Write whatever he/she wants to that person
◦ Assume the role of the person who has received the
letter, and respond in writing as if she/he were that
person.
◦ Respond in writing to the response of the adoptive
family member, and so on.
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Journaling
Different forms: from very free-flowing to
very structured
Growing body of research: writing can have
therapeutic benefits that help psychologically
as well as physically
As therapy progresses, it is useful to have the
client return to material written weeks earlier
to revisit those feelings in light of therapeutic
progress made since then.
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Incorporates appropriate books or other written
materials, usually intended to be read outside of
psychotherapy sessions, into the treatment regimen
Goal: to broaden and deepen the client's
understanding of the particular problem that requires
treatment
◦ The problem itself
◦ The proposed treatment
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Can facilitate active participation in treatment and
promote a stronger sense of personal responsibility
for recovery
May find relief in knowing that others have had the
same problem and have coped successfully with it or
recovered from it
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Symbolic acts that provide support for people and
provide an environment for expressing and
containing strong feelings
Means of connecting the past to the present, and the
present to the future
Can provide a powerful bridge to adoption when
celebrated with openness, love, and pride -powerful message of validation
The outcomes of rituals may be:
◦ A release of feelings of grief, anger and confusion toward a
situation or person
◦ Ability to put memories in a safe place so that they do not
interfere with moving forward
◦ Clear definitions of family relationships
◦ People joining together in new roles
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The entrustment ritual
Rituals marking a transition from the past to
the future
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Being a birth parent: Isolating experience –
shame, guilt, unwillingness to share the
experience with others
“Talk therapy” can be very beneficial, but
talking within the safety of a group of other
birth parents might be even more useful
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Handout #4.7
Donna: Clinical Interventions
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Handout #4.8
The Good Grief Program of Boston Medical
Center: What Children Need
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1. Understanding: knowing what happened
to the person who left and why, or knowing
what situations caused the loss and why it
happened
 What are some specific considerations that
we must take into account in helping
children understand their losses?
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 The developmental stage and cognitive ability
to understand the loss
 The child’s unique temperament and
personality
 Tendency for children to assume responsibility
for what has happened to them
 The fact that some children regress under
stress
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2. Grieving: experiencing the painful feelings
associated with a loss
 Some key considerations when they think
about how children grieve are:
◦ Children grieve in spurts
◦ Their grief can be described as sad, mad and bad
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Five factors that have an impact on a child’s
grief response are:
◦ Their developmental stage and cognitive ability to
understand the loss (as with Understanding)
◦ Their need to re-grieve as they grow and develop
◦ Their relationship with the people they have lost
◦ The suddenness or anticipatory nature of the loss
◦ The secondary losses that often accompany a
primary loss
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We cannot rush the grieving process in
children
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3. Commemorating: remembering the persons,
places, things that are no longer part of the
child’s daily life
 Commemoration as a vehicle for expressing
 Ambiguous loss: Informal commemorations
What might be some informal
commemorations that we could work with a
child to create to remember his/her losses?
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4. Going on: The child learns that the pain of
grief subsides and the legacy of their loved
ones lies within themselves
 Going on involves a transformation over time.
Children maintain an inner connection with
those they have lost
 Connection and memory of the people they
have lost depends on our willingness to help
them integrate this loss within themselves.
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Unresolved separations will interfere with
formation of new relationships
New attachments are not to replace old ones
We can free children from the past by providing a
process to grieve past losses
Children fear re-occurrence of pain of losses and
avoid intimacy
Adults who show support of child’s emotions as
the child copes with grief support the
development of new attachments
Adoptive parents must accept that loyalty issues
will exist but that children can love more than
one person
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Life Books
 Loss Box
 W.I.S.E. Up
 CASE’s Teen Treatment Model
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Individual Therapy
Group Therapy
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Written Role Play
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What it is
How a loss box is made
A loss box made by a teen
at the Center for Adoption
Support and Education
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What are your thoughts about the loss box as a
way of helping young people identify and
acknowledge their losses?
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During the middle childhood years: children
encounter questions from school mates about
adoption -- may trigger additional feelings of
grief and loss.
What might be some questions from school
mates that could trigger these feelings?
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Who is your real mother? How come she didn’t keep you?
Don’t you want to find your real mother?
I hear you were left in an orphanage. What was wrong with
you?
Is your mother a prostitute?
Do you have a dad? Where is he? How come he didn’t
marry your mother?
I hear that all kids in foster care were abused. What
happened to you?
How do you know what you will look like when you grow
up?
How can that be your mother? Her skin isn’t dark like
yours.
How much did your parents pay for you?
Is your real mother a drug addict?
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Developed by the Center for Adoption Support and
Education for younger children
W.I.S.E. Up the Owl leads young readers through the book
with questions about feelings, different ways the topic of
adoption is brought up by peers, and how to handle
situations as they arise
The letters in WISE stand for the four options children have
for responding to questions and comments about
adoption:
W
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Walk away or ignore what is said or heard
It’s private and I don’t have to answer it
Share something about my adoption story
Educate others about adoption in general
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The W.I.S.E Up! Powerbook can be ordered
from the Center for Adoption Support and
Education Store at:
http://www.adoptionsupport.org/pub/index.p
hp
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Childhood grief is often based on different issues that those
that impact adolescents and adults.
Donna O’Toole, author of Helping Children Grieve and Grow:
“Especially for children a loss may be based on safety,
comfort, and familiarity rather than on what adults speak of
as love or affection.”
Six categories of childhood loss:
 Relationship loss (usually people and animals)
 Loss of objects that give comfort (toys, blankets, clothing)
 Loss of a secure, familiar environment
 Loss of self (ways of being and doing that define us
uniquely)
 Loss of skills, abilities, and competencies
 Loss of familiar habits and routines
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Theresa Anderson:
“You can’t take a child from home, put them
on an airplane, cross the world, surround
them with thousands of people at the airport,
have them met by strange people, smells,
textures, food and voices, and not expect
them to be traumatized.”
Donna O’Toole: Children do not tell us they
are grieving. We must look at what they say
and do.
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Possible reactions:
Anger
Sadness
Hyperactivity
Changes in appetite
Hoarding food
Clinginess
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Inappropriate emotional
response
Headaches
Difficulty making
decisions
Repressive behaviors
When children feel overwhelmed by intense
feelings they may naturally make their world safe
by distancing themselves physically and
emotionally, by pretending or by denying the
reality of the loss.
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Handout #4.9
Case Example: Sara
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As the therapist for Sara and her family,
how would you have supported Sara’s
parents in revealing the adoption story to
her?
What interventions might you use with Sara
as she attempts to absorb these new losses
on top of the existing losses?
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Handout #4.10
Examples of Feeling Charts
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Two books recommended by the C.A.S.E.
therapist are:
The Invisible String
Twice Upon a Time
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3. How might you work with Sara’s parents in
helping them help Sara as she experiences the
disbelief, anger and sadness at learning her
adoption story?
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Involves the teen in individual and group
therapy, the family in family therapy and parent
support and education.
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Individual Therapy: The therapist:
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Provides a safe place for exploration of
adoption issues
Give permission to the teen to grieve losses
Validates the teen’s sense of confusion as
he/she moves to consolidate a sense of self
Educates the teen to developmental issues in
adoption
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Handout #4.11
David
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What factors have contributed to David’s
complicated grief?
As the clinician, how would you begin your
work with Marla and David?
What are some clinical interventions that
you would consider as you complete the
assessment and begin the development of
the treatment plan?
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Group Therapy
A social milieu for growth and emotional
healing
 Opportunities to identify with other teens and
normalize experiences (“I’m not alone!”)
 Helps teens release stigma and shame
 Validates for teens the universality of their
issues
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Research evidence: Effectiveness of group
therapy for adolescents when the therapeutic
relationships in the group have relationship
structure and relationship quality.
Structure: The direction of the relationship.
Vertical cohesion refers to a group member’s
perception of the group leader’s competence,
genuineness, and warmth.
Horizontal cohesion describes a group member’s
relationship with other group members and with the
group as a whole.
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Quality of the group relationships:
how members feel with their leader and with
other members (positive bond)
 by the tasks and goals of the group (positive
work)
 the empathic failure with the leader and
conflict in the group (negative relationship)
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“I thought I was the only one who ever thought
about what it would have been like to have
been raised by my birth parents.”
A teen in a group therapy program for adopted
adolescents
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Handout #4.12
C.A.S.E. Scripted Group Schedule: Group
Therapy with Teens
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Can help a young person open
communication.
Process: Write a letter to his birth
mother/father, which can be followed by the
young person composing his or her reply to
the letter by imagining how his/her birth
mother/father might respond
Also can help an adoptee prepare for meeting
his birth mother/father
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Handout #4.13
Amy
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What are your thoughts on written role play?
How might you see yourself using this
approach with adopted older children, youth
and young adults?
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Critical to clarify at the outset of therapy, both
with the child and parents, how
privacy/confidentiality of information shared by
the child will be handled
Gregory Keck: Parenting Adopted Adolescents:
◦ When parents bring an adolescent to therapy, he
discusses what information will not be confidential –
such as physical or sexual abuse, dangerous use of
alcohol or drugs, and safety issues.
◦ There is usually an understanding that family matters
are shared with the people who are involved in
treatment.
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Adolescent asks, before saying something: “Will
you tell my parents?”
In response, Dr. Keck says, “It depends on what
you tell me,” and then goes over what he would
either need or want to share.
One of the most important ethical
considerations: Creating a zone of safety for
clients
erapist should always be aware of situations that
may be beyond his/her current level of expertise.
In such cases, be sure to reach out for
consultation or supervision with colleagues who
have more experience in this area.
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Assessments of the range of losses that
adoptive parents may experience is essential
to our quality work with them and their
families.
Dyadic Developmental Psychotherapy (DDP):
focuses on assessing and addressing
adoptive parents’ grief, loss, separation and
attachment experiences in the context of
meeting their children’s needs
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Far more work on separation and loss has been
done with respect to clinical interventions with
birth parents and with adopted children and
youth than has been the case with adoptive
parents.
Why do you think that this is the case?
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“Families linked in adoption come in as great
variety as the range of human possibilities permit.
Regardless of their particular link to adoption, they
must deal with the universal human needs for
attachment, generativity, and coping with loss. The
only certain commonality among these families is
that they have undergone fundamental loss
experiences beyond those that any family can
normally expect. No other common experiences
can be assumed for all families linked in adoption.”
(p. 13).
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To learn more about the people featured on
the documentary:
http://unlockingtheheart.com/www/index.htm
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Define ambiguous loss and describe how birth
parents and adopted children and
youth
experience ambiguous loss.
Describe the continuum of children’s
reactions to loss
Define disenfranchised grief and how birth
mothers and birth fathers and adopted
children and youth experience
disenfranchised grief
Compare two different frameworks for
understanding birth parents grief and loss and
describe how these frameworks could be
utilized in the students’ clinical practice
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Define complicated grief and prolonged grief
disorder (PGD) and how the DSM-V treats these
conditions
Using case studies, identify at least five clinical
interventions that can be utilized with birth
parents in helping them with grief and loss
issues and discuss how the student would use
these in his/her clinical practice
Describe the four principles of the Good Grief
Program
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Identify at least three clinical interventions
that can be utilized with adopted children
and youth in helping them with grief and
loss issues and discuss how the student
would use these in his/her clinical practice
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Identify, based on the stories depicted in
Unlocking the Heart of Adoption, the
losses experienced by all members of the
adoption kinship network in same race
and transracial adoption
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The Brief Online Survey
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Trauma and Brain Neurobiology
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