1/29/2016 Disclosures/Conflicts of Interest Clinical Case Presentation: • None Creating space for the father (and child) A. Yuri Iwaoka-Scott, MD, AM Southeast Child/Family Therapy Center San Francisco Department of Public Health UCSF Child & Adolescent Psychiatry A note about confidentiality Fellowship I Some of the case material presented here has been de-identified to • Child and Adolescent Services, preserve client confidentiality. supervised by Dr. Patricia Van Horn and Dr. Betsy Wolfe. • CTRP, supervised by Dr. Lieberman with coverage from Dr. Ghosh Ippen. SFGH 1
1/29/2016 Mother requests treatment for child Referral information from mother • “Brayden” – 3 y.o. old biracial (Filipino/Eastern European American) boy • Hitting, biting, kicking, throwing temper tantrums, sleeping poorly. • Domestic violence + physical/verbal abuse of child by father. • Mother says she and child are “afraid” of violent and sociopathic father • Four months prior, mom called the police, filed for a restraining order, and left with Brayden to stay with friends. A “Triadic Lens” McHale, 2007 2
1/29/2016 First contact with Dad • Dad is angry/unpleasant with staff on phone. • Mom consents to • Dad is mad at mom. treatment with child. • Dad does not think that dyadic therapy is the right treatment • Mother thinks Dad would for child. not consent to treatment. • Dad calls. 3
1/29/2016 • Ensuring physical safety is the highest priority. • Baseline of safety established. • Ongoing and continuous monitoring Lieberman & Van Horn 2008 Assessment of safety in this case Phone Referral Information: Per Dad • No current violence. • “Brayden” – 3 y.o. biracial boy. • Multiple CPS reports filed by mother or at Father reports: mother’s urging. • No symptoms in the child. • Bidirectional allegations of violence between • “Mother is crazy.” parents. Both parents denying. • Father denies domestic violence or physical abuse of child. • CPS/Police/Family Court dropped case and restraining order and awarded joint legal and physical custody. • Child does not appear afraid of either parent. 4
1/29/2016 What to do? A child stuck in the middle Assessment, Feedback, and Treatment Assessment of Father Father’s Experience: • Only child Clinician 1 Clinician 2 • Immigrated from Eastern Europe with parents at age of 3. Parent-Child Dyad 1 Parent-Child Dyad 2 • From a country where there was war. • Strict parents + corporal punishment • Had to “fend for myself” • Felt socially isolated because of immigrant parents, “didn’t fit in, Child Mother Father other kids would tease me” 5
1/29/2016 Assessment of Father Assessment of Father • College-educated, professional. Father’s Experience of Child • Doesn’t believe in dyadic treatment. • “He’s a normal kid.” • “sometimes angry” and “sometimes I scare others” • “I don’t know what to do with a baby.” • Denied being physically violent to Brayden or his mother. • Worry: “Too clingy.” • Wants to work on managing anger. Angels in the Nursery – A Port of Entry Angels in the Nursery “There are angels that pass on from one generation to another, but they are seldom noticed or talked about.” -- William Harris • Evokes the parent’s benign, loving, and protective memories of childhood • To facilitate the intergenerational transmission of loving and growth-promoting influences to the child Fraiberg, Adelson & Shapiro, 1975; Lieberman, Padrón, Van Horn, & Harris, 2005; Lieberman & Van Horn, 2008. 6
1/29/2016 “Fishing Moments” Beginning to get a sense of the whole person • “Don’t like to talk about past, but…” • Understanding of his parents and himself as a boy.. • Talked to his own parents. • Sadness that there weren’t more memories • Wish for Brayden to have many memories, “fishing moments,” with him. • Reflects on son’s individuality/preferences. The Triangle: Explaining Treatment to the Child Initial Assessment of Child • Playful, does not appear depressed. • No symptoms in assessment play session. • With mother is often dysregulated; with father no symptoms in initial observations. • No cognitive, speech/language, motor delays Treatment • Seeks out both parents for play and comfort Lieberman & Ghosh Ippen, 2014 7
1/29/2016 Triangles Explaining Treatment to the Child • Frame of creating space for the child to love both parents. Meeting the client where he is… Dad’s worry Dad Therapist “Clingy” Explore worry I want him to be social Validate and highlight dad’s attachment motivation/socialization goal Connect with dad’s past experience Wants “normal” childhood Wonder with dad about child’s experience *The Port not entered Developmental Guidance 8
1/29/2016 “Daddy will you huggy me? Powell, Cooper, Hoffman & Marvin, 2013; Diagram Cooper, Hoffman, Marvin & Powell, 1998 Fostering bond through play: “Mud Pits” “No symptoms.” 9
1/29/2016 Validate the feeling + Redirecting aggression Dad laughs Creating Triadic Space in Therapy Child-Parent session: • Child gets upset, Dad laughs • Child escalates. Session with Dad: “I feel helpless.” Child-Parent session: Can you tell Dad how you feel? • “I am sad because you tease me.” • Dad: “I am sorry. I don’t want to make you sad.” 10
1/29/2016 “It’s okay to talk about mommy.” “I miss Mama.” Summary “Mud pit moments” • The triadic lens was essential. • Father ≠ Mother’s descrip�on of Father • Empathic therapeutic stance � engagement • Empathic therapeutic stance � treatment gains • Having single therapist or good communication between therapists is essential. • Father able to create space for child’s feelings. • Father increasingly able to create space for mother. 11
1/29/2016 References Acknowledgments • Fraiberg, S., Adelson, E. & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired mother- infant relationships . Journal of the American Academy of Child and Adolescent Psychiatry , 14, 387-422. • Lieberman, A. F., Ippen, C. G., & Marans, S. (2009). Psychodynamic therapy for child trauma. In E. Foa, T. Keane, M. Friedman & J. Thanks to all at CTRP, especially to the clinician who worked with this Cohen (Eds.), Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies (pp.370- 387). New York: Guilford Press. who worked with this family and the supervisors. • Lieberman, A. F., Ghosh-Ippen, C., & Van Horn, P. (2006). Parent–child psychotherapy: Six-month follow up of a randomized control trail. Journal of the American Academy of Child and Adolescent Psychiatry , 45, 912–918. And thanks to the UCSF Child and Adolescent Psychiatry Fellowship. • Lieberman, A. F., Padrón, E., Van Horn, P., & Harris, W. W. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant mental health journal , 26 (6), 504-520. • Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early development. New York: Guilford Press. • Lieberman, A. F., & Van Horn P. (2005) Don’t hit my mommy!: A manual for child-parent psychotherapy for young witnesses of family violence. Washington, D.C.: ZERO TO THREE Press. • McHale, J.P. (2011). Assessing coparenting. In J. P. McHale & K. M. Lindahl (Eds.) Coparenting: a conceptual and clinical examination of family systems (pp. 149-170) APA:Washington, D.C. • Powell, B., Cooper, G., Hoffman, K., & Marvin, B. (2013). The Circle of Security Intervention: Enhancing attachment in early parent- child relationships. New York, NY: Guilford Press. • Stover, C. S., & Morgos, D. (2013). Fatherhood and intimate partner violence: Bringing the parenting role into intervention strategies. Professional Psychology: Research and Practice , 44 (4), 247. 12
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