Thanks to a series of workshops by Dr. James Webb, I have been reading more about the social and emotional needs of gifted individuals. Dr. Webb is the President of a publishing company that publishes books on many different topics related to understanding and working with gifted individuals. For more information on Dr. Webb's company, please check http://www.giftedbooks.com/. I have also included a few links below.
In working with all age clients, I have noticed that individuals who are highly intelligent present with mental health challenges especially with self-soothing, relationships, and at times, sensory integration issues. Because I focus on a client's strengths, I explore possible logical explanations for the client's symptoms. Young children who are highly intelligent often present in the therapist's office with parents reporting that the child's symptoms include high activity, temper tantrums, difficulty in school, impulsivity such as blurting out questions and being disrespectful to teachers, and difficulty self-soothing. What is especially noticeable with children is the discrepancy between what the child can cognitively think about, but cannot emotionally handle. This discrepancy often is evidenced in emotional dysregulation and difficulty self-soothing and/or calming. Preverbal toddles often struggle until language develops that is commensurate with intellectual level and speed.
Many children who are gifted may have also experienced a range of traumas because they can't relate to other children and struggle socially, adults may have difficulty with these precocious children who asks many questions, and gifted youngsters may be mislabeled with mental health disorders. Gifted individuals may experience existential depression, anxiety, obsessions and compulsions, and varying degrees of trauma. This is where using EMDR with gifted individuals can be very successful. Targeting the clients symptoms through the additional lenses of giftedness and trauma can be very helpful.
Therapists need to assess all clients for level of intellectual functioning and possible giftedness. It isn't always necessary to conduct intellectual assessments, but therapists can ask the older client about what classes the client was placed in school. There are many indications of a client's giftedness that are evident without formal psychological testing.
http://www.psychotherapyservicesforthegifted.com/Gifted/UserFiles/File/GROBMAN_Underachievement_in_Gifted.pdf
http://www.sengifted.org/
http://www.sengifted.org/articles_counseling/Amend_MisdiagnosisOfAspergersDisorder.shtml
http://www.sengifted.org/articles_counseling/Webb_dabrowski_s_theory.shtml
http://www.hoagiesgifted.org/social_emotional.htm
My goal with this post is to get all therapists providing psychotherapy to consider the role that giftedness may play with each client. I hope this begins your exploration of giftedness in mental health.
Sunday, May 31, 2009
Saturday, May 30, 2009
EMDR With Children Living in Residential Treatment Centers
When children are living in a residential treatment center (RTC), the therapist may be working to stabilize the child and the episode of care may be short. The therapist may not be able to move to the trauma processing phases of EMDR, yet EMDR is still important to use with children in RTCs. After completing the Client History and Treatment Planning Phase and establishing clinical rapport, I would spend time in the Preparation Phase with positive affect tolerance and RDI focused on installing mastery experiences. For children in RTCs, trauma processing of the EMDR Phases 3 + may be too much and the therapist may need to focus on the Preparation Phase for a period of time. What is the goal of this episode of care for the child? Many children are in RTCs because they struggle with affect regulation and need to learn affect regulation and emotional literacy. Psychoeducational training while installing successes with RDI and mastery can be extremely beneficial, but it may take some successes in therapy before the kids are ready to proceed with trauma processing. When I have children who balk at desensitization, I know that I need to provide more resources to continue. I need to help the child be ready for trauma processing. Children in RTCs are often in high stress situations and may need to focus on coping with issues in RTC. So, in case conceptualization, I might ask the child about something that's happening at the RTC that's bothering them and then do a future template focused on the child handling the situation in a different way. I need to determine if there is anticipatory anxiety and/or missing skills and information as I continue by installing the future template of the child's definition of being successful at the RTC.
Living in an RTC is an ideal opportunity to move through the phases of EMDR with children. If I have taught the child 2 portable self-soothing techniques that the child is reportedly using (and I check with staff about the child's success on the unit) then I most likely will move forward to reprocess any minor traumas while teaching the child to contain the more severe traumas from the past. Before targeting any significant past traumas, I explain to the residential staff what they might expect from the child and how to provide additional support for the child during this difficult process.
This brief overview is intended to encourage therapists to consider how to conceptualize the use of various phases of the EMDR protocol when the child is living in a residential treatment center.
Living in an RTC is an ideal opportunity to move through the phases of EMDR with children. If I have taught the child 2 portable self-soothing techniques that the child is reportedly using (and I check with staff about the child's success on the unit) then I most likely will move forward to reprocess any minor traumas while teaching the child to contain the more severe traumas from the past. Before targeting any significant past traumas, I explain to the residential staff what they might expect from the child and how to provide additional support for the child during this difficult process.
This brief overview is intended to encourage therapists to consider how to conceptualize the use of various phases of the EMDR protocol when the child is living in a residential treatment center.
EMDR and Case Conceptualization With Children With Symptoms of Reactive Attachment Disorders
How do I conceptualize the use of EMDR with children with symptoms of reactive attachment disorder? This is a question that I struggled with when first learning EMDR and process with many EMDR therapists. This blog is just an overview, but I wanted to document a few strategies for case conceptualization.
1. The psychosocial intake is very important in order to add the appropriate valence to targets. I would suggest that interviewing the parent and the child both together and separately are important. Why is the child in your office? What do the parents want to accomplish and what does the child want to accomplish? Many children are very present oriented and in order to feel successful in therapy and in turn engage in the process of EMDR, I focus on selecting targets initially that the child wants to address. "I don't want to get in trouble so much." Set up the treatment plan focused on this goal of treatment from the child's perspective and explain to parents why this is important in treatment. It is important to remember that in the new training, we discuss that if the client is too overwhelmed by the process of defining the targeting sequence plan, the therapist may need to move to Preparation Phase and IMHO this more circular process of EMDR in psychotherapy makes great sense clinically. Moving to Preparation to teach self-soothing and calming and emotional regulation skills and RDI may be necessary before being able to identify a targeting sequence with many children because of the severity of trauma, less than secure attachment, as well as, the developmental overlay of the child's age and funcitoning.
2. When the child chooses targets as we do during the "Mapping" process, the child is much more likely to be engaged in the process of psychotherapy. Many therapists encounter what is labeled "resistance." I am uncomfortable with the word "resistance" and instead believe that is my job as the therapist to get the child to engage in the therapeutic process. If the child chooses the target and experiences the therapist as the child's ally in the treatment process, the child is much more likely to actively participate.
3. With children the presenting problems (symptoms) identified by the child may result in targeting sequences focused on a presenting problem defined by something other than a dominant core negative cognition (NC). Since children may be more focused on emotions and body sensations, a negative cognition or "what bad thought do you have about you" may be too confusing. In case conceptualization with children, this makes sense for children and parents to start with the symptom and focus on a presenting problem while a targeting sequence plan is developed. Children with symptoms of RAD, especially those adopted internationally may have no cognitive or verbal history, at least in English. Many of the children I work with were adopted from non-English speaking countries so even if they do remember, they remember in another language that they may have forgotten which makes it even more confusing! Again, this is part of learning about the unique issues of this population. At some point in treatment, it is helpful to have the child create a narrative of their own history and even make a Life Book can be helpful to resolve the past history that is often unknown. Using Joan Lovett's narrative is helpful to teach kids. I have kids write a Life Book with a story that tells what we know about their parents, their former home (s), their childhood before adoption and then what we know about the adoption process and what has happened since adoption. Adoptive parents can help with some of the information, but then this becomes the parents' story, not the child's. It surprises me what many children will report if I ask them to write their own story. Once the story is written, we can identify targets from the book that the child might think would have been uncomfortable for a child. This is very simplistic overview of the process, but I wanted to give the reader some thoughts about using EMDR with children.
4. Often when children are in unstable home and community environments such as foster care, residential treatment and/or groups homes, parallel interventions may be necessary - developing and enhancing resources, teaching replacement behaviors, and/or new skills, etc. in addition to, and concurrent with, reprocessing of appropriate targets. This process of establishing a base from which to process the trauma is important because many children with symptoms of attachment trauma and/or RAD do not have the emotional scaffolding with which to tolerate additional distress that may arise from trauma processing. Parallel interventions are often necessary with children with attachment trauma and the therapist may need to spend a great deal of time in Preparation Phase with children AND parents because parents often have their own unresolved attachment traumas, sometimes fertility trauma, and often trauma from trying to love and parent a child with attachment trauma.
5. Targeting chronologically may not be an appropriate course of treatment because the child/adolescent is not prepared to reprocess any past traumas. This is often true with children with trauma and especially with children with symptoms of RAD. So, I'm suggesting that establishing a targeting sequence may not be the first choice for children with RAD or for any client with a chronic trauma history if the client does not remember or is too overwhelmed by the target selection process. I actually am more likely to install mastery experiences and a positive future template with any child. Installing mastery is asking the child, "Tell me about something you are really good at or something you've done that's made you really proud." Installing this mastery experience with short, slow sets of bilateral stimulation helps to build scaffolding for self-esteem, positive feelings about self, and establishes a positive association with the therapy process. In addition, installing a positive future template often helps the child have hope and believe that he or she has something to work towards in the future. Remember, with trauma and depression, a foreshortened sense of future and a negative lens of life may prevent the child from engaging in treatment. If by installing a positive future template, the client has hope for the future, the child may be more likely to engage in treatment. Installing mastery and a positive future template can also help when the therapist has a limited episode of care with the child such as occurs in residential treatment, group homes, shelters, schools, and other programs where the therapist may not have a great deal of time to treat the child. If the episode of care engages the child and creates a positive association with psychotherapy, the therapists has provided the foundation for the next therapist who works with the child.
These are some simple ideas for using EMDR in case conceptualization with children with EMDR EMDRIA has a Children's SIG, there are advanced trainings on using EMDR with children listed in the EMDRIA website, there are at least 5 books on using EMDR with children, and we are in the process of starting a new EMDR HAPKIDS website to share experiences in using EMDR with children.
1. The psychosocial intake is very important in order to add the appropriate valence to targets. I would suggest that interviewing the parent and the child both together and separately are important. Why is the child in your office? What do the parents want to accomplish and what does the child want to accomplish? Many children are very present oriented and in order to feel successful in therapy and in turn engage in the process of EMDR, I focus on selecting targets initially that the child wants to address. "I don't want to get in trouble so much." Set up the treatment plan focused on this goal of treatment from the child's perspective and explain to parents why this is important in treatment. It is important to remember that in the new training, we discuss that if the client is too overwhelmed by the process of defining the targeting sequence plan, the therapist may need to move to Preparation Phase and IMHO this more circular process of EMDR in psychotherapy makes great sense clinically. Moving to Preparation to teach self-soothing and calming and emotional regulation skills and RDI may be necessary before being able to identify a targeting sequence with many children because of the severity of trauma, less than secure attachment, as well as, the developmental overlay of the child's age and funcitoning.
2. When the child chooses targets as we do during the "Mapping" process, the child is much more likely to be engaged in the process of psychotherapy. Many therapists encounter what is labeled "resistance." I am uncomfortable with the word "resistance" and instead believe that is my job as the therapist to get the child to engage in the therapeutic process. If the child chooses the target and experiences the therapist as the child's ally in the treatment process, the child is much more likely to actively participate.
3. With children the presenting problems (symptoms) identified by the child may result in targeting sequences focused on a presenting problem defined by something other than a dominant core negative cognition (NC). Since children may be more focused on emotions and body sensations, a negative cognition or "what bad thought do you have about you" may be too confusing. In case conceptualization with children, this makes sense for children and parents to start with the symptom and focus on a presenting problem while a targeting sequence plan is developed. Children with symptoms of RAD, especially those adopted internationally may have no cognitive or verbal history, at least in English. Many of the children I work with were adopted from non-English speaking countries so even if they do remember, they remember in another language that they may have forgotten which makes it even more confusing! Again, this is part of learning about the unique issues of this population. At some point in treatment, it is helpful to have the child create a narrative of their own history and even make a Life Book can be helpful to resolve the past history that is often unknown. Using Joan Lovett's narrative is helpful to teach kids. I have kids write a Life Book with a story that tells what we know about their parents, their former home (s), their childhood before adoption and then what we know about the adoption process and what has happened since adoption. Adoptive parents can help with some of the information, but then this becomes the parents' story, not the child's. It surprises me what many children will report if I ask them to write their own story. Once the story is written, we can identify targets from the book that the child might think would have been uncomfortable for a child. This is very simplistic overview of the process, but I wanted to give the reader some thoughts about using EMDR with children.
4. Often when children are in unstable home and community environments such as foster care, residential treatment and/or groups homes, parallel interventions may be necessary - developing and enhancing resources, teaching replacement behaviors, and/or new skills, etc. in addition to, and concurrent with, reprocessing of appropriate targets. This process of establishing a base from which to process the trauma is important because many children with symptoms of attachment trauma and/or RAD do not have the emotional scaffolding with which to tolerate additional distress that may arise from trauma processing. Parallel interventions are often necessary with children with attachment trauma and the therapist may need to spend a great deal of time in Preparation Phase with children AND parents because parents often have their own unresolved attachment traumas, sometimes fertility trauma, and often trauma from trying to love and parent a child with attachment trauma.
5. Targeting chronologically may not be an appropriate course of treatment because the child/adolescent is not prepared to reprocess any past traumas. This is often true with children with trauma and especially with children with symptoms of RAD. So, I'm suggesting that establishing a targeting sequence may not be the first choice for children with RAD or for any client with a chronic trauma history if the client does not remember or is too overwhelmed by the target selection process. I actually am more likely to install mastery experiences and a positive future template with any child. Installing mastery is asking the child, "Tell me about something you are really good at or something you've done that's made you really proud." Installing this mastery experience with short, slow sets of bilateral stimulation helps to build scaffolding for self-esteem, positive feelings about self, and establishes a positive association with the therapy process. In addition, installing a positive future template often helps the child have hope and believe that he or she has something to work towards in the future. Remember, with trauma and depression, a foreshortened sense of future and a negative lens of life may prevent the child from engaging in treatment. If by installing a positive future template, the client has hope for the future, the child may be more likely to engage in treatment. Installing mastery and a positive future template can also help when the therapist has a limited episode of care with the child such as occurs in residential treatment, group homes, shelters, schools, and other programs where the therapist may not have a great deal of time to treat the child. If the episode of care engages the child and creates a positive association with psychotherapy, the therapists has provided the foundation for the next therapist who works with the child.
These are some simple ideas for using EMDR in case conceptualization with children with EMDR EMDRIA has a Children's SIG, there are advanced trainings on using EMDR with children listed in the EMDRIA website, there are at least 5 books on using EMDR with children, and we are in the process of starting a new EMDR HAPKIDS website to share experiences in using EMDR with children.
Sunday, May 24, 2009
"EMDR and the Art of Psychotherapy With Children"
EMDR and the Art of Psychotherapy With Children (Adler-Tapia & Settle, 2008). If you are interested in reading about EMDR with children of all ages, Carolyn Settle and I have written a book that provides detailed steps of how therapists can use EMDR with children. Published by Springer Publishing in New York, this book explains the subtleties of using EMDR with children including play therapy, sand tray, and art therapy techniques. The book also includes several original techniques that we have created to assist therapists with eliciting the procedural steps of EMDR with clients including "Mapping" and "Graphing." Along with the book, we wrote a manual that includes the protocols and forms that therapists need for using the EMDR 8 phase protocol created by Dr. Francine Shapiro. This manual can be copied and used by therapists during the psychotherapy process. We wrote the book to encourage therapists to use EMDR with clients and the book includes practical applications, protocols, research, specific diagnoses of children including attachment and dissociation, and recommendations for future research on EMDR with children. We hope you enjoy the book!
Eye Movement Desensitization and Reprocessing (EMDR)
What is EMDR? EMDR is a integrative psychotherapy created by Dr. Francine Shapiro. After more than 20 years of practicing psychotherapy, I began training in EMDR and found that with EMDR I had a comprehensive psychotherapy approach with which to assist clients in dealing with the stress and traumas with which clients presented in my office. Since learning EMDR and using the 8-phase protocol, I find that I am more effective at assisting clients in dealing with the symptoms that initially brought clients to my office. You can learn more about EMDR at the EMDR Institute website at http://www.emdr.com/ or the the EMDR International Association website at http://www.emdria.org/ or at the EMDR Humanitarian Assistance Program (HAP) at http://www.emdrhap.org/.
Along with my colleague, Carolyn Settle, I have also written a book EMDR and the Art of Psychotherapy With Children (Springer Publishing, 2008). Carolyn and I have provided presentations on using EMDR with children and have two chapters that are included in several other soon to be published books. Our work has been focused on advancing the use of EMDR with children in order to gain support for EMDR with children as evidence based practice. We have undertaken this work so that EMDR will some day be available to the poorest and most vulnerable children around the world. In this quest, I have collaborated with EMDR HAP to begin the development of an EMDR HAP project entitled HAPKIDS. This project is being developed by EMDR HAP in order to promote training, research, and treatment of EMDR for children on an international basis.
If you have interest in learning more about EMDR, seeking EMDR treatment, and/or getting training or volunteering to help with any EMDR HAP Projects, I would be happy to assist you with additional information.
I intend to include many future posts on EMDR so feel free to ask questions that I will attempt to answer or at least assist you in finding links to others who might have the answers.
Along with my colleague, Carolyn Settle, I have also written a book EMDR and the Art of Psychotherapy With Children (Springer Publishing, 2008). Carolyn and I have provided presentations on using EMDR with children and have two chapters that are included in several other soon to be published books. Our work has been focused on advancing the use of EMDR with children in order to gain support for EMDR with children as evidence based practice. We have undertaken this work so that EMDR will some day be available to the poorest and most vulnerable children around the world. In this quest, I have collaborated with EMDR HAP to begin the development of an EMDR HAP project entitled HAPKIDS. This project is being developed by EMDR HAP in order to promote training, research, and treatment of EMDR for children on an international basis.
If you have interest in learning more about EMDR, seeking EMDR treatment, and/or getting training or volunteering to help with any EMDR HAP Projects, I would be happy to assist you with additional information.
I intend to include many future posts on EMDR so feel free to ask questions that I will attempt to answer or at least assist you in finding links to others who might have the answers.
Namaste'
So why do I use the word Namaste' in my blog?
Well for me this word is one of love and respect for all others.
The translation I like the most follows:
I honour that place in you
where love and truth dwell and
when you are in that place in you and
I am in that place in me, we are one.
I think that what is important is that we are all connected and impact each other.
For me it is very simple - we all need to take care of and respect each other!
Well for me this word is one of love and respect for all others.
The translation I like the most follows:
I honour that place in you
where love and truth dwell and
when you are in that place in you and
I am in that place in me, we are one.
I think that what is important is that we are all connected and impact each other.
For me it is very simple - we all need to take care of and respect each other!
Welcome
Welcome to my new blog! I hope this is the beginning of a great learning process for all of us as we maneuver the adventure of life. I have chosen to start a blog to share information about my work and the amazing individuals with whom I have the opportunity to meet. The longer I practice as a psychologist the more I realize how much I have to learn. And, I typically learn the most from my clients with whom I have the honor to work - especially children. I also enjoy the company of many brilliant and compassionate professionals both within the mental health community and other professions. Even though I will never share any confidential information, posts will include descriptions of what I have learned from the experience of being a psychologist, woman, wife, mother, daughter, sister, and friend. The posts that review clinical practice and literature are designed to provide information that may benefit you in your life. The blogs may challenge you to learn, or question your life, or experience many different emotions. Ultimately, the goal is to share what I've learned to help you in fulfilling your life goals and finding peace and happiness. Namaste!
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