Child Parent Psychotherapy Strength-based Strategies in Working with Traumatized Children and their Families Melony Williams, LMHC, Good Beginnings of Sullivan County Erin Barnett, PhD, Dartmouth and West-Central Behavioral Health

Effects of Trauma on Very Young Children: Attachment Relationships Loss of sense of mother/father as reliable protectors Disturbed mental representations of who is safe and who is dangerous Loss of capacity to sustain representations of mother/father as secure base Intense emotions coexist and serve a defensive function in relation to one another Lieberman & Van Horn, 1998

Effects of Trauma on Very Young Children: Social and Emotional Development Social development: Outgrowth of attachment impaired attachment processes with caregivers. Socially immature, withdrawn, or aggressive Emotional development: Difficulty identifying and managing strong emotions (numbness, out of control feelings and behavior) Other milestones: delayed, regressed development of milestones such as bottle, thumb, potty-training These difficulties occur as a result of changes in brain pathways and chemicals that interfere with healthy development (Schore)

Effects of Trauma on Very Young Children: Later functioning Associated with: Substance use/abuse Adult mental health problems School problems Risk taking behaviors

Child Parent Psychotherapy Model A model of psychotherapy that focuses on the relationship between parent and child. Client is not the child or the parent but the relationship between the two. Focus is on attachment. Different than many traditional models of psychotherapy. Focus is on young children. Therapy done with newborns to 6 y.o. and a caregiver

Development of CPP Created by Alicia Lieberman and Patricia Van Horn Another pioneer of the work is Dr. Joy Osofsky of LSU who leads a team of CPP clinicians there and helped to launch a comprehensive family intervention program that includes CPP in Miami.

Applications of CPP Designed to help families who have experienced a trauma that has affected the parent child relationship. Typically the trauma is domestic violence, but this is not always the case. Treatment ideally occurs weekly for one year.

Focus of Treatment parental responsiveness, attunement increasing parental capacity for nurturance and protection assistance with emotional/behavioral regulation developmental guidance- getting children back on normal developmental trajectory looking at ghost and angels from parents past and how those effect parenting choices- prevention of intergenerational transmission of abuse resolution of traumatic experiences within the context of the parent child relationship.

CPP and Protective Factors Parental Resilience Social Connections Knowledge of Parenting and Child Development Concrete Support in Times of Need Social/Emotional Development

Theoretical Roots of CPP Based in attachment theory but also integrates psychodynamic, developmental, trauma, social learning, and cognitive behavioral theories. Most of the work is done through play.

Setting for Treatment Much of the treatment provided in NH is office based. Patricia Van Horn’s team at UCSF does home based work Safety considerations must be addressed but home based work often reduces many barriers to treatment such as lack of transportation, child care for other children in the home, reluctance to go to a mental health facility. Meeting families where they are at.

Course of Treatment

Session 1 Focus on building an alliance Assessment of relationship Gathering a rich history of parent’s childhood, child’s development and relationships among family members Share details of CPP Safety

Session 2 Parenting Stress Index Child Behavior Checklist Crowell Assessment

Modified Parent Child Relationship Assessment (Crowell & Fleishmann, 1993) Videotaped Variety of age appropriate activities used to assess the relationship between mother and child under different circumstances Free play, clean-up, bubbles, developmentally appropriate tasks, separation/reunion Use information gained to build on strengths of parent, child and dyad and develop goals to address challenges

Consultation after Assessment After questionnaires and Crowell completed, information and video brought to CPP and group determines if family is a good fit for program. At third session this information is shared with the family and then the parent is asked if they feel that CPP would fit well for them and if they are willing to make the commitment to treatment. If CPP is not a good fit, referrals for further services are made. Assessments repeated at midpoint and termination

Specific strength-based strategies within CPP Strength-based aspects of observational relationship assessment (Crowell) Mutual positive engagement Awareness of developmental needs

Using video clips strategically to “build up” and “hold” parent in positive light From Crowell video or session video; have also used photos

Focus on identifying and processing “Angels” from caregiver’s childhood Ghosts and angels Moments of nurturance, safety to draw from

“Catch them being good” Particularly useful with families involved in child welfare system

CPP Implementation: Training Outcomes To date, over 20 therapists have been trained in three counties across six settings Claremont Good Beginnings, West Central Lebanon West Central Concord and Franklin Riverbend DHMC Expert training and consultation followed by internal consultation groups Over 70 families in NH have begun treatment with CPP, a substantial proportion of referrals come from DCYF and family courts Stakeholders requesting more training and presentations

CPP Implementation: Client outcomes Mid-treatment outcomes (after 13 sessions) for first 15 cases for which mid-treatment data was available Significant improvements in clinician-reported parent-child relationship quality 0-100 PIRGAS Significant improvement in parent-reported TOTAL CBCL scores – child emotional and behavioral problems No changes in parent-reported stress or clinician rated relationship quality based on Crowell

CPP Case Example

Treatment Process and Protective Factors Parental Resilience Social Connections Knowledge of Parenting and Child Development Concrete Support in Times of Need Social/Emotional Development

Questions