“Self-abandoned, relaxed and effortless, I seemed to have laid me down in the dried-up bed of a great river; I heard a flood loosened in remote mountains, I felt the torrent come; to rise I had no will, to flee I had no strength.” ―Charlotte Brontë, Jane Eyre

A friend recently told me that convenience is the root of all evil. I knew exactly what he was talking about. Call it codependency, call it enabling. The caretaker, the hero, this person has been deemed the criminal in many cases, the one who “allows” the undesirable behavior, whatever it is, to exist.

But it takes two to tango. We caretakers—yes, that’s the role I have most often played; I have, in fact, fought to not be in the role of the helpless—often set ourselves up by rescuing those we perceive to be in need. So often, though, this is a power play to feel better about ourselves. Do we get something out of it? Oh, yes we do. For one, by being the provider or caretaker, we feel helpful, not helpless, and that is key. By being of service, we believe we are out from underneath (we’ve probably observed or experienced feeling helpless), we are above and in control, and this in many ways determines our self-worth and success. Caretaking behavior negates low self-worth that may come from being under someone’s thumb or auspice, and we feel we are free and in charge. Thus, there is a sense that we should feel better about ourselves. In control. Safe.

But what about the so-called helpless ones whom we perceive to be in need of rescue? The irony is that the ones in need, who are grown adults (since we’re referring to this position within adult relationships) and thus very capable in many cases to take care of themselves, often end up being the ones in control because we enable them to the point where learned helplessness enters the picture. Learned helplessness renders them incapable of doing things, and as much as I want to take responsibility for this and say caretakers are to blame, the truth of the matter is this is a dance created by two willing individuals who want to feel good and relinquish control because it’s easy and convenient—or take control because it also feels good and therefore is oh-so-very convenient. This is the irony of the dance and the self-talk.

We caretakers love to make things convenient for others; it’s what we do best. What we see as being a do-gooder—our need to be on top, to prove to ourselves we are not helpless by being overly helpful—actually renders others helpless and dependent on us. Although this should feel good, and perhaps it does initially, in the end it often enslaves us to our “victim,” who learns to, by no fault of his or her own, manipulate us (and probably others as well) and to settle into a role as the helpless one. Since they’re grown adults, we know they are capable in whatever way suits them, but once this pattern begins, we see the helpless one as the victim, unable to care for himself or herself, and then the caregiver becomes the martyr.

This pattern then becomes ingrained in us, and can and most likely will be repeated in other relationships. The irony is that both roles are similar, if not identical, as the martyr often also plays the victim and vice versa. It’s a two-way mirror and a two-way street, with both roles continuously going back and forth. Both people think they are being helpful and noble, but both are suffocating in their inability to take care of their own needs.

So how does one take care of his or her own needs? It’s simple once you recognize the patterns. The helpless individual starts doing things on his or her own instead of always relying on the other to “fix” problems, and of course the fixer does less fixing. This may come in a form of abstinence in the beginning. I don’t mean sharing less; I do mean expecting less. It means sharing without expectations. It means sharing the details of your horrible day without your partner giving you advice. If your partner continues to give you advice, thereby suggesting helplessness, you are likely to avoid sharing. This is where caregiving becomes harmful. So keep sharing, keep listening, take care of your own needs, and help only when someone asks for your help, give advice only when someone asks for it, and don’t expect help or advice unless you specifically say so.

Communication is key when it comes to breaking these patterns. Recognizing our role as either fixer or helpless one comes first, and then recognizing what we do in those roles. For example, a “victim” or helpless individual may manipulate by not offering to do something or by simply avoiding something, suggesting incapability. The fixer takes this cue and will do it for him or her anyway. These types of patterns become ingrained in the relationship.

Do you take control when the other person is in need? How often do you do this? Part of being in a relationship is to be there for our partners. However, doing it every single time and rendering them helpless is counterproductive to a healthy relationship. Do you expect your partner to handle many things for you? How often do you expect this? Expecting our partners to come through for us when we are in dire straits is one thing, but expecting this more often than not suggests a very unhealthy pattern for your relationship.

The symptoms of fixing and being a victim will be apparent in the bedroom, and possibly other areas of your life as well. Sexual satisfaction within a relationship is often a great indicator of these aspects within a relationship. Sexual issues often are symptomatic of much deeper issues. A fixer is like a parent, and a victim is akin to a child. Sexuality quite often will cease to exist in this sort of parent-child dynamic, as it suggests imbalance.

Sexuality thrives in autonomous situations, with autonomous people. We are well aware of the fact sex is more exciting when there is some level of mystery involved, some level of distance, some level of taboo. That taboo is often the unknown. Let’s face it: Being self-sufficient is a huge turn-on because it provides some distance. Not detachment, but distance. We can still be there for our partners, be their moral support, and be autonomous and self-sufficient when it comes to our emotional needs.

If you think you and your partner may be caught in this type of vicious cycle, just remember this: It may take two to tango, but it takes one to break the cycle.

There is a question that has been asked of me multiple times over the past few months that I would like to answer. The question is: “Should a child’s foster parent(s) be granted access to their child’s psychotherapy notes?” The answer is not as straightforward as it may seem.

The short answer is: “No, a child’s foster parent(s) should not be granted access to their child’s psychotherapy notes.”

First, we must understand what the HIPAA privacy rule is, as it will ultimately answer the question. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, is a federal law which resulted in the establishment of the HIPAA Privacy Rule in December 2000. The HIPAA Privacy Rule is designed to protect information about individuals’ health care treatment. To understand privacy protections in the United States, you must start with this federally established framework and then consult state laws to determine whether there are any additional requirements to observe.

Second, we must understand what the HIPAA Privacy Rule has to say about “individual personal representatives.” An individual personal representative is any person with the authority to receive or access another individual’s protected health information (PHI).

In some cases, adults and emancipated minors have individual personal representatives, such as someone holding “power of attorney” or in a court-appointed adult guardianship or conservatorship. Otherwise, adults and emancipated minors do have uniquely boundaried privacy protections, whereas minors (children under 18 years old, with the exception of children—typically 16 or 17 only—who have been formally “emancipated” from dependency status by a court of law) always have at least one individual personal representative.

Children and adolescents in foster care tend to have many individual personal representatives, including representatives from Child Protective Services, attorneys, designated child-placing agency representatives such as case managers, foster parents acting as medical consenters, and, in some cases, juvenile probation officers. In rare cases, even court-appointed special advocates (CASA) may obtain status as medical consenters through a court and would, then, hold the distinction of an individual personal representative.

In addition, foster kids benefit from an extensive continuum of care including doctors, dentists, psychiatrists, clinical psychologists, school psychologists, school counselors, collaborative treatment team participants such as child-placing agency treatment directors (such as myself), and other consultants (at my agency, we have psychiatric fellows and residents as well as a program manager, intake coordinator, and, in some cases, a higher-level program administrator who all may participate in the ongoing treatment staffing related to a child’s case planning), therapists (individual, sibling, family, group), early childhood interventionists (speech, physical, and occupational therapists), and skills trainers. Each of these treatment providers freely accesses PHI of other providers in the course of treatment, which is necessary and beneficial for collaborative treatment.

Ultimately, these supports are beneficial, but often, along this stream of care, the “minimum necessary requirement,” a best-practices principle generally recognized and affirmed through the HIPAA Privacy Rule, is not sufficiently revered, and foster kids’ private and protected health information may not always be protected in practice with the same degree of diligence that it is in so many other sectors of health care. It is in this current that foster parents often believe that they, too, are entitled to the most private of health care information, their child’s therapy providers’ psychotherapy notes. I know this to be true from my own professional experience.

The third thing that you must understand to answer this question is that psychotherapy notes are given unique privacy protections within the HIPAA Privacy Rule, more so than all other protected health information (PHI), including purely diagnostic or evaluative information, case notes, other treatment services such as developmental therapies (speech, physical, occupational), as well as other treatment summaries or reports. Even reports via email from a therapist summarizing general or overall progress of therapy—or any other generalizing or summarizing report—are not given the same protections as psychotherapy notes themselves (U.S. Department of Health & Human Services [HHS], 45 CFR 164.508, 2006).

There is one final piece of this puzzle: The HIPAA Privacy Rule clarifies that, in certain circumstances, parents are not privileged to act as their minor children’s personal representatives—with respect to certain protected health information—and thus neither control the child’s health care decisions nor the protected health information related to that care:

1. If no existing state statute or binding legal precedent requires a parent’s consent prior to a minor child obtaining psychotherapy treatment, and if the minor child then consents to his or her own psychotherapy treatment without the expressed consent of a parent, then, with respect to the minor child’s participation in that psychotherapy treatment, no parent acts as the child’s personal representative and, thus, the parent(s) will not be provided access to the psychotherapy notes without the child’s written consent.
2. If a court grants or other law authorizes another adult to act as the personal representative for a minor child as it relates to the child’s health care, then the minor child may obtain consent for such psychotherapy treatment from another personal representative, as provided, without consent from a parent. Similarly, in this case, with respect to the minor child’s participation in that psychotherapy treatment, the parent(s) will not be provided access to the psychotherapy notes without the child’s written consent.
3. If a parent provides a written and signed waiver expressly relinquishing his or her own right to participation in a confidential relationship between their minor child and a psychotherapist, then the privacy of the psychotherapy notes—as well as, in some cases, other protected health information—will remain boundaried and protected between the provider and the minor child, and parent access will be restricted unless the minor child provides written consent to the access of these protected records.

Further clarification in the Code of Federal Regulations (CFR) should be noted: “Even in these exceptional circumstances, where the parent is not the ‘personal representative’ of the minor, the Privacy Rule defers to state or other laws that require, permit, or prohibit the covered entity to disclose to a parent, or provide the parent access to, a minor child’s protected health information. Further, in these situations, if state or other law is silent or unclear concerning parental access to the minor’s protected health information, a covered entity has discretion to provide or deny a parent with access to the minor’s health information, if doing so is consistent with state or other applicable law, and provided the decision is made by a licensed health care professional in the exercise of professional judgment”(U.S. Department of Health & Human Services [HHS], 45 CFR 164.502, 2003).

Because foster children do not require the consent of foster parents before they can obtain psychotherapy services—and may obtain consent, if required, by way of other representative adults (such as child welfare caseworkers, child-placing agency case managers, etc.), whether the child independently consents or secures a nonparent consent to participate in such therapy, then, under the HIPAA Privacy Rule, the foster parent(s), for the purposes of this particular health care service, will not be provided distinction under the law as the child’s personal representative, and, thus, will not be provided the right to access documentation from the treatment record.

However, again, it is not that the HIPAA Privacy Rule expressly denies that foster parents have access to their children’s therapy notes, and, in fact, a “covered entity,” or provider (meaning, the child’s therapist) does retain prerogative to provide or deny a parent access with discretion if doing so is consistent with state and other applicable laws. Yet, this should be justified therapeutically.

In most cases, it is difficult to make a case that it is in the best interests of the child, therapeutically, to take away what is typically the only confidential outlet a foster child or teen has within the convoluted and institutional system in which they live and, thus, it is best practice in my state (K. Teutsch, personal communication, January 4, 2013) and in every state to preserve the therapeutic relationship by preserving the boundaries of confidentiality within that relationship and of privacy concerning the psychotherapy notes.

References:

1. K. Teutsch, Division Administrator for Medical Services, Texas Department of Family and Protective Services, personal communication, January 4, 2013.
2. U.S. Department of Health & Human Services – Office for Civil Rights (2006). HIPAA Administrative Simplification: Regulation Text [45 CFR 160, 162, & 164]. Washington, DC: US Government.
3. U.S. Department of Health & Human Services – Office for Civil Rights (2003). OCR HIPAA Privacy: Personal Representatives [45 CFR 164.502(g)]. Washington, DC: US Government.

Nicole is 16, and Ethan is 14. Their father, Jack, has battled brain cancer for the past two years. Jack was told recently that further treatment had a less than 10% chance of being successful. Jack wants to enjoy whatever time he has left feeling good and not being wiped out by chemotherapy. While no one wants to say it out loud, it’s clear that this will be Jack’s last Christmas (please substitute Hanukkah, Kwanzaa, etc., as appropriate).

How is Jack’s family supposed to come to terms with this? It can’t possibly be true. After the shock and complete denial subside, the painful reality begins to sink in. A flood of emotions comes with this realization, with profound sadness and anger often topping the list. It’s harder to face if your loved one is young and he or she has young children. The holidays speak of possibilities and are supposed to be a magical time for children; belief is suspended, and all holiday stories have happy endings.

The first step in dealing with this situation is to acknowledge that this will be someone’s last Christmas. Just saying that out loud will address the elephant in the room and help to decrease the stress that family members have been carrying internally. There will be tears, to be sure, but then the family can begin the process of grieving this sad reality together, rather than each member trying to deal with it alone. It is often the case that people don’t share their feelings with each other because they don’t want to be a burden, or want to protect the other person. In reality, family members are usually feeling at least some of the same things: fear, sadness, anger, and disbelief, to name a few.

After getting the topic out in the open, it’s time to think about how you want to celebrate this year. Don’t hold on to traditions if they don’t feel right. If you usually decorate your house to the rafters and host a cocktail party and an open house, it’s perfectly fine to do only some, or none, of those things this year. Every year, we all search for ways to make the holidays less commercialized and more significant. This year, it is especially important to ask yourself what makes the holidays meaningful for your family and your loved one. It may be as simple as sitting on the couch with a cup of eggnog and looking at the lights on the tree. Watching Christmas movies.  Listening to Christmas music. Going to a lights display. If your loved one is too ill to go out, he or she may still enjoy the experience by seeing photos of what others have done.

The person who is ill can give the gift of memories to those he or she will be leaving behind by writing letters or creating videos. If you are a parent, your children will one day be interested in what your life was like when you were young/their age. What words of wisdom do you have for them when they get their first boyfriend/girlfriend? Graduate from high school? Get their first job? Get married? Have a child? For some people, it is too daunting to consider making videos/writing letters; it puts them face to face with their own mortality too directly. In that situation, I suggest trying to think about it from your child’s point of view, not your own. The reality is that all of us will die, but not all of us will have the opportunity to choose how we spend the time we have left.

“It is not the magnitude of our actions but the amount of love that is put into them that matters.” —Mother Teresa

Last month, we talked about how figuring out why someone is doing something is key to changing his or her behaviors. We learned that most behaviors are motivated by getting something, getting away from or stopping something, feeling good, or are simply automatic (a reflex, for example).

In order to change behaviors, we must learn about reinforcement, not merely the functions of the behaviors.

Case Example
Imagine this scene, one that is played out in countless grocery stores every day around the world. Picture, if you will, a harried mother trying to get the shopping for the house completed. She is tired and in a rush to get home. With her is her young son. In the checkout line, as Mom tries to load the groceries on the little conveyor belt, her child asks for a candy bar (located conveniently an arm’s reach away, at child eye level). Mom, being a kind and benevolent mom, says, “No, we’re going home and having dinner. You don’t need a candy bar right now.” Her son, being like most children of his age, doesn’t like this state of affairs. In response to the denial of sucrose refreshment, he starts wailing at the top of his lungs, “PLEEAAAASEE! I WANNA CANDY! I WANNA CANDY! I WANNA CANDY!”

Other store patrons stare at the impending debacle. Mom feels embarrassed and more than a little ticked off. She still has to get the groceries home, get them unpacked, and make dinner. Dealing with a tantrum is the last thing she wants to do. At first she tries to calmly explain to her child that dinner will be soon, but the child screams louder. Then she commands him to cease his tantrum. That works about as well as can be expected (not at all). Finally, Mom gives in and buys her little angel the candy bar, at which point he immediately ceases his caterwauling.

Can you name all the reinforcement that occurred in the above example? What do you think will happen next time Mom brings her son to the grocery store?

What Is Reinforcement?
The technical definition of reinforcement is anything that occurs after a behavior that increases the chances of that behavior occurring again. Simply put, when your child does something (a behavior) and you do something immediately afterward, if your child repeats the behavior, whatever you did was a reinforcer.

This idea is key to behavior change. We want to provide rich and powerful reinforcement for the behaviors we wish to see (start behaviors) and avoid reinforcement for the behaviors we do not wish to see (stop behaviors). This interaction is at the heart of everything we wish to accomplish.

Important points:

• Reinforcement occurs only if you see the behavior again. You might feel you are rewarding your child, but if the reward does not result in increased frequency, intensity, or other improvement in the behavior, then the reward is not reinforcing.
• Reinforcement can be anything. It doesn’t have to be pleasant, either. For example, a person who likes fighting might enjoy when he is in a fight and find getting hit or yelled at reinforcing.
• Reinforcement always increases behaviors. Anything that decreases the chances of seeing a behavior is called a punisher.

The bottom line? Reward your kids when they do what you want them to do and they will do those things more. If you simultaneously remove the rewards from the behaviors you want to see less of, you will see less of those behaviors.

Isn’t this just bribery, you may ask? Nope. There are some key differences between bribery and reinforcement. Bribery is typically something (often money) given to someone in advance of behavior. It is generally given to get a person to do something unethical or illegal. Reinforcement always occurs after a behavior, and we are not using it to get our children to do anything unethical or illegal (hopefully!).

You might also ask: Why should I be rewarding my kid for doing what he is supposed to do? Shouldn’t he just do it? In a perfect world, yes, your child would do what he or she is supposed to do. However, in the real world, children are compelled by the “drive-your-parents-nuts accord” to not always follow directions. If we, as parents, want to keep our sanity, it behooves us to use all the tools at our disposal to encourage and reward our children, and ultimately to teach them what to do and when to do it.

Types of Reinforcement

• Positive: This is the most common type. It is something that is added to the situation (money, candy, praise). Basically, if you give your child something because he did something good, that’s positive reinforcement. In the case example, the mother positively reinforced her child’s checkout-line tantrum behavior by buying him the candy.
• Negative: This not punishment. (That decreases behaviors.) It is the removal of something. In the case example, the child negatively reinforced his mother’s candy-buying behavior by ceasing his tantrum when she gave in and bought it.

Classes of Reinforcers

• Primary: These are typically those things that all people need—food, air, companionship, etc.—and are often tied to basic survival. These are good because almost everybody will respond to them. However, they suffer from the “too-much-of-a-good-thing” effect, also known as satiety. When you’ve had enough of something, it loses its reinforcing qualities.
• Secondary: These are learned reinforcers. Typically paired in some way with primary reinforcement, these can be anything. Money is perhaps one of the most prevalent secondary reinforcers in the world. It always amazes me what people will do for colored bits of paper.

Putting This Information to Use

Follow these simple steps:

1. Ask yourself: Is this a start behavior or a stop behavior? (Do you want to see this more or less?)
2. Ask yourself: What is the function of the behavior?
3. For stop behaviors, the answer to question No. 3 will tell you what you need to decrease or eliminate from the situation to make the behavior go away. Do that.
4. For start behaviors, the answer to question No. 3 will tell you what you need to do to get the person to do the behavior more (or better).

As with all things simple, there is a lot more to look at, but it ultimately comes down to these four points. (We will discuss more about reinforcement and how to set it up and deliver it in future articles.)

What’s the Best Reinforcer?
The best reinforcer is the one that works in a given situation. However, my preference is praise. I will cover praise in more detail in a future article, but here is why I like it as a reinforcer: Just about everybody responds to praise. The more you praise someone, the more he or she likes you. The more he or she likes you, the more he or she will respond to you. Praise is free. It takes up no space. People rarely get tired of it. It pairs well with every other kind of reinforcer (thus making the praise and the other reinforcer more effective). In your experiments with reinforcement, try adding a little praise to your efforts and see how it enhances things.

I hope this information helps make your day-to-day challenges less challenging. Please comment below, ask questions, or make suggestions. Let me know about creative ways you have found to reinforce your children (or anyone else, for that matter). Hang in there, parents!

When parents view their child’s “problematic” behavior, attitudes, or troubles as a reflection of them, it can be a terrible blow to the ego. For parents with positive self-feelings, anger, hurt, and disappointment can occur when they don’t see themselves reflected in their children. (“My child should be just like me.”) For parents who do not feel very good about themselves, seeing a child as being “just like me” can feel devastating. Parents who lack self-esteem often feel like their child’s problems are their fault. Their inability to differentiate themselves from their children can also result in guilt and painful feelings of responsibility that are often overstated and inaccurate. Many parents who struggle with the idea that their child is a reflection of them (for better and worse) have not separated from their children. These parents tend to feel some responsibility for their child’s situation. Most often they believe that, either in their early behavior with their children or in their biological contribution (or both), they have profoundly affected their child’s life and character.

“Peter” came to his therapy session in a rage about “Adam,” his 25-year-old son. He had just come from his son’s apartment and was disgusted about the dirt and disarray he encountered: “What is the matter with that kid? He’s such a slob. There is stuff everywhere. It feels so chaotic! I have the same feeling when I think about how he gets drunk with his friends on the weekend. He’s a mess!”

When I asked Peter what made him so angry about this, he began to express remorse about being so enraged. Choking up, he said, “I guess I’m really hurt. I feel like Adam is being disrespectful to me. He knows I hate his messes and his drinking behavior. I feel like he’s on a terrible path of disorganization and disaster. I keep asking myself, ‘How did he turn out this way?’ ”

I asked Peter what he thought about why Adam was like this. “I don’t really know,” Peter said. “But I honestly believe it’s my fault. You know I was a terrible workaholic during Adam’s first 10 years. I neglected him when he was growing up. Then I think, if I was a workaholic, will he be an alcoholic? I know I made him this way. I’m a mess of a father.” Peter was tortured by his painful feelings and disappointment that his son hadn’t turned into the ideal adult that Peter wished he could be.

Over time, as we explored Peter’s feelings, it became apparent that he put all the responsibility for the person Adam was at age 25 on himself. He found it very difficult to see Adam as a separate individual with his own reasons for behaving the way he did. Slowly, Peter was able to consider that his influence hadn’t only been negative and that he wasn’t the only influence on Adam’s development. Adam’s mother was nurturing; Adam had many friends growing up. Peter could even recall some teachers who were influential in Adam’s life. He acknowledged, for example, that a high school teacher had encouraged Adam to stay with his music, and Peter admitted that Adam was a successful musician.

“I guess I haven’t focused enough on Adam’s successes, just on the ways I see him as a failure and blame myself,” Peter said. “Sometimes I still think that maybe Adam is punishing me when he messes up in ways he knows I hate. I guess I really have to admit that it isn’t all about me. Adam is a different person from me. It’s just hard to be OK with that. But I do want to get there. I know that would be best for our relationship.”

Peter is slowly beginning to separate from Adam and experience Adam’s successes and failures as more about Adam than him. He is also beginning to take Adam’s character and behavior less personally. Giving up the idea that “it was all my fault” makes space for Peter to see Adam as a separate individual.

“Rose,” another client, began to talk about her 10-year-old daughter, “Jessica,” in our therapy sessions.  Rose was obsessed with worry that Jessica, who had learning disabilities, would never have a successful life. She said with some sadness: “Her brain is damaged. How will she ever be OK?”

“What do you mean, ‘Her brain is damaged’?” I asked.

“You know that we had her tested and she has so much trouble focusing and organizing her thoughts,” she responded.

“Yes, I know she has some learning disabilities, but seeing her as ‘a person with a damaged brain’ seems a rather extreme way of defining your daughter,” I said.

“I sort of know what you’re saying is true,” she said. “But you know I had learning disabilities as a kid. No one identified them; no one did anything about it. I still struggle at work and in my life in general with being focused and organized. I get so depressed and anxious when I forget things or don’t get stuff done like I promise my husband or my boss. I know my brain is messed up, and Jessica is just like me. Why would I think her fate is going to be any different?”

Rose had a very strong belief that biology was determining her future as well as her daughter’s. She was reluctant to consider that her daughter’s life could take a different path from hers. She had a difficult time thinking about Jessica as a separate person with her own unique characteristics. I reminded her that she and her husband had been addressing Jessica’s learning problems and getting help for her. I also pointed out that this was very different from her own experience growing up. I emphasized that there are many influences other than biology that influence a person’s development. I also asked Rose to tell me anything she could think of about Jessica’s accomplishments. We both listened to the list Rose came up with: “Great piano player, really good artist, hula-hoop champion, kind person, good swimmer, and I guess other stuff, too.” Rose reluctantly acknowledged, “Yes, I suppose her brain works OK in some ways.”

Rose and I spent a lot of time talking not only about Jessica, but also about Rose’s negative sense of self. It was harder for her to take seriously that she has her own accomplishments. It was even more difficult to consider that Jessica was like her in some ways and not others. (Rose is a terrible artist and swimmer!) Our work has centered on Rose’s struggle to experience herself in positive ways and on seeing Jessica as a separate, differentiated individual. We have also been talking about how painful it is to see your child have areas of deficit, and even worse when you feel you are the cause. Helping Rose to talk about her impaired sense of self and its development has allowed her to make distinctions between her own experience and Jessica’s. I have tried to help Rose consider that while there could be some biology at work in regard to Jessica’s learning disabilities, so much more than being “just like me” is involved in what makes Jessica who she is.

We are familiar with parents feeling great pride in how they played a role in their children’s successes. But when parents boast incessantly about their children’s accomplishments to the extent it doesn’t feel like typical parental pleasure, we typically consider them to be narcissistic. For Peter and Rose, their great dismay in what they perceived as their children’s deficits, problems, and failures was also narcissistic.

The term narcissism comes from the Greek myth of Narcissus, in which Narcissus falls in love with his own reflection in a pool. The notion of reflection is pertinent to the experiences of Peter and Rose. Rather than experiencing narcissistic pleasure, these distraught parents experienced a narcissistic wound. They couldn’t tolerate the pain of looking into the pool (i.e., at their child who also represents the parent) and seeing something that is not “beautiful” reflected back. When they looked at their children, they saw a reflection of themselves. It was intolerable that the reflection they saw was “a mess” or had a “damaged brain.” It was not “beautiful.”

These parents are responding narcissistically, and they have not differentiated themselves from their children. One has to wonder how parents, who view their children as reflections of themselves, may have influenced their child’s separation/individuation process. As parents become more aware that their beliefs that their children are or are supposed to be “just like them” are assumptions, they will be in a better position to examine those beliefs. As a result, parents will experience less pain, and their children will be helped to develop into separate, unique individuals.

One of the reasons many children do not tell anyone about being sexually abused is because they fear that their loved ones will not believe them. Often, their abuser is a friend or family member, and although children may know that what occurred is wrong, they may be confused and worried that their caregivers will think they have misconstrued the behavior. Children who feel neglected or maltreated by caregivers may feel reluctant to disclose abuse, and many abusers threaten children, creating more reasons for nondisclosure. However, when children do reveal abuse, getting them to explain the abuse in a way sufficient to lead to prosecution can be challenging.

Various methods of interrogation are used on child-abuse victims, including open-ended questions, yes/no questions, “What happened?” questions, and “How did that make you feel?” questions. For the most part, open-ended questions and “what” questions tend to provide the least amount of detail. Children often are unable to articulate the details of their abuse. And while “how” questions that prompt children to reveal their physical reactions and feelings allow them to detail their personal experience in great detail, this is the most rarely used form of interrogation. To explore which method would provide the most accurate recollection of abuse and elicit emotional responses that could demonstrate credibility to jurors, judges, and therapists, Thomas D. Lyon of the Department of Psychology at the University of Southern California recently examined transcripts from more than 100 child-abuse cases.

Lyon discovered that when children were asked closed-ended questions such as yes/no, their responses were narrow and they exhibited little emotion. Similarly, when they were asked “What happened?” they were hesitant to reveal details and appeared emotionally undisturbed. But when children were asked how the abuse made them feel and what their physical reactions were, the responses were extremely vivid and consistent. They demonstrated emotional responses and used words such as angry, sad, afraid, confused, “sick to my stomach,” and dirty. They manifested facial and physical reactions that allowed those interviewing them to see the damage of the abuse in ways that the children could not articulate when prompted with direct questioning. “Children can be surprisingly articulate about their reactions to sexual abuse, despite their apparent lack of affect in describing the abuse itself,” Lyon said. He hopes that these findings will motivate interviewers, prosecutors, and mental health professionals to evaluate physical and emotional reactions of abuse as a means to gather details from child sexual abuse victims.

Reference:
Lyon, Thomas D., Nicholas Scurich, Karen Choi, Sally Handmaker, and Rebecca Blank. ‘How did you feel?’: Increasing child sexual abuse witnesses’ production of evaluative information. Law and Human Behavior 36.5 (2012): 448-57. Print.

What was once considered a rarity—step-siblings, step-parents, and step-in-laws—has become more common than not. When couples marry, there is a very good chance that one of them brings an extended family that branches by halves and steps. And if that couple winds up divorcing, the tree splinters even further. Because there is no biological bond that obligates a step-family member to stay in contact with other steps, the rules of engagement can be confusing and tense. In a recent article, marriage experts explain how to navigate the rocky road of step-relationships after divorce.

Take, for example, the case of an ex-wife who spent decades raising her step-children. Should she continue the relationship with these nonbiological children, even though she has no legal claim to them? Mary T. Kelly, a marriage therapist from Colorado, notes that often step-children can be a contributing factor to divorce. Many blended-family parents disagree over how to raise his, hers, and their children. Tension that exists between step-children and step-parents seems like normal childhood rebellion, but in many cases may actually run deeper.

Paul Hokemeyer, a New York therapist, says couples and children need to determine if they want those relationships to continue after divorce. Many children may not be permitted to make contact with their ex-step-parents while they are minors, but can make the choice whether to have a relationship with that significant person when they reach adulthood. Even step-grandparents get caught in the mix when step-families divorce. Grandparents who become attached to step-grandchildren, only to have them taken away, may not be willing to invest as much into future step-family members.

One Massachusetts psychologist, Patricia Papemow, recommends that clients try to initiate contact through letters rather than personal visits or phone calls. It is important for step-children to be allowed to have time to process the shift in the relationship on their own terms. Letting them know a step-parent is there through cards and letters is a noninvasive and subtle way to continue contact and keep the door open for future communication. Regardless of how an individual chooses to stay in contact with their step-children, Hokemeyer insists that they review their motives so that all parties will be receptive. “Make sure that you are acting out of genuine love and concern for the other person, and not out of anger and attempts to manipulate,” Hokemeyer says. Following these tips could help step-exes maintain important family ties in a world of ever-changing family dynamics.

Reference:
Gootman, Elissa. When branches tangle in a stepfamily tree. (n.d.): n. pag. The New York Times. 3 Oct. 2012. Web. 8 Oct. 2012. http://www.nytimes.com/2012/10/04/fashion/-step-family-trees-with-tangled-branches.html?pagewanted=all&_r=0

There are many parallels between living with a disability and dealing with an uninvited house guest. If you have ever had an uninvited house guest, I am sure you remember moments when things may have been uncertain and, at times, tense or uncomfortable. At the very least, having an uninvited guest requires some adjustments, much like living with a disability.

An uninvited guest may arrive unannounced, leaving no time to plan or prepare. Likewise, in many cases people living with disability have little or no time to plan for the many changes to come. While there may have been no way to prevent the disability and requisite life changes, having time to prepare—psychologically and literally—can make a huge difference in a person’s ability to adapt and cope.

A period of psychological adjustment is required for a person who has a disability, his or her spouse/partner, parents, and other family members. The adjustment process people frequently talk about resembles the grief process in many ways. Like the grief process, people often experience feelings in what seem to be stages. Similar to the grief process, this adaptation process usually begins with a period of denial.

Denial
In my work with couples and families living with multiple sclerosis, I often hear concerns that one person seems to be “stuck in denial.” To people who have moved through the initial denial stage, it may seem as if their loved one is not progressing as quickly as others. The truth is, different people work through this period of adjustment differently, and it takes as long as it takes. The denial stage usually happens at the time of diagnosis or disability, and may come up again at other times. For example, in a progressive illness, if one begins to lose mobility or other limitations arise, the initial stage of the adjustment process may be triggered again.

It may seem clear to a caregiver/partner or family member who has been helping someone walk even short distances that a mobility device is needed (cane, walker, scooter). For the person who is having mobility difficulty, admitting that it is time to talk to a doctor about a mobility device may affect his or her identity, hope for recovery, or future progress. If so, working through the denial and bargaining, and then later stages of adaptation, may be necessary. It is not unusual to see all members of the family triggered by new developments that start the process over.

Denial is believed to be a protective measure that prevents us from becoming emotionally overwhelmed. Denial slows down the process of coping with traumatic events, giving us more time to psychologically prepare ourselves for the onslaught of feelings. The process of denial, known as a defense mechanism, should not be rushed or sabotaged by well-meaning loved ones who are at a different place in the adaptation process. Doing so can cause the person who needs more time to become emotionally overwhelmed without the necessary skills to cope effectively.

Coping skills: A person with disability and his or her family members should try to be empathetic and understand things from the perspective of others. Be honest, but gentle, about your perceptions. Choose the time to discuss these issues carefully—not when either of you are tired, frustrated, or angry. Always talk to your loved one(s) before bringing up concerns with doctors or other professionals.  Caregivers and family members should keep in mind that their needs are important, too. Take care of yourself and make sure you have plenty of support. When children are involved, be very careful what and how you share information with them. Children need to hear things based on what is appropriate for their age and stage of development. Ask for guidance from a professional if you are unsure how much to tell children or how to talk to them about disability.

Bargaining
The stage that usually follows denial is bargaining. During this time, people often are looking for second opinions, alternative therapies, and other remedies. It can also be a time when we promise the gods that we will turn our lives around if given a second chance without the disability or diagnosis.

It is true that finding the best medical providers, keeping a positive outlook, and staying informed of new research and possibilities is important. However, this can also be a time when people are vulnerable to scams and false promises. Unfortunately, there are a lot of companies and people who offer products and services that guarantee outcomes without doing the necessary research required to back up those assurances.

It is a good idea to check out any new or experimental treatments carefully before trying them—particularly if there is a large commitment of money, resources, or time involved. Check with local and national nonprofit organizations that provide services to people with your specific issue or health challenge. Agencies such as the National MS Society, American Cancer Society, and others often have information about ancillary and alternative therapies. They may be able to send you information or answer your questions.

Coping skills: Make decisions together based on facts. Find local and national organizations that you trust to support you and provide well-researched information. Be sure that any second opinions or ancillary providers have access to all the information you have from other providers. In some cases, taking medications or treatment without being fully aware of how they interact with your other treatment can be life-threatening. Make a commitment to fully investigate any new or experimental treatments before deciding to try it. Ask for and check references when appropriate. Verify the credentials of all providers before visiting them. At some point, you may have to accept a new reality that you had not planned for and do not welcome. If you have prolonged difficulty coping with the diagnosis or prognosis, find support from a professional or support group to help you with the transition.

Over the next few months, I will explore additional aspects of disability, how it affects the lives and relationships of the people involved, and ways of coping with these situations. If you have ideas to share about how you have effectively coped with any of the situations presented, please join the discussion by leaving comments below. Likewise, if you have questions, feel free to ask for input from others who read the blog.

A client recently described how thrilling it was to take her daughter to see the Broadway musical Annie.  She recalled that her mother took her to see it when she was a child, and it had been an indelibly wonderful experience. Now she had the pleasure of providing the same thrill for her daughter. I thought how special it was for my client to share this with her daughter and how lucky my client was that her daughter had the same feelings about the experience. It also reminded me that so many parents who want to provide what they believe to be all the right things for their children are not always met with such good feelings.

I recalled another client whose desire to recreate his delight for his son was dashed when he took him to the rodeo and was met with the response, “This is stupid.” In spite of their most nurturing and positive intentions, parents may find that their wishes and rules for their children are met with rejection. This can create painful feelings, including insult, hurt, anger, and disappointment. “Drew,” a 42-year-old client, was in a prolonged struggle with his 8-year-old daughter about piano lessons she adamantly refused to take. He told me, “When I was a kid, I refused to continue piano lessons after a few months. My parents never insisted I continue. I’m not going to let that happen to my daughter. She isn’t old enough to know what she wants or what the consequences of her actions will be.”

As Drew and I explored his feelings, it became clear that he not only felt disappointed, he felt rejected by his daughter. “It feels like she is telling me, ‘Get out of here, you don’t know what’s good for me,’ ” he said. I responded: “I can see how upset you are about this, but I wonder what it is that makes you feel so personally rejected. Is it possible that your daughter is different from you?” Drew’s first response was, “She’s my daughter and she is like me. I just know this is very important for her to do. When I was a child, I didn’t know I was making a terrible mistake. My parents should have known and pushed me to continue.”

It took a lot of talking for Drew to become aware of his many disappointments about the ways his parents had been involved in his life when he was a child. He began to consider that he might not need to protect his daughter from this disappointment. He recognized that his daughter might, like him, regret not learning the piano, but forcing her to take lessons could easily turn her away from the piano. He realized that her experience and development was and will be different from his and she is a different person with her own thoughts and feelings. After all, she has different parents than he did. The more Drew could understand his daughter’s need to differentiate from him, the easier it was not to feel so rejected and hurt.

When parents assert their desires for their children, it is not unusual for them to be met with expressions of different or opposing wants and needs. Pushing back against what parents want is a necessary part of a child’s development. For a healthy sense of self to grow, children need to differentiate from their parents and become unique, separate, individual selves. This doesn’t mean children are totally different from or always in opposition to their parents. It does mean children need to develop minds of their own. Having one’s own mind is about being able to think about your needs and wants without being overly influenced by others. Ideally, the wishes of others are considered, but ultimately one makes his or her own life choices. Obviously, the degree of autonomy for a 4-year-old differs from that of a 13-year-old and again for a 20-year-old. When children are not given the space to differentiate from their parents and don’t develop a self that is confident and strong, they will not have developed the autonomy to make life choices and get what they want as they enter full adulthood.

At age 53, “Anne” was struggling with her teenage son, “Noah.” She came to therapy expressing feelings of anger and insult from their encounters. She explained that he fought her at every turn about anything she asked of him: cleaning his room, doing household chores, getting his college applications completed.  “I don’t believe how he treats me,” she said. “He says things like, ‘Leave me alone and mind your own business.’ Is that any way to speak to your mother? I feel so hurt and insulted. Doesn’t he know I only want what’s best for him?” In great distress, Anne added, “He has become a terrible person. He is so mean and inconsiderate. He seems like a completely different person than the son I felt loved me a year ago.”

As we talked, Anne described how when she was growing up she never went against her parents. When we explored her past and present relationships, Anne began to wonder if her early experiences being compliant are related to her difficulty asserting herself as an adult. She described how difficult it is for her to disagree with her husband and how she doesn’t always feel so good about herself. She realized that it wasn’t just with her son that she felt so badly treated. “I guess I don’t feel very powerful,” she said. “I have a lot of trouble believing that what I think and feel is OK. I always followed the rules with my parents. Maybe I didn’t develop what Noah needs to do—be someone who feels OK asserting himself when there is opposition.” Many parents with teenagers experience difficult feelings in their parent-teenager relationships. For Anne, the feelings of insult and rejection were intolerable. Even worse for her was the terrible shame she felt about her negative feelings toward her son: “I’m the terrible person. Mothers shouldn’t feel this way.”

How to handle this kind of situation with teenagers is controversial. Furthermore, how any parent hears what a child says is open to interpretation and may be related to how the parent differentiated from his or her own parents. While Anne felt insulted and hurt, another parent in these circumstances might shrug and think, “When will these awful teenage years pass?” On one end of the continuum of parental response, parents might believe that a child of any age should never be permitted to say anything that is hurtful, disrespectful, or angry to a parent. At the other end of the response continuum, parents might accept any expression their child makes without intervening. An extreme example might be if a teenager said, “You’re an awful parent, you have no business having children,” and a parent made no protest about being treated that way. On this far end of the continuum, the lack of a parental response to push against doesn’t provide the child with the feeling that there is a strong parental self to separate from. If there is no other out there to individuate from, it becomes difficult for a child to develop a sense of who he or she is and the ability to be autonomous. The child is left wondering, “Who am I?” Potentially more problematic, the child may be left with a feeling of powerlessness. He or she has not been given the experience of successfully asserting his or her developing self in the world.

There is a lot of room along this continuum for parents to develop responses that feel comfortable to them while allowing some room for their children to develop their unique selves. It helps if parents let their children know what behaviors are acceptable. For instance, telling a child, “You can’t talk to me that way” is not the same as saying, “You can’t be angry at me,” or “You are hurting my feelings.”

When children respond to parents in disappointing or unacceptable ways, it is important that parents stop and consider how they will meet that response. Each situation requires thought. Sometimes, interfering with the child’s wishes or experiences provides an opportunity for the child to push back against the parent and feel a sense of his or her developing self. At other times, supporting the child’s differentiation provides the child with a sense of confidence and recognition of his or her developing self. No matter the age of the child, parents who are curious and interested in why there is disparity or opposition are communicating their openness to more than one way of behaving and/or feeling. This openness to difference helps children develop into self-confident, autonomous adults. Moreover, parents are less likely to repeat the dynamics of their own childhoods if they consider their children’s behavior from a developmental perspective. They will be in a better position to not take things so personally and will feel less hurt, insulted, or disrespected by their children.

One of the most common methods for assessing the behavioral and emotional state of a child is a parental report. This type of evaluation usually comprises a parent’s observation and evaluation of the child’s feelings, mood states, and behaviors over a period of time. But just how accurately do parents gauge the emotional temperature of their children? That was the question at the center of a recent study conducted by C. Emily Durbin of the Department of Psychology at Michigan State University. Because parental reports can vary quite dramatically from reports obtained by other observers, such as teachers, counselors, and classmates, Durbin wanted to determine what factors, if any, skewed parents’ perceptions.

Durbin chose to focus on the effects of maternal depression on parental reports. She based her decision on the fact that other conditions, such as alcoholism, parental anxiety, and family distress, have been shown to influence maternal reports. Durbin extended the existing research and compared mothers’ reports with those of unbiased observers on a sample of 190 children ranging from 3 to 6 years old. Participants were instructed to rate levels of sadness, fear, happiness, surprise, and anger in the children after they completed 10 emotion-inducing tasks. Durbin found that the mothers with a history of depression or anxiety tended to rate their children as less happy than mothers with no such history. Additionally, these same mothers viewed their children as overly fearful, and rated girls as sadder than boys. This could be a result of maternal sensitivity to emotions such as fear and sadness. However, the outcome showed a significant disparity between observers’ ratings and those of the mothers with a psychological history. “These mothers may have greater difficulty setting aside their perceptions of the child’s typical emotional adjustment to focus solely on rating the behavior the child is currently exhibiting,” Durbin said. Although the sample size was limited to young children and did not contain a large number of mothers currently exhibiting depressive symptoms, the results warrant further investigation. Durbin believes it is essential to expand this research to include older children, comparison to other assessment tools, and evaluation of other aspects of childhood development.

Reference:
Durbin, C. Emily, and Sylvia Wilson. Convergent validity of and bias in maternal reports of child emotion. Psychological Assessment 24.3 (2012): 647-60. Print.

I was talking with a new client and he was telling me about his temper when he gets mad and what consequences he receives. As he was talking, he stated, “when I’m bad…” and continued the conversation about his consequences. When he was done, I asked if he thought he was a “bad” kid. He said no. I was glad to hear that because I think overall, we are inherently good. Yes, there are people out there who would fit more in the “bad” category, but that is not what is being addressed.

As parents and disciplinarians, we try to shape our kids to make wise decisions so the negative consequences can be few or needed when necessary. When a kid gets angry and has tantrums and it happens over and over, it can be very frustrating to deal with. When the kid understands the consequence of his behavior but continues to still get angry and throw tantrums, parents may not be sure of what else to do. Parents slip. Teachers slip. The slip is telling the child that he is “bad” even though the behavior that he is doing may be more the focus of “bad.” I do not think that parents or even teachers slip on purpose and telling the kid that he is “bad,” but we are human and make mistakes, and it happens. Repeating this slip impacts the child’s self esteem. Over time, these children may see themselves as “bad” because they keep repeating the “bad” behavior, receiving the consequence, and having parents become frustrated, and a negative self-image begins to form. I know that is not what we as parents want for our kids. We want them to have a good sense of self and know what is “bad” behavior. So, how can this happen?

Here’s an idea: How about getting away from “bad” and “good” behavior. I know it’s hard to do because “good” and “bad” has been around for a very long time; it’s habitual and creating a newer way can be difficult.

What I am suggesting is to name what is “bad.” For example, your child is hitting a younger sibling because the sibling did not want to share a toy with the child. Instead of saying, “that’s bad,” point out that “hitting is bad.” Tell the child, “It’s not okay to hit when you are angry.” When we point out the behavior that is not okay, it helps us to not get into the “good” versus “bad” cycle. Another example: When your child is sitting on the floor and waiting patiently and you tell him “good boy.” Point out the WHAT that he is doing: sitting and waiting patiently. When he knows what he is doing that makes him a “good” boy, he will be able to associate that behavior in other areas and he will know he is doing well.

Objectifying the behavior takes away the “good” or “bad” titles, which decreases the opportunities for us parents to accidentally say that the child is “bad.”

Remember when your child was a baby and you were telling him what type of person he was going to grow up to be? If not, it’s okay. What I am getting at is when a kid is younger, parents may encourage the child a little more than at an older age. We encourage young children to try new foods, feed themselves, and use utensils, and we teach/show them how to do it then praise them for what they learned, even if it may not turn out well. Somehow as the child ages, the cycle of “good” or “bad” begins or replaces the encouraging aspect of parenting. Yes, kids do need to know right from wrong AND they still need to know that they are capable of doing great things.

Objectifying the behavior can help start a different way of helping your child to know how to make healthy choices. Continuing to encourage your child to try new things or to keep trying something can also help. Asking children what they think about their behavior and maybe what they could have done instead to not receive a consequence can also help. The asking can help your child learn how to see the cause and effect of a particular behavior. This can be a great learning and shaping tool for preparing the child to see more cause and effect as he or she ages and matures. Reminding the child that he or she is a wonderful child, has great possibilities, and is loved unconditionally can also reinforce a positive sense of self, regardless of whether the child has made a mistake or chooses wisely.

The goal of parenting is to help shape a child to have a good sense of self, to know how to behave appropriately, and to be able to self correct or recognize when he or she does not make a good choice. When the “bad” behavior is directly addressed, it takes away from parents accidentally slipping and saying that the child is “bad” when the focus needs to be more on the actual behavior.

It takes awareness and practice to create a new way of responding. Hopefully, this article will enlighten and small steps can be made to get out of the good/bad cycle and help the child to still have a good sense of self, even when he or she makes a poor choice.

Related articles:
Temper Tantrum Behaviors
Building Self-Confidence From the Ground Up
Adolescent Consequences, 100% Natural and Organic!

If you are reading this article, then you probably have completed Codependency Workbook Exercise Two by creating a list of your troubled relationships. Congratulations for completing this. Generally, in codependent relationships there is some pain and emotional abuse. They tend to be rather lopsided, with you doing most if not all of the giving. When you realize this, you may get angry and feel as though others are using you. You may wonder why this is. It is because when they meet you, they sense that you are a caretaker who will want to help them. When you do this, it is because you care about them and believe that you can love and care some of their problems away. Most of the time this cannot be done. Often, by giving to them, you are actually making it easier for them to continue their maladaptive behavior.

If your loved one gets a DWI, you may rush out and hire a good lawyer who may get him or her off. Had this person suffered the consequences of the DWI, he or she might have been ordered to complete substance abuse treatment, which might have ended or at least interfered with the drinking. So if you are in a relationship with a person with an alcohol or drug problem, can you think of a boundary that you could set that would be good for you and, in the long run, him or her? For example, you might tell this person that if he or she has another legal problem related to substances, that you will no longer help. The person will be on his own. Of course, he or she may not like this and try to push your guilt buttons. Remind yourself that you are not only doing what is best for yourself but also for the other person. You might take your boundary a step further and tell the person that effective immediately, you will no longer undo any of the consequences of his or her using. I suggest you only set the boundary when you are ready. The hard part will come when you have to stick to the boundary. You will need some support from a therapist, your sponsor, or a friend to hold to it. Once you maintain a boundary you will find that it is easier to stick to the next one.

What are some other boundaries that you might set? Maybe you have a friend who borrows money from you and has never paid it back. The next time the friend asks to borrow money, you might tell him or her that you are unwilling to loan any more money until the person repays you the funds already owed. Maybe you have someone who always asks you for rides but never offers to pay for your gasoline. You might decide to tell this person that you cannot afford to continue giving him or her rides. Make a list of all the boundaries that you need to set to take care of yourself. While you are identifying them, do not worry about actually setting them. Try to take one step at a time. I know that the thought of setting them is very scary. You may also be scared about what will happen to your friend if you set them. If your friend is dysfunctional, something will happen to this person no matter what you do. Once you get the hang of doing this, you are going to feel an enormous sense of relief. You will realize you are not responsible for everybody, nor do you have to help someone just because that person needs it.

If you are like some people, you may fear that if you stand up for yourself, you will be abandoned by your friend. I believe that if this happens, then that person was not really a friend to begin with. Can you imagine treating someone that you care about like that? I am sure that you cannot. Now you will have more energy to direct toward taking care of yourself. You will no longer feel so angry at others. The next time you feel like a victim, you may need to check and see if you need to set another boundary.