Thursday, 18 October 2012

Building Resiliency in Children

The rise in mood and anxiety disorders in children and adolescents plus the concerns over teen suicide - which is now the second leading cause of death for adolescents in Canada - is of growing concern for parents.

Why can some children navigate the hazardous waters of peer pressure, bullying, and academic pressures, while others find themselves overwhelmed or distressed?

It’s all about resiliency, and resiliency in children can be fostered by parents.

Daniel Siegel, MD and Tina Payne Bryson, PH.D are one team that is leading the way on how parents can accomplish this in their book The Whole Brain Child.

The main message they deliver is that - barring any profound developmental delays -  children have the tools they need to develop a healthy state of resiliency; The ability to bounce back from life’s hard lessons or crises.  The methods they suggest are all about connecting the various parts of the brain; The downstairs to the upstairs, the upstairs to the downstairs, the left to the right, and right to the left.

To understand the science behind their approach, one has to first understand the parts of the brain and their function;

The “downstairs” part of the brain is comprised of our brainstem and our limbic system.  Combined, these organs control our breathing, heart rate, blood pressure, and body temperature.  They also react to changes in our environment, seek attachment, and respond to threats.

The “upstairs” part of our brain is our Cortex.  This is where we live – where our memories are stored and the part of our brain that dictates how we view the world and ourselves, plus how we reason, problem solve, and make all executive decisions.

The cortex is also divided into the “left” region of logic and reason, and the “right” region of emotion – although there is a lot of crossover, we can all agree that we have two distinct ways to approach life; logically or emotionally.

Siegal and Bryson have keyed into the emerging science of Neuroplasticity and applied it to children.  Neuroplasticity is the brain’s ability to change its function and structure.

To help your child become a “whole brained child” we, as parents, have to help them connect all the parts of their brain when facing adversity.

First we connect the right and left, and we can do this by aligning with our child before we correct them.  Dr Gordon Neufeld coined the term “collect before you correct”.  Siegal and Bryson call it “connect and redirect”.

For example, if a child is upset because they can’t have the toy they want, we connect with them emotionally; right brain to right brain.  We acknowledge that they really want the toy and we demonstrate empathy for them not being able to have it.  Second we help them connect to the left side of their brain, by telling the story about what is upsetting them – “name it to tame it”.  In this way their left brain will begin to make sense out of what is upsetting them, and by doing so they can feel more in control.

Next, we must connect the upstairs brain to the downstairs brain and this is a bit of an art form.  The concept is that when in distress, the downstairs of our brain can hijack the upstairs of our brain – that our threat response can be so out of control that we lose the ability to reason.  Again, Siegal and Bryson suggest beginning by aligning with our child; “engage, don’t enrage”.  Instead of playing parental trump cards like “Because I said so”, ask questions, play a “what would you do?” game, even negotiate the situation.  And negotiating doesn’t mean giving in to every whim a child has, it’s about allowing them age appropriate choices; If they can’t have the toy they wanted, which of the other two toys available to them would they like to play with? [If the answer is “none” then we have some more connections to make.]

If a child has lost touch with their upstairs brain, get them moving to help the regain emotional balance by reconnecting with their body – “upstairs to downstairs”.

Another method of this form of upstairs/downstairs connectivity is drawn from Multimodal Therapy and mindfulness by helping your child pay attention to “S.I.F.T.” – Sensations, Images, Feelings, and Thoughts inside them while at the same time reminding them that these things will change – that what they are feeling in the moment isn’t going to last forever.  We can help them with the latter by reconnecting them with memories of times when they weren’t distressed.  As Siegal and Bryson put it “remember to remember”.

Another important piece to help children learn resiliency is for us to remember that we are hardwired for “we” – our principal defense against distress or danger is attachment.  Always look for ways to connect with your child – use the word “we” as often as possible when problem solving or helping them face challenges.

The flip-side of the “we” strategy is to help your child in perspective taking; Of helping them see the other person’s point of view in any conflict.

The last part of the “we” experience is to make sure you have fun together; connecting with caring and trustworthy people in their lives will pay dividends as they grow into adolescents and adults.

The Whole Brain Child is an informative read, and don’t think that you’ve missed the bus if your children are into their teens, all of the methods in the book can be scaled for any age.  You might even learn some things about yourself.

Aaron D. McClelland, RPCc -

Sunday, 14 October 2012

Mindfulness & the Art of Quitting Smoking

I’m coming up on a year since I gave up smoking, so I think enough time has passed that I can disclose how I did it, and offer it as a potential method for others.  But first, some background ...

I started smoking when I was 15 years old, and by my late teens was smoking a pack a day.  Throughout the 40 years I smoked, my consumption varied between a pack and three packs a day - which would put me in the hardcore camp of the smoking continuum.

From the 90s onward I made a number of attempts to quit; acupuncture, laser treatments, the nicotine patch, hypnosis, pharmaceuticals, etc ... and the one thing they all had in common was they didn’t work worth a hill of beans.  Whether it was the intervention that failed me or simply that I lacked enough motivation, I’m not sure. But each attempt to quit resulted in me becoming miserable and anxious, starting to smoke again, then being angry with myself for failing.

So, I resigned myself for a time to being a “lifer” and just enjoyed that tingling body rush that smoking a cigarette provided.  But as cigarette’s grew more expensive I began to become aware of the financial impact was having on me; I was smoking $3,600 of cigarettes a year.  Once I made that calculation, it was ever present in my mind along with the thought that if I quit, I’d be giving myself a $3,600 raise.

In 2007, I made an interesting observation; I switched from cigarette’s to a pipe in order to reduce my spending on tobacco.  I was surprised when, as I lit up and inhaled the pipe smoke, anticipating that tingling body rush, it never came.  I had made the shocking discovery that it wasn’t the release of nicotine that had been causing the body rush - it was the chemicals that are added to tobacco or are produced when it burns.  I did some research and discovered that there are 4,000 chemicals present in cigarette tobacco smoke.  Here’s a few that alarmed me; carbon monoxide; arsenic; ammonia; hydrogen cyanide; cyanide; acetone; butane; DDT; formaldehyde; sulfuric acid; cadmium; freon; geranic acid; methoprene; maltitol.

As I perused the list it occurred to me that the tingling body rush I felt when I smoked cigarettes wasn’t my body rejoicing over it’s dose of nicotine, it was my body starting to die from these deadly chemicals I’d just inhaled.  Pipe tobacco has far fewer chemicals, but there are still too many.

So I then had two motivators to quit using tobacco entirely;
  1. Financial
  2. The truth about what it contained
Over the past few years as I researched self-injury and concluded that for many it is a biochemical addiction, a muse of hypocrisy began to nag me; If I intended to support clients to stop self-injury, how could I in good conscience continue to smoke?

So I moved from the thought I really should quit smoking to I’m going to quit smoking.  What remained unknown was How?

Through my experience working with various therapeutic approaches, I’d learned quite a few methods to help my clients resolve issues and move forward through difficult periods of their lives.  So, being a Multimodal Therapist, I began to cobble together a plan to make it a reality.

On September 20th of last year I set a quit date of October 15, 2011; I’d learned that quit dates have to be set within a 30 day window to be effective.  Living with a quit date beyond the 30 day mark defuses its importance and immediacy.

Second, using a combination of Cognitive Behaviour Therapy and Mindfulness, I accepted the two following realities;
  1. I am addicted to nicotine.  I accepted this without judgement, without self-criticism; It is what it is.
  2. It is going to suck for a very long time.  I’d heard from many who had successfully quit smoking that decades later they still felt the urge to smoke.  By accepting this - again without judgement - I prepared myself.  The way I looked at it was; For 40 years I would crave smoking and would give in to the craving each time.  From October 15th forward I would crave it and choose not give in to it.
I also decided that during those periods in the day when I would relish smoking, I would go for a short brisk walk instead.

I had also heard during my ongoing education into Mindfulness, that if one sits with a feeling without judgement or reacting to it, within 40 seconds that feeling will begin to change.  I decided to employ that strategy in the form of an experiment to see if indeed it was true.

So on the night of October 14th, 2011, I smoked my last bowl of tobacco and set my pipe down and went to bed. In the morning I was no longer a smoker.

Was it easy?  No.  But armed with my new strategies it was a hell of a lot easier than pervious attempts.

I discovered that the Mindfulness trick of sitting with a feeling for 40 seconds was true - Every time I was hit with one of those cold-sweat cravings, I would sit with it and time it - it’s true; Not one craving lasted the full 40 seconds, and I realized that for 40 years I had lit up within those 40 seconds or at least make a plan to smoke.

The physical cravings didn’t last long, but what fascinated me was the process addiction; Smoking was associated with other activities - intertwined with the fabric of my life.

For example; When I went out for lunch with colleagues to Kelly O’Brian’s, as I was leaving I had a craving to smoke.  I answered that craving with the thought I don’t do that any more and the next time I went to Kelly O’Brian’s that craving didn’t recur.  However, when I went for lunch with colleagues to Milestones, I again got the craving as I was leaving.  The cessation of the associated process addiction wasn’t transferable!  So, I have spent the past year learning not to smoke in various locations and situations, and I’m sure I have more to come.

So that is how I used CBT and Mindfulness to successfully quit a 40 year smoking addiction.

Your mileage may vary.

Aaron D. McClelland, RPCc –

Monday, 1 October 2012

Self-Injury – Tips from the Experts

The following are some techniques I have gathered from members of the world-wide Self-Injury/Self-Harm support community.  They are used by people who self-injure to help with the distressing emotions, sensations, or dissociation/depersonalization when it arises;

Senses Game
Sit quietly and breathe deeply and slowly in a quiet safe place.  As you do, notice;

5 things you see
4 things you feel
3 things you hear
2 things you smell
1 thing you taste

Repeat as necessary to distract from the urge to self-injure.

Locus of Focus
Like the 5 senses game, sit quietly and breathe deeply and slowly in a quiet safe place.  As you do, notice your surroundings and focus on one thing at a time; what it looks like; what colour it is; what the texture is; etc.  Try not to think about them in  judgemental way, simply be present and observe the space around you.

For those who may find themselves feeling numb, dissociating, depersonalized; Try the Senses Game; Try clapping your hands, stamping your feet; Going for a walk in a safe place – do your best to reconnect to your surroundings.

Write it out.  Take your thoughts or feelings and write them down in a journal – get them out of your head.  You can swear, rage, cry, complain, or scream in your journal.

Make sure you keep it safe so no one else will read it unless you wish to share it.   These are your thoughts and feelings – and your story is yours; who you choose to share it with is up to you.

Colour a picture, or if you’re not artistic, scribble using pencil crayons.  It’s like journaling, but using colour instead of words.

The Butterfly Project
Using Sharpies, draw and colour a butterfly on the place you typically self-injure to remind you not to hurt the butterfly.  A variation on this that may have more meaning is to have someone you love draw the butterfly for you.

Rubber Band
Wrap a rubber band around the area you normally self-injure [such as your wrist] and when you have the urge to self-injure “snap” the rubber band to give yourself a sharp stinging feeling.

Use Pens, Not Tools
Using a Sharpie or other pen, draw the lines on your body where you would normally cut.

Some use red paint which gives the effect of seeing the “blood”.

Ice Cubes
Squeeze an ice cube as hard as you can to get an intense physical sensation.

The Layer Plan
Keep your tools in the bottom of a box or a drawer.  On top of them, arrange “layers” of things that might help you avoid self-injuring; a note from your therapist; a note from someone who loves you; a note from yourself to yourself; exercises you can do; lists you could make; your Journal; pencil crayons and paper; Sharpies; rubber bands … anything that will distract you.

Be sure to work your way through the layers, using each thing inside the best you can before moving to the next.  And if you find yourself down to the layer of your tools; Please, be safe.

I welcome any other suggestions in the comments below.

Previous articles in the Self-Injury series;
Aaron D. McClelland, RPCc –

Self-Injury - Treatment Options

“Having [immediate cessation of self-injurious behavior] as a primary goal may well be counter-productive.  Techniques based on the premise that self-injury should not be reinforced by attention, or on the use of sanctions such as withdrawal of treatment, will almost certainly cause greater distress.”
(Solomon, Farrand, 1996)

The Therapist
Therapists need to check-in with themselves before working with clients who self-injure; If the therapist has a strong desire for a client to cease self-injury, or wishes to have a zero-tolerance demand on their client, they should ask themselves if this is based on what is best for their client or because they are not comfortable with the idea of a person self-injuring.  As a therapist, if you find yourself repulsed by self-injury it would be best practice for your client and yourself to make a referral to someone more practiced and comfortable with those who self-injure.

Basic Approach
The first tenet of an effective therapist/client relationship is to take a non-judgmental approach.  Keep in mind that wounds and blood may be everyday occurrences to someone who self-injures.  Also keep in mind that it is a very private and intimate activity and your client may never choose to show you their wounds or scars.

Treating self-injury without addressing the underlying causes may be a self-defeating exercise and be setting the person who self-injures up for failure.  Therefore, therapists must complete a thorough assessment and build a strong therapeutic alliance as a foundation prior to considering treatment options.  Other things to keep in mind are;
  • Most people who self-injure are of above average intelligence and should be engaged with a respectful, collaborative approach.  They will ferret out any duplicity or condescension pretty quickly
  • Self-injury is a powerful coping strategy and one that may be a large part of a person’s life or identity – to change an ego state that has relied on self-injury involves a great deal of work by the client and that work should be respected
  • Therapists must understand what role self-injury plays in a person’s life.  For example; If the individual uses self-injury to drive away suicidal thoughts or urges, taking that away from them may be a dangerous proposition
  • Self-injury can have a strong biochemical addictive quality, so for many people who seek to stop, a therapist should approach it as they would any other addiction
Foundations of Care
The first goal of therapy should be to help the client stabilize their life – this may require short-term medications such as SSRIs as suggested by Favazza.  If their self-injury is out of control, the need it is meeting should be explored and alternatives taught and practiced.

Many who self-injure were never taught to self-regulate their emotional states as children, so we often times need to back up the therapeutic bus in order to teach and have them practice these skills before moving forward in therapy.

Breathing, relaxation, and mindfulness can aid a client to regulate their emotions and physical sensations, but care should be taken to tailor the techniques to the individual; For some, mindfulness techniques that require them to “focus-in” can have the opposite affect than intended – by focusing on what they are feeling may increase their anxiety and tension.  For these individuals, “focus-out” mindfulness may help them move away from the distressing feelings that they use self-injury to alleviate.

The best practice in a treatment plan for an individual who self-injures would include a team comprised of professionals the client trusts and multimodal approaches (Favazza, 1998);
  • The client should have access to non-judgmental and compassionate medical care for their wounds that honours their dignity and autonomy (Dallam, 1997).  This may require the therapist to educate medical practitioners involved in their client’s care [The Bill of Rights for Those Who Self Harm is a good place to start]
  • Any hospitalization should be brief and reserved for clients who are at-risk for suicide or severe self-injury - (Dallam, 1997) – because hospitals are artificially safe environments and the client will be best served to learn alternative coping strategies in real life situations
  • The client should be under the care of a psychiatrist who can monitor any stabilizing medications, their side-effects, and the client's preferences
  • Specific therapeutic approaches should be tailored to address the client’s underlying issues [See below]
  • Group therapy and support groups are extremely helpful for someone recovering from self-injury.  If no such group is available, there are online resources where individuals can be part of a support network, anonymously if they choose [Two such online resources are Self Injury Friends, and Pandora's Project.  YouTube has a number of channels by individuals offering help for self-injury recovery as well, Self Harm Support has hundreds of videos]
  • The therapist should monitor any suicidal ideation frequently.  I would recommend setting up a SUDs scale so that the client can check in each session on how  they are feeling.  Best practice on this is to have the client detail what each number means – [One individual who uses an SUDs scale states that “5” is her safe zone, for her “5” means; “I don’t want to live, but I’m not going to do anything about it”] 
Specific Therapy
Depending on the underlying contributing factors, a number of therapeutic approaches can be employed;

Borderline Personality Disorder - Dialectical Behaviour Therapy combined with interpersonal group therapy has shown a high efficacy.  Therapists who are considering employing DBT should understand that it takes a strong commitment to the process and often the therapist has to be available  to their clients outside of normal office hours

Posttraumatic Stress or Complex Posttraumatic Stress – Depending on  the ability of the client to tolerate the distress of a “trauma-narrative, Rational-Emotive Therapy or Trauma-Focused Cognitive Behaviour Therapy are two options.  Eye Movement Desensitization and Reprocessing is another, however the intensity of “reliving” traumatic events have proven too much for some individuals and have led to an increase in self-injurious behaviour due to the emergence of repressed memories, flashbacks, or nightmares.  Let your client be your guide.

Hypnosis and Relaxation Therapies used in conjunction with other therapies have shown solid results in reducing the distress and tension that can trigger self-injury.

In the working stage of treatment, there are a myriad of tools found in Cognitive Behaviour Therapy that can be tailored to fit any client.

My own approach is rooted in Multimodal Therapy – First addressing the seven modalities that make up who we are; Behaviour; Affect; Sensory; Imagery; Cognitions; Interpersonal Relationships; and Drugs & Biology – then being able to draw on any other therapeutic technique that best fits my client.  As always, when conducting a comprehensive assessment, I look for the client’s “SNAP” – Strengths, Needs, Abilities, and Preferences.  It is their life, their disorder, and their journey toward healing, so I believe that we should build on their strengths, meet their needs, never over-burden their abilities, and always honour their preferences.

I invite comment on this and all the articles in the Self-Injury series, especially from those who self-injure or have recovered from it.  I am always willing and eager to learn …

Previous articles in the Self-Injury series;

Aaron D. McClelland, RPCc –