Friday, October 3, 2014

What would it mean to believe this?

In working with children with developmental disabilities, my job is to treat the child's challenging behaviors, including aggression, tantrums, non-compliance, self-injury, and property destruction.  My treatment typically consists of first conducting a functional assessment, which is an assessment method through which I observe the child's behavior in a number of manipulated situations to determine why he engages in the challenging behavior (i.e. to determine what function his behavior serves).  During the functional analysis, I observe the child for a 10-minute period, typically with a caregiver, and I count the frequency of the challenging behaviors.  Treatment, then, stems from this: once I have determined the "reason" a behavior is occurring, then I am able to develop a treatment plan that creates a functional way for the child to get that need or desire met.

Like any good research, I also have a control condition to make sure there isn't something else going on that might cause the child to be engaging in challenging behaviors.  In this condition, the child has access to attention, to preferred items, and demands are not placed.  Basically, the parent just sits and plays with the child for 10 minutes.  Typically, there are no challenging behaviors during this condition: the child chills out and enjoys watching "Bubble Guppies" or "Blue's Clues" or playing with beads or puzzles or their Nintendo DSi. 

A few years ago, I worked with a young man with a significant developmental disability who had very significant challenging behaviors.  As with most of my patients, I began with a functional analysis, and we started with the control condition -- the condition in which parent and child sit and play together.  For this particular child, though, the control condition was a mess.  I sent mom into the session room with the directions to "just sit and play as you normally do.  Do not place demands, just sit and talk to him and watch Bubble Guppies together."

He engaged in challenging behaviors throughout the session...but the issue was clear.  In the 10- minute "play" session, his mother placed 60 demands.  That's 6 demands a minute, every minute, and kid was having none of it.  He tantrumed, he was aggressive, and he was noncompliant with just about every demand that was placed.  After conducting multiple observations in session and at the family's home, it became clear that this was their normal: mom just placed constant demands all day, every day.  Even though it led to aggression.  Even though it increased his tantrum behavior exponentially.  Even though the functional analysis was incredibly clear that he only engaged in tantrum behavior when demands were placed...she continued placing demands.

For months, we talked about why he was being aggressive.  I showed her all of my graphs of data supporting this hypothesis.  We talked about how we had to back off on the demands and then slowly increase his tolerance to them.  We talked about how the number of demands she was placing was unrealistic for ANYONE to follow.  We laughed about how even I would probably throw myself on the floor if someone asked me to do something 6 times a minute.  I used analogies about how even simple demands such as "what color is this?" and "where is your nose" are "work" for him, and that he was working 24/7 without much of course he was bitter and resentful.  Mom got it, and she was able to explain back to me why she had to back off, and she understood that it wasn't forever...that we had to just back off to gain some compliance and to decrease the rate of problem behavior.  She understood that even though she was placing 6 demands a minute, he wasn't complying, and that it would be better to have one successful demand and no aggression than to have 6 unsuccessful demands and bite marks.  She saw that he complied with me when I placed demands at low-rates.  And she continued to place all of the same demands.

After months of this work with no change, I knew there was something I was missing.  There was a piece of the puzzle I wasn't seeing, no matter how many ways I tried to explain it.  I thought I was asking the right questions: "what is hard about decreasing the number of demands?"  "What makes it difficult to cut back on the number of tasks you ask your son to do?"  "What is most challenging piece of following through with these recommendations?" 

Her answers were always the same: "It's not hard.  It's not challenging.  I'm trying to do it, I see that it works.  I just can't."

Finally, I called her in for a session by herself for us to really hash things out.  After talking for a good 30 minutes and getting the same answers, I finally changed my question.

"What would it mean for you to not place as many demands on your son?" I asked.  Here, mom's eyes filled with tears.

"It would mean I'm not doing everything I can," she said.  "It would mean I don't care about him.  It would mean I'm not setting him up for success."

We talked about this for a long time, until she said, "I know that what you are telling me is right.  I know it is more important to go slowly now so he will listen more in the future.  But I need him to be successful.  I need to teach him everything now."

"Tell me what success would mean for your son," I said.  "When you picture his future, what does success look like?"

"He will have his own business," she said.  "He has to have his own business."  I reflected internally on her non-verbal 13-year-old son, and considered the feasibility of this plan. 

Very gently, I asked, "What would it mean for you if this is not something that happens for him?  What would it mean if he does not have his own business?"

Here, she began crying.  "If he is not a successful businessman," she said, "my parents will disown me.  Having an adult son who cannot have a job will bring such shame on the family, he and I will be disowned."

And in that instant, everything changed. 

Naming the fear for me, naming it for herself, discussing it enabled her to change her behavior.  After another few months, we were able to end treatment as he was engaging in no challenging behaviors at home or at school.  Mom was able to place a reasonable number of demands at home, and he was able to comply.  Thanks to the simple shift of one question, everything changed.

This question is now one that I use frequently in therapy, and I am rarely disappointed.  It takes us out of the realm of what is happening or not happening, and into the realm of meaning and possibility. 

To the young man who is cutting: "What would it mean for you to find another way of expressing your anger and hurt?"

To the parent who yells that their child does not have autism: "What would it mean for you if autism is an accurate diagnosis?  What would it mean to your child?  What would it mean for your future together?"

To the dad who refuses to stop spanking his 3 year old: "What would it mean to find other methods of discipline?  What would it mean to find other ways of getting your little guy to respect your authority?"

These questions take us so much further.  They often evoke tears, and they take us straight to the heart of the issue. 

I'm so far past exhausted, I can't even see where I passed her.  I'm pretty sure I ran over her somewhere on the highway around Wednesday or so, and I've been running on fumes ever since.  Due to several client cancellations, I was able to come home from work early today and tried to take a nap, but my mind is busy and refuses to shut off -- ever.  I decided to read, and was preoccupied by all of my thoughts about what I should be doing instead: grading papers, writing notes, responding to emails, washing dishes, reading the chapters I'll be teaching in my class this week, ending rape culture and racial inequalities...the list is endless. 

Instead, I laid on the couch with the dog for a bit and made myself focus on being and breathing. 

What would it mean, I asked myself, to just let myself have this time?

I let myself follow this thought further and further down the rabbit hole until I landed on the final question...the one that is hiding behind the walls and resistance:

What would it mean to allow myself to believe that I am worthy of time, and love, and self-care?

Pffffft, I thought, I already believe that.  Come on now...

But do I really?

What would it mean...what would it REALLY mean to believe embody it?

What would it mean for us -- any of us -- to give our souls the time and love they are looking for?  What would it mean for us to admit that we need time to cry, and fall apart, and put ourselves together again?  What would it mean to believe that we don't have to earn this time?  That we have already arrived, are already worthy, are already enough?

What would it mean to accept the fact that our energy is finite, that our body is a resource that can feel depleted, that we need time and care and love in order to survive?  What would it mean to remember, and re-remember, and re-remember that survival is not always something we need to do alone?

What would it mean to remember that it's okay that this is hard?  That all we ever do in this life is practice, and practice, and practice, and hopefully learn to give and receive love?

What would it mean to let ourselves do just that -- to practice, and to give and receive love?

Are you ready?  Can we practice, and give love -- and receive it -- as already-worthy human beings together?

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