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Clinical Case Presentation:Creating space for the father

(and child)A. Yuri Iwaoka-Scott, MD, AMSoutheast Child/Family Therapy CenterSan Francisco Department of Public Health

Disclosures/Conflicts of Interest• None

UCSF Child & Adolescent Psychiatry Fellowship

• Child and Adolescent Services, supervised by Dr. Patricia Van Horn and Dr. Betsy Wolfe.

• CTRP, supervised by Dr. Lieberman with coverage from Dr. Ghosh Ippen.

I

SFGH

A note about confidentiality

Some of the case material presented here has been de-identified to preserve client confidentiality.

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Mother requests treatment for child Referral information from mother• “Brayden” – 3 y.o. old biracial (Filipino/Eastern

European American) boy• Hitting, biting, kicking, throwing temper tantrums,

sleeping poorly.• Domestic violence + physical/verbal abuse of child

by father. • Mother says she and child are “afraid” of violent

and sociopathic father• Four months prior, mom called the police, filed for

a restraining order, and left with Brayden to stay with friends.

A “Triadic Lens”

McHale, 2007

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• Mom consents to treatment with child.

• Mother thinks Dad would not consent to treatment.

• Dad calls.

First contact with Dad• Dad is angry/unpleasant with staff on phone.• Dad is mad at mom.• Dad does not think that dyadic therapy is the right treatment

for child.

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• Ensuring physical safety is the highest priority.

• Baseline of safety established.• Ongoing and continuous

monitoring

Lieberman & Van Horn 2008

Assessment of safety in this case• No current violence.• Multiple CPS reports filed by mother or at

mother’s urging.• Bidirectional allegations of violence between

parents. Both parents denying.• CPS/Police/Family Court dropped case and

restraining order and awarded joint legal and physical custody.

• Child does not appear afraid of either parent.

Phone Referral Information: Per Dad• “Brayden” – 3 y.o. biracial boy.Father reports: • No symptoms in the child.• “Mother is crazy.” • Father denies domestic violence or physical abuse of child.

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What to do? A child stuck in the middle

Assessment, Feedback, and Treatment

Clinician 1Parent-Child Dyad 1

Clinician 2Parent-Child Dyad 2

Mother Child Father

Assessment of FatherFather’s Experience:• Only child• Immigrated from Eastern Europe with parents at age of 3.• From a country where there was war.• Strict parents + corporal punishment• Had to “fend for myself”• Felt socially isolated because of immigrant parents, “didn’t fit in,

other kids would tease me”

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Assessment of Father• College-educated, professional.• Doesn’t believe in dyadic treatment.• “sometimes angry” and “sometimes I scare others”• Denied being physically violent to Brayden or his mother.• Wants to work on managing anger.

Assessment of FatherFather’s Experience of Child• “He’s a normal kid.”• “I don’t know what to do with a baby.”• Worry: “Too clingy.”

Angels in the Nursery – A Port of Entry

Fraiberg, Adelson & Shapiro, 1975; Lieberman, Padrón, Van Horn, & Harris, 2005; Lieberman & Van Horn, 2008.

“There are angels that pass on from one generation to another, but they are seldom noticed or talked about.” -- William Harris

• Evokes the parent’s benign, loving, and protective memories of childhood

• To facilitate the intergenerational transmission of loving and growth-promoting influences to the child

Angels in the Nursery

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“Fishing Moments”• “Don’t like to talk about past, but…”• Understanding of his parents and himself

as a boy..• Talked to his own parents.• Sadness that there weren’t more

memories• Wish for Brayden to have many

memories, “fishing moments,” with him.• Reflects on son’s

individuality/preferences.

Beginning to get a sense of the whole person

Initial Assessment of Child

• Playful, does not appear depressed.• No symptoms in assessment play session. • With mother is often dysregulated; with father no symptoms in initial

observations.• No cognitive, speech/language, motor delays• Seeks out both parents for play and comfort

The Triangle: Explaining Treatment to the Child

Lieberman & Ghosh Ippen, 2014

Treatment

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Triangles Explaining Treatment to the Child

• Frame of creating space for the child to love both parents.

Meeting the client where he is… Dad’s worryDad Therapist“Clingy” Explore worryI want him to be social Validate and highlight dad’s attachment

motivation/socialization goalConnect with dad’s past experience

Wants “normal” childhood Wonder with dad about child’s experience*The Port not enteredDevelopmental Guidance

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Powell, Cooper, Hoffman & Marvin, 2013; Diagram Cooper, Hoffman, Marvin & Powell, 1998

“Daddy will you huggy me?

Fostering bond through play: “Mud Pits” “No symptoms.”

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Validate the feeling + Redirecting aggression

Dad laughsChild-Parent session:• Child gets upset, Dad laughs• Child escalates.

Session with Dad: “I feel helpless.”

Child-Parent session: Can you tell Dad how you feel?• “I am sad because you tease me.”• Dad: “I am sorry. I don’t want to make you sad.”

Creating Triadic Space in Therapy

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“It’s okay to talk about mommy.” “I miss Mama.”

“Mud pit moments” Summary

• The triadic lens was essential.• Father ≠ Mother’s descrip�on of Father• Empathic therapeutic stance � engagement• Empathic therapeutic stance � treatment gains• Having single therapist or good communication between therapists is

essential.• Father able to create space for child’s feelings.• Father increasingly able to create space for mother.

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References• Fraiberg, S., Adelson, E. & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired mother-infant relationships. Journal of the American Academy of Child and Adolescent Psychiatry, 14, 387-422.• Lieberman, A. F., Ippen, C. G., & Marans, S. (2009). Psychodynamic therapy for child trauma. In E. Foa, T. Keane, M. Friedman & J. Cohen (Eds.), Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies (pp.370-387). New York: Guilford Press.• Lieberman, A. F., Ghosh-Ippen, C., & Van Horn, P. (2006). Parent–child psychotherapy: Six-month follow up of a randomized control trail. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 912–918.• Lieberman, A. F., Padrón, E., Van Horn, P., & Harris, W. W. (2005). Angels in the nursery: The intergenerational transmission of benevolent parental influences. Infant mental health journal, 26(6), 504-520.• Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early development. New York: Guilford Press.• Lieberman, A. F., & Van Horn P. (2005) Don’t hit my mommy!: A manual for child-parent psychotherapy for young witnesses of family violence. Washington, D.C.: ZERO TO THREE Press.• McHale, J.P. (2011). Assessing coparenting. In J. P. McHale & K. M. Lindahl (Eds.) Coparenting: a conceptual and clinical examination of family systems (pp. 149-170) APA:Washington, D.C.• Powell, B., Cooper, G., Hoffman, K., & Marvin, B. (2013). The Circle of Security Intervention: Enhancing attachment in early parent-child relationships. New York, NY: Guilford Press. • Stover, C. S., & Morgos, D. (2013). Fatherhood and intimate partner violence: Bringing the parenting role into intervention strategies. Professional Psychology: Research and Practice, 44(4), 247.

AcknowledgmentsThanks to all at CTRP, especially to the clinician who worked with this who worked with this family and the supervisors.And thanks to the UCSF Child and Adolescent Psychiatry Fellowship.