Therapeutic Experiences at NW AEE 2011 Conference

I've been putting together the second annual Therapeutic Experiences strand for the upcoming Association for Experiential Education's Northwest Regional Conference (March 2-27 in Salem, OR). I'm excited about the lineup...

Experiential learning can be a highly effective tool when working with clients in mental health counseling, substance abuse treatment, and other human services settings. Join us for workshops focused on practical skills, clinical applications, and theoretical concepts relevant to the use of experiential activities in our work as helping professionals. Intended for therapist, counselors, and others in the helping professions, these workshops are open to anyone with an interest in the clinical applications of experiential learning. Workshops in this strand will be held on all three days of the conference.

Fri. 1:30-5:00 ~ Fun 'n Games in Treatment Settings, presented by David Flack
Sat. 9:00-10:30 ~ Yoga Calm for Children, presented by Jeff Albin
Sat. 10:45-12:15 ~ Super 8mm Filmmaking in Treatment Settings, presented by Mark Noakes
Sat. 1:30-3:00 ~ Existential Factors Within Wilderness Therapy, presented by DB Palmer
Sat. 3:30-4:45 ~ Experiential Spin to Individual Counseling, presented by Monika Parikh
Sun. 9:30-11:00 ~ Experiential Therapy for School Counselors, presented by Annie Flansburg-Spiess

For more information about the conference, visit the NW AEE website.

Activity: Obstacles to Recovery

This activity is often called “Minefield.” I’ve changed the title to something less violent and more treatment-oriented. Call it whatever seems appropriate for your group. This is one of my favorite group session activities. I love the metaphoric possibilities, the layers of meaning, and the fact that it works well in a small-ish group room.

Props: 3-4 blindfolds, about 10 sticky notes per participant, 2 lengths of tubular webbing (or rope), and as many obstacles as possible—tossables, rubber chickens, polyspots, inflated beach balls, whatever you’ve got.

Instructions: In advance, set up an obstacle course. At one end of the room, stretch out a length of webbing and at the other end stretch out the other webbing. The more space between start and finish, the more challenge involved in the activity. In between, distribute all the props (except the blindfolds) as obstacles.

Start off by briefly talking about obstacles to change, or recovery, or whatever is appropriate for your group. I think of this discussion as a chance to prime the pump, not exhaust the topic. Once a few obstacles have been identified and discussed, pass out about 10 sticky notes each and have the clients label each one with a different obstacle, preferably one that is true (or potentially true) for her or him.

Next, either 1.) Collect the sticky notes, briefly talk about the “interesting” ones, then use them to label the obstacles, or 2.) Have the clients label the obstacles themselves. Either way, look for potential metaphors. For example, in a substance abuse group, you are sure to get “using friends” as an obstacle, perfect to label beach balls. If bumped during the activity, the beach balls are likely to roll forward and be in the way again and again. Sound familiar?

There are lots of different ways to facilitate this activity. I prefer this variation, which minimizes instructions, maximizes client problem solving, and requires asking for help, often a challenge for teens in substance abuse treatment:

Explain the basics of the activity. I keep this very simple: The task is to get from the start to the finish line, while blindfolded, without touching any of the obstacles. Explain that if an obstacle is touch, there will be a setback of some sort.

Once the participants are aware of what they are agreeing to, ask for a volunteer willing to be blindfolded. Blindfold the participant, spin her a couple times, and then instruct her to start.

My clients (especially the ones most likely to volunteer to be first) will almost always attempt the task on their own. After a couple setbacks, the volunteer or another client will realize help is needed, a perfect opportunity to process in-the-moment. Sometimes, one person will become the helper; sometimes everyone will start shouting out directions, a real world parallel that my clients strongly relate to and another wonderful opportunity for in-the-moment processing! ("Everyone is always telling me what to do!")

The first time generally takes a while to complete because there are several issues to resolve—asking for help, improving the quality of help received, and both volunteer and other clients learning what kind of advice is useful. After the first volunteer has successfully completed the obstacle course, do it one or two more times. Next, have two or more volunteers go consecutively, alternating starting from opposite sides of the obstacle course.

Finally, consider moving the obstacles around. I usually do this only with the final participant, making barriers that have to be detoured around, then making another, and another. This sounds more mean that it is, because undoubtedly the helper or other observers will shout out what it happening and good spirited groups will enjoy the humor of it. Besides, my clients expect such things from me.

Comments: I present this activity as being about obstacles, but that’s something of a red herring. This activity is really about trust, support, and asking for help. Why not just frame it that way? Well, in my experience the self-discovery of needing help is much, much more powerful than me pairing the participants off into teams in advance.

Determine setbacks based on what is appropriate for your population. I usually have the participant answer a question relevant to the label, except if they touch a polyspot. I don’t use client labels for these. Instead, they are “relapses” and require the participant to start over.

I see activities like this one as opportunities for clients to practice real world skills. As such, I let them struggle with learning curves (i.e., I don’t suggest asking for help and I don’t suggest asking for only one person to provide that help). I also do these kinds of activities over multiple times, with a few variations along the way to keep things fresh, so that clients can improve their skills, and so they can even engage in some generalizing of those new skills.

Perpetual Stuckness: The Role of Trauma in Adolescent Substance Abuse

According to the National Child Traumatic Stress Network (2008), one in four American teens will experience at least one potentially traumatic event by the age of sixteen. Although not all of these adolescents experience long-term traumatic exposure, those that do are highly likely to develop ongoing, significant drug problems and other mental health issues (Perry & Szalavitz, 2006).

In fact, in surveys of adolescents receiving treatment for substance-related disorders, more that 70% reported a history of traumatic exposure (National Child Traumatic Stress Network, 2008). The National Child Traumatic Stress Network (2008) also reported that up to 59% of all teens that warrant a diagnosis of post-traumatic stress disorder are likely to develop a co-occurring substance-related problem. As these statistics show, there is a clear and strong connection between substance abuse and a history of exposure to traumatic stress.

Adolescents can turn to a variety of potentially destructive behaviors in an effort to avoid or defuse the intense negative emotions that accompany traumatic stress. In addition to abuse of alcohol and other drugs, these behaviors can include sexual promiscuity, self-mutilation, bingeing and purging, and suicidality, among others (Perry & Szalavitz, 2006). In this paper, I shall examine the ways that trauma has shaped the cognitive scripts of substance abusing adolescents, resulting in these youth being “stuck” in cycles of maladaptive behaviors. As we shall see, these behaviors can frequently result in a state of perpetual stuckness.

Defining Cognitive Scripts
As a substance abuse counselor working with adolescents who have co-occurring disorders, I have observed that nearly all my clients with histories of traumatic exposure have predictable responses to stressful situations. These predictable responses can be thought of as cognitive scripts. Hebb wrote, “Any two cells or systems of cells that are repeatedly active at the same time will tend to become ‘associated,’ so that activity in one facilitates activity in the other” (qtd. in Siegel, 1999, p. 26). In other words, “Experience, gene expression, mental activity, behavior, and continued interactions with the environment are tightly linked in a transactional set of processes” (Siegel, 1999, p. 19). These processes begin at birth.

Repeated similar experiences lead the brain to make generalized representations that form the basis of mental models used to “interpret present experiences as well as anticipate future ones” (Siegel, 1999, p. 29), suggesting that an individual is most likely to respond to life events in standard, predictable, and learned ways. These mental models can be conceptualized as cognitive scripts. Cognitive scripts are learned. For an individual who experienced a positive childhood environment, these scripts will be generally adaptive and flexible. However, “multiple exposures to interpersonal trauma… have consistent and predictable consequences that affect the many areas of functioning” (van der Kolk, date unknown, p. 6).

Perry and Szalavitz (2006) wrote, “The systems in your brain that get repeatedly activated will change and the systems in your brain that don’t get activated won’t change” (p. 29). However, they also stated that repeated activation of the stress response system could lead to “a cascade of altered receptors, sensitivity, and dysfunction” (2006, p. 24). In other words, over-activation of a system can result in becoming over-reactive, or what they described as sensitized.

Herman (1992) referred to this state as hyperarousal. She wrote, “Hyperarousal reflects the persistent expectation of danger… After a traumatic experience, the human system of self-preservation seems to go onto permanent alert, as if the danger might return at any moment” (p, 35). For individuals who have been sensitized, or are in a state of hyper-arousal, their cognitive scripts have become focused on stress and survival.

In my experience, substance-abusing teens with complex trauma generally have two basic cognitive scripts for dealing with life problems or stressful situations. They act up or shut down. Their use of illicit substances may be part of either script. With such limited options, these teens have no choice but to rerun their same maladaptive scripts, perpetrating already internalized beliefs that they are ineffective, incapable, and destined to remain stuck. Eventually, acting up and shutting down become so normalized that they no longer see these responses as problematic.

Trauma, Abuse and Neglect in Early Childhood
Research indicates that adolescents who enter substance abuse treatment are more likely than their peers to have experienced childhood abuse, neglect, and other significant family problems (Riggs, 2003). In fact, studies have found that these types of early childhood trauma are reliable predicators for substance-related problems in both adolescents and adults" (Romer & Walker, 2007, p. 245).

Adversity in early life alters the development of neural systems in a manner that predisposes individuals to disease in adulthood,” both physical and psychiatric (Romer & Walker, 2007, p. 149). In addition, “childhood adversity, in the form of trauma, neglect, deprivation, or abuse, may be especially harmful during critical periods in brain development… External stressors impact the structure, organization, and activity of the CNS [central nervous system]” (Romer & Walker, 2007, p. 350).

Several laboratory studies on the impact of neglect and early childhood stress have been conducted on rats. “Maternal care [in rats] alters the expression of genes in brain regions that subserve emotional, cognitive, and endocrine responses to stress (Romer & Walker, 2007, p. 161). This conclusion comes from a study that tracked levels of maternal care based on exhibited licking and grooming behavior, both natural variations and imposed differences.

When less maternal licking and grooming occurred, the rat pups exhibited increased fearfulness, heightened HPA (hypothalamus-pituitary-adrenal) axis responses to stress, and reduced performances on tasks requiring sustained attention or declarative learning. This was especially true when the rat pups were under stressful conditions (Romer &Walker, 2007).

The HPA axis is a neural system activated by stress that is “sensitive to environmental challenges and is activated in response to physical and psychological factors that threaten homeostasis” (Romer & Walker, p. 265, 2007). When activated, a chain of events occurs that leads to the release of cortisol, a hormone that increases both blood pressure and blood sugar levels, as well as having an immunosuppressive action (Romer & Walker, 2007), helping assure a quick return to normal functioning following stressful events.

According to Siegel (1999), the hippocampus is “the major center for conscious, declarative, explicit memory processing” (p. 178). He wrote that high levels of stress, especially when severe or ongoing, blocks hippocampal functioning and can even lead to “neuronal death” (p. 50) and decreased hippocampal volume. In other words, trauma can lead to a brain that is less capable of effectively responding to the stress caused by trauma. When this occurs, adolescents have begun experiencing stuckness. As we will see these adolescents are also likely to have these neurological challenges further compounded by developmental debt.

Experiencing Developmental Debt
When individuals already exposed to childhood trauma move into adolescence, they often face a cascade of problems, including a higher incidence of mental health disorders, school-related concerns, placement in separate classes, and increased association with peers who exhibit similar maladaptive issues (Romer & Walker, 2007). Coping with external stressors such as these, not to mention the original traumatic experience or experiences, “overtaxes the available resources allocated for developmental tasks” (Gil, 1996, p. 9) likely leading to what I conceptualize as developmental debt.

According to Gil (1996), trauma “interrupts and disrupts the developmental process” (p. 22). The National Child Traumatic Stress Network (2008) reported that “delays in the developmental processes that would normally enable them [adolescents] to better consider the consequences of their behavior, to make more realistic appraisals of danger and safety, to moderate daily behavior to meet long term goals, and to make increased use of abstract thinking” (p. 16) are compromised by traumatic experiences.

When this occurs, normal developmental tasks go uncompleted. As this developmental debt accrues, the individual starts to fall behind in normal social, emotional, and cognitive progress. Herman (1992) wrote, “The experience of terror and disempowerment during adolescence effectively compromises the three normal adaptive tasks of this stage of life: the formation of identity, the gradual separation from the family of origin, and the exploration of a wider social world” (p. 6).

Teens with a history of trauma exposure often become so focused on day-to-day survival that the emotional and cognitive resources normally allocated to developmental tasks are simply unavailable (Gil, 1996). With each uncompleted developmental task, the individual falls farther behind, further increasing the likelihood of even more life problems (Riggs, 2003) and the possibility that these life problems will negatively impact multiple areas of his or her life.

Bronfenbrenner (1979) identified four dimensions of influence upon adolescents: family, school, peers, and work or play. When an adolescent experiences disruption in any of these dimensions, a ripple effect is likely to occur with negative impacts in the other worlds. For adolescent survivors of trauma, the likelihood of problems rippling out into in all four dimensions seems especially high, resulting in these adolescents moving ever deeper into a cycle of stuckness, where childhood adversities, school failure, negative peer relations, environmental stressors, mental health disorders, and substance abuse all start to co-evolve. For an adolescent already suffering the negative impacts on the brain due to early childhood stressors, the additional impact caused by this developmental debt would ever further contribute to his cascade of problems.

Jittery and Paranoid is My Normal
A former client, Andrew, effectively illustrates this co-evolution. Andrew’s parents were both heroin dependent and the family was homeless, living in a car. It is reasonable to make two assumptions at this point. First, the environmental stressors caused by addicted parents and homelessness had already negatively impacted his hippocampus and general brain development. Second, with both parents being heroin dependent, Andrew was born with a high genetic predisposition for addiction.

At age four, Andrew witnessed the death-by-overdose of both parents. With no relatives willing to provide care, he entered the foster care system. Between the ages of four and fifteen, he had over a dozen different placements. Andrew reported, “I was moved around so much that I stopped unpacking my suitcase.” Not surprisingly, his behavior became increasing problematic. He reported first use of alcohol at age ten and first use of marijuana shortly thereafter. At thirteen he went to detention for the first time. At fifteen, he ran away from the group home where he was living.

When I met Andrew at sixteen years old, he had just moved into a transitional living program after being homeless for almost a year. He reported two recent assaults and had mental health diagnoses that included post-traumatic stress disorder, conduct disorder, attention deficit/hyperactivity disorder, and major depressive disorder. I added additional diagnoses for alcohol dependence, cannabis dependence, amphetamine dependence, and opiate abuse. In addition, Andrew exhibited difficulty remembering details, time frames, and other factual information. He reported using because “it makes me feel normal,” even though he acknowledged amphetamines made him “jittery and paranoid.” With a blank look he continued, “I guess jittery and paranoid is my normal.”

Andrew clearly exhibited what the National Child Traumatic Stress Network (2008) defined as chronic trauma: “the experience of multiple traumatic events” (p. 14). The Network continued, "Complex trauma is a term used by some experts to describe both exposure to chronic trauma—usually caused by adults entrusted with the child’s care, such as parents or caregivers—and the impact of such exposure on the person. Children and adolescents who have experienced complex trauma have endured multiple traumatic events (such as physical or sexual abuse, profound neglect, or community violence) from a very young age" (p.15).

I propose that it is complex trauma that lead to Andrew’s cascade of problems and developmental debt described above. Erickson (cited in Gil, 1996) wrote that the primary developmental task for adolescents is to create a sense of ego identity. He stated that adolescents must create “some central perspective and direction, some working unity, out of the effective remnants of childhood and the hopes of anticipated adulthood” (cited in Gil, p. 45, 1996). For Andrew, this did not happen. He certainly had the ruins of childhood, but he had no direction and no hopes for adulthood. As a result, his already existent developmental debt may have been destined to deepen, resulting in the creation of an existential vacuum.

Frankl (2006) defined an existential vacuum as “a feeling of emptiness and meaninglessness” (p. 141). Such a vacuum is likely to lead to depression, aggression, and addiction (Frankl, 2006). In his autobiography of addiction, Sheff (2007) wrote, “Using is such a fucking ridiculous little circle of monotony. The more I use, the more I need to kill the pain, so the more I need to keep using. Pretty soon it seems like going back, facing all my shit, well, it’s just too goddamn overwhelming. I’d rather die than go through it” (p. 146).

Regarding his use, Sheff continued, “I don’t care. Isn’t that the greatest gift in the world—just not to care? I feel so grateful for it. That’s nothing I ever knew sober” (p. 60). It seems clear that Sheff’s addiction is an attempt to fill this his own existential vacuum, at least temporarily, even if in a maladaptive and unsustainable manner. I believe this is also true for most adolescent survivors with substance-related disorders.

Addicted to Chaos
Working with adolescents that have co-occurring disorders, I see a lot of clients with a history of complex trauma. Like Andrew, these adolescents often appear to be stuck in an endless cycle of chaos, often seemingly of their own making. In my experience, the more severe the history of trauma, the more likely the client will be using stimulants. Stimulants replicate trauma by releasing dopamine and noradrenaline, which are released during the hyperarousal response. According to Perry and Szalavitz (2006), the brain changes related to hyperarousal “may make some trauma victims more prone to stimulant addiction” (p. 190).

Based on how stimulants affect the brain, it seems likely to me that stimulant use may be an attempt to recreate the feelings of trauma from the pasts. By using stimulants, adolescent trauma survivors may be attempting to artificially stimulate the production of those neurotransmitters that they have become physically accustomed to being present. Perhaps these individuals are, in fact, using stimulants to avoid withdrawal caused by a decrease in their accustomed level of dopamine and noradrenaline caused by their history of complex trauma. Likewise, perhaps the extreme behavior many of these youth engage in—auto theft, prostitution, drug dealing, risky sex, graffiti, running away, assault, and more—is also a way to increase levels of dopamine and noradrenaline, thereby avoiding withdrawal from stress-related neurotransmitters.

This type of risky behavior helps assure the perpetuation of chaos in the lives of these teens. Self-sabotaging behavior functions differently. In this case, when things are going well for these clients, they do something to create chaos or stress: the client about to graduate from an inpatient program acts out and has her graduation canceled; the court ordered client who cusses out a judge during a hearing; the client who gets arrested for dealing, but insists he did not use so his treatment should not be affected.

Self-sabotaging incidents such as these are fairly common among adolescents in substance abuse treatment. I have always attributed them to a mix of poor decision making skills, an unconscious desire to stay in counseling, and a fear of success. Perhaps, though, these behaviors should be viewed as relapses. In the above cases, the clients did not use drugs, but they certainly did get a jolt of stress-related neurochemicals.

For years I have referred to these clients as “chaos junkies”—a term most adolescent clients readily understand and frequently acknowledge as true—but always thought of this as a psychologically based behavioral pattern, a repeating of life strategies that had been modeled in chaotic family environments, another example of a maladaptive cognitive script. Could there be something more happening here, though? Could these youth be addicted to chaos? More precisely, could these youth be physically dependent upon the chemicals released due to the stress caused by complex trauma, chaotic lifestyles, and unhealthy environments?

If this is true, then I believe these individuals are not simply stuck in chaos. Rather, their brains have become wired in such a way that they are now creating their own trauma.

Perpetual Stuckness
Thus far I have examined traumatic experiences as causal pathway for substance abuse in adolescents. While this appears to be the primary causal pathway, it is also possible for substance abuse to lead to trauma (National Child Traumatic Stress Network, 2008). As we have already seen, it is not uncommon for substance-abusing youth to engage in high-risk behavior such as prostitution or drug dealing.

For Andrew, drug dealing supported his substance abuse. It also led to several physical assaults and to him being the perpetrator of violence. Andrew also acknowledged frequently trading sex for drugs and engaging in various criminal activities. High-risk behaviors such as those seen with Andrew can serve to re-traumatize these adolescents. In other cases, such high-risk behavior could be the cause of the initial trauma (National Child Traumatic Stress Network, 2008). Either way, these adolescents find themselves in a cycle of stuckness.

Paradoxically, even though risky behavior is evident in the lives of most adolescents with complex trauma, these teens are generally risk-adverse. Indeed, it seems possible that their risky behaviors are often ineffective attempts to avoid risk. In my experience, youth that engage in high-risk activities can be so distracted by these behaviors that they simply do not have time to think about their past trauma.

On the other hand, adolescents obsessed with safety often resort to substances and other maladaptive, risky methods of finding it. Still other teens lead lives that are so constricted that they barely even participate in existence. For these cases, trauma has “cast the victim into a state of existential crisis” (Herman, 1992, p. 51) where all choices lead to further stuckness.

Jon, a client with a significant trauma history, vividly described his existential crisis caused by intrusion. “Lots of times I feel like I’m living in some kind of black hole. I’m alone, but not really, because everything is there, because I just can’t escape shit, ever, no matter how much I try. It’s black, because that’s what black holes are, right? But, black is really all the colors at once, every single fucking one of them. And that’s too many colors if you ask me.” Being faced with all the colors at once immobilized Jon in a dark, lonely, constricting vacuum.

Herman (1992) wrote, “By avoiding any situation reminiscent of the past trauma, or any initiative that might involve future planning and risk, traumatized people deprive themselves of those new opportunities for successful coping that might mitigate the effect of the traumatic experience” (p. 47). Many adolescents avoid those past experiences by escaping into addiction. While escape may temporarily possible, as we saw with Sheff’s statement, it ultimately only perpetuates the problem, because the only escape is into an existential vacuum filled with all colors.

For adolescent survivors, it is likely that few adaptive cognitive scripts were ever modeled. Through modeling or other methods, an individual learns a certain response and starts putting that behavior into practice. As we have seen, if an individual repeats the behavior enough times, it becomes an integrated part of that person’s cognitive scripts. This is, of course, the basic idea of brain development: “Neurons that fire together wire together” (Siegel, 1999, p. 26). For these teens, what has wired together is inherently problematic.

Rose (1998) wrote that most youth with life problems “seem to have dedicated and rigid strategies of dealing with problems and are disinclined to look at other possibilities” (p. 177). These rigid strategies have been born from a life of traumatic stress. Looking at other possibilities requires a willingness to try something new, to take risks, and as we have seen, these adolescents are—at their core—risk adverse. For a teen who has had much unpredictability, even the most painful known option can feel far less risky than any unknown one. For adolescents like Andrew and Jon, who have had lives filled with traumatic stress and unpredictability, even the most painful known option can feel fall less risky than any unknown one. Andrew said it this way: “What I like about shooting [meth] is that I know what to expect. I use. I get high. No surprises.”

Chemical Constriction
Andrew stated once, “When I smoke weed, all the bad feelings go away. I don’t want to do stupid shit. I don’t want to think about the past. I don’t care about the future. As long as I’m high, everything’s gonna be okay.” This statement by Andrew perhaps points to a simple truth for these adolescent survivors of complex trauma. Ultimately, substance abuse is a form of constriction.

A vacuum filled with all the colors is overwhelming, but a vacuum filled with no thoughts can seem promisingly safe. Herman (1992) wrote, “When the victim has been reduced to a goal of simple survival, psychological constriction becomes an essential form of adaptation. This narrowing applies to every aspect of life—to relationships, activities, thoughts, memories, emotions, and even sensations” (p. 87).

While in treatment, Andrew lived in a group home with a drug testing policy. Continued use could have resulted in losing his placement. Yet, he continued. Some chemical dependency counselors would say Andrew was in denial, or perhaps resistant to treatment. I believe such an assessment would be both simplistic and pessimistic, and so I offer a different possibility: Andrew was not resistant and was not in denial. In fact, he readily acknowledged the problems in his life, including his addiction. He was, however, stuck. His lifelong cascade of problems had impacted his brain’s architecture in ways that had shaped his behavior, determined his cognitive scripts, and assured his stuckness.

Andrew was incapable of making more adaptive choices. His brain was not physically able to complete such a task. Does that mean he was beyond help? I do not believe so. For adolescents like Andrew and Jon, remaining stuck is a safe, tempting possibility, but it is not destiny. Substance-related disorders and complex trauma are frequently an intricate, co-evolving, cascading cycle of stuckness. Helping adolescents overcome this stuckness requires challenging them to risk developing new cognitive scripts, so that they are able to move beyond their perpetual stuckness and see all the colors, not just black.

References
Frankl, V. (1984). Man’s Search for Meaning. New York: Simon and Schuster.

Herman, J. (1992). Trauma and Recovery. New York: Basic Books.

Gil, E. (1996). Treating Abused Adolescents. New York: Guilford Press.

National Child Traumatic Stress Network (2008). Adolescents and Substance Abuse. Retrieved October 5, 2010, from http://www.nctsnet.org/ncct/nav.do?pid=ctr_top_adol

Perry, B. & Szalavitz, M. (2006). The Boy Who Was Raised as a Dog. New York: Perseus Books Group.

Riggs, P. (2003) Treating Adolescents for Substance Abuse and Comorbid Psychiatric Disorders. Science & Practice Perspectives, 18-28. Retrieved October 5, 2010, from www.drugabuse.gov/PDF/Perspectives/vol2no1/03Perspectives-Treating.pdf.

Romer, D. and Walker, E. (Eds.). (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.

Rose, S. (1998). Group Therapy with Troubled Youth. Thousands Oaks, CA: Sage Publications.

Sheff, N. (2007). Tweak. New York: Simon and Schuster.

Siegel, D. (1999). The Developing Mind. New York: Guilford Press.

Van der Kolk, B. (n.d.). Developmental trauma disorder: A new, rational diagnosis for children with complex trauma histories. Psychiatric Annals.

Three Activities for Creating Connectedness

This post includes three activities intended to help build group cohesion and create connectedness. They were shared during The Therapeutic Backpack workshop at Counselor Camp '10.

PASS THE PIG
I generally use this activity as a warm-up.

Supplies
- A rubber pig. Or, do this activity with an empty clean coffee can, a Koosh Ball, a rubber chicken, whatever you have handy!

The Activity
Have the participants sit in a circle, in chairs or on the floor/ground. Explain that the object of this activity is to pass the object all the way around the circle with no one using hands or forearms and the pig (or whatever) not being dropped. If the pig is dropped, we start over.

Once the group has successfully passed the pig all the way around the circle, consider doing the activity a second time. This time, send the pig in one direction and a second object the other way.

Processing
I usually use this as a warm-up activity and don’t spend time processing unless something obvious comes up. However, we always talk about happened during the second round when the two objects collide.

Notes
Don’t be surprised if this seemingly innocuous activity brings up some personal boundary issues.

COMMON GROUND
This is a common activity, which people know under several names. Here’s my version.

Supplies
- 1 less space markers than the number of participants (including the facilitator as a participant)

The Activity
Have participants stand in a circle, with you (the facilitator) in the middle. Pass out a space marker to each person and instruct him or her to stand on the marker. Explain that this activity is about “finding common ground with each other… The person in the middle – me to start – says something that is true for them. For example, ‘I want to find common ground with people wearing jeans.’ If this is true for you, too, you need to leave your space marker and find a new one. While you are looking for a new one, I’m also going to be looking for a space marker, because I want to get out of the middle. The person left without a space marker is the next person to look for common ground…”

I like this activity as a safe way to practice self-disclosure. With that in mind, if participants are sticking to “easy questions” (wearing white shoes, hair color, etc), I usually challenge them to engage in greater disclosure. Since I’m working in a substance abuse setting, I encourage questions such as: I want to find common ground with … people who have felt triggered in the last week; come from families with a history of drug problems, etc.

Processing
Who stuck to safe questions? Who asked riskier questions? Did anyone not leave their space marker when they should have? Why?

Notes
I always participate in Common Ground, just like I do with many activities that focus on group cohesion/connectedness. After all, I’m part of the group.

POLYSPOT SHUFFLE
This activity is basically a portable version of TP Shuffle, for those of us without a ropes course readily available.

Supplies
- 1 polyspot (or other type of space marker) per participant
- Deck of playing cards

The Activity
Have participants stand shoulder to should in a line, all facing the same direction. Pass out a space marker to each person and instruct him or her to stand on the marker. Tell the participants that their goal is to line up by height, without talking and without touching the floor/ground. In other words, they can only touch the space markers. If anyone talks or touches the floor/ground, everyone will go back to his or her original marker and the group will start over.

After the first round, have the participants line up by something less obvious, such as alphabetically by their middle name, again without talking our touching the floor. For the third and final round, give each person a playing card, with the instruction to hold it up to his or her forehead without looking at it. Have the line up in order.

Processing
I process between rounds. There is rarely much to talk about following Round 1. Round 2 processing usually focuses on problem solving. Round 3 processing usually focuses on how it was different, which was easier—relying on others or yourself.

Notes
I think even simple, cohesion-focused activities like Polyspot Shuffle can have a secondary objective of skills building. Like a lot of the activities I do, Polyspot Shuffle repeats with variations with the goal of helping participants generalize learning from one situation to a slightly different one.

Handout: The Therapeutic Backpack

Here's the handout from the Counselor Camp workshop. I'll have directions for activities sometime soon!

THE THERAPEUTIC BACKPACK: The Use of Experiential Activities with Substance Abusing Teens
Presented by David Flack

Backpack Contents
• Tossables. 8-10 objects such as Koosh Balls and stuffed toys.
• Chiji Processing Cards. Set of 48 cards, each with a different image.
• Poly Spots. 12 durable vinyl spots, 9” in diameter.
• Human Handcuffs. 10 sets.
• Bandanas. One for every 2 people in a typically sized group, plus extras.
• Sharpie markers. Why Sharpies specifically? Because they don’t smudge on balloons. One per person in a typically sized group, plus extras.
• Coin. I use a sobriety coin, but a quarter works just fine.
• Tubular webbing. 12-15 feet long each; I have 3 in my Backpack.
• A bag of some sort. A stuff sack about 12” deep by 6” inches in diameter.
• Mousetraps. 6-8 (or more) never-used-before wooden mousetraps.
• A rubber chicken.
• A rubber pig.
• A plastic puffer fish.
• Scissors.
• A ball of yarn.
• Playing cards. 2 decks.
• Masking tape. 4 rolls.
• Index cards. 4 packages.
• Balloons. About 100 total, various sizes and shapes.

Experiential Activities in Clinical Settings
When I use experiential learning in clinical settings, I usually have one of three therapeutic objectives in mind. They are:
• Creating connectedness. In clinical settings, teambuilding activities might not be the best use of time. However, a sense of connectedness is vital for effective group work. Shared fun experiences + Trust = Connectedness
• Exploring new skills. Practicing a new skill in a safe environment, even in metaphorical or symbolic ways, significantly increases the likelihood of someone using that skill in the Real World.
• Fostering self-efficacy. Self-efficacy is the belief that you are capable of being successful. A strong sense of self-efficacy is vital for successful change.

What is connectedness? It is a sense of being a part of something larger than oneself. It is a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone. It is a sense that, no matter how scary things may become, there is a hand for you in the dark. While ambition drives us to achieve, connectedness is my word for the force that urges us to ally, to affiliate, to enter into mutual relationships, to take strength and to grow through cooperative behavior.
~ Edward M. Hallowell, Finding the Heart of the Child

Processing in Clinical Settings
• Processing involves creating connections between an experiential activity and the Real World.
• These connections help assure transfer of learning and lasting change. As such, I believe this is a vital part of using experiential approaches in treatment settings.
• Many people think of processing as a discussion or Q&A session.
• These approaches may not be especially effective with teens in treatment.

Obstacles to Effective Processing
• Being insightful is a skill that requires practice. In many cases, teens have had little or no prior opportunities to practice this skill.
• Processing seems risky. Despite all you may have heard, most teens are risk-adverse, at least when the risk is interpersonal in nature.
• Many teen participants are mandated. These youth often have no desire to engage. Now they’re faced with an adult stranger trying to get them to talk about how they feel. Of course they’re resistant!

Alternatives to Q&A Processing
• Discussion Starters. Using objects or activities as a prompt is often more effective than simply asking a question. The Chiji Cards, included in the Backpack, is a good example.
• Random Questioning. The pressure to respond can get in the way of responding! Tossing an object around a circle is one way to make answering random and help reduce that pressure.
• Action Processing. The amygdala is the brain’s Fear Center. However, if the brain is busy with a cognitive task, the amygdala doesn’t have time to sense fear. So, keep those brains busy!

A Favorite Activity: Balloon Tower

From time to time, I plan to post directions for a favorite activity. First up is Balloon Tower.

Supplies
* 10-12 balloons per participant; ideally various sizes and shapes.
* 1 Sharpie marker per participant.
* 1 roll of masking tape for every 3-4 participants.
* A few small balloon pumps; optional but nice.

The Activity
PART ONE - Distribute 10-12 balloons to each participant, with the instruction to inflate them. It isn't necessary for participants to keep track of their balloons. Just add them to the collective stash of blown-up balloons. As the facilitator, blow up some additional balloons. The inflating of the balloons can take a little time, so you might want to plan a discussion or didactic talk during this part, ideally something related to the purpose of the activity.

Once all the balloons are inflated, distribute a Sharpie marker to each participant, with the instruction to write a trigger for using on each balloon. Encourage them to use triggers that are real for them, but if they run out they can use “general triggers.” Continue until all balloons are labeled. (If you don't work in a substance abuse treatment setting, see the notes below for alternative framing ideas for this activity.) Participants don't need to keep track of the balloons they labeled. Just add them to the collective stash of labeled balloons.

When all the balloons are labeled, explain that the group is going to “practice managing their triggers” by making the balloons into the tallest possible free-standing tower using nothing but the balloons and masking tape. Give a roll of masking tape to every third person, set a time frame (I usually give 15-20 minutes), and have them get to work.

If the group is large enough, I suggest splitting into teams of 4-5 participants each, and have the teams compete to make the tallest free-standing tower within the given time frame. Once the time is up, declare a winner and process the activity thus far. Use lots of metaphoric language related to controlling/managing triggers.

PART TWO - Instruct participants to find one balloon labeled with a trigger that they did not write, but is true for them, and then pull the balloon out of the tower causing the least harm possible. When everyone has a balloon, sit in a circle. Ask a participant to share the trigger/balloon selected, why, and something he/she could do to make the trigger less triggering. Encourage feedback from other group members as appropriate.

One the participant has a plan for managing the trigger, instruct her/him to pop the balloon. I usually say something such as, “Now that you have a way to control this trigger, instead of it controlling you, go ahead and pop that balloon. Continue around the circle until everyone has shared his/her trigger, described a strategy, and popped the balloon. Once everyone has done so, allow the participants to pop all the balloons… and then clean up the mess!

Processing
The majority of the processing for this activity occurs at the end of Part One, since Part Two is basically a discussion. As such, I almost never do any significant post-activity processing with this activity. Often, though, I’ll follow the activity with a discussion about the difference between managing balloons with masking tape and strategies for dealing with Real World triggers. I typically start that discussion with a question such as, “In this activity, we managed triggers with masking tape, but is it that easy in the Real World?”

Notes
As written, this activity is meant for substance abuse treatment groups. However, I believe you could easily adapt it to other settings. Anger management and stress reduction are obvious examples of other clinical contexts. Instead of “triggers,” you could have participants label balloons with obstacles relevant to the setting. And, you could forgo the labeling (and the entire clinically focused Part Two), and simply have this be a tower building activity.

NW AEE presents Beyond Basics: Taking Facilitation to the Next Level

Beyond Basics: Taking Facilitation to the Next Level
Saturday, September 25, 2010
9am-5pm at Camp Long in Seattle, WA
Facilitated by David Flack & Katie Miesle
Cost: $15/per person

Schedule
9:00- 9:15 Meet & greet, overview of day

9:15-10:00 Place-Based Teambuilding (Katie)
We’re going to kick off this day event by building community within our group. We’ll be exploring place-based teambuilding through hands-on experiences, personal reflection, group collaboration, and lots of laughter. Using the principles of DO-REFLECT-ACT, we’ll practice different ways to introduce team challenges relevant to each participant’s organization and client groups.

10:00-10:10 Break

10:10-11:20 Gray Matters: What Neuroscience Tells Us About Learning & Change (David)
In this workshop, we’ll use brain-based learning methods to explore the intersection of neuroscience, learning, and change. We’ll examine basics concepts of neurobiology, explore in-depth five brain-based learning concepts particularly relevant to experiential education, and look at ways to integrate these concepts into our work as facilitators.

11:20-11:30 Break

11:30-12:15 Facilitating for Solutions (David)
Solution Focused Therapy is an evidence-based clinical approach that views participants as competent and strives to help them visualize the changes they want by building on the strengths they already possess. In this workshop, we’ll examine important core concepts from Solution Focused Therapy, and look at the use of In-The-Moment processing as a practical tool for facilitating solutions.

12:15-1:00 Lunch

1:00-1:40 Open space & activity planning

1:40-3:40 Facilitation Mentoring & Feedback (Group led)
We'll divide into small teams of 3-4 people. Each team member will facilitate a simple activity they’ve chosen (from start to finish: front-loading/metaphors, activity, and processing.) There will be a forum for feedback and collaboration.

3:40-4:00 Coffee Break & contact info

4:00-4:45 Transfer of Learning (Katie)
We’ll be leading activities to assess the day's events, process the activities, and apply it to your practice. Reflection & goal-setting pieces included.

4:45-5:00 Closing

For directions or more about Camp Long, visit their web site.

For questions about the event or to register, contact Katie at kmiesle@yahoo.com or David at david@davidflack.com.

We look forward to seeing you in Seattle!!!

Hands On Mindfulness

As I wrote last time, I've found that the abstract nature of mindfulness can make it challenging to teach to teens in treatment. As a result, I’ve been experimenting with ways to use experiential activities to assist with this process and it seems to me this works well for “everyday” mindfulness. The activities presented here are an attempt to introduce teens in treatment to a hands-on approach to mindfulness, to increase the attractiveness of mindfulness, and to assist clients in integrating mindfulness into their daily life.

Defining Mindfulness
Jon Kabat-Zinn wrote, “Mindfulness means paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.” These activities explore these three elements of mindfulness.

On purpose: Raisin’ Awareness
Raisin’ Awareness is a guided exercise involving eating a single raisin with full intentionality. This script is adapted from Mindfulness-Based Cognitive Therapy, by Segal, Williams, and Teasdale.

In a moment, we’re going to do an exercise, but before we start, let’s take a few moments and focus on our breathing… Pay attention to your in-breath; imagine releasing the stress from your day, all the tension and frustration, making space for more calmness…

While you continue to focus on your breathing, I’m going to come around to each of you and give you an object. Don’t do anything with the object until I ask you. Just look at it… Look at it like you’ve never seen anything like it before… Like you have just dropped in from outer space this very moment, and have never seen anything like it in your life…

And now, holding the object between your finger and thumb, look even more carefully at it, as if you’ve never seen such a thing before… Turning it over between your finger, and paying attention to how it feels, as if you’ve never seen such a thing before… Explore every part of it, as if you’ve never seen such a thing before…

And while you’re doing this, if any thoughts come to your mind, like “what a strange exercise this is” or “I don’t get what this has to do with drug treatment,” that’s okay… Simply acknowledge those thoughts, accept that you’re having those thoughts, and then bring your focus back to the strange object in your hand…

And now, bringing the object up to your nose, and smelling it… With each in-breath you take, carefully notice the smell of the object… With each in-breath, notice something new about the smell… Something different and distinct… Another layer of noticing…

And without putting the object into your mouth, slowly bring it up to your lips… Slowly move your arm, noticing how your hand and arm knows exactly where to put the object… Maybe noticing your mouth watering just a little… Again, don’t put the object into your mouth, not yet, just observe what it feels like to move the object toward your lips…

And, now, without biting the object yet, place it into your mouth… Without biting the object yet, notice it being in your mouth… Notice the sensation of having the object in your mouth… Maybe roll it around on your tongue… maybe press it to the top of your mouth…

And when you are ready, without swallowing the object, go ahead and take one single bite into it… Notice the tastes that it releases.,. And again, without swallowing the object, slowly chew it… Notice the way your jaw moves, and the way your teeth come together, and the way it feels to chew this object… Notice the flavors, and the changes that happens to it while you chew…

And then, slowly keep chewing, one jaw movement after the other… Until the object is completely gone…

I often use M&Ms or Skittles instead of raisins. These seem a bit more “teen friendly” to me, and I like the added contrast between the crunchy shell and soft interior. I’ve found that participants with especially poor impulse control or who tend to perform for their peers may be challenged by this activity in a group setting. With these teens, it may be more effective to do the activity during individual sessions.

Present moment: Three Minute Observation
Distribute a sheet of paper and pen or pencil to each participant. Explain that the group will spend three minutes quietly paying attention to everything going on in the environment—sounds, sights, smells, all the senses—and writing down what they observe.

After the time is up, have participants share what they recorded and discuss differences between what was recorded. Some participants are likely to have noticed primarily visual observations; others are likely to have noticed primarily sounds. Some will likely record primarily external observations; others will likely record internal observations. After some discussion, consider re-doing the Three Minute Observation, then discussing differences in participants’ awareness of the environment.

Non-judgmentally: The Dragon of Non-Judgment
The Dragon of Non-Judgment is a small stuffed dragon, but you can obviously you a different object. To change the challenge level, you can use different objects. For example, a water bottle would provide fewer obvious comments.

The group sits in a circle and passes the dragon around the circle. As each participant receives the dragon, he makes one non-judgmental comment about the dragon, such as “The wings are shiny” or “The tail curves upward”.

If you pass the dragon around the circle several times, the most obvious comments quickly get used and participants will have to try harder to make non-judgmental comments. If a judgmental comment does gets made, stop and discuss, encouraging the participant to restate the comment in a non-judgmental way.

This activity can be harder than it sounds, so expect some participants to struggle with it. I’ve found that some teens will exhibit resistance to the activity, making comments such as “This is stupid.” These tend to be participants who exhibit all-or-nothing thinking and are most challenged by making non-judgmental statements.

Respond, Don’t React
Responding is about making a thoughtful choice that meets your needs both in the moment and in the future. Reacting is about doing without thinking or acting a certain out of habit. There are times when reacting would be appropriate—you’ve been attacked by a cougar, you’re standing on a train track and a train is coming. However, those are rare occurrences. In most cases, responding is more effective.

When an individual reacts, the situation is in control. When an individual responds, he or she is in control. This is a concrete skill useful for dealing with triggers and emotion regulation. These two activities provide opportunities to practice responding and are highly engaging for most teens.

Whack ‘Em
Participants form a circle seated on the floor or in chairs with their feet extending into the middle. One participant stands in the middle of the circle with a foam pool noodle in hand. This game is easy, but the explanation is a little complicated. I usually start in the center of the circle and say something like:

The object of this game is to not be he person in the middle. When we begin, someone in the seated circle will start us off by saying the name of someone else in the circle. Once that name is called, I’ll try to tap that person’s feet before she can call out the name of somebody else. If I’m able to tap her feet before she calls out someone else's name, then she becomes It, I take her place in the circle, and we start again by me calling out someone else's name. However, if she calls out another person's name before I tap her with the noodle, then I will try to tap that person before he calls out someone else's name. And so on…

When calling a name, it must be someone in the circle and cannot be your own name. You might be surprised how often that happens! Be sure to plan some time to debrief this activity and make connections between the game, mindfulness, responding, reacting, and trigger management. One of my favorite processing questions: What does this game have to do with The Real World?”

S.O.B.E.R. Mousetrap
S.O.B.E.R. is an acronym originally developed by Marlatt. My version of this acronym varies somewhat from the original, with the letters standing for Stop; Observe; Breathe; Evaluate your choices; Respond. A catchy, treatment friendly acronym is nice, of course, but even more important it getting participants to transfer the learning into their lives. In my experience, this activity does that extremely well.

After introducing the acronym, I pull out an old-fashion wooden mousetrap and announce that we are going to practice this new skill. In an effort to increase the sense of perceived risk, I do a fair amount of front-loading about safety and risk-taking. I then set the trap, place it on the palm of my left hand, and smack my right hand—palm down—on top. This makes a “mousetrap sandwich” with the now tripped trap between my hands.

With the mousetrap between my hands, I spend 12-15 minutes further discussing mindfulness in general and especially S.O.B.E.R as recovery skills. It is common for at least a few participants to become nervous along the way. Neuroscience tells us that moderate stress increases retention of new learning, which is probably what makes this activity so memorable, so embrace the nervousness! With the mousetrap still sandwiched, discuss perceived risks, how reacting would make things worse, and ask participants for their own real world examples of making things worse by reacting.

Now what? Obviously you let go of the mousetrap. I suggest practicing alone a few times before doing this with participants. Here’s the trick (or skill if you prefer): Let go of the mousetrap by calmly, but quickly, lifting your right hand straight upward. If you placed the mousetrap in your hand with the trigger mechanism pointing away from you, the mousetrap will fly away from you, not into your face. You don’t want that. Also, when you let go of the trap, be sure you aren’t too close to other people. That way it won’t fly into anyone else’s face, either.

The inevitable next step is to have group members trip mousetraps. Before doing this, review the safety precautions—place the trap on the hand the participant doesn’t write with (that way if things go bad they can still sign their name!), the trigger mechanism should point away, don’t be not too close to anyone else, and release the trap calmly but quickly. For added safety, I set the traps and place them onto the palm of each participant. The perceived risk for this activity can be fairly high, so it is important to honor the choice of any participant who does not want to handle a mousetrap.

Finally, pass a set mousetrap around the circle. Even better, pass one trap to your right, give it a moment, then start another trap going in the other direction. What do you do when you have dangerous situations coming at you from two directions? Be sure to plan lots of time debriefing this activity when done, focusing on mindfulness, perceived versus actual risks, managing triggers, and other related topics.

A final note: When used for its intended purpose, a wooden mousetrap would catch a mouse and then the whole mess would be disposed of. With that in mind, mousetraps are cheaply made. I recommend tripping a mousetrap no more than three or four times and then disposing of it.

Don’t Believe Everything You Think

Research shows that practicing mindfulness can be extremely helpful to those challenged by addiction, as well as depression, anxiety disorders, ADHD, and more. However, the abstract nature of mindfulness can make it challenging to teach in a way that is meaningful and—more importantly–actually translates into the daily lives of our participants.

There is a paradox about using mindfulness with teens in treatment that amuses, challenges, and energizes me. Namely these resistant youth with impulse control issues are exactly the ones who need to most learn mindfulness! I’ve found that when these youth learn a tool that really works, such as mindfulness, they will readily embrace it. However, these youth often have deeply rooted thinking habits that often prevent them trying something new. As such, I believe the journey to mindfulness for these youth starts by helping clients challenge their own thinking habits. Most cognitive-behavioral approaches talk about thinking errors. I prefer to conceptualize these as thinking habits, not errors, because I believe that—like any habit—they can be changed.

I recall a bumper sticker I saw once which said, “Don’t believe everything you think.” To me, this bumper sticker succinctly states one of the most important lessons of mindfulness in a treatment setting. In his book, Full Catastrophe Living, Kabat-Zinn (1990) presents seven methods that will help an individual to not believe everything he thinks. They are non-judging patience, beginner’s mind, trust, non-striving, acceptance, and letting go. Returning to the bumper sticker, in an effort to not believe everything you think, it seems to me that non-judging is perhaps most relevant.

Non-judging allows an individual to transcend thinking habits such as personalization, or relating negative events to oneself when there is no basis; dichotomous thinking, or all-or-nothing thought patterns; selective abstraction, or focusing on limited aspects of a situation; and, magnification or minimization, also defined as distorting the importance of particular events or behaviors of others (Herkov, 2006).

When an individual engages in maladaptive thinking habits, she believes that her thinking is reality. For example, not only might she think all people are good or bad, she also believes this to be true and unchanging. Through the practice of mindfulness, this individual is would begin to discover that thoughts are actually temporary, that her belief that all people are good or bad is subject to change, and that she does not need to believe this thought.

Linehan (qtd. in Baer, 2003) stated that thoughts are “like waves in the sea.” Through mindfulness practice, an individual is able to develop an awareness of the transitory nature of his own thoughts. Once this awareness has been established, an individual is able to engage in “urge surfing,” a concept common in many forms of traditional cognitive therapy. Urge surfing can also be applied to responding to thinking habits. Instead of believing what you think, choose to ride the wave through the thought, letting it crash on the shore and then retreat.

Perls (qtd. in Walsh and Shapiro, 2006) stated, “Awareness—in and of itself—is curative.” If he was correct, then developing an awareness that one’s thinking habits are transitory, not a permanent reality, will allow an individual to separate oneself from those habits. This suggests that by developing an awareness of one’s maladaptive thinking habits, they will automatically decrease. Through this process of disidentification, when a thinking habit does occur then the individual is able to “observe it, recognize it as merely a thought, and [remain] unaffected by it” (Segal, William, and Teasdale, 2002).

The use of disidentification would seem to offer significant therapeutic promise for individuals with a wide variety of hard-to-treat thinking and behavioral habits, including, of course, alcohol and drug related problems. Indeed, dialectical behavior therapy, originally developed for use with individuals diagnosed with borderline personality disorder, is now being regularly utilized in the treatment of many other issues stemming from maladaptive behavioral or thinking habits. In my own clinical practice as a chemical dependency counselor, I regularly utilized this concept of disidentification as a strategy for relapse prevention.

Practicing mindfulness and developing a non-judgmental perspective can assist an individual in establishing new cognitive patterns (Baer, 2003). These new patterns are likely to be free of maladaptive thinking habits, since the individual has developed an awareness that previous thoughts were “just thoughts” (Kabat-Zinn, qtd. in Baer, 2003). In other words, developing a non-judgmental perspective can lead an individual to realize that he truly does not have to believe everything he thinks, that he is not his thoughts, and that thoughts aren’t facts (Kabat-Zinn, 1990).

This goal of developing a non-judgmental perspective can be found in both traditional cognitive therapy and mindfulness-based systems, such as that developed by Segal, Williams, and Teasdale. It can also be found within dialectical-behavior therapy, where a strong focus exists on fostering non-judgment with the objective of increasing mindfulness, as well as interpersonal effectiveness, emotion regulation, and distress tolerance.

Kabat-Zinn (1990) wrote, “Recognizing you thoughts as thoughts can free you from the distorted reality they often create and allow for more clear-sightedness and a greater sense of manageability in your life.” Developing an awareness of the difference between thoughts and reality is perhaps the core value of cognitive therapy (Segal, Williams, and Teasdale, 2002). Ingram and Hollen wrote, “Cognitive therapy relies heavily on helping individuals switch to a controlled mode of processing that is metacognitive in nature” (qtd. in Segal, Williams, and Teasdale, 2002).

Based on their analysis of cognitive therapy, Segal, Williams, and Teasdale (2002) concluded that metacognition was necessary for individuals to develop an awareness of thoughts as thoughts, not reality. Indeed, they suggest that disidentification is not the result of cognitive therapy, but rather the essential component for this approach. So, if you do not have to believe everything you think, then disidentification is the method for developing this non-believing.

Disidentification, as developed through mindfulness meditation practice “allows us to look at the problems our thinking creates for us” (Kabat-Zinn, 1990). These problems of thinking include not only the maladaptive thinking habits previously mentioned, but also self-defined limits on one’s own thoughts. Kabat-Zinn (1990) wrote, “We tend to see more through our thoughts and opinions than through our eyes.” In other words, what an individual believes not only determines what that individual thinks, but also what that individual perceives. Perhaps the bumper sticker should be amended: You don’t have to believe everything you think or see.

When an individual does believe everything she thinks or sees, she is likely to become stuck in predictable behavioral patterns, and these patterns will likely reinforce her erroneous beliefs, perpetuating a cycle of maladaptive thinking habits that become ever more difficult to escape. Kabat-Zinn (1994) wrote, “The simple act of recognizing your thoughts as thoughts can free you from the distorted reality they often create.” Through the practice of mindfulness, an individual is able to develop awareness and disidentification, which allows her to discover what the bumper sticker declared, that he truly does not have to believe everything she thinks.

References
Baer, R. (2003). Mindfulness training as a clinical intervention: a conceptual and empirical review. Clinical Psychology: Science and Practice, 10(2), 125-142.
Gunaratana, B. H. Mindfulness in plain english. Boston: Wisdom Publications.
Herkov, M. (2006, December 10). About cognitive psychotherapy. Retrieved from http://psychcentral.com/lib/2006/about-cognitive-psychotherapy/
Kabat-Zinn, J. Full catastrophe living. New York: Random House.
Kabat-Zinn, J. Wherever you go, there you are. New York: Hyperion.
Segal, Z., Williams, J., and Teasdale, J. Mindfulness-based cognitive therapy for depression. New York: Guilford Press.
Walsh, R., and Shapiro, S. (2006). Meeting of meditative disciplines and western psychology. American Psychologist, 61(3), 227-239.

The Freedom To Change: Existential Approaches & Experiential Methods

According to Yalom (1989), the primary task of a therapist is to make him or herself obsolete. I strongly agree with this statement, and also believe that therapy should assist the client to build the skills necessary to no longer need therapy or the therapist. As an alcohol and drug counselor, I have been working within a cognitive-behavioral framework for many years.

While I continue to believe that cognitive-behavioral therapy is a useful component in the therapeutic process, I have come to believe that lasting change requires opportunities for deeper exploration into fundamental issues that adolescents face. It seems to me that existential psychotherapy is an excellent, although uncommon, approach for working with adolescents, as it addresses those fundamental issues central to adolescence. In fact, this seems such a natural approach for working with teens that I am surprised that literature searches on the topic resulted in extremely little on the use of existential psychotherapy with adolescents.

Yalom (1989) wrote,
To explore deeply from an existential perspective does not mean that one explores the past; rather, it means that one brushes away everyday concerns and thinks deeply about one’s existential situation. It means to think outside of time, to think about the relationship between one’s feet and the ground beneath one, between one’s consciousness and the space around one; it means to think not about the way one came to be the way one is, but that one is (p. 11).

These would be challenging therapeutic objectives with any client. To strive for these goals with teens seems especially difficult. However, as I am primarily interested in working with adolescents, this is the challenge I give myself.

All adolescents face the psychosocial tasks of developing identity, autonomy, intimacy, sexuality, and achievement (Steinberg, 2005). According to Fitzgerald (2005), there is “a stark similarity” between what adolescents experience in their daily lives and the concepts of existentialism. He wrote, “It is commonly agreed that adolescence is a time filled with conflicts. A number of these conflicts closely resemble existential issues” (p. 795).

Defining Existential Psychotherapy
Existential psychotherapy “examines individuals’ awareness of themselves and their ability to look beyond their immediate problems and daily events to problems of human existence” (Sharf, 2008, p. 146). Yalom (1980) wrote that existential psychotherapy “is a dynamic approach to therapy which focuses on concerns that are rooted in the individual’s existence” (p. 5).

Yalom (1989) wrote, “I have found that four givens are particularly relevant to psychotherapy: the inevitability of death for each of us and for those we love; the freedom to make our lives as we will; our ultimate aloneness; and, finally, the absence of any obvious meaning or sense to life. However grim these givens may seem, they contain the seed of wisdom and redemption” (p. 5). Below I look more closely at these four givens—death, meaning, freedom, and isolation—with special consideration to their potential relevance for adolescent clients.

Death
Yalom (1980) wrote “a core existential conflict is the tension between the awareness of the inevitability of death and the wish to continue to be” (p. 8). Death may seem like a strange topic to be at the core of a theoretical approach for working with adolescents. However, based on my personal experience with this population, I have I believe it to be extremely relevant. Adolescents confront death regularly. For example, my current caseload includes a client whose father died from liver failure within the last year; another client in foster care due to drug overdoses by both parents; a third client’s best friend recently died from leukemia. In addition, I have five clients who attend a school that has seen two student suicides this academic year. Clearly death is not a stranger to teens.

Yalom (1980) wrote that in general adolescents show higher death anxiety than other age groups. He also said that individuals who exhibit pathology express higher death anxiety than does the general population. This seems to suggest that adolescents in therapy would exhibit an especially heighten likelihood for death anxiety. Not only are they are at a vulnerable age, but if in a clinical setting also exhibit some form of pathology. One reason of this heightened likelihood for death anxiety may be that teens experience both biological and symbolic death with some regularity.

According to Fitzgerald (2005), “[A]dolescents not only must face biological death, but also the death of a once-accepted world view” (p. 797). Neither child nor adult, the adolescent lives in a transitional state, required to suffer the death of his or her childhood years before being fully allowed into adulthood. The transitions of adolescents are examples of what Yalom (1980) termed boundary situations, “an event, an urgent experience, that propels one into confrontation with one’s existential ‘situation’ in the world” (p. 159).

As teens confront the many boundary situations inherent in their transitional status, they are forced to face both actual and symbolic deaths. In my experience, for teens in clinical settings this boundary situation is often made more confounding by unresolved developmental tasks due to substance abuse, mental health issues, trauma, abuse, neglect, and various environmental challenges. Clearly therapists working with adolescents should be prepared to address death, both biological and symbolic, as well as the anxiety it may create.

Meaning
For Yalom, death is the most important of the four givens. For Frankl, though, meaning was clearly of primary importance. Indeed, Frankl (2006) wrote, “[S]triving to find a meaning in one’s life is the primary motivational force in man” (p. 99). Logotherapy, an existential approach developed by Frankl, focuses on the concept of will to meaning, a belief that it is the striving to find meaning in one's life that is the primary motivation for individuals.

Frankl (2006) wrote that logotherapy focuses on the future, specifically on “the meanings to be fulfilled by the patient in his future” (p. 98). I believe that the future focus of logotherapy, and existential psychotherapy in general, is particularly valuable with adolescents. Again, I come back to my core belief about psychotherapy, that therapy should be a tool to assist the client in moving forward into the future. Helping clients discover the meaning in their lives is an important part of this forward movement.

According to Yalom (1980), “Each of us must construct our own meanings in life” (p. 9). When this does not occur, when an individual is living a life devoid of meaning, that individual is likely to face existential frustration. Frankl (2006) wrote, “[E]xistential frustration is in itself neither pathological nor pathogenic. A man’s concern, even his despair, over the worthwhileness of life is an existential distress but by no means a mental disease” (p. 102).

Existential frustration due to feeling that life is meaningless does not indicate mental illness. If anything, I would suggest it indicates mental health, for one should feel frustrated by meaninglessness. This psychic pain, like physical pain, indicates that something is wrong. For adolescents who have not yet developed a clear sense of identity, such psychic pain is likely to be especially common (Blair, 2004).

According to Yalom (1989), “[M]eaningfulness is a byproduct of engagement and commitment, and that is where therapists must direct their efforts” (p. 13). In other words, by assisting adolescent clients to more fully engage in their own lives and more authentically connect with others, meaningfulness will naturally result.

More specifically, according to Frankl (2006),
[T]here are three main avenues on which one arrives at meaning in life. The first is by creating a work or doing a deed. The second is by experiencing something or encountering someone… More important, however, it the third avenue to meaning in life: even the helpless victim of a hopeless situation, facing a fate he cannot change, may rise above himself, may grow beyond himself, and by so doing change himself. He may change a personal tragedy into a triumph (p. 145).

For many adolescents in therapeutic settings, personal tragedy is a given. It seems to me that a vital goal of therapy should be helping these clients find the meaning in their life experiences.

Freedom
Yalom (1980) wrote, “Ordinarily we think of freedom as an unequivocally positive concept… [However,] in its existential sense freedom refers to the absence of external structure” (p. 8). He continues, “Freedom in this sense, has a terrifying implication: it means that beneath us there is no ground—nothing, a void, an abyss” (p. 9). In my experience, most teens in therapeutic settings have already slipped into this abyss.

In a limitless universe, we are forced to make choices daily. With each choice, we must take responsibility for having eliminated other options. Yalom (1980) wrote that existential anxiety can be “lurking when any major event, especially an irreversible one, occurs in a patient’s life” (p. 171). Irreversible decisions create “the impossibility of further possibility (Yalom, 1980, p. 171). As teens confront new and unique boundary situations, and are regularly faced with reducing possibilities, the likelihood of existential anxiety is predictably high.

Jon, a client of mine, recently stated, “Lots of times I feel like I’m living in some kind of void, a black hole. I’m alone, but not really, because everything is there. It’s black, because that’s what black holes are, right? But black is really all the colors at once, every single one of them. And that’s too many colors if you ask me.”

Being faced with all the colors at once is a boundary situation common to adolescence. The limitless possibilities Jon described immobilize him in a dark, lonely void. His freedom to choose among all the colors was a clear source of existential anxiety. Frankl (2006) wrote, “[I]ndividuals search for ways to fill the void and quickly become vulnerable to symptoms such as depression or other problems” (p. 335). For Jon these problems include generalized anxiety disorder, social anxiety, and substance abuse.

Isolation
Adolescents are often experiencing their first true autonomy. Indeed, developing autonomy is a primary developmental task of the teen years. However, according to Yalom (1980), “We yearn for autonomy but recoil from autonomy’s inevitable consequences—isolation” (p. 251). This isolation is fundamental, “an isolation both from creatures and from the world” (Yalom, 1980, p. 9), and can lead to existential anxiety, alienation, and various developmental challenges.

Bronfenbrenner (as cited in Cross, 2007) identified four dimensions of influence upon adolescents: family, school, peers, and work or play. Subsequent research suggested that alienation is the result of disruptions in these dimensions. Calabrese (cited in Cross, 2007) stated, “Trouble comes when an adolescent experiences alienation in more than one world at a time, or finds no solace in their other worlds” (p. 5). When an adolescent experiences a disruption in any of these dimensions, a ripple effect is likely to occur with negative impacts in the other worlds. This ripple effect is likely to increase the teen’s sense of alienation and decrease his or her sense of autonomy.

Since establishing autonomy is a primary developmental task of adolescents, when this happens Yalom’s paradox can become magnified and distorted in profound ways that likely lead to a sense of alienation. Dean (as cited in Cross, 2007) stated that alienation is the result of three factors: powerlessness, or feeling unable to influence one’s own choices; normlessness, or feeling one’s value system is inconsistent with that of society; and isolation. Neither normlessness nor powerlessness is one of Yalom’s givens. However, both have strong existential reverberations through all the four givens of death, meaning, freedom, and isolation.

The impact of existential anxiety on the core developmental task of establishing autonomy is clear. Teens striving to establish autonomy, but recoiling from isolation have approached a truly significant boundary situation, one that forces them to confront responsibility for their own lives and their own ultimate isolation. The safety of childhood is in the past, the future is inherently unknown, and the adolescent is alone in an undefined existential vacuum filled with all the colors at once.

The Adolescent Existential Vacuum
Frankl (2006) defined this existential vacuum as “a feeling of emptiness and meaninglessness” (p. 141). Jon, the client who told of his void of many colors, is clearly trapped in such an existential vacuum. Like many adolescents, this client’s primary complaint is not his substance abuse, his family problems, his school failure, or his anxiety. It is boredom. According to Frankl (2006), “The existential vacuum manifests itself mainly in a state of boredom” (p. 106). Such a vacuum is likely to lead to depression, aggression, and addiction in adolescents (Frankl, 2006). This is evident among my clients, who generally report boredom as the most commonly given reason for substance use, closely followed by anger.

Ironically, not only does addiction result from boredom, it leads to it. In his autobiography of addiction, Sheff (2007) wrote, “Using is such a fucking ridiculous little circle of monotony. The more I use, the more I need to kill the pain, so the more I need to keep using. Pretty soon it seems like going back, facing all my shit, well, it’s just too goddamn overwhelming. I’d rather die than go through it” (p. 146). It seems clear that Sheff’s addiction is about escaping—at least temporarily—his own existential vacuum. He wrote, “I don’t care. Isn’t that the greatest gift in the world—just not to care? I feel so grateful for it. That’s nothing I ever knew sober” (p. 60). Not only is Sheff attempting to escape his own existential vacuum, it would appear he is attempting to avoid responsibility. Perhaps he is even trying to avoid awareness of responsibility.

According to Yalom (1980), “One of the more common dynamic defenses against responsibility awareness is the creation of a psychic world in which one does not experience freedom but exists under the sway of some irresistible ego-alien force” (p. 225). Yalom continues by stating that this ego-alien force is compulsivity. In this framework, addictions can be seen as an attempt to avoid responsibility. This conceptualizing of addiction certainly seems true, at least with some adolescents.
Yalom (1989), “The first step in all therapeutic change is responsibility assumption” (p. 100).

In my experience, even teens committed to sobriety often avoid true, full responsibility. Tina, a current client, illustrates this well. She states with absolute conviction that she is “an insane druggie,” yet avoids true responsibility by continuing to use. Since she identifies her alcoholism as something outside her own control, calling it “a genetic joke played on me by my alcoholic parents,” she has no reason to change. For Tina, creating change requires increasing her “readiness to accept responsibility” (Yalom, 1980, p. 231).

Creating Change
Yalom (1989) wrote that responsibility assumption is “extraordinarily hard, even terrifying” (p. 38). It is precisely because of this difficulty that I believe skills building is an appropriate component of any to working with teens. I believe that therapy should be about creating change and that my role as a therapist is to facilitate the change process. This change process takes effort from the client, a willingness to be challenged. However, adolescents frequently require assistance in identifying the action necessary to move forward (Blair, 2004).

Part of helping clients create change, then, must be helping them to define and take the necessary steps. Rugalal and Waldo (as cited in Blair, 2004) wrote, “When employing an existential theory, mental health counselors are free to borrow techniques from other approaches, provided they are consistent with the therapeutic encounter” (p. 334). One approach that I believe to be especially effective for working with adolescents in therapeutic settings is experiential learning.

Experiential learning is “a philosophy and methodology in which educators [or clinicians] purposefully engage with learners in direct experience and focused reflection in order to increase knowledge, develop skills, and clarify values” (AEE, n.d.). Having utilized experiential learning in clinical settings for about ten years, and having facilitated experiential learning in other contexts for another decade before that, I am a strong believer in the efficacy of this methodology. I have seen experiential learning engage even the most resistant clients and lead to life-changing therapeutic breakthroughs.

Experiential learning has two critical steps, doing and processing. The doing step is the activity. Common activities include hikes, kayaking, initiative games, and ropes courses. In clinical settings, the doing step is often focused on skills building. Other common clinical uses of experiential learning are building group cohesion, illustrating concepts, and increasing self-efficacy. In the processing step, participants reflect on the experience of doing, with the facilitator or therapist helping them to review the activity and generalize the learning to other areas of their lives (Luckner & Nadler, 1997).

Processing within an existential framework could focus on discovering the meaning within the activity, exploring choices and decision making during the activity, and examining interpersonal connections made or required to successfully complete the activity.

Experiential learning theory includes a core belief that learning and change occurs most readily when the participant is “confronted with a balance between stress and comfort” (Webb, 2007, p. 3). In other words, when the participant is confronted with tension. This idea fits well with ideas of Frankl. According to Frankl (2006), “[M]ental health is based on a certain degree of tension, the tension between what one has already achieved and what one still ought to accomplish, or the gap between what one is and what one should become” (p. 104).

This tension can be manufactured through experiential activities in three ways. First, experiential activities generally strive to present an uncertain outcome. Second, experiential activities most often contain a high level of perceived physical, emotional, or social risk. Finally, experiential activities often occur outdoors or in an environment unfamiliar to the client (Coons, 2004).

Whatever the experience, it is the unknown aspects of the activity that force the client to leave his or her comfort zone and enter into a state of tension. Central to experiential learning is the idea that “we encourage people to try things that they would not generally do on their own. In other words, they leave their safe, familiar, comfortable and predictable world for uncomfortable new territory” (Luckner & Nadler, 1992, p. 28). When clients enter this new territory, they are likely to experience the tension Frankl (2006) stated is necessary for change.

Rose (1998) wrote that most youth with life problems “have dedicated and rigid strategies for dealing with problems and are disinclined to look at other possibilities" (p. 177). Steve, a former client, provided a good example of this when he said, “What I like the most about drugs is that I know what to expect. I smoke. I get high. No surprises.” For youth like Steve, there is an inherent reinforcement in a life of “no surprises.” And, that predictability is appealing. That predictability allows him to avoid the tension necessary to create change. An individual’s comfort zone contains only what is already known, feels safe, and presents no tension.

It is only when a client leaves his or her comfort zone and confronts tension that learning and change can occur. Frankl (2006) wrote, “[I]f therapists wish to foster their patients’ mental health, they should not be afraid to create a sound amount of tension through a reorientation toward the meaning of one’s life” (p. 105). Through this reorientation, the adolescent client is able to find meaning and then exit his or her existential vacuum. According to Blair (2004), this ultimately leads clients to “an increasing awareness of the freedoms and choices they possess” (p. 341), including the freedom to change. And, that freedom to change is ultimately what therapy is all about.

References
Blair, R. (2004). Helping older adolescents search for meaning in depression. Journal of Mental Health Counseling, 333-347. Retrieved February 15, 2010, from EBSCO.

Coons, V. (2004). Advantages of adventure therapy for adolescents. Counselor, 42-44. Retrieved February 12, 2010, from EBSCO.

Cross, R. (2002). The effects of an adventure education program on perceptions of alienation andpersonal control among at-risk adolescents. Journal of Experiential Education, 247-254.Retrieved February 8, 2010, from EBSCO.

Fitzgerald, B. (2005). An existential view of adolescent development Adolescence, 793-799. Retrieved February 15, 200, from EBSCO.

Frankl, V. (2006). Man’s search for meaning. Boston: Beacon Press.

Luckner, J. & Nadler, R. (1992). Processing the Experience. Dubuque, IA: Kendall/Hunt Publishing.

Rose, S. (1998). Group Therapy with Troubled Youth. Thousand Oaks, CA: Sage Publications.

Sharf, R. S. (2008). Theories of psychotherapy and counseling. Belmont, CA: Thomson Brooks/Cole.

Sheff, N. (2007). Tweak. New York: Antheneum.

Steinberg, L. (2005). Adolescence. Boston: McGraw Hill.

Webb, L. (2006). Learning by doing. Training Journal, 36-41. Retrieved February 8, 2010, from EBSCO.

Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books.

Yalom, I. D. (1989). Love’s executioner. New York: HarperCollins Books.

Handout: Fostering Resiliency with LGBTQ Teens

This handout was for a workshop presented at Saying It Out Loud, May 14, 2010

Defining Resiliency
• Resiliency is the ability to “spring back” from adversity.
• Most people have some level of natural resiliency.
• Children from troubled families or environments often develop skills that help them cope with the adversity in their environment and grow emotionally stronger in the process.
• The idea of natural resiliency goes against much traditional thinking about outcomes for youth who grow up in challenging situations.
• Resiliency can be learned.

The Relevance of Resiliency with LGBTQ Teens
• A disproportionate number of “at-risk” youth are LGBTQ.
• Various studies have shown this population to be particularly high risk for:
-- Suicidal ideation and attempts.
-- Self-harming behavior.
-- Verbal and physical harassment.
-- Substance abuse.
-- Sexually transmitted diseases.
-- Engagement in prostitution.
-- Truancy and poor school performance.

According to the National Network of Runaway and Youth Services, up to 40% of all youth who experience homelessness identify as LGBTQ.

The psychosocial problems of gay and lesbian adolescents are primarily the result of societal stigma, hostility, hatred and isolation… These youth are severely hindered by societal stigmatization and prejudice, limited knowledge of human sexuality, a need for secrecy, a lack of opportunities for open socialization, and limited communication with healthy role models… [This] may lead to isolation, runaway behavior, homelessness, domestic violence, depression, suicide, substance abuse, and school or job failure.
~ American Academy of Pediatrics

The Risk of At-Risk Labels
• When we define a group as at-risk, the way we work with that group changes.
• As professional helpers, we start looking for deficits and pathologies.
• Interventions and clinical work becomes about fixing problems.
• We forget to ask, “What do you have already that makes you strong?”
• Avoiding the At-Risk Label does not mean ignoring the real challenges or dangers faced by LGBTQ teens.

Five Resiliency Skills
• Insight – Honestly assessing one’s situation.
• Initiative – Remaining determined to prevail despite adversity.
• Integrity – Doing the right thing even when it is hard.
• Creativity – Using imagination to relieve troubling emotions and environmental chaos.
• Connectedness – Building positive relationships with others.

What is connectedness? It is a sense of being a part of something larger than oneself. It is a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone. It is a sense that, no matter how scary things may become, there is a hand for you in the dark. While ambition drives us to achieve, connectedness is my word for the force that urges us to ally, to affiliate, to enter into mutual relationships, to take strength and to grow through cooperative behavior.
~ Edward M. Hallowell, Finding the Heart of the Child

Fostering Resiliency
• Intentionally integrate the five resiliency skills into your work as a helping professional.
• Provide opportunities for youth to use their natural resiliencies and develop new ones.
• Without ignoring real challenges that may exist, focus on strengths.
• Create opportunities for meaningful contributions.
• Help youth improve self-efficacy.

Further Reading
• Lesbian and Gay Youth: Care and Counseling, by Caitlin Ryan and Donna Futterman
• The New Gay Teenager, by Ritch C. Savin
• Queer Kids, by Robert E. Owens, Jr.
• Resiliency In Action, Nan Henderson, editor
• The Resilient Self, by Steven J. Wolin and Sybil Wolin
• We Don’t Exactly Get the Welcome Wagon, by Gerald P. Mallon

Handout: Playing Catch Up

Presented by David Flack
AEE Northwest Regional Conference • March 27, 2010 • Bellingham, Washington, USA

Humans have an intrinsic need to play.
• Play helps expand self-expression, self-knowledge, and self-efficacy; relieve feelings of stress and boredom; stimulate creative thinking; regulate emotions.
• Play allows us to practice skills and life roles.
• Play is fun, and fun results in a sense of connection.
• For many clients, this sense of connection is missing. Play helps these individuals move from isolation toward connection.

Most developmental theories have some things in common.
• Each stage of development is tied to an age range, but not set in stone.
• Each stage of development includes a task that needs to be accomplished.
• Most were developed by white upper-middle class males.
• Erik Erickson’s model is probably least criticized of classic developmental theories.

Erickson’s Stages of Development
Infant-Trust v. Mistrust-Needs maximum comfort with minimal uncertainty to trust self, others & the environment.
Toddler-Autonomy v. Shame & Doubt-Works to master physical environment while maintaining self-esteem.
Preschooler-Initiative v. Guilt-Begins to initiate, no imitate, activities; develops conscience.
School-Aged-Industry v. Inferiority-Tries to develop a sense of self-worth by refining skills.
Adolescent-Identity v. Role Confusion-Tries integrating many roles into a self-image.
Young Adult-Intimacy v. Isolation-Learns to make personal commitment to another person.
Middle Adult-Generativity v. Stagnation-Seeks satisfaction through productivity in career, family, and community.
Older Adult-Integrity v. Despair-Reviews life accomplishments, deals with loss, & prepares for death.

What happens when a task isn’t successfully completed?
• Traditional thought is that the person becomes stuck in that stage.
• However, sociocultural and biological factors are likely to keep pushing the individual forward. Also, there is the possibility of partial completion of a task.
• The main reasons a task isn’t successfully completed are trauma, abuse, neglect, caregiver addiction, and an individual’s own substance use.
• With every push forward and partial completion of a task, the individual becomes increasingly less likely to successfully complete the next developmental stage.
• This can lead to an ever-growing developmental debt.

Developmental debt exhibits itself in maladaptive behaviors, various life problems, and disconnectedness. These problems become "hard wired" into the brain.

Brains are lazy.
• More accurately, brains are efficient.
• The brain uses 20% of all calories burned. In an effort to conserve some energy effort, the brain would rather do what it already knows how to do, even if the known behavior is maladaptive.
• Neuronal networks become strengthened with repeated use, which lead to habits of thought and behavior.
• Practicing new skills in a safe environment allows the brain to build new, more adaptive networks.

Intentional Regression
• Regression usually has negative connotations. However, the use of play and playfulness can be thought of as being intentionally regressive.
• In other words, we are helping our clients go backward in order to catch up.
• Foster intentional regression by creating an environment that nurtures play, playfulness, and connection.