Case of Ariel
The following case study will illustrate how CPP was used in treating the parent-child relationship. The case study highlights the importance of the parent-child relationship to repair the rupture that has affected the relationship. All identifying information has been changed to protect confidentiality.
Athena is a 38-year-old Portuguese female, of Cuban descent, and her daughter, Ariel, is 12 months old. They were referred by the Early Childhood Court, through her dependency case manager, for CPP, as Ariel was removed from her care due to exposure to domestic violence. Ariel was first placed in foster care and then placed with her maternal grandmother. CPP was recommended to help Athena address her extensive trauma background and to aid in the reunification process with Ariel.
Family and Background Information
Athena described a long trauma history from the age of five years to 21. She was sexually abused around the age of five by a family friend till she was 11 years. She described witnessing the separation of her stepfather leaving her mother when she was 12 years old, and indicated that during his departure from the home, he often visited with her siblings, but neglected her during those visits. The abandonment and rejection she experienced led to her involvement with alcohol. Her continued negative life experiences resulted in her use of opioids, which led to her addiction. In her early twenties, she described giving birth to her first child, even though she continued to struggle with substances. Shortly after, she gave birth to a second child. Her two children were eventually removed from her care and placed in the custody of her mother. She described numbing the pain by resorting to drugs. During these challenges, she entered eight substance abuse treatment facilities but continued to struggle with drugs, resulting in her being arrested 38 times. While incarcerated, she discovered that she was pregnant with her fourth child, in addition to being diagnosed with breast cancer. These painful experiences became difficult for Athena to accept but she was determined not to lose her last child to the system. After her release from jail, she was placed in residential treatment, as her daughter was placed in the custody of her mother. In the midst of her treatment, she was given a great opportunity to heal the intergenerational cycle of her trauma by participating in the Early Childhood Court. This court is a problem-solving program that helps parents to heal the intergenerational cycle of their trauma by addressing its impact on the attachment relationship with their child.
At the time of the initial treatment, Athena was residing in a residential substance abuse facility, due to her extensive substance abuse history. Ariel was not residing with her at that time, although Athena was able to maintain weekly supervised visitation on weekends. These visits were supervised by her dependency case manager. During this period, CPP weekly sessions began in an outpatient clinic setting.
Intervention and Treatment Phase
Treatment goals were discussed with Athena during the feedback stage of the assessment to help her recognize areas in the attachment relationship that she felt had caused a rupture (Slade, 2007). In helping Athena view the video observation during the feedback session, it was the intention that it will would provide her with insights into her own struggles with substances, and her trauma issues that had affected her overall ability to become emotionally available in the relationship with Ariel (Schecter et al., 2006). In doing so, the clinician utilized the “triangle” (see Figure 12.1) to help name and identify those things that were traumatic to Ariel, such as her mother’s departing and returning, and her parents’ constant loud and angry voices, and to link those events to her behaviors and fears, in order to help heal the trauma that Ariel experienced (Lieberman, Ghosh Ippen, 8c Van Horn, 2015). Excerpts from the recorded interactions were discussed, utilizing a reflective stance, to help Athena recognize her strength during the interaction, as well as areas that were challenging to her as a parent (Stern, 1995).
Initial Phase (Sessions 1-6)
Ariel initially presented as a very quiet and shy infant, she rarely smiled, even when modeling was provided by the clinician. Her mother was encouraged to practice modeling those behaviors to her to increase affect regulation. During the first session, the clinician utilized the triangle model (Lieberman, Ghosh Ippen, Sc Van Horn, 2015) as a springboard to explaining the trauma narrative to the mother and the child (see Figure 12.1).
Figure 12.1 Introducing Ariel to Child-Parent Psychotherapy.
Used with permission from the authors, Lieberman, Ghosh Ippen, & Van Horn (2015).
Below is an excerpt from the first session with Athena and Ariel:
Therapist: I am so glad that you both are here today, how are you doing today Ariel?
(Ariel stares at therapist, then looks at mom.)
Therapist: Mom, how about you, how are you doing today since we last met at the feedback session?
Athena: I am a little nervous, the feedback session has allowed me to see how my baby is functioning as a result of what she has been exposed to. I feel so bad that I put her through this, I can’t believe it. 1 didn’t realize that they are seeing, hearing and taking in things that we do. 1 am willing to help my baby but I really don’t think 1 have any trauma issues right now, even though the judge keeps telling me that I have to address my trauma issues before the healing process starts in order to get my baby back.
Therapist: That sounds very scary and overwhelming for you and 1 am glad that you are sharing your honest feelings. My job here is to help Ariel and you work through those underlying feelings that may have affected the relationship to ensure that you both are able to rebuild trust, and safety in your relationship.
Athena: 1 just don’t see how we are going to do that.
Therapist: I certainly understand your concerns, it’s a long process and I will be guiding you throughout your journey. One of the first thing that we need to do is validate Ariel’s thoughts and emotions based on what she has been exposed to, so she knows that you understand and will try your best to always keep her safe. Are you okay to begin?
Athena: Yes, I am a little nervous.
Therapist: It is okay to be nervous; I am here for you and Ariel. Ariel, your mommy told me that you have heard and seen some really bad things that daddy said and did that she is concerned about, because when daddy yells at her and hits her it has made you sad—made you cry and become scared. All little kids who have seen and heard really bad things happen to their mommies get scared and afraid. It is my job to help you and your mommy work through the bad things that you saw and heard, so you will not be scared anymore, and mommy will keep you safe.
Athena: And I love you so much that I will not allow anyone to hurt you or mommy.
- (Ariel looks at mom, looks at therapist, and turns to play with toys.)
- (Mom reaches for Ariel to comfort her.)
- (Ariel walks towards the wall and begins to bang her head on the wall.)
Athena: 1 wonder why she is doing that, she does the same thing at home.
Therapist: Sometimes, that is babies’ way of communicating their pain through their behavior. What is it like for you when you see her doing that at home?
Athena: I get scared and I feel helpless because I don’t know what she is thinking, so I actually yell at her and tell her not to bang her head on the wall.
(Ariel looks at mom, then returns to banging her head on the wall.)
Therapist: As we continue the sessions, we will begin to make meaning of what she is trying to tell us. One question that I have is, has she ever been directly exposed to the act of her father hitting you?
Athena: No, she was always in the other room.
Therapist: Sometimes when we think babies are not hearing and seeing us, they are, it’s just that they do not have the language to communicate their needs and wants.
Athena: I am pretty sure that she did not see anything.
Therapist: Mom, 1 liked the way you comforted Ariel today, it tells her that you do care about her and will always do your best to keep her safe.
Middle Phase (Sessions 7-13)
As the therapy progressed, Ariel began to demonstrate an increased level of comfort in the therapy room. She continued to maintain close proximity to her mother, but at times would go outside the play and return to her mother, as if seeking validation (Ainsworth, Blehar, Waters, & Wall, 1978).
Figure 12.2 Keeping the baby’s emotional well-being in mind. Source: ©lstockphoto.com/Atikinka2
Athena tried hard in learning how to read Ariel’s cues and helped her to verbalize her thoughts more openly. When Ariel became dysregulated during difficult times as Athena began to share her painful story, Athena demonstrated an increased level of awareness as she provided Ariel with comfort to help regulate her emotions (Van der Kolk, 2003). This type of comfort became so familiar to Ariel that she began asking for a hug when she felt dysregulated (Bowlby, 1969). Athena continued to be provided with a consistent level of praise during her response to Ariel. Athena appeared to be better able to keep Ariel’s thoughts and feelings in mind, and help Ariel reflect on those feelings.
Advanced Phases of Treatment (Sessions 14-20)
By the 14th session, Ariel continued to demonstrate the behavior of hitting her head on the wall. Athena’s level of concern began to increase to worrisome feelings as she discussed how these behaviors often trigger her. The clinician asked Athena what about Ariel’s behavior that triggers her. Athena spoke about her own pain of receiving punches in her head from Ariel’s father. During the session, as Ariel proceeded towards the wall to bang her head, the clinician used this opportunity as a port of entry with Ariel and Athena. As I wondered with Athena what Ariel might be telling us, Athena became more concerned. The clinician used the intervention, “speaking for the baby” (Carter, Osofsky, tk Hann, 1991) and replied to Athena, “I feel no pain when 1 bang my head on the wall mommy because when I saw daddy hitting you, it made me angry as I watched.” Athena began to cry, then reached over to Ariel and gave her a hug. They both began to cry as Athena consoled Ariel and told her how sorry she was for not protecting her and allowing daddy to hit her in her head (Tronick et ah, 1978). As this critical moment transpired, the clinician reached for Athena’s feelings to explore how she felt about what had just occurred (Fonagy et ah, 1991). Athena cried and shared her feelings of shame and embarrassment as she spoke about not knowing how much young children are absorbing and internalizing their emotions in the absence of their parents not knowing (Bowlby, 1969). As the session progressed, it became clear that Ariel felt that her pain was acknowledged and understood by her mother. Ariel discontinued banging her head during the sessions, moving on from session 16 forward. This excerpt demonstrates how rupture in the parent-child relationship, due to trauma, can impede progress, unless the rupture is recognized and acknowledged.
Final Phase (Sessions 20-38)
The therapist and Athena worked very hard in improving the attachment relationship with Ariel by first helping Athena establish a consistent level of trust and safety in their relationship. Play therapy continued to be utilized to help Athena and her mother facilitate verbal communication. Athena was better able to recognize and identify the various developmental progression that Ariel experienced.
Athena and Ariel completed treatment successfully after 38 sessions of CPP intervention, over the course of 10 months. Throughout the course of treatment, Athena was able to reflect on her overall traumatic experiences and their connection and impact on the parent-child relationship with Ariel. She became more empowered in prioritizing safety within the relationship with Ariel, in addition to recognizing her own trauma triggers. Athena was better able to develop a new level of independence as she was able to obtain her own apartment, and with Ariel she rekindled the strained relationships with her two other children, who were ages 10 and 12 years at that time. Athena’s work has allowed her to reflect on those important relationship within her family that had been ruptured. One relationship that became important for Athena was her relationship with her own biological mother. Athena’s relationship had ruptured with her mother for nine years due to Athena’s substance use, which led to lack of contact. Due to her efforts in treatment, she was able to work through the trauma of those painful relationship and make amends (Lyons-Ruth, Bronfman, & Alwood, 1999). At the time of the case, Athena was enrolled in a local community College as a paralegal, obtaining grades of “A’s”, while she held a part-time job cleaning houses.
During a discussion with Athena to help her reflect on her progress, she conveyed the following in this excerpt from the final session:
Therapist: You have worked so hard to repair your relationship with Ariel and other important persons in your life. I have watched you grow throughout this journey and seen the many thorns that you had to work through. Tell me what has that journey been like for you?
Athena: It has been a very rocky, scary and lonely road to travel. I had given up hope of a future but when I came in the system this time around, Ariel gave me the motivation to fight harder. But even though she gave me that motivation, 1 still was not at that place where 1 needed to be until I was able to come face to face with my demons, that demon who took a whole of me.
Therapist: As I hear you share your thoughts, 1 can sense the very essence of the pain that you endured, and it sounds as if those demons have allowed you to reflect on your past trauma to fully understand the healing process, moving forward. What has that been like for you?
Athena: My reality became real when I came face-to-face with my “pimp” on the city bus. He approached me and tried to convince me to work but it struck me real hard because for the very first time 1 was sober and able to clearly see the kind of men that I chose over my kids. I tried hard to tell him that 1 don’t do those things no more but he didn’t believe me and tried to offer me a huge sum of money. As the bus approached my stop, 1 ran, and I cried. For the very first time, 1 realized that I needed to work through my pain and past trauma to fully heal. He made me realize that after all these years, that I have been putting a band aid on my pain. 1 have been arrested thirty-eight times and 1 have been in residential care for at least eight times, but I had never addressed my past trauma. I thank God for that day because it made me realize how deep my pain was. All those years, 1 have been avoiding addressing my trauma, but I did not realize how using substances have allowed me to put a band-aid on my life. Each time 1 became high, I was not available emotionally to meet Ariel’s needs. Now, as 1 reflect on my progress, I am better able to understand her emotions and read her cues more readily. Had I had this therapy when my two girls were removed from my care, and my rights terminated, life would have been completely different. 1 just thank God for this opportunity. Every substance abusing mother should be given this opportunity to experience this therapy.
Therapist: And I thank you so much for allowing me to create that holding environment, that safe and honest place, where you felt safe doing the work. I know that this work is difficult and that you really worked hard in giving it your best, and in sharing those ghosts, but in spite of those ghosts, I am so proud that you were able to see the hope of a brighter future.
Athena: 1 thank you so much for being patient with me and not giving up on me, especially my judge, she saw something in me that I never saw. I have learned to be fully present when I am with Ariel now. I am better able to read her cues.
(Ariel walks over and gives mom a hug.)
Athena: 1 love you baby and I will always keep you safe.
During the termination of treatment, Athena was encouraged to maintain a consistent level of positive familial support system, utilize her sponsor, and reach out when help is needed. She was praised for her overall efforts and risk in sharing those sacred moments that contributed to her treatment progress.
Reflective Supervision: Presence and the Therapeutic Use of Self
During GPP with parents, one of the core components of this treatment is reflective supervision. Reflective supervision is a distinct field from clinical supervision, in that it helps the clinician to give credence to the various relationships, such as the one between the clinician and the supervisor, between the clinician and the parent, and between the parent and the child, to gain a deeper understanding into how these relationships affect one another (Weatherston, Weigand, & Weigand, 2010). In order for the reflective process to be successful, the relationship formed must be trusting, predictable, consistent, and regular. During these encounters, clinicians examine their own thoughts and feelings while exploring the parallel process. When working with a reflective supervisor, the supervisor can provide a holding environment for the supervisee to help contain and reflect on a wide range of emotions that the child and parent present.
The clinician is faced with many emotions that often become overwhelming at times due to the complexities of the parent’s trauma, substance histories, and its impact on the child. However, when the clinician, with the help of the supervisor, is able to listen, wonder along with the client, remain in the present and create a safe holding environment, the clinician is able to recognize and reflect on emotions and thoughts that help to facilitate gradual healing (Parlakian, 2001). This also helps the clinician to make meaning of the family’s story and its impact on the parent-child relationship (Watson, Harrison, Hennes, & Harris, 2016). The supervisor’s keen sense of perception helps the clinician to recognize the role that her own thoughts and feelings play within the therapeutic relationship. In doing so, it is important for the clinician to recognize how to keep the baby in mind, while trying to balance the perspectives of the relationship. Therefore, a critical component in doing this work is to ensure that reflective supervision is part of the healing process which helps to prevent losing perspective of the relationship.
Reflective supervision during this case has allowed the clinician to ponder along with Athena in trying to understand her perspectives, while holding her thoughts and feelings as it relates to her need to be a “good enough mother” (Pawl, 1995). It was during those difficult moments of reflective supervision that clinicians can wander along the path along with a parent to fully understand the journey, hold the story and most importantly, keep the child’s story in mind.
This case demonstrates the link between the past and the present throughout the course of treatment with a mother, and her extensive ghosts. The Infant Mental Health clinician helped the mother to make meaning of her memories to better understand how her past experiences have impacted her relationship with Ariel. In therapeutic work with families,
the ghosts, we know, represent the repetition of the past in the present. We are also the beneficiaries of the method Freud developed for recovering the events of the past and undoing the morbid effects of the past in the present.
(Fraiberg, 1980, p. 166)
At the close of treatment, Ariel and Athena were securely bonded and Athena demonstrated delight and pleasure in her daughter. They both finally understood each other. Athena was able to engage in a new-found dance with Ariel, giving new meaning to her role as a “good enough mother” and accepting what this all means to her. This experience has allowed Athena to reparent herself to see Ariel through a different lens, one that she had not experienced with her prior children. Although residues of her past (ghosts) (Fraiberg, Adelson, & Shapiro, 1975) remain, she is able to recognize those triggers and disown aspects of the baggage they have placed on her and Ariel, while embracing those angels (Lieberman, Padron, Van Horn, & Harris, 2005) in the present as part of her continued journey through healing. This work reminds clinicians that change is possible when a safe, nurturing, noil-judgmental, culturally sensitive and caring approach to relationship-based interventions is employed.
- 1 Describe the core components of Child-Parent Psychotherapy and its impact on the attachment relationship.
- 2 Discuss the importance of creating a safe, nurturing, and holding environment when addressing trauma within the parent—child relationship.
- 3 Discuss the importance of reflective supervision when working with clients with complex trauma challenges.
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