Clinical and Cultural Perspectives:

Transcription

1 DISCLOSURES & CONFLICT OF INTEREST Clinical and Cultural Perspectives: Integrating a Diversity-Informed Lens as We Move from Dyadic to Triadic Intervention None Chandra Ghosh Ippen, Ph.D. Chandra.ghosh@ucsf.edu 2 HONING OUR LENSES MY GOAL CASE PRESENTATION CPP FIDELITY CORE CONCEPTS FOR DIVERSITY-INFORMED PRACTICE 3 4 1

2 DYADIC RELATIONAL FIDELITY DYADIC RELATIONAL FIDELITY: KEEPING OTHER CAREGIVERS IN MIND = therapist = caregiver = child = therapist = caregiver = caregiver = child Ghosh Ippen, Van Horn, & Lieberman, Ghosh Ippen, Van Horn, & Lieberman, ENGAGEMENT CHALLENGES Client drop-out rates from outpatient clinics range from 30-60% - Staudt, 2007 Urban mental health setting:36% of families who requested services never came McKay, Pennington, Lynn, & McCadam, 2001 Fathers are less likely to participate in child s treatment when asked 91% mothers 63% fathers Duhig, Phares, & Birkeland, 2002 ENGAGEMENT CHALLENGES: DIVERSITY Poor uptake and low retention related to aspects of diversity Ethnicity socioeconomic status environmental context (Kazdin et al., 1995; Kummerer & Lopez-Reyna 2006; McCurdy, Gannon, Daro, 2003; McGuigan, Katev, & Pratt, 2003; Snowden & Yamada, 2005) Ghosh Ippen, Ghosh Ippen,

3 CPP FIDELITY: INCORPORATING A DIVERSITY-INFORMED APPROACH GOALS OF CPP Develop Empathic Relationship with Family Members Understood caregivers mistrust of providers and reluctance to engage in treatment in light of their past history and current experiences with potentially punitive systems Safety - Environmental Context Discussed ways that contextual risks (e.g. poverty, community violence, immigration related-risks, inadequate or unsafe housing, and inadequate access to services) affect child and family functioning Considered the impact of racism and historical trauma on child and family functioning Are you physically safe? Are you psychologically safe? Are you like me? Do you belong to my group? Do we have similar perspectives? Do you value my perspective? Are we equals? What are the power dynamics? Between us? Between our groups? Ghosh Ippen, Van Horn & Lieberman, Ghosh Ippen, 2013 DIVERSITY-INFORMED PRACTICE: CONCEPT #1: DIVERSITY-INFORMED PRACTICE: CONCEPT #1: PAST EXPERIENCES ASSUMPTIONS INTERACTIONS PAST EXPERIENCES ASSUMPTIONS INTERACTIONS Our past experience, including our personal history, family history, and cultural group history shapes our assumptions about others Can I trust you? Will you help me? Could you harm me? Do you see me? Will you understand me? These assumptions in turn affect the way we interact with others Ghosh Ippen, 2012 Ghosh Ippen,

4 WHAT ARE OUR INTITIAL REACTIONS? DIVERSITY-INFORMED PRACTICE: CONCEPT #1: PAST EXPERIENCES ASSUMPTIONS INTERACTIONS Which therapist would you choose? Ghosh Ippen, 2012 Ghosh Ippen, ENGAGEMENT: IS TREATMENT SAFE REFLECTIVE PRACTICE FIDELITY How do we feel about the family member? How do we respond? SAFE UNSURE DANGEROUS Ghosh Ippen,

5 REFLECTIVE PRACTICE: GOALS EMOTIONS AND PERSPECTIVE TAKING For a specific family or session, cultivate 1. Awareness of your own emotional reactions 2. Awareness of personal and/or cultural biases 3. The capacity to recognize and regulate your own strong emotions prior to intervening Stance: Regulated and integrated Underlying CPP Principles: It is difficult to think clearly when you are triggered. Engage your frontal lobes before intervening. When affect is strong, the first affect to regulate is your own. It is best not to intervene without your frontal lobes When we are angry we are... More likely to see people rather than situations as responsible for a problem Less likely to trust others More likely to make judgments based on stereotypes Positive affect is associated with increased flexibility in thinking and action When emotions are charge, executive functioning is disengaged Bodenhausen, Sheppard, & Kramer, 1994; DeSteno, Dasgupta, Bartlett, & Cajdrie, 2004; Dunn & Schweitzer, 2005; Fredrickson, 2001; Keltner, Ellsworth, & Edwards, 1993; Tiedens & Linton, 2001 Ghosh Ippen, Van Horn, & Lieberman, Ghosh Ippen, CHILD-PARENT PSYCHOTHERAPY: PHASES FOUNDATIONAL PHASE: CPP Wish for fishing moments Desire to protect Introduce Child to CPP Love & good intentions Feedback Session Acknowledged: Sometimes angry, yelled mean things, scared others Assess & Establish a Trauma Framework Lieberman, Ghosh Ippen, & Van Horn,

6 CONSTRUCT A SHARED FRAMEWORK WITH EACH CAREGIVER WHAT IS OUR THEORY? What are the strengths? Is there a problem? If so, what is the problem? What can be done and who should do it? What is the broader ecological, cultural, historical context? García Coll & Meyer, 1993; Ghosh Ippen, 2012 DIVERSITY-INFORMED PRACTICE: CONCEPT #2 CONCEPT 2: SHARED VS. DIFFERENT PERSPECTIVES SHARED VERSUS DIFFERENT PERSPECTIVES The success of our interventions and systems depends in part on whether those we serve share our assumptions and perspective. Ghosh Ippen, 2012 What happens when we do not agree? What are the cultural contributions to our perspective(s) Are there any historical power dynamics between our groups? (power, privilege, oppression) In this situation who has power and how do they use it? Does this have any connection to history? Ghosh Ippen,

7 IS THERE A PROBLEM? DAD S VIEW Why is there a problem? Mom wants him to cling to her Mom has been training him to be clingy CLINGY What can be done? Tell him to stop I need to train him to be normal Counteract mom s training 25 CLINICIAN S POTENTIAL VIEW Why is there a problem? What can be done? CPP FIDELITY: INCORPORATING A DIVERSITY-INFORMED APPROACH GOALS OF CPP Safety Within Caregiver Child Relationships Fostered caregiver s ability to socialize child in ways that are consistent both with the caregiver s cultural values and beliefs and the family s context Ghosh Ippen, Van Horn & Lieberman,

8 UNDERSTANDING DAD S PERSPECTIVE WHEN SOCIALIZATION GOALS ARE NOT ALIGNED Understand and honor the socialization goal Independence Normal boy Able to go off with his peers Can you connect the dots between the intervention and the caregiver s socialization goal? He might need to win Can t just let him win. Need to earn it MOMENTARY RUPTURES: DIFFERENCE IN PERSPECTIVES DIVERSITY INFORMED PRACTICE: CONCEPT 3 DIVERSITY-RELATED CONFLICTS Diversity-related conflicts can arise when differences in our experiences lead us to hold different assumptions, values and perspectives. In a diversity-related conflict, we tend to view the other person as part of the problem and use stereotypes rather than consider the other person s perspective or the broader context

9 MOMENTARY RUPTURES: DIFFERENCE IN PERSPECTIVES REFLECTIVE PRACTICE FIDELITY Are we equals? What are the power dynamics? Between us? Between our groups? MAKING MEANING: LINKING PAST AND PRESENT BUILDING BRIDGES Present: Dad is not sensitive to child s emotional state Dad: Experience as a child Not a lot of warmth Had to fend for myself and felt socially isolated because of immigrant parents, didn t fit in, other kids would tease me What is the broader ecological, cultural, historical context? Grandparents: Experience War Immigration Loss of culture, family, status Survival mode

10 CPP FIDELITY: INCORPORATING A DIVERSITY-INFORMED APPROACH GOALS OF CPP Enhance Understanding of the Meaning of Behavior Helped caregiver consider (reflect on) the meaning of child and/or caregiver behavior (thinking about developmental stage, past experiences, cultural beliefs) Normalize the Traumatic Response Acknowledged effects of child s and caregivers experience of trauma and historical trauma Support Dyad in Acknowledging the Impact of Trauma Helped caregiver think about his/her own trauma history (ghosts in the nursery) and ways this history may affect her/him and the way s/he parents Help Dyad Put the Traumatic Experience in Perspective Integrated historical trauma as part of the family and personal narrative ACCESSING ANGELS & ANCESTRAL ANGELS Ghosh Ippen, Van Horn & Lieberman,