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In Part II (which was posted on November 9th, 2010), I looked at such topics as …
- The David Olds Home Visitation Program
- How trauma (like domestic violence) affects early child development
- Core concepts surrounding most home visitation programs
- A (not so successful) example of a home visitation program in Hawaii
- Matching interventions to cultural beliefs or worldviews
- Home visitation program risk factors such as domestic violence, poverty, hunger, etc.
- The parent’s role as a protective shield
- Family beliefs or patterns surrounding attachment needs and how they should be satisfied
Lets pickup, then, where we left off.
- Dr. Ippen-Ghosh tells us that early trauma can affect brain development often leaving behind an overactive amygdala. (Our Foundation is currently funding research by Dr. Lyons-Ruth designed to look at the connection between trauma and brain development—see my posts of June 21st and September 30th, 2010, for more information.) Simply put, the amygdala is the “fight, fight, or freeze” part of the brain. Ippen-Ghosh told us that when the amygdala is activated—often in response to the attachment behavioral system becoming activated—the part of the brain that controls executive functioning tends to go “offline” to use a computer metaphor. When executive functioning goes offline, we tend to lose such cognitive abilities as “cognitive flexibility, abstract thinking, rule acquisition, initiating appropriate actions and inhibiting inappropriate actions, and selecting relevant sensory information” (quoting from the Wikipedia entry on executive cognitive functions). Ippen-Ghosh sketched out the following sequence for us:
- a threat in the environment is perceived
- the attachment behavioral system becomes activated
- the amygdala, in turn, becomes activated
- the door to executive functions begins to shut
- our ability to maintain perspective and engage in perspective-taking (e.g., see someone else’s perspective) goes down
- this overall anger constellation then causes us to engage in concrete forms of cognition whereby we tend to associate problems with individual people using linear causation, while at the same time causing us to close the door to a systemic causation view that recognizes that environments and contexts also play a role in creating, maintaining, and expressing problems.
- Ippen-Ghosh told us that one of the core goals of a home visitation program should be to increase reflective function (which tends to slow down or buffer the above process). To do this, a therapist must be willing to engage in the following …
- think about each person’s perspective
- think about each person’s emotional response
- think about where all of this is pulling the therapist
- think about all of this within the therapist’s own supervision
- Ippen-Ghosh then talked about how conflict can often arise when different groups try to impose their own version of what it means to provide “better care.” Ippen-Ghosh told us of situations where kids, parents, Head Start teachers, regular teachers, and home visitation workers were in conflict because they all had their own version of “better care.” Again, Ippen-Ghosh told us that when this type of conflict exists, it is hard if not impossible for the child to know where to turn for help and care once the attachment behavioral system has become activated. Ippen-Ghosh told us that marital conflict is tough on kids for the same reason—it clouds any clear-cut path toward a safe and secure attachment figure.
- Ippen-Ghosh told us that often home visitation workers will view the help that they give during the day as a gift to the family when in fact it is viewed as a curse at night when the real troubles start—when the home visitation worker isn’t there—and when the so-called “gift” fails. When I worked at a RTC (residential treatment center), the kids would often be great during the day but would then blow out at night. A seasoned therapist (with over 20 years working in RTC settings) told me that it’s a form of “sundowning”—the kids are blowing out at night because the night represents for many kids …
- increased vulnerability
- a time when parents argue
- a time when parents (or other caregivers) drink or take drugs
- a time when domestic violence patterns increase
- a time when kids are offended
- Ippen-Ghosh then talked about other barriers that parents might put up with respect to home visitation:
- transportation issues
- money issues
- language barriers
- child care issues
- trust issues (which may arise from a history of trauma)
- Ippen-Ghosh said that the “providing help” assumption that home visitation workers make may be erroneous in the minds of the people they are working with. The people they are working with may be thinking …
- I don’t want to invite eyes into my home
- Historically, social service groups have engaged in oppression
- I don’t want to be forced to immunize my kids
- I don’t want to be judged
- I believe the stories that the government is trying to exterminate people with HIV (e.g., propaganda issues)
- I don’t want our domestic violence, substance abuse, crime, etc., issues to be discovered
- Ippen-Ghosh said that many home visitation workers will assume that if they are just nice, the above assumptions will just float away. Ippen-Ghosh simply stated: “Generally, if a family is charged, they will keep assumptions alive to stay safe, to preserve their worldview.”
- Next up, Ippen-Ghosh told us about a home visitation program designed to work with Latinos. Again, like the Hawaii example above, this Latino program sustained a 51% drop out rate. Here are some of the reasons given that might account for the poor outcome:
- mothers (families) did not ask for the service
- mothers (families) felt that the service was a burden
- mothers (parents) felt that their position as primary caregiver was threatened
- mothers (families) may have been under economic stress
- Ippen-Ghosh then talked about what she called “fur coat” therapy—interventions that are “one size fits all.” Ippen-Ghosh told us that intervention programs in general and therapists in specific are under heavy pressure to develop shortcut or “cookbook-like” approaches to the work they are doing. Ippen-Ghosh said, ”We keep developing shortcuts to be more effective, but a shortcut for one group may be a trauma reminder for another.”
- Ippen-Ghosh told the audience that in LA county, service providers can only receive reimbursement if they are using an evidenced-based modality. Here in New Mexico (in large part because of the New Mexico Behavioral Health Collaborative and their ties to OptumHealth) practitioners are under pressure to only use cognitive-behavioral modalities. Ippen-Ghosh simply stated: “If an intervention isn’t working, that’s valuable evidence.”
- In effect alluding to the continuum I mention in Parts I & II, Ippen-Ghosh gave us this bottom line: “All treatment modalities have biases.” She continues, “If you do not hold the same worldview as the people you are working with, then theory may not hold up.” Ippen-Ghosh asked us to think about Native American groups and their history of cultural oppression. She then asked us a question along the lines of, “Shouldn’t therapists consider cultural oppression and how a history of cultural oppression can affect parenting patterns. And shouldn’t therapists think about that reality first before imposing an outside worldview?”
We’ll stop here and pick back up in my next post. To whet your appetite, Ippen-Ghosh provides some interesting historical information that might give us some insight into why Maslow arranged his hierarchy of needs the way he did.
