TREATMENT PROTOCOL

We are designed for relationship.

Healthy, loving, consistent connections support development in all areas, strengthen our character, and allow for us to heal the fractured places in our hearts.  If ignored, hidden, or misunderstood over time, unhealed hurts and traumas change our ability to connect... We begin to unconsciously repel; this is often our attempt (in vain) to protect ourselves from further injury.  Instead, our unattended wounds allow for the injury to multiply, leaving us in dire need of a session in reconnection. 

Strong, attuned, intentional connection is essential for the healing and emotional support we need to thrive.

Intake:

            Families seeking counseling services often schedule appointments with Inward Bound’s administrative staff.  While services are also available for individuals and couples, the primary client population at Inward Bound consists of internationally adoptive families seeking services based on referrals from other families in the adoption community.  Families are asked to complete and submit an Intake form prior to the initial counseling meeting.  This general information is reviewed by Jennifer Winkelmann, and addressed more in depth with the parental unit at the initial session, if services through Inward Bound are deemed appropriate based on Intake information.

At the first session, necessary paperwork and treatment consent forms are discussed and signed.  During the initial session(s), parents meet together with Jennifer Winkelmann, MA, LPC, NCC without their child(ren) present to discuss their child’s history, behavior patterns, and goals for treatment.  This also includes interviews with the parent(s)/caregiver(s) to obtain information about the child’s Health History, Developmental History (including pregnancy and birth), Trauma History, and prior treatment.  Families are invited to share assessments and information from previous therapists/counselors, doctors/physicians, educational personnel, etc.  Because the primary client at Inward Bound are families who have adopted internationally, often significant and comprehensive information about a child’s first year or two of life is not available.  A general and informal assessment of the child is made primarily based on caregiver(s) report. 

Psychoeducation is provided to help parents understand basic brain development, the formation of the regulatory system, and the impact of disruptions/trauma on a child’s functioning in all areas, including behavior and relationship.  Research informing this psychoeducation is based on the work of Bruce Perry, Allan Schore, Daniel Siegel, Tiffany Fields, Karyn Purvis, etc.  The following key concepts (adapted from definitions offered by Coaching For Life and Juli Alvarado, MA, LPC, NCC; visit Coaching for Life at www.Coaching-forLife.com), applicable for both children and parents, are shared with parents so that they may actively participate in sessions and continue to provide a healing environment for their child outside formal therapy:

Regulation:  The emotional, physical, and psychological state of calm.  This includes the ability to be thoughtful, attuned, responsive, coherent, and connected.  As we gain greater and greater mastery in our ability to self-regulate, we are more and more able to remain calm when faced with stress. 

Dysregulation:  The emotional, physical, and psychological state of stress beyond your tolerance.  This includes a state of hyper or hypo-arousal, reactivity, confused/distorted thinking patterns, and a general disconnectedness.  Dysregulation is a label for the inability to remain calm in the face of stress.

Bonding:  Actions taken for the purpose of uniting, tying, or connecting two people in a regulated, attuned, attentive relationship.  For children, the first experience of bonding should be the result of gestures on the initiative of the parent(s).

Attachment:  A deep, enduring connection between two people.  It is a response to consistent, attuned bonding gestures.  The first attachment for a child is to its parent (often Mother) during the first 3 years of life.  This “first relationship” profoundly influences all components of the human condition and the future relationships of the child.

Trauma:  A state of dysregualtion or stress which is prolonged, unpredictable, and overwhelming.  Trauma can be an isolated event or chronic experiences which continue to be unexpressed, unprocessed, and misunderstood.

An understanding of these concepts aids the treatment team (parents, therapist, and any other helping individuals invited by the family) in discussing and evaluating the child’s behavior and functioning in relationships without the use of labels or formal DSM-IV diagnoses, unless absolutely necessary.  Inward Bound has found this approach helpful as many children treated here have already been identified as “broken” by other professionals and are viewed (often by themselves and their parents) as the “problem” in their family.  This shift away from traditional diagnoses, when possible, relieves some of this unnecessary pressure from the child and allows the entire system to assume mutual responsibility for their family culture and relationships.

Assessment:

            Parents will continue meeting with Jennifer without their child(ren) present.  Following the initial parental report and psychoeducation period, parents will participate as active members of the treatment team (in collaboration with the therapist).  This cannot occur, however, until thorough assessment of all family members is complete, particularly the parental system.  This includes, but is not limited to: narrative family of origin exercises used to highlight/understand current family dynamics, collaboration with other treatment providers/professionals to ensure continuity of care, and conceptualization of the child’s attachment challenges based on increased understanding of treatment through regulatory models.

            The severity of attachment challenges may be evaluated using traditional DSM-IV criteria and symptom checklists.  Because, however, the intent is to shift the focus of treatment from the child’s behavioral difficulties to the overall health and functioning of the family system, attachment challenges (i.e. difficulties in relationship to others) are applied to each member of the system; Success or failure in relationships is directly linked to our level of stress, or regulation, and regulatory ability tends to fluctuate for all human beings depending on the corresponding stressors.  This holds true not just for children, but for parents and caregivers as well.  When our physiological and emotional systems are regulated, we function on the end of the attachment spectrum indicating healthy abilities in relationship.  When our physiological and emotional systems are dysregulated, we function on the end of the attachment spectrum indicating challenges in relationship.

            As, based on parents’ self-report and therapist observation in session, parents indicate that they are managing and noticing their individual levels of regulation in various situations with their child, the therapist and parents will begin to identify and implement changes the parents can make to increase their ability as their child’s regulatory foundation, the foundation of healing, for their child.  In this vein, assessment will be an ongoing task of the treatment process.  Interventions will continuously be assessed for efficacy and adapted as necessary to best serve the family system as a whole.

            When interventions by the parents in the home with the clinical support of the therapist during weekly meetings (and in between by phone, if necessary) do not appear to be having the desired impact on family dynamics, the parents and therapist may conjointly decide to initiate sessions to include the child.  In this case, the parents will always be present for treatment.  Assessment tools used with the child may include:  an interview in which the child is asked about his/her satisfaction with life and his/her family, gaining information about the child’s sense of why he/she is participating in family meetings with a therapist, sentence completion exercises, completion of the Kinetic House-Tree-Person drawing, family as animals drawing, etc.

            If at any time during the course of treatment, the identified attachment challenges may be better served by another program or clinician, referrals to alternate resources and/or treatment programs are discussed.

Treatment Planning:

            Each family’s experience is unique, and so the treatment plan may continually evolve to support attuned and healthy family-specific dynamics.  Because of the nature of the emotional and psychological wounds caused by attachment trauma, treatment is geared toward offering corrective experiences to the child so that they can engage in relationship in ways that are reciprocal, nurturing, and healthy.  The safety of the family and child psychologically, emotionally, and physically during the discussion and implementation of interventions is of utmost importance.  Before any therapeutic intervention is executed, verbal consent from parents and children is obtained.  Children are not invited into the treatment process until the parental system has established a greater understanding of the neurological and emotional impacts of early trauma; both parents must also commit to working toward managing their levels of regulation (in and out of session) in relationship, particularly in relationship to the child. 

Treatment Techniques:

            The treatment approach is family centered, using a combination of psychoeducation, regulatory therapy, and methods to address the biophysiology of stress.  Parental clients may also participate in the Life Script and Attachment Communication Training exercises developed by Dr. Terry Levy, PhD and Michael Orlans, MA.  If/when holding occurs as part of therapy, (regulated) parents hold their children with the therapist as a verbal and emotional support.  Children are never held against their will or to manage “rage.”  Other common treatment tools include: “Inner Child” work, referrals to other educational resources (training opportunities, books, articles, audio programs, connection with other families further in the process, etc.), efforts to intentionally fill in developmental gaps for the child, and in between session support (by phone), when needed.  Progress toward the goals of treatment is co-determined by the parental unit and therapist.

Safety/Risk Management Plan:

            Jennifer Winkelmann, MA, LPC, NCC and Inward Bound, Inc. are unable to provide services on an emergency basis; families are instructed regarding emergencies at the beginning of treatment and by voicemail message if the therapist is unavailable for emergency calls. 

            Parent(s) are present for the full course of treatment, are collaborative members of the treatment team, and respected as the “expert” on their child.

            The psychological, physical and emotional safety of all parties is of utmost importance and continually monitored.

            Treatment is never coercive, forceful, intrusive, or demeaning in any way.

            Holding and nurturing touch are utilized as part of the treatment process; this only occurs with the consent of all involved parties.  Touching that is sexual in nature is not permitted (ethically or legally) in any therapeutic relationship.

            Inward Bound, Inc. and Jennifer Winkelmann, MA, LPC, NCC support and adhere to the principles of safety established by ATTACh.

Evaluation/Outcomes/Follow-Up:

            Because Inward Bound, Inc. provides longer term (when needed) outpatient counseling to address attachment trauma, the parental unit determines the times at which they wish to “take a break” from treatment and/or discontinue services.  Treatment goals are reviewed and adjusted on an on-going basis to reflect the family’s motivation for therapy, and as desired goals are achieved, many families elect to systematically phase out of therapeutic support.  Inward Bound, Inc. continues to be available for consultation or to re-open a case, if necessary.  Also, additional follow-up services or referrals are provided as needed. 

Qualifications of Staff:

Jennifer Winkelmann, MA, LPC, NCC is the Founder and Clinical Director of Inward Bound, Inc. As a psychotherapist for individuals, couples, and families, Jen’s primary clinical focus is adoption and foster care issues, including the impact of early trauma and the spectrum of relationship difficulties that result from disrupted attachments.  In addition, Jen works with couples addressing marital issues and with adult individuals to resolve depression, anxiety, relationship difficulties, stress, and struggles related to grief and loss.

Her approach is family centered, using a combination of psycho-education, regulatory therapy, and methods to address the biophysiology of stress.  She comes to you with 11 years of experience working with children of high-risk populations and their families.  Jen completed her graduate studies (2004) in Counseling Psychology with an emphasis in Couple and Family Therapy at the University of Colorado at Denver.  Her clinical experience includes:

• Therapy, consultation, and coaching for families with attachment challenged children adopted domestically and internationally
• Intensive attachment and regulatory therapy
• Treatment foster care programs
• Training for parents, educators, and mental health professionals on facilitating healing for wounded children
• Counseling for Couples and Adult Individuals
• Residential and day treatment facilities for high-risk youth
• Clinical Supervision and Consultation Services for other mental health professionals