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Interview: Craig Haen on Treating Childhood Trauma

June 18th, 2007 by Dr. Bromberg

This interview should be of great interest to clinicians specializing in, or curious about, work with children and adolescents who have experienced traumatic events. Craig Haen is a Registered Drama Therapist and Certified Group Psychotherapist. He is currently Clinical Director of Adolescent Services for Kids in Crisis, in Greenwich, CT, and has a private practice working with children, adolescents, adults and families in White Plains. He is co-editor, with Anna Marie Weber, of Clinical Applications of Drama Therapy in Child and Adolescent Treatment (2005, Brunner-Routledge), and serves on the Advisory Board for Creative Alternatives of New York. For five years, Craig was employed in the Child and Adolescent Psychiatry Division of New York Presbyterian Hospital—Cornell Medical Center in White Plains. He has worked with youth and families in shelters, community centers, hospitals, residential facilities, schools, and on Native American reservations. Craig was particularly active in the treatment of children, families, and service professionals in the New York area following the 9/11 terrorist attacks.

Contact information for Craig Haen is provided at the end of this interview.

 

Dr. Bromberg: Craig, how did you first become interested in working with traumatized children?

C. Haen: I always knew I wanted to work with children. When I was in graduate school I pursued an internship working on Long Island in a program that treats child witnesses to domestic violence, and I think that’s when my interest really crystallized. I saw the powerful impact that traumatic events had on those kids. Also, in my work with adults, so many of them were talking about wounds from childhood, and had become quite fixated on those wounds. So I became interested in the promise of early intervention—the idea that doing the right work at the right time can really alter someone’s course in life.

Dr. Bromberg: How long have you been working with this population?

C. Haen: It’s been about eight years postgraduate.

Dr. Bromberg: Your training is as a drama therapist?

C. Haen: Yes. I received my master’s degree from NYU. It’s a niche field, but I’m really glad I have the training I do. I grew up as an actor, and at a certain point, as an adolescent, I realized how powerful learning can be when you’re in a role. It allows you the distance to be a character and also to be yourself. In working with traumatized kids, much of the work I do is play therapy based, because with trauma, there are these dual-symptom patterns of hyper-arousal and avoidance. When you can work in terms of metaphor, play, and stories, it becomes much safer for children to take the risk, to do graduated exposure to trauma material and still feel grounded.

Dr. Bromberg: Can you help me get a sense of what, over a series of sessions, the graduated exposure to trauma material looks like?

C. Haen: Typically, in the first session, we usually begin by drawing, because I think it’s the least threatening way for children to engage with me. They don’t have to make eye contact, or they can make as much eye contact as they want. I give them a pretty simple drawing task, and we begin talking about the contract we have for working together, in terms of what will make it a safe space for each of us.

Dr. Bromberg: Is it often clear from the outset what has brought them in? Is that explicitly articulated, or is there an unspoken understanding that there has been a traumatic event?

C. Haen: Different practitioners have different ways of approaching this. It is my belief that you have to be really honest with the child from the outset about why you’re working together. I usually explain that we’re here to play about their worries, and, specifically, their worries connected to whatever single event or multiple events have taken place. I will also let the child know that some adults in their life are concerned because of x, y, or z. I want them to feel that there is honesty from the beginning. I also find that kids who have had horrific events happen to them are very mindful of protecting the people around them. So, unless they feel that it’s okay to talk about these things, that you can tolerate it and they have your permission, there’s a taboo that exists.

In terms of the play therapy work, I usually frame it in terms endemic to film—that we’re going to create a movie, using the toys. A lot of sexual abuse involves pornography or being filmed, so, obviously, if that’s the case I would not use that language, but I find a lot of kids today connect to terms like pause, rewind, and fast forward. I tell them that we’re going to create a movie or a story, and that the events may be similar to the things that happened to them, but it’s going to be pretend, we’re going to use pretend names, and the story can be about anything they want. If I feel that a child needs more direction, I may make some suggestions, like, “Maybe your story will be about dads, or about scary things that have happened, but you’re the director, you have control of it.”

In the first session I let them play out their story, and I observe. It’s part of an assessment period, and I learn a tremendous amount about where the kids need intervention from how they frame their story, how detailed their story is, where they get stuck, and where they tend to pull out of their play. From there, the course of therapy is really about going back and reworking some of the aspects where it’s clear they need intervention. A lot of kids, in the beginning, in order to do the work, need to contain the perpetrator. So, they may spend some time building a jail for the bad guy. Even that can be diagnostic. I had one boy who would build a jail for his perpetrator, and the perpetrator kept escaping. He’d have hundreds of police outside, to make sure the perpetrator wouldn’t escape. Other kids will build jails for their perpetrator, and they’ll put a bed in, and a mattress, and a television. They want to make sure that he’s comfortable in there. It speaks to the type of relationship that they had, and their concerns about that person.

I don’t think you can effectively do this work without also teaching coping skills and providing psychoeducation. So, I fold that into the process, especially when we’re de-roling or debriefing from their play at the end of session.

Dr. Bromberg: What are common themes that you’ve seen come up in therapy for children who’ve dealt with trauma? What is it that you see across the spectrum of people who’ve dealt with trauma?

C. Haen: Let’s separate it out. What’s great about play and metaphor is that there are a lot of themes that come up that perhaps children aren’t able to articulate. In their play, you see clashes between good and evil, monsters, invasion, bodily damage, and a lot of reworking of the same event over and over in a dull, monotonous way.

In terms of the treatment themes, different populations of traumatized kids have different things that tend to resonate. What keeps drawing me to this work is that each individual processes his or her trauma so differently. So, for some kids who have been sexually abused, it is the betrayal of trust that they thought they had with that person, and how that forms a map for them in terms of future relationships and how they relate to people. For other kids, it’s a specific aspect of the abuse; a physical pain associated with it or the bodily arousal they felt, that leads to a lot of confusion about what it means about them. For other kids, it may be the series of questions that they were asked by whoever came in to investigate the abuse, and that might have been the most traumatizing aspect. Nightmares are very common as well and provide an opportunity to work in vivo in the room and to practice skills for dealing with nightmares. How the parents process and understand the trauma events tends to influence what comes up for the child. Kids are very savvy; I’m always amazed at how bright they are, and how they are keyed in to what’s going on in their family. They know, for example, if mom can’t tolerate talking about whatever happened to them. Maybe they feel they need to be functional, because somebody else in their family isn’t functional.

Dr. Bromberg: Do you ever do family work as part of the treatment?

C. Haen: I do. When I was working at New York-Presbyterian Hospital, we developed an interesting model for trauma treatment. I would do individual, trauma-specific work in a play room that only the child and I entered. The parents never went into that space. It was a very consistent space; the rest of the staff didn’t use it for any other purpose. The social worker would work with the family. I didn’t meet with the family. After we had done the individual work, we spent the last five minutes of our session sitting down together—the child, the social worker, and me. We would discuss what information the child wanted to transfer from the session to the social worker. So, the child and I would have an active dialogue about what to tell their social worker about what he or she worked on, and it did not become a secret that the child and I held. Then, from there, the child would share that material with the social worker, and they would meet together with the family. I think that split really helped children with a lot of their conflicts over loyalty, because they were doing that work with a different person than the person who met with their family.

Obviously, when you’re doing outpatient or private practice work, you don’t always have the luxury of working with multiple clinicians. I think it’s important, from the beginning, to establish trust and understanding with the parents about the work I am going to be doing with their child, what I will and will not be sharing with them. The child is very tuned in to all this, and I do not share things without the child’s permission. I’ve adapted this model so that at the end of each session, the child decides what information he or she wants to transfer to mom and dad, and then we sit down and talk about that.

At a certain point, for any traumatized child, there is a need to talk about follow-through. How do we transition skills they’re building in session to the home? When you’re working with kids where domestic violence is involved, you really can’t do trauma work until they’re in a safe environment. So, if the domestic violence is still happening, it becomes tremendously difficult. You’re really just talking about how to stay safe, how to manage themselves when frightening events happen. If the home can become a safer place, then there’s a lot of great work to be done with the parents around: understanding their child’s symptoms, understanding the triggers that exist in the environment, and helping to empower the family to make it a safer place for the child.

The other key thing is that traumatized people can look very crazy to the rest of us, because their bodies have been wired to protect them in dangerous situations, and it continues to utilize what it’s wired to do in situations that the rest of us know are safe. It’s important to help parents understand that, even though the situation may be safe, children are just doing what their bodies are wired to do, because they have been exposed to things that aren’t safe. That’s really critical, because traumatized kids can look like they have ADHD or Oppositional Defiant Disorder, or they can look like they’re psychotic, at times. That doesn’t mean that those other things aren’t comorbid, but I think these children often get misunderstood, because they’re at school and having intrusive thoughts, or something in the environment triggers them, and they respond in a way that looks, to the rest of us, very inappropriate. But for children who are trying to protect themselves, while receiving cues that they are in danger, it’s an appropriate response.

Dr. Bromberg: It sounds like an important part of the family work is this expert consultation you provide, giving psychoeducation and helping everybody better understand what’s going on.

C. Haen: I think so. Trauma can be intergenerational. So, one thing I’ve frequently found that has surprised me, especially in working with boys that have been sexually abused, is that sometimes mom has experienced sexual trauma herself. It can become a very complex dynamic, because she now has this son who is perhaps acting out sexually, and cueing her trauma triggers of her own abuse, and that can be very difficult to sort out. For dads, there can be a lot of fear that their son is gay, and what does that mean, how do they respond to that? There’s a lot of understanding that must be achieved in the family for them to be supportive in the right kind of way.

Dr. Bromberg: I’d like to talk a little about your definition of trauma, and just how broad that is. Would you include children whose parents have recently divorced, or who are having significant difficulties after adjusting to a new environment?

C. Haen: This is a good question, because I think the word trauma has become ubiquitous in our culture. Lots of people say they are traumatized: “I was so traumatized yesterday because I was stuck in traffic.” I think this has done a tremendous disservice to people who are truly traumatized. Even in the mental health field, I think there is a misunderstanding about what trauma means. Now, I’m going to say something that sounds a little contradictory to what I’ve just said: I don’t think you can define trauma by the event itself. You can have an event happen that would seem significantly impactful and traumatizing, but one person doesn’t experience it as trauma. You can have another event happen that, to most of us, would just be a bump in the road in our lives, but for someone else, that becomes a trauma.

I like the distinction that people in the field make between big t Trauma and little t trauma. With kids, I tend to think of it developmentally; it’s an event that blows them off the developmental trajectory they were on. I often talk to kids about it in terms of, “We’ve gotten off the highway, off on an exit somewhere,” and our work is about getting them back on the highway and back on the developmental path they need to be on. Big t Traumas are the ones that can halt normal development and functioning. Events that happen that bring about a lot of strong feelings, but may not necessarily impact how we go about our lives, are little t traumas. Those can have a cumulative impact over time.

I also think there’s an important distinction between single-event trauma, or Type I Trauma, and chronic, or Type II Trauma. Much of the trauma research has been done with those people who have experienced single and often public events, like September 11. When you’re looking at somebody who’s traumatized because of 9/11 and a child who’s being chronically sexually abused, there are two major differences. One is that, in public trauma, there’s an opportunity to process the event afterwards, sometimes as a community. There’s a normalization that can occur, because a lot of people have experienced the same event. With children who are being chronically sexually abused, secrecy is common. So, they don’t have the opportunity to process it in safety with adults afterwards. Also, because it’s chronic trauma, the impact goes beyond challenging their notions about a safe world to continually reinforcing that the world isn’t safe. Those kids can look very different, and I think the work with them can be more complex. Of the children I saw during my inpatient work who were diagnosed with severe mental health issues, as many as three-fourths of them had significant Type II Trauma.

Dr. Bromberg: You described this difference between public and secret traumatic events. I would suspect that correlates highly with the degree of shame—the more secretive and non-public the trauma, the more shameful it is for the child, and perhaps the whole family.

C. Haen: Absolutely. I think it was William Pollack who said, “Girls are shame sensitive, but boys are shame phobic.” For boys, culture has already taught them that they have to be strong, and that the only emotion they’re entitled to is anger. To be victimized is tremendously difficult for them to cope with. I think shame can become the mitigating factor for a lot of acting out and sexual reactivity in sexually abused kids. I just presented a workshop on working through revenge fantasies with traumatized people. I believe that shame can really fuel that desire for revenge, that desire to identify yourself as more powerful, because you felt so minimized and so disempowered during the trauma.

Dr. Bromberg: There’s a dyad that the child has internalized, with a powerful aggressor and a very powerless victim, and the child would prefer to be in the aggressor role than the victim role. The child may act out based on this, but in doing so, remains trapped within that dyad.

C. Haen: I would add a third person: the bystander. Often, when a child is engaged in play about the aggressor and the victim, I find myself sitting with being the bystander, watching the play and looking for places to bring in safe intervention. It is common that these kids are reenacting this posttraumatic play of aggressor and victim in many different ways, in their drawings, in school, or out in the playground. Often, the people who care about them really aren’t sure how to respond, and they find themselves trapped in the bystander role.

Dr. Bromberg: By being present in the bystander role in therapy, with a goal of intervening in a positive way, you create an opportunity to develop a new, healthier relationship, which may be internalized as a different kind of dyadic template.

C. Haen: I worked with a kid who framed it beautifully. I asked him what he wanted his future to be, and he drew a road with a series of stop signs. He said to me, “I want to be able to drive down this road, my life, and periodically stop and remember that this thing happened to me, and then move on and keep driving. And then stop again later, and remember, so that it’s a part of me, but it doesn’t define me.” One of the things that drama therapy has taught me is that, in order for kids to reach that point, understanding of the other is really important. So, in the play, we do spend time role reversing—having them understand the bystander role, for example, because maybe someone in their life was a bystander at the time. Being able to gain different perspectives makes them feel less locked into this one role of victim, or less desperate to be a perpetrator in their life in order to feel more empowered. It gives them control of that story.

Dr. Bromberg: Going back to my question about how you define trauma, if an event happens at a time when a child is developmentally vulnerable, and other temperamental vulnerabilities are present, then it could be a big t Trauma.

C. Haen: Yes. We haven’t talked about loss and how it figures into trauma. In my full-time job, I work with a lot of kids who are part of the foster care system. For them, moving to a new environment can mean a lot of loss: loss of a community, a particular person in that foster home, a pet, or a bedroom that felt safe to them. As adults, I think we discount how big those losses are to children. We forget what it was like, and how much certain objects meant to kids. I’m not saying that constitutes trauma, but I think loss is a significant piece of trauma. So, a divorce could be traumatic to the extent that, now that a family has reconfigured, it may not feel safe enough for the child, they may not be able to function in the same way. The loss may create certain fears.

Dr. Bromberg: Are you drawing a distinction between losses and big t Trauma?

C. Haen: Well, there is a distinction. In cases of complicated grief and traumatic grief, where a child has been witness to domestic violence that led to homicide, for example, or with a child who lost a parent in the World Trade Center, what often happens is that the trauma symptoms mask the grief and provide a barrier, so the child can’t grieve, because he or she is getting so overwhelmed by the trauma material. In these instances, you often have to do trauma work first, until it’s safe enough for the child to really grieve. I think that applies to a lot of the work. Whether you’re talking about adjusting to a loss, or divorce, or having been sexually abused, there is a component of the treatment that is about grief work. Because the clients are grieving for that lost relationship or that lost period of time, the loss of the part of themselves that was innocent, or the part of the self that they feel was robbed from them. So I am making distinctions, but for each person who I see, I want to understand what’s going on without worrying too much about quantifying and defining what he or she is going through.

Dr. Bromberg: At the same time, it seems there’s a fairly consistent rhythm to this, where you deal first with the blockages created by trauma, and then, eventually, there is work around grief and loss.

C. Haen: That’s correct.

Dr. Bromberg: How has your training as a drama therapist helped you in working with this population?

C. Haen: In trauma research, there is current work pointing to the importance of including the body in treatment. Trauma happens to us as physical beings, and it impacts us verbally, iconically, and kinesthetically. So, to just do verbal psychotherapy with traumatized people seems inadequate these days. One of the things that drama therapy has taught me is the value of experience, whether it’s the play a child engages in around the trauma in therapy, or whether it’s graduated exposure to treat panic attacks related to trauma. I’ll run groups with kids who say, “I’m not angry,” but you look at their fists, and they’re balled up like they’re ready to hit somebody. It’s important to ask about what it is their fists are saying. I think our bodies hold a lot of things that we can’t put into words, and that’s particularly true for traumatized people. The ability to talk about what happened gets split off from what they’re feeling inside. So, you can gain insight into your trauma experience, develop a cohesive narrative, and alter your cognitions about the events, yet your brain stem is still firing in response to those same trauma cues. Until you find ways to address that, you can’t fully resume development. I find the arts are a powerful way in. It’s using the back door, in a sense, because they help to bypass a lot of the defenses. The kids can say, “I’m just playing, that’s not me.” They can disown certain aspects of their expression, and the distance gives them permission to safely deal with things that would otherwise be intolerable to put into words.

 

Craig Haen’s contact information is:

Craig Haen, MA, RDT, CGP, LCAT
510 North Broadway
White Plains, NY 10603
(917) 439-7892
CraigHaen@gmail.com

Interview: Allison Bell on Custody Mediation

April 11th, 2007 by Dr. Bromberg

In this post, I’m presenting Part I of a two-part interview with Dr. Allison J. Bell. Dr. Bell is a child psychologist, marital therapist, Divorce Coach, Child Specialist in Collaborative Divorce, mediator and negotiator. She has over a decade of experience working as a forensic custody evaluator, and has recently begun working as a custody mediator with divorcing parents. In addition, Dr. Bell is a trained dance therapist, who has developed a series of workshops and seminars on movement and physical presence for corporate clients, public speakers, and others. In today’s post, I’m discussing her work with divorcing families. In Part II, I will present our discussion on the movement work.

Dr. Bell’s contact information is provided at the bottom of this post.

 

Dr. Bromberg: I’m interested to hear about the custody mediation project that you recently launched. What is it you offer?

Dr. Bell: I’m offering a way for divorcing parents to retain control over their decision-making regarding their children, rather than presenting those concerns to court, where someone else will take over the decision-making.

My ideas about custody mediation are coming from the collaborative divorce model, particularly the interdisciplinary model, and from having been in the role of a forensic custody evaluator.

In the Interdisciplinary Collaborative Divorce model, each parent has a coach, and there may be a neutral Child Specialist that’s called in to explore with the parents what their questions and concerns are regarding parenting plans, access, scheduling, and other issues. The Child Specialist also addresses concerns involving children’s particular needs, including how one or the other parent is going to meet those needs. Generally, the Child Specialist brings the voice of the children into the negotiation process. The role of a Child Specialist, in part, is to keep aspects of the negotiation process child-centered.

When I interview kids as a forensic custody evaluator, I am limited in terms of what I can convey back to parents. I’m a data gatherer in that role, rather than an interventionist. And I’ve certainly seen that, even in litigated divorces, when parents get on the same page regarding their concerns about their kids, it really feels like that whole piece should be taken out of the court realm. It has no business being there. Figuring out what is going to work well for the kids is much more of a family issue than it is a legal issue, and so families should be talking with someone who has expertise in family systems and psychological well-being, a strong working knowledge of child development, and who also has mediation and negotiation training and expertise.

Dr. Bromberg: If the parents are in agreement that they can solve this problem outside of the court system, even if they’re in the midst of a litigated divorce, then they’re free to do so?

Dr. Bell: Absolutely. Even in the most amicable divorces, there may be questions that come up for the parents about the impact of the divorce on their kids, and they really need someone to talk to about it – not necessarily a therapist. The work isn’t about an in-depth exploration of the family dynamics, though family dynamics that have preceded the divorce certainly come into play in thinking about post-divorce life. The focus is different, the emphasis is different. The emphasis is much more about moving forward, problem-solving, and helping these parents who are in the throes of dissolving a life that they made together to remain united in their parenting roles and decision making.

Dr. Bromberg: Is this short-term or time-limited work, or can it potentially go on through early stages of adjustment to post-divorce life?

Dr. Bell: Both. I think that, again, it’s not therapy, and doesn’t necessarily involve weekly meetings. It is solution-focused and divorce-focused, and yes, beyond the signing of the divorce agreement, it is certainly possible that a family may come back around particular sticking points that come up. This often happens. People devise what are now called parenting plans, and the research shows that, within the first 18 months after the divorce has been finalized, people come back to court because there are glitches in the parenting plan. Why? Because life changes. Something comes up that somebody didn’t foresee. Well, instead of going to court and involving lawyers, why not go back to the mediator and say, “Here’s this problem that we ran into,” or, “Here’s this particular issue. How do we rethink this?”

Dr. Bromberg: It sounds like there’s an ongoing consultation role.

Dr. Bell: There can be, or not, depending on the needs of a particular family.

Dr. Bromberg: What is the child’s place in all this? When there’s a custody mediator working with both parents, how is the child’s voice incorporated?

Dr. Bell: I think a central part of the role is incorporating the child’s voice. Not only do I want to meet with the parents, but if it’s possible for me to meet with the kids, I want to be able to do that. I want the kids to know that I’m talking to their parents, and their parents are talking to me, and that everybody is thinking about what’s going to work for the whole family. The child should know that someone is asking, “What works for you? What works in terms of how you feel about things? We’re thinking about your safety, your comfort, and your particular concerns.” So I see the role as one that really utilizes that Child Specialist expertise.

Dr. Bromberg: Tell me a little more about the interdisciplinary, collaborative divorce teams.

Dr. Bell: Collaborative Divorce practice groups can consist of members of the legal, psychological and financial disciplines. When a case comes in to a Collaborative attorney, that attorney, and his/her colleague, can offer the names of coaches to the parties, and the names of neutral financial consultants that the parties may choose. The work of divorce negotiation is then conducted in 4-way meetings with lawyers, 2-way and 4-way meetings with coaches; a Child Specialist may be called in, who also acts as a neutral and meets with both parents together. The financial person meets with both parties together, and the team has releases to be able to communicate about the process, and potential glitches in the process, so that the negotiations move along as smoothly as possible.

When there are children involved, and if the Child Specialist is called in, parents will meet jointly with the Child Specialist, which preserves the neutrality of the Child Specialist. The Child Specialist is one neutral party, and the Financial Specialist is the other neutral party. Both parents will meet together with the neutral specialists, so that information is being given to both people at the same time, in the same room.

Often times the Child Specialist meets with the parents and also meets with kids. It’s very important to clarify that that this is not a therapist role. Often people are in therapy, and that’s great. But this is about helping people, very specifically, to navigate the rough waters of the divorce process. The Child Specialist meets with kids to find out what they think of the divorce, and to discern what works for them. The approach is focused on answering questions like, “How is this going for you? Is there something different you’d like to see happening? What are you worried about here?” The Child Specialist explains that his/her job is to bring that list of concerns back to the parents and figure out how they can help make the divorce process easier for the child.

Dr. Bromberg: I imagine that, sometimes, children are not sure how to articulate what they’re feeling, or are afraid in some way to voice what they want.

Dr. Bell: My impression, thus far, is that children are not afraid to voice what they want. They are incredibly eager to have a voice. They may not be able to fully articulate what they want or what they need, but they are able to articulate their feelings about what’s going on, and can work with the Child Specialist to develop some ideas about what might be better, or what needs revision. My experience has been that they’re so hungry to be able to tell somebody that they have some idea about this, too. That overrides any fear.

Dr. Bromberg: How old are the kids that you work with, at the youngest end of the spectrum?

Dr. Bell: I can think of a case where I’ve been a coach, and a Child Specialist was called in, and the youngest kid was five.

Dr. Bromberg: That’s young.

Dr. Bell: Yes. This was a very articulate girl, who was having some issues with her dad, and was feeling frightened. Not because he was a terrible person or was doing anything terrible, per say. She simply was not used to being alone in his care, and there were a couple of things that happened that didn’t feel right to her. And they scared her, and she was very happy to be able to tell somebody. “I don’t like that. I don’t want that to happen that way.” And that, then, was able to be talked about with the coaches, and raised in coaching sessions, both with the dad, and then between the mom and dad, so that they could come up with ways of thinking about this problem for this girl.

Dr. Bromberg: So you’ve worked in a team like this, in the capacity of coach for one of the parents, and also as a Child Specialist. How does custody mediation work differ? How did that grow out of the team oriented approach that you were involved in?

Dr. Bell: Rather than working with a team, the custody mediation work takes the same principles, and makes it a stand-alone role. The work doesn’t have to be something that happens in the context of a collaborative divorce team. The same model can really be used in the mediation forum.

Dr. Bromberg: You’re still in a neutral role.

Dr. Bell: Right.

Dr. Bromberg: You said earlier that your custody mediation work grew out of the interdisciplinary collaborative divorce team work, but also out of your role as a forensic custody evaluator. What does that work entail, and how does it inform your practice as a custody mediator?

Dr. Bell: As a forensic evaluator, you are an ally of the court. You are the neutral appointee of the court, and your job is to provide factual data to the Trier of fact, who is the Judge. So, your clinical skills, your clinical acumen and intuition are vitally important, but the kinds of questions that you ask, and the information you want to gather are different. The role is much more about using your investigative skills in a systematic way. There is a focus on trying to be rigorous and scientific in maintaining a level of neutrality and consistency across cases.

You’re being asked to get to know a family and the dynamics of a marriage in a very short amount of time. You’re being asked to offer an opinion about the impact of parents’ behaviors on children, such as a parent’s extramarital affair, a parent’s temper, or a parent’s use of alcohol. You’re being asked about relocation issues: What the impact is on the family if Parent A moves to Australia, or to California, or ten miles away. You’re being asked about the impact of domestic violence. And you’re being asked all of these kinds of things, not just in terms of your clinical impressions of people, but in terms of the current state of the research on any of those issues. For example: Overnight visitation for three year olds. You can’t just give a clinically based opinion about that, you have to know what the research literature says, and you have to be able to use that as a basis for your viewpoint.

Dr. Bromberg: Does a forensic custody evaluation involve neuropsychological testing of multiple family members?

Dr. Bell: No.

Dr. Bromberg: Of any family members?

Dr. Bell: This is highly debatable. My practice has always been to do a battery of psychological tests with both parents. That position is an arguable position. There are people who do this work who feel that that’s really important. Then there are people who do this work who feel that psychological testing has no place in it at all, because there are no statistically valid, normed psychological tests out there that test for parental fitness or parenting capacity.

Dr. Bromberg: And, ultimately, in the role of forensic evaluator, you have to make that determination and offer it as an opinion to the court.

Dr. Bell: You’re offering an opinion about that, that’s right. Now, at this point, in 2007, there are even questions about whether the evaluator ought to be offering any kind of recommendation to the court. So that, perhaps, the limits of what the evaluator should be doing is presenting the information, pros and cons, and then leaving it there.

Dr. Bromberg: Are there people questioning the validity of the data presented, or are they questioning a psychologist’s ability to use that data to make empirically based, valid recommendations?

Dr. Bell: The latter.

Dr. Bromberg: But the ability to present data with a scientific foundation is not in jeopardy?

Dr. Bell: That part doesn’t seem to be in as much jeopardy, no. My own objection to the position that’s being promoted is that it takes all of the ‘art’ out of the work. It is reductionist kind of thinking, to me. Scientific evidence is very nice, but it isn’t the sum total of everything. What is so readily dismissed is the clinical feel, the eye and experience and intuitive gut of a clinician who has a backlog of experience with families and with people. That’s always my struggle with people who want things to become formulated and manualized. The nuance gets lost. I have been thought of by some professionals as being ‘too intuitive’. I personally think intuition is a critical aspect of understanding and working with people, and is something to be cultivated, not shut down. But there are some people out there who consider intuition to be sloppy, random. Clinical intuition is not quantifiable in the scientific sense, but that doesn’t mean it’s not valid.

Dr. Bromberg: That reminds me of a story I recently heard about Pablo Picasso. A woman came to Picasso and asked him for a drawing. He did something very elegant and simple with a single line. I don’t remember what it is he drew, but he did it very quickly. And then he charged the person a thousand dollars. She said, “A thousand dollars! Why should I pay you a thousand dollars for that? It took you all of two seconds!” And Picasso replied, “Madam, it took me a lifetime.” The idea that intuition may look sloppy and tossed off to some people, but it’s the product of years of training.

Dr. Bell: It’s built on something. It’s the product of years of work. My own experience and training is such that I’ve been a custody evaluator for more than ten years; I also have training in collaborative law, and mediation training from the Center For Mediation In Law in NYC. I completed the Program for Senior Executives at The Harvard Program on Negotiation last fall, and have been reading pretty much anything on negotiation that I can get my hands on. Along with my clinician skill set as a child psychologist, this provides me with the foundation necessary to feel that I am on solid footing in this arena. It is essential to know something about New York State Law, to know something about family law, and to know something about divorce law in the state. Otherwise you could be saying something that is ultimately going to be harmful.

Dr. Bromberg: It seems like very difficult work, but also very meaningful work, regardless of whether you are functioning as an evaluator, a member or a collaborative team, or as a custody mediator.

Dr. Bell: Divorcing couples are trying to make rational decisions that have durability, but are also life-altering, at a point in time when strong emotions could potentially interfere with good judgment. So it’s a complicated time to be making thoughtful choices and decisions. In part, that’s why the process needs to take time. Because it is process, it’s not product. It’s not about getting from point A to B. If you read Pauline Tesler’s book on collaborative law, she writes about achieving “a deeper peace.” It is about the notion of helping families not just get to where they can sign a document, but get through enough of that emotional nitty-gritty that, by the time they sign the document, they’ve reached agreements that they really feel that they can live with. And live reasonably well by, so that there continues to be a sense of family, and that fabric has not been completely torn apart. It’s been reconfigured, restructured. It morphs into something different from what it was, but it isn’t negated, it isn’t annihilated, it isn’t obliterated, which is typically the outcome of litigated divorce.

 

 
Dr. Bell’s contact infomation is:

Allison J. Bell, PsyD.
190 Goldens Bridge Road
Katonah, New York 10536
Office:  (914) 232-1211
Fax:      (914) 232-3479

Interview: James Hull Discusses "The (Almost) Paperless Practice"

March 12th, 2007 by Dr. Bromberg

 

Dr. James W. Hull is a clinical psychologist in private practice in New York City. He is a member of the Personality Disorders Institute of the Weill Medical College of Cornell Univesity, and a former supervising psychologist at the Westchester Division of The New York-Presbyterian Hospital in White Plains, NY.

We met recently to talk about a system he has developed for the computerized management of his clinical practice. I believe that Dr. Hull on the cutting edge of what will be a more and more indispensible way of tracking and organizing appointments, documents, billing, and chart information for clinicans in almost every professional setting I can think of.

I am very pleased that Dr. Hull was willing to provide me with the first interview for the DrBromberg.com blog. I hope and trust that you will find his ideas to be interesting food for thought. For those who would like to learn more about “The (Almost) Paperless Practice” from Dr. Hull, I have included his contact information at the end of the interview.

 

Dr. Bromberg: You’ve developed something you call “The (Almost) Paperless Practice.” Can you describe what that is?

Dr. Hull: It’s a system that I have developed for myself, but that may be of interest to other clinicians, in which almost everything related to my practice is managed and stored electronically. I have almost no paper records for my practice at all.

Dr. Bromberg: You call it, rather than “The Paperless Practice,” “The (Almost) Paperless Practice.” How come?

Dr. Hull: There are certain kinds of paper you probably can never dispense with. For example, there are always going to be patients who want statements that they can submit to their insurance. And you’ll always get letters from patients that you want to save. Also, there are some kinds of paper you don’t want to dispense with, like checks for payment. But with a few exceptions like this, everything else is digital.

Dr. Bromberg: How did this develop?

Dr. Hull: When I decided to go into full time practice, I struggled to find a way of keeping records and organizing them in an efficient system. What I particularly wanted was a system that didn’t take me much time to manage. I practice in the city, so I ride the train every day, and I set as my goal that all of my practice record keeping should be able to be done on the train. And I’ve certainly come close to that.

Dr. Bromberg: What are the components of the system?

Dr. Hull: I think the minimum is to have a digital system to manage appointments, patient records, and payments, as well as a digital file cabinet for storing scanned images of every document that comes into my practice, and everything that I send out. These two components, the daily record system and the digital file cabinet, form the complete system.

Dr. Bromberg: So, what has it been like for you to actually implement this?

Dr. Hull: I began in an effort to increase my efficiency and minimize the maintenance costs of running a practice. And then, as I got into it, I thought ‘This is really interesting.’ First of all, it’s something almost no one in our field does, but people in other fields do this sort of thing a lot. Your bank, for example, doesn’t keep any of your checks. They scan them and archive them digitally. And if banks can do it, the IRS must be on board. So it seems other fields are moving in this direction.

Dr. Bromberg: I’m curious about the potential benefit of this to other clinicians. You mentioned efficiency, for one.

Dr. Hull: Some clinicians, clearly, should not do this. If you run your practices out of a Filofax, use notebooks to take patient notes, and keep track of fees and payments using an account book, this probably isn’t for you. I think this is more of a system for somebody who is already using computers and is heavily into it, someone who sees and values the potential of unlimited, easily searchable archives. Imagine if every document, every phone call, every letter, every piece of paper you’ve ever gotten from a patient, or ever gave to a patient, was stored forever and was easily accessible. That’s really what this is about. And there’s an obvious advantage to that.

Dr. Bromberg: Practices include paper, letters, etc., but you’re choosing to store that information digitally. What becomes of the paper? Do you dispose of it?

Dr. Hull: It gets shredded immediately, except for IRS records. I keep those in both scanned and paper form.

Dr. Bromberg: It sounds very simple, but there must be complications.

Dr. Hull: Sure. I think this can be customized, depending on the clinicians needs and preferences. For example, I don’t like to carry a laptop, so I keep all of my day to day practice information on my phone, using Excel Mobile and Outlook Mobile. When I get home at night, I sync the phone with my desktop, then I move that data over into my practice software. It’s an extra step, but for me it’s worth it because I don’t have to carry a laptop.

Dr. Bromberg: Other aspects of running your practice generate paper: Rent, malpractice insurance, etc. Can you, using your system, also manage those parts of your business?

Dr. Hull: Yes. That’s exactly how I do it.

Dr. Bromberg: How do you guarantee the information on your hard drive is safe?

Dr. Hull: Well, that’s a very important question. What I do is, I have an external hard drive connected to my computer. The computer runs all the time, and every night at about 2 AM all documents are backed up to the external hard drive. So, I know, at least that if the hard drive fails, I’m not going to lose more than one day’s data. My external hard drive has a removable cartridge that holds 35 gigabytes. Once a month I put in a new cartridge and take the full one to a safe deposit box. So, worst case scenario, I can never lose more than a few weeks worth of data. I think that’s good enough.

Dr. Bromberg: There’s a parallel concern. There’s the physical safety of your data, and then, as a clinician in the field, there’s also the issue of HIPPA. I imagine that starting to run your practice digitally heightens some of those risks and concerns. How do you navigate the compliance requirements?

Dr. Hull: Not long ago, I went to one of the HIPPA compliance courses offered by the APA Insurance Trust, and they talked about this. What they were advising was entirely consistent with what I’m doing. It seems that the key think is to have the hardware physically protected and the data password protected, so that if somebody got to your computer, they couldn’t access your records. This is especially relevant to me, because I carry a lot of my data around with me on my phone. If I lose my phone and somebody finds it, they will not be able to access that information because of the password protection. Given these safeguards, I think this type of system is actually more secure than a paper-based system.

Dr. Bromberg: How much time does it take to set up this system?

Dr. Hull: Well, you have to acquire the hardware and the software. Then, depending on how computer literate the clinician is, I would say this is something most people could set up in a couple of weeks. Not working full time, but just working on it a little here and there. It’s not hard to do. You have to decide what your archives are going to look like, where you’re going to store files, things like that. There are decisions to be made along the way, but this isn’t rocket science.

Dr. Bromberg: I imagine the real moment of truth for somebody converting to this system is when they’re comfortable enough with their archives to actually start shredding their old paper records.

Dr. Hull: Yes, that’s the moment of truth. But it becomes an acquired taste. Pretty soon you can’t stand to not shred things.

Dr. Bromberg: In terms of keeping the system running, you’re really able to manage all your notes and bookkeeping and everything just on your train ride to and from the city?

Dr. Hull: I would say train ride to and from the city, and sometimes sitting down in the evening for ten minutes or so. I do all of my scanning on the weekend, and I never spend more than 30-45 minutes per week on this.

Dr. Bromberg: How long have you been doing this?

Dr. Hull: Five years.

Dr. Bromberg: You had said initially that you don’t know anybody else that’s doing this, and I can’t think of anybody I know who does this either, but as you’re describing what you do it sounds fairly intuitive. Why do you think other people haven’t put together some kind of system like this for themselves?

Dr. Hull: I don’t know many therapists who actually use a computerized system to record notes, do you? I mean, I know some. But it seems to be more the exception than the rule. I’m not sure why. It’s an interesting question. I think you probably have to have a taste for these things, and you have to enjoy doing it. It’s much easier for younger clinicians who grew up with computers. I think it’s a fair guess that this will be done more and more in the future.

Dr. Bromberg: Are there perhaps any disadvantages to doing this?

Dr. Hull: I think the big disadvantage is if you don’t attend to the security and backup you could get really badly stung. That’s the main disadvantage that I see. Like I said, maintaining it doesn’t take much time, setting it up is not hard. And there is a tremendous relief in knowing that if you ever need to access a document, you can.

 

Dr. Hull’s contact infomation is:

James W. Hull, Ph.D.
286 Madison Avenue, Penthouse
New York, NY 10016
(212) 361-9418