Child-Parent Psychotherapy (CPP) is an evidence based practice originally designed by Alicia Lieberman, PhD, with the University of California, San Francisco. In this episode Pete Cudney from VT-CWTP interviews Vermont psychologist Kaitlin Zura, MA, from the NFI Family Center, about how children are impacted by trauma, how the CPP model guides the healing process for the child, and how to access CPP for children in Vermont.
Cassie Gillespie (00:03):
Welcome to the Field, a podcast of targeted trainings for child welfare professionals. I’m Cassie Gillespie. Join us as we chat with local experts about topics that are pertinent to child welfare in Vermont.
Pete Cudney (00:15):
Hello everyone. I’m Pete Cudney and I’m really excited to bring you a discussion with my colleague Kaitlin Zura. Kaitlin is a licensed psychologist who works with the Northeastern Family Institute of Vermont. Kaitlin is part of a brilliant team of clinicians at the NFI family center, where she provides psychological evaluations and practices as a family therapist. Among other areas of practice. Kaitlin has expertise in assessing and providing treatment for young children who have experienced trauma. Kaitlin practices using the Child-Parent Psychotherapy model, which we’ll also discuss Kaitlin. It is so great to have you with us today.
Kaitlin Zura (00:58):
Thank you so much, Pete. I’m so happy to do it with you.
Pete Cudney (01:01):
Yeah, it’s really great that you’re taking time out of your schedule to talk about this. We really appreciate it. So I should probably pause to note that we’re recording this on April 17th, 2020 during the global coronavirus pandemic. So we’re working in recording from home Kaitlin, before we dive in, how are you doing in the midst of this whole situation?
Kaitlin Zura (01:26):
You know, it’s, it’s an adjustment, this is my first full week finally having a functional home office space to be working remotely from. But I was thinking about it last night in preparing for the conversation with you about this whole situation, it has really made me think a lot about what I love most about my job and CPP and working with these families in particular is one of my favorite things. So it’s kind of nice that I get to talk about it today. And think about all the things I really appreciate about my job.
Pete Cudney (02:07):
Yeah. Well, that’s a great segue. So before we dive into family therapy in general or the CPP, the Child-Parent Psychotherapy model in particular, we talk about when, when young children experience something that is so scary or so upsetting to them, the term we use for it is trauma. I wonder if you could just talk generally about what is it that we know happens for really young children when they experienced trauma?
Kaitlin Zura (02:37):
Yeah. So one of the most important things is the attachment between the young child and their caregiver. And one of the most profound things that happens when a child experiences trauma is the loss of a protective base during a really critical period of development. So kids have this natural developmental expectation that their caregiver is going to keep them safe and they’re going to protect them from danger. And when a kid, a young child experiences a traumatic event, they lose that sense of safety and security from their primary caregiver. And the loss of that has a tremendous impact on their development across a lot of different domains of functioning.
Pete Cudney (03:36):
Okay. So if I’m understanding what you’re saying correctly, there’s this expectation that we probably take for granted most of the time for really young children that they may not even be aware of, maybe just a feeling that they have or something like that, that if they have a need or if something is scary, that they can always just count on their parents to, to take care of them and keep things safe. And you’re saying that if they have an experience, that’s powerful enough that, that can disrupt that and just cause them to suddenly not be able to have that predictable sense of safety from their parents. That even one experience if it’s powerful enough, can disrupt that for kids.
Kaitlin Zura (04:21):
Yeah. And I think that, you know, the extent to which an experience really impacts a child, does depend on some factors. I think that there are ways that healthy attachment can buffer an experience, the impacts of an experience. So if a caregiver is able to modulate that stress response for the child, maybe it has less of an impact across their development. And the degree to which the caregiver can kind of understand what’s going on and effectively respond to the child can really determine how much. So we talk a lot about how kids, a lot of different kids, can experience the same traumatic event and respond in really different ways. And how do we explain that? And a lot of that has to do with the response of the adults around them.
Pete Cudney (05:23):
That seems critical. I mean, that seems really central. So a child can have a traumatic experience where the source of the trauma is not the parent or the caregiver. And then if the parent or the caregiver knows about that, and responds in a way that soothes the child and helps the child feel safe and secure, that may resolve it for them kind of fluidly just within that relationship. But you’re saying if either the parent isn’t able to do that, or if potentially the parent’s actions themselves are to some degree, a source of the trauma, then the child is left alone with it, and they’re not able to resolve it in that relationship.
Kaitlin Zura (06:07):
Right. And I think one of the things that we talk a lot about in CPP, we’re talking about both the caregiver and the child. And I think when a parent and a child experience a traumatic event together, sometimes that means that the caregiver is less able or available to attend to the child’s needs because they’re having their own post traumatic response. And so then the post traumatic response of the caregiver and the responses of the child are kind of exacerbating each other.
Pete Cudney (06:43):
So it can be really complicated. Okay. So, now that we have this kind of basic understanding of how traumatic events can impact a young child I’m hoping maybe you could help us understand in a general sense at first, what do children, what do they need to recover from those kinds of experiences and in particular, what do they need from their caregiver?
Kaitlin Zura (07:12):
So I guess the most simple answer is they have to reestablish that security that they have lost, or the sense of security that they have lost. And one of the important things about trauma is not only addressing real threats to safety, but also perceived threats to safety. So really having the parent or the caregiver understand how to reestablish themselves as a secure, predictable safe base for that child and understand that even though the traumatic event may be over or the the things in their environment that were traumatic are removed the perception of threat and lack of safety may still be there.
Pete Cudney (08:09):
Okay. Yeah. So the experience can be powerful enough to shift the child’s kind of how they make sense of what they experience their perception of, of events. And parents may understand that, but oftentimes I would guess parents don’t necessarily know that unless they’re guided in that process.
Kaitlin Zura (08:30):
Yeah. I think that’s one of the really important things, I’ve had really helpful conversations with parents who are able to acknowledge some traumatic events that have occurred, but were maybe not aware of a lot of other things in the environment that were contributing to, what we call chronic stress in the environment. And so maybe there was one single traumatic incident that the parent is acknowledging and very aware of and working towards addressing and healing from that one incident. And they maybe didn’t realize that there are a lot of other things actually in that child’s environment that are also creating toxic levels of stress.
Pete Cudney (09:17):
Okay. So I know that NFI Vermont and the NFI family center in particular have really been among, in my opinion, among the leaders in Vermont, in the field of childhood trauma. And one of the treatment approaches that your team has really strongly endorsed is family therapy. Could you speak a little bit about how you and your colleagues support parents in meeting their children’s needs for recovery through family therapy? So for example, based on what you were just saying, is it fair to assume that you would begin that process just with the parents?
Kaitlin Zura (09:56):
Yeah, you know, obviously like you’ve said, child-parent psychotherapy is a subset of family therapy. And so there are a lot of areas where the process overlaps. In Child-Parent Psychotherapy that first initial phase of treatment has a specific name, which is the assessment and engagement phase. That’s usually just with the caregiver and the clinician, and that’s the same process that we would typically follow with regular family therapy, which is developing a relationship and a working therapeutic Alliance with the caregiver. And one of the unique things about CPP is really the diving into the parent’s own traumatic experiences from their childhood, how they were parented, how they grew up and how they hope to parent in the future. And there’s quite a bit of time spent on talking that through and co-creating a treatment plan together where they’re a really active participant in deciding, you know, what we’re going to do to help them through treatment.
Pete Cudney (11:17):
Okay. So that makes sense to me. So it sounds like you’re beginning with the parents, helping them feel safe with you, helping them explore the situation that their child has experienced, but also their own life experiences. And it sounds like because those have an impact in each parent’s ability to respond to their children’s needs, their own early life experiences are a factor as well. And so, when you assess that, are there times where you will assess a caregiver’ s capacity to meet their children’s needs, and you may determine that they need to do a fair bit of work themselves to be ready. And how do you approach that?
Kaitlin Zura (12:07):
Yeah, that whole initial phase is part of that assessment of readiness, and it’s pretty variable in terms of length and how long we’re gonna work together with the caregiver before we invite the child into treatment. And it really depends on who the caregiver is, were they present for the traumatic experience, what their history is, what their skill levels are and where they are in terms of recognizing their role in whatever has occurred. And sometimes we determine through that process, like you’re saying that they need to do some additional work on their own trauma history or their own coping skills, responding to triggering events in their environment so that they’re better able to assist their child and walk with their child through treatment. But that’s something that we work through together and again, I’ve had times where that phase kind of lasts a couple of weeks and I’ve had times where that phase lasts several months, and it really depends on where they’re starting out and what level of support they need to prepare for inviting the child in.
Pete Cudney (13:28):
And if there’s a family service worker who is working in the field of child protection, if they’re working with a family where this may be a helpful approach, but they have concerns themselves about the parent’s capacity for it. Do you encourage them to make that determination? Do you encourage them to make the referral and then know that you’ll share that some degree of that assessment with them about the parent’s readiness? How do you advise people?
Kaitlin Zura (13:57):
Yeah, I don’t think there’s ever a reason to not give a call and make a referral, and we can sometimes assess over the phone just by getting some basic information, whether or not it’s an appropriate fit. And other times I’ve had just a couple of initial sessions to gain a better understanding of what’s going on for that family and whether or not it’s appropriate to start this kind of modality of treatment. But I think it can be a collaborative effort. Personally, in my work with CPP have worked with several women who are part of the Lund residential treatment program. And I have gotten referrals from Lund Family Educators where we started right away and it was a great fit and it was totally appropriate. And other times I’ve gotten referrals where we decided collectively that there was some other treatment work that needed to be prioritized. And I was able to kind of give them a sense of what would need to happen to transition to this type of work. And so I was able to kind of help inform some of their treatment goals and we didn’t start CPP right away, but eventually they were re-referred. And I think it was a helpful process and I’m happy to be a part of that type of process.
Pete Cudney (15:18):
Excellent. So I’m imagining that a family service worker might also have the opportunity to refer a young child for individual therapy, and an individual therapist, may really have the capacity to respond to the child in the ways that we’re talking about. But I understand that that’s not generally understood to be really effective at meeting the child’s longterm needs, the way family therapy is even if the parent has to do some work to get ready themselves. Could you speak a little bit about that?
Kaitlin Zura (15:59):
Yeah, and I think that that’s been one of, I mean, this is the case with all family therapy, but particularly with CPP I’ve, I’ve established these really strong working relationships with, particularly with mothers and have really been able to establish a relationship where they’re empowered to take the lead in sessions. So one of the things that we do in treatment is after the assessment and engagement phase, I talk with the parent we plan together about, how do we want to present treatment to the child? How do we want to explain this to them? And we go through this exercise called the triangle of explanations, how are we going to explain how all of this has occurred and why we’re engaging in treatment and why we’re inviting the child in. And then it’s up to the parent to kind of introduce treatment to the child.
Kaitlin Zura (17:03):
And I’ve had situations where the parent is really intimidated by that. And they want me to. “Well, can’t, can’t you just say it can’t you just take lead. I think it would be better coming from you.”, and, I’m able, but I’ve been able to support them in doing it themselves. And they’re ability to take ownership and to take lead is so critical in terms of laying that foundation if their parent is going to be the one that keeps them safe. Their parent is the one that’s going to be in charge and I’m there as a support, I can share a lot of information about trauma and how it impacts them and how it impacts their kid, but they still are the expert on their kid. And, it’s nice when kids really love seeing me and feel really supported by me, that’s lovely and I love kids, but that doesn’t help that parent be able to do this on their own at home all day, every day. And so, while I love when kids feel like they can trust me and talk to me, it’s way more important for them to be able to trust and talk to their parent. And so that’s, that’s the priority.
Pete Cudney (18:25):
Yeah, that sounds really critical. I mean, going back to what you explained at the beginning, that really the core impact of the trauma is that it disrupts the child’s ability to predict that their parent will keep them safe and meet their needs. And so if a therapist establishes a relationship with the child where the child feels like the therapist will keep them safe and meet their needs, that still doesn’t resolve the core impact of the trauma, it really has to be with the caregiver, for the, for the child to move forward developmentally, it really has to be reestablished with the caregiver. You explained that. Thank you. So, let’s say you’ve, you’ve worked through the early phases of treatment and you do decide to bring a child. And my understanding is that CPP as a model is designed really for young kids six and under, I know sometimes tenets of it may be used with older kids, especially if they’re developmentally younger, but typically we’re talking about really young kids. So, if there’s a toddler or a preschooler I would imagine that you probably have to speak their language in some way in terms of helping them understand. So what does that look like? What does it sound like? Yeah, help us understand this.
Kaitlin Zura (19:40):
So, yeah, so because CPP is an evidence based treatment model, there are these parameters around the demographic. And for CPP it’s zero through five. But I’ve absolutely used the tenants of the CPP treatment model with older children as well. It just doesn’t it count towards the body of evidence, that shows the effectiveness of the model, but to your point, it’s been a very interesting journey to get creative and to tailor interventions based on the child’s age and their developmental stage. And it was, to be honest, intimidating a little at first, like I’m going to have a three year old come into my office, and what does that mean? And how do we explain this in a way that you know, we can’t, you can’t just sit on a couch and talk things through, that’s not going to happen with the three old, so getting creative and tailoring interventions was a challenge, but it was a really fun challenge to get creative. And so sometimes that happens through artwork and creating things together, sometimes most of the time it’s happening through play and storytelling. And so really depending on the child’s age and stage, like I said, it’s going to be pretty variable in terms of how much you are talking.
Pete Cudney (21:17):
Okay. And so I liked that you said, you know, you can’t really just sit on the couch with them and read a three year old, doesn’t even stay on the couch, I would imagine. And so now I’m picturing you on the floor and I’m picturing toys and I’m picturing, so then do you encourage the parent to raise the subject? Do you wait for that subject to present itself in whatever the child’s doing? How do you approach that?
Kaitlin Zura (21:45):
Well, I think it’s a little bit of both. And so one of the principles of the treatment model is this idea of speaking the unspeakable, which was probably one of the most powerful things that has kind of infiltrated all of my clinical work. Is this idea that we’re going to put things out there. I think a lot of parents come from the perspective of when the child is ready, they’ll bring it up or they’ve never talked about it so I don’t think it bothers them, or I don’t think that they’re old enough to really understand. And so when they’re older, we’re going to talk about it. And this idea that we’re going to acknowledge this has been a significant traumatic event, and we’re going to talk through it and we’re going to, of course, in developmentally appropriate ways, but we’re going to put it on the table. And so that might just mean sometimes putting toys in the room that could evoke certain responses from the child and you still are letting them kind of take the lead and see how it plays out and how it comes up. It might be more figurative rather than literal, discussions around this. But we really don’t shy away from talking about what happened. And I think one of the things that was a change for me as you were getting all these toys ready for doing play in the office. And part of that is police stations and fire stations and guns and stuff that you normally wouldn’t just hand kids to play with especially depending on how young they are, but by providing those of toys it can lead the play in a certain direction where they’re going to start to process some of the things that have happened.
Pete Cudney (23:53):
Okay. I think I understand. So you may have a dollhouse and in that dollhouse there might be a crib and there might be a baby. And there over to the side, there might be a police car, a police officer. And so if there was an experience that the child had of neglect, where they were left in the crib and the caregivers weren’t there, or domestic violence and the police had to come to the house, then having those present creates opportunities. So that hopefully it naturally comes up. And then if it does come up, then the parent responds in that moment in a way to try to help reestablish that safety and security for the child.
Kaitlin Zura (24:33):
Yeah. And again, I think that during that planning the assessment and engagement phase with the parents, we’re talking through what could come up, how do you want to respond? What’s that gonna evoke for you personally? Because again, a lot of times they’ve both shared in a traumatic experience together. And so the parent has their own emotional response to when we’re talking about this stuff. And so preparation is really important to support the parent. And again, you’re really aligning with them to ensure that when this stuff comes up, they’re prepared and they know exactly what they want to say and how they want to approach it.
Pete Cudney (25:17):
Yeah. And so, as you mentioned, this is an evidence based practice. My understanding is that there’s a pretty rigorous training process to become rostered in it. And that has happened once kind of widely throughout Vermont. And did you mention to me, is there another upcoming cohort of that that’s being offered?
Kaitlin Zura (25:40):
Yeah, so I think actually I was part of the second cohort. The first one was a lot smaller, the learning collaborative, cohort, that I was a part of was much larger and broadly throughout the state. And we also included not only clinicians from social service agencies, but also private practitioners, which was a unique thing about our group. And yes, there will be a third, I think it’s the third, learning collaborative that will be coming to Vermont in November, 2020. And again, you know, expanding even more to make sure that we’re getting all the different pockets of the state, all the different designated agencies it’s grown from being sponsored by NFI and Easter seals to including Howard center. And really the push is to get as many people as we can rostered and to go through this process, which is typically, 18 months, the learning collaborative is 18 months, and that included three pretty intensive in person sessions.
Pete Cudney (26:55):
So if there are family service workers throughout the state who have found that there are not the kind of family therapist resources in their region if they know a licensed clinician in their community who may be inclined to learn this model, they should mention it to them. They should maybe point them to the NFI family center, at least as a starting place to get connected with the next learning collaborative.
Kaitlin Zura (27:20):
Yeah, absolutely. They can go to the NFI family center website and find more information. And like I said, the goal is that every district for family service workers will have providers that are trained in this and and to continue to spread the model throughout the state.
Pete Cudney (27:41):
Yeah. Excellent. And so I have maybe one more question for you before we, before we wrap up. So I did mention early on, I mean, we’re in the, we’re in the middle of physical distancing right now. And so I’m curious, I mean, I think we’re all figuring this out as we go. What have you figured out so far, are you able to still provide CPP services? How are you doing that? What’s that looking like right now?
Kaitlin Zura (28:06):
Yeah, so, you know, it depends on the family. I am still providing virtual therapy for all of my clients, but depending on the family and the child’s ability to kind of engage it’s played out a couple of different ways and it’s really pushed me again to adapt and change what I’m comfortable with and what I’m used to in terms of engaging in treatment. But some parents have really taken advantage of using this time to go back to basics to because people are home with their kids full time and perhaps some of the things that are going on in the community and the feelings of insecurity or lack of safety might be provoking some old feelings and behaviors. And so going back to basics around, establishing a connection with the parent and focusing on attachment, focusing on regulation and providing safety for their child. And then there are also some kids who are able to continue the work that we’ve been doing and, and playing and getting creative about how to stay connected and do the work that we have started. So it’s been a really interesting process to see how kids have adapted and, and how to meet families needs during this time.
Pete Cudney (29:33):
Well, thank you for the work that you’re doing with this. And if there was a family service worker who suspected there might be a clinician who was rostered in CPP, but they didn’t know in their community could they reach out to the NFI family center? Do you, do you have a list of who’s rostered.
Kaitlin Zura (29:50):
Well, yeah, you can actually go to a Child-Parent psychotherapy. I don’t know if it’s dot org or.com. But you can Google it and on their primary website, there’s a map that has all of the rostered clinicians everywhere. And so you just click on Vermont and it will show you based on County and region and who’s rostered in your area. You can find all of that online.
Pete Cudney (30:14):
Ah, that’s super helpful. Excellent. Kaitlin, you have been fabulous to talk with. You’ve been so generous with your time and your expertise. I can’t thank you enough. Thank you.
Kaitlin Zura (30:24):
Thank you so much. It was fun.
Pete Cudney (30:27):
It really was fun. Take care of yourself.
Kaitlin Zura (30:30):
Thank you so much. You too.
Cassie Gillespie (30:33):
Thanks for listening. If you have any ideas about topics that you want us to cover or episodes that you’re interested in hearing, shoot us a message. You can reach me by email at Cassie.Gillespie@uvm.edu, or you can leave us a comment on the webpage where you downloaded this podcast. Welcome to the Field is produced by the Vermont Child Welfare Training Partnership and the State of Vermont and a special thank you to Brickdrop for composing and recording our music. See you next time!