To Therapy or Not to Therapy?

A theme came up in the Paradigm Shift Program this week that I wanted to share with you: Therapy and why our children resist it or why it works for a while, and then stops working.

First, I want to say that I am not against therapy for PDA children or teens in any way.

My son has been in occupational therapy for four years and it has been transformational for him, both as a means of providing scaffolding for learning to expand his eating repertoire, integrating gross motor movements that have somehow resulted in him becoming quite athletic (!) as the threat response has come down, and forming deep and safe relationships with other adults besides me. 

During a time when we literally had no structure, school, or activities outside of the home during burnout recovery, his occupational therapy clinic felt like a safe place FOR ME, where at least I had the support of another adult focused on nervous system safety, which allowed my hypervigilance to be dialed down at least a few notches.

At the same time that I think therapy is great, I often see therapy – or the push for our PDA children to acquire skills on a particular timeline - working against the primary needs of our child and teens: true nervous system safety, perceived autonomy and equality, and connection.

And what can often be so confusing for parents is that their child might really enjoy a therapist at first – especially during the “building trust” phase – but then they begin to resist, avoid, and activate as the energy and subtle pressure shifts within the therapeutic space to “ok, now we have built the foundation of trust, let’s move on to making some progress and learning skills.”

The PDA child or teen senses the shift energetically, and it immediately shuts down trust and activates the survival part of their brain that perceives on a subconscious level a loss of autonomy and/or equality to the therapist and session structure.

The key mindset shift here for parents and therapists alike is that the “building trust and safety” is not a pre-cursor or prologue to the therapy. It is the therapy.

Skills will emerge organically and over longer time periods, when they child feels ready, within a context of true connect and trust. PDA children and teens are auto-didactic, as hard as that is to believe if your child or teen is in burnout (believe me, I thought this idea was ludicrous three years ago, because my son refused all “learning” and engagement during burnout).

Within the safety of a connected relationship and deliberate nervous system scaffolding over time, skills can be built or accessed in a non-linear way.  

In a therapeutic context, this includes counter-intuitive things like allowing the child to fully opt-out of all planned activities, a therapist who can sit with the discomfort of equalizing behavior and allow the child to be above them in perceived power and authority, and following fluidly what the child gravitates towards even if it doesn’t seem relevant to goals. It includes sitting with the idea that witnessing and accepting the child for who they are and allowing autonomy within the session IS. THE. THERAPY.

Let me give you some examples of the energy shift to skills and goals and why it works against us:

Parents take their children to Parent Child Interaction Therapy (PCIT) and the first half of the protocol goes great, they are following the child’s lead, building trust, learning how to be with the child. However, as soon as the “compliance” part is introduced, things go wildly off the rails (I have had so many clients with this experience). The therapy actually undermines the trust and pushes the child further into their survival brain.

Or

Parents and children have a great start with a really flexible Speech Language Pathologist or Occupational Therapist who is super adept at building trust, but then, the therapist switches into a vibe of “ok, now, let’s work on some skills” - no matter how subtle - and the trust dissipates and progress stalls. The PDA child avoids or equalizes, the therapist feels defeated, the child feels activated. Things fall apart, but as parents we keep pushing, because it is what we are “supposed” to do to help our kid.

Or

We jump too fast into the therapeutic protocol. For example, a TON of families have asked me – Why isn’t Dr. Ross Greene’s Collaborative Problem Solving (CPS) working for my PDA kid? The answer is that they likely aren’t there yet in terms of perceiving true connection and autonomy with you AND you need to incorporate PDA-friendly accommodations, like “strewing” or “offering” declarative sentences (rather than asking questions to prompt CPS) and maybe even sitting on the floor to pre-empt the perception of a lack of equality before you even say a word. It’s not that the therapeutic protocol itself is wrong. It’s that we need to view it through the PDA lens and adjust it to your child's unique nervous system. 

These dynamics happen regardless of therapeutic protocol: family therapy, Cognitive Behavioral Therapy, occupational therapy, etc.

This is not your fault, nor frankly is it the therapists’ fault.

These are structural and systemic issues that individuals can’t overhaul or change in a day or alone.

Insurance companies require plans of care and parents need financial coverage.

Therapists have bosses and supervisors. They are trained in how to facilitate skill acquisition and feel successful when they see linear progress.

Most therapists are taught strategies and modalities that are premised on a different logic than simply “providing a safe nervous system container."  They do what they are trained to do and for many kids who are not PDA, it honestly may be a perfectly great approach.  

Operating within a culture of compliance and the current medical system and therapeutic norms in a way that works for your kid is a tall order, often too big a burden for a parent in burnout and crisis or a therapist who has their own stressors, life pressures, and constraints.

But you can make choices.

You can opt out of therapies or specific clinics that make your child more activated, despite the pressure from Those That Know More Than You, M.D., Ph.D., Fancy Pants Harvard degrees.

You can look for – or simply make space for – the gems, unicorns, diamonds, and shining bright stars of humans who are finding ways to creatively work within the therapeutic system, to support your child. I am seeing it more and more and it makes me so hopeful for all of us and our children.

Another point of agency is that as parents, we often need to let go of our own attachment to skills, goals, and short timelines. To signal to the therapist, Hey, I’m Ok with my child just being with you. I’m not judging you or how long things take.

We can model that it is OK if the only thing that happens during a session is that your child demands you and the therapist play basketball with each other, while they stay in a hammock swing, correcting you, directing you, and telling you that you are terrible players.  And yes, it will feel weird that you are just playing a basketball game with the therapist while your child “does nothing,” but what if you can have some fun and silliness with it?

This example is a personal one, but not unusual in my family. And in fact, it was one of my favorite memories with this particular therapist because we ended up laughing so hard in the end. This session was incredibly therapeutic for my son even though no specific gross or fine motor “skills” were worked on. He simply needed to get back to nervous system safety after the cumulative activation got too high.

So I’ll leave you with this inquiry – in what ways are you energetically holding on to timelines, skill acquisition, or goals, no matter how subtle? How might you bring or deepen a feeling of non-attachment to therapy?

This might also include letting go of making your child attend therapy for six months or a year, and waiting until your child is ready to come back to working on things like sensory integration, eating, or communication and doing so through a place of true autonomy.

I know it feels scary to let go of what feels like control, but you got this! Remember, it is a long-game and I have faith in you and your child.