Addressing Core Issues in a Teen's Life using the Courage Circle

September 24, 2021

Episode Transcript

Selina
Hello, and welcome to On Air with Elk River Treatment Program for Teens, the residential program at Pinnacle Behavioral Health. I'm Selina Mason, the Director of Marketing and Outreach. Today, we welcome Amy Moor, Clinical Coordinator for Elk River Treatment Program. Thank you, Amy, for taking time out of your busy schedule to talk to us today.

Amy
Thanks for having me, Selina.

Selina
When did you join the team at Elk River?

Amy
I have been with Elk River since May 2015. So going on six years, this year.

Selina
Wow. That's awesome.

Amy
Yeah, I can't believe it's been that long.

Selina
Yeah, it's gone fast, and you've had a couple of kids since then, right?

Amy
Yes. Add some more to the treatment team.

Selina
To be students? No, no, no. I'm kidding. What experience did you have when you joined Elk River?

Amy
I came from an adult substance abuse program and I was honestly scared to work with teens. We did have a teenage program at the place that I worked previously. I didn't have a lot of experience with them, and they were kind of like this anomaly to me. And so I was nervous, but I had people who worked at the program who introduced it to me. And I liked the style of therapy that I heard about. And so I became interested. And when I joined, I was just amazed with the team approach. That was very different from what I came from, as far as how all of the staff worked together, from the medical director to the psychiatrist, you know, all the way down to our group leaders, and how everyone had a say in a client's treatment. It was really cool.

Selina
So that comes into play twice a week when you have treatment team meetings, right?

Amy
Yes. Well, twice a week when we actually meet with the psychiatrist and then once a week is our big treatment team where everyone is involved.

Selina
Amy, I'm sure you get a lot of questions from parents once their child is admitted to the program. I know they're in crisis when they call admissions, so we go through the process of assessments and evaluations and see if they're a good fit. Then they're admitted to the program. Then, say you are assigned as their therapist, their primary therapist. They have a lot of questions for you. Can you maybe answer some of those questions, maybe the most common questions they ask?

Amy
Yeah. So, you know, in general they want to know how we do things clinically. And so first and foremost, we function in a “positive peer culture” manner, meaning that the majority of our therapeutic work is done in a group format. And that may be different from what they've experienced on either an outpatient basis or even in other programs. And that's okay. We all have our different styles, but we have found that, for our setting, the group dynamic works the best with the kids. Peers are really important to this age population. And so being in a mixture of kids that are taking emotional risks and working to change their behaviors and seeing that there are positive consequences for the other teenagers in the program, doing that tends to motivate other kids to want to participate in that too.

While group is our priority, we do also have individual work that we do with our clients, including the family. Families receive weekly update calls from the therapist that's working with their child. We also have sessions with the families and the child either via phone or Zoom - given the nature of today's day and age, we've had to cross over into the virtual world. We also have on-campus visits that parents are able to also participate in - a training where we educate them and assist them and support them in their journey.

Selina
I'm guessing it’s important that they're practicing the things that they're learning with their child, and that the child is practicing. Maybe better communication skills with their parents. And so that one-on-one with their parents on campus has got to be a good practice for them.

Amy
Very much. The family component is vital to a kid's success. I like to use the example of maybe a mobile that you would put above an infant’s crib. You know, it works all balanced together, so when one of those tiers is not active, everything's off-balance. And that's how a family is, you know, we are all united and we all work together towards one goal as a family. And when one person is off, it is not just the one person's fault or responsibility to fix it. It is everybody’s, because we're a family and a solid unit. And so those family interactions are really important. And like you said, helping improve that communication. But also learning how to parent differently, you know - we as parents - there is no manual that comes with our child when they're born.

Selina
I also found that out.

Amy
Exactly. I'm in process of finding that out. We parent based off of how we were parented, and if we haven't done the therapeutic work that may be necessary, depending on some of our backgrounds, you know, our child is not us. And so parenting them the way we were parented sometimes doesn't work.

Selina
Right. Well, it's a different age.

Amy
Yes, it definitely is. And so being able to receive the training that we provide, but also figure out how to interact with your child in a different way is vital too, which is also why we encourage the family not just to participate in our part of the programs that involve the family, but how vital it is for families to do their own therapeutic work during this time.

Selina
So they should be in therapy at home while their child is in therapy at Elk River.

Amy
Yes. And in therapy, not talking about their child but addressing instead how they parent their child, or maybe how they were raised, and how it impacts their ability to parent their child, or just maybe any unresolved trauma that they may have themselves.

Selina
Do you find that it's common with parents whose children are at the program to discover something about themselves while their child is in treatment?

Amy
Yeah. We've had some parents that say they have discovered things about themselves because we actually asked the parents to do the same therapeutic work that we asked the kids to do. Our base model is a cognitive behavior therapy tool called the Courage Circle. And we asked the parents to do their own Courage Circle as well, and take that to their therapist. And so sometimes they may find something new or they may just make some realizations or connections that maybe they didn't have previously. There’s a variety of directions it can go for families.

Selina
Okay. The Courage Circle. Can you explain to me what that exercise is?

Amy
The Courage Circle is how we help our kids connect their thoughts and their feelings and their behaviors together. When it's drawn out on a piece of paper, it looks like a big ol’ bullseye. In the center of that bullseye is what we call ‘core issues.’ At Elk River, we believe that we all have losses that were out of our control in our life. And those losses could be a variety of things. Sometimes they're really obvious, like different forms of abuse or abandonment or death, things of that nature. Or sometimes it can be more covert - what we call ‘adverse childhood experiences,’ where it could be divorce, moving a lot, growing up in a neighborhood where your safety was at risk, or growing up with a parent or family member that's important to you in jail or having their own mental health issues, things of that nature.

And so that's what they eventually get to identify. Most kids are not able to identify that in the beginning. Our goal with the Courage Circle is to have them work inwards. And so we encourage them to look on those outward circles before core issues. The next one is their feelings and being able to look at what feelings are related to those core issues. The third circle is the behaviors. So you've got core issues and feelings and thoughts, and then negative behaviors. And typically negative behaviors are where we have the kids start. That's the most obvious and easiest to identify. And the very last, fourth circle of the Courage Circle is new tools and coping skills. That's typically towards the end of the program that we really have them hone in on that circle.

Selina
Let's give parents an example of negative behavior. Maybe some out-of-control anger over a situation that you really don't think warrants it. Would you stop the group at that point and try to process with that child what that behavior might be connected to?

Amy
Yeah, they're exhibiting something like that in the moment. Definitely. We would want to be able to deescalate that situation and help walk them through. “What do you feel” and “what's going on underneath that” and for our kids, helping them understand that, as has been discussed in a previous broadcast, that anger is an action. What is the true feeling underneath that sadness, that hurt, that disrespect? While we have our clients, we definitely want to address things in the moment, in real time. So they're able to walk through this process.

Selina
So they're not sitting in like a dorm room type atmosphere waiting on group. They're actually doing something, say something happens positive or negative, and you're able to process that right then.

Amy
Yep. Very much. So we've got our group leaders that go through a very thorough training. Most of them also have backgrounds in mental health and criminal justice, something of that nature. So they're very skilled to be able to see in the moment what's going on and be able to help the clients in those moments, say, “What's this behavior about?” and “What is that connected to?”

Selina
Do they connect this to core issues? Or do they just try to take a stab at it every day? I mean, is this something that you work on every week? You know, every few days, do they work on a Courage Circle? Does it change?

Amy
Yeah. Great questions. So we have a Courage Circle group that they do once a week while with us, but this language and this approach we use every day. It does take a little bit of time, you know, for most of our kids, when they first come in the Courage Circle, they tend to be very blaming with the Courage Circle. And so to your other question: does it change? It does. A lot of times it's, well, “It's their fault. That's why I was acting this way” versus towards the end, when a client is getting ready to graduate from the program, there's a little bit more ownership. An example I like to use is this – say there’s a teen that tends to punch holes in the walls when they get angry. In the beginning, when they first get to the program, the Courage Circle, it may be, well, “Mom and Dad fighting makes me punch holes in the walls cause I'm angry.” Oh, okay. And you know, parents may be able to say, “Yeah, we do fight a lot.” But I still don't understand how that makes you punch a hole in the wall. And so, as they go through the program, it may progress to, “Well, it's not anger. It's actually ‘scared’ when you guys are fighting. And that's what makes me punch a hole in the wall.” Okay. You’re giving me a little bit more information, and hopefully by the time they leave the conversation becomes: “Well, Mom and Dad, when you guys fight, you say really scary things to each other and you talk about divorcing each other. And I get really scared and I don't know what to do with that. And so I want you guys to stop fighting. So then I punch a hole in the wall to distract you guys, so you guys don't say those things anymore.” Now we're addressing what is going on in the family, which is a true thing, but the client has taken ownership for the choices that they're making in that moment and being able to connect everything together. And so now we're able to do the work: “How do we work together as a family to communicate and fight in a healthy way?” Also how does the client learn to express or deal with their feelings of scared in a more productive way?

Selina
So that would be that last circle on better coping skills.

Amy
Yep. Definitely. Some of those coping skills may be journaling. What we use the most at our program is journaling and communicating. I have yet to meet a kid who can't tell me a healthy coping skill. The issue is what is preventing them from choosing to use that healthy coping skill. And that's where those initial circles of the Courage Circle assist in that process. We have found that talking to the family, attending therapy, and journaling are the three basic foundations of a client being able to deal with what they need to in a more productive manner.

Selina
Can you tell me why journaling is so important even with adults? I'm sure most teenagers don't journal.

Amy
No, they think that we're crazy when we first ask them to do it. And typically with a pen, yes. Old school pen-and-paper, doing the journal (and not text words you know,) actually full sentences and that whole process. It’s also not a diary: most of the time kids initially approach it as if it's a diary, you know, “Today, the sun was shining and we started off eating biscuits and gravy. And you know, this is what I did today. And this is what so-and-so said…” versus true journaling: “This is the feeling that came up for me, or this is the behavior that was going on. And this is what I was feeling in that moment. And this is the hurt that I have” Most of our kids, once they get in the habit of journaling, find that it's really beneficial for them. And it's because our brain works in a couple of different ways. You know, talking serves one purpose for us, thinking serves another purpose for us, writing serves another purpose. And when we put all of that together which writing allows us to do, it's making all parts of our brain work on the one issue. And so we're able to accomplish more in problem solving.

Selina
Something that I hear a lot in the recovery world is, “I just got in my head, I was just in my head.” I didn't understand what that meant. Later, I think through Elk River, I realized that writing something down allows me to get it ‘out’ of my head so I'm not in that constant merry-go-round where I can’t concentrate on anything else because this one thing is plaguing my brain cells. If I can get those out on paper, it doesn't solve the problem, but it certainly releases some of that tension. At least, some of the tension.

Amy
And it also helps us to realize maybe what we have to do. I can talk anything into sounding really good inside my head, because I have no one else competing with me. I have no one else hearing it, and saying “Amy, that's not great.” But when I take what's in my thoughts and I put it on paper and I read it out loud, sometimes it's like, “Well, that doesn't make much sense,” or “No, that's not exactly true.” Or I'm able just to confront maybe what the issues are related to that, and be able to realize maybe I'm minimizing something or maybe I'm making something a really big deal and it's not that big of a deal. Maybe it just flat-out doesn't make sense at all. And so it helps give us some clarity for sure.

Selina
Do kids learn to recognize patterns of their behaviors and identify maybe certain triggers?

Amy
With substance abuse, we are able to recognize what feelings they are attempting to cover or avoid or change. Substance abuse is all about putting yourself into a different state. And so being able to figure out what it is about your sober state that you are uncomfortable with, and what leads to you choosing the substances . . .

Selina
Because a lot of parents admit their children when they believe that their substance use is out of control. I certainly would agree with that. Safety is a number-one issue here. We want to make sure the kids are safe, but it's almost never really just substance abuse that's going on. Am I right?

Amy
Correct. Yeah. We are not just substance abuse treatment, but we also manage everything else that comes along with it. With substance abuse, what we explain to the kids in regards to the Courage Circle is: that's a behavior yes (it's in our diagnosing manual for clinicians) but it's a behavior. And so what is it that you're trying to treat with that behavior? And most of the time they're able to relate it to sadness and hurt and anxiety or thinking errors or “I feel alone and I have found this peer group that participates in this. And so I want to be with that peer group.” And so we're able to help them identify, well, “What's going on for you? Why is being a part of this peer group, who's doing these behaviors, so important for you?”

So yes, it’s usually a lot more than just the substance use at hand. As kids get used to journaling and putting their words to paper, we also actually have them continue practicing that skill by communicating with their family through letter writing. I mentioned that we have phone sessions and Zoom sessions and the parent visits, but in-between all of that, we still want families working on their communication. We still want kids explaining what they're learning about the Courage Circle and what they're learning about themselves. And so they do this through letter writing. And again, that's another way to help take what's in your thoughts and put pen to paper - it slows the communication process down, which is actually really beneficial in today's day and age. Everything is done so fast, and you're tweeting that thought or sending that text or shooting that email before you're able to really think it through, and you can't take it back. And then you're having to cover that up. So writing slows it down a lot, which allows them to be able to hear what the other person is saying, and then come up with a response. It's actually pretty cool to see a lot of our families choose to have a family journal to keep this method going when they bring a child home, because they have found that it helps open up that door of communication.

Selina
That's really interesting. I know it's an important part of the therapeutic process. To wrap up, can you revisit the Courage Circle? The center is the core issue or core issues. But you start with the negative behaviors or the maladaptive behaviors, right?

Amy
Correct. That’s the easier way to do it. If a child is exhibiting maladaptive behaviors, you're helping them trace that to the core issues, you know, “How do they get there? What's that journey?” Yes. So they start by identifying those negative or maladaptive behaviors: running away, drug use, yelling, fighting, self-harm, suicidal ideation, whatever the case may be. And the next question is: “How do you feel when those things are happening? What feeling is going on before you make the choice to do one of those things?” That’s typically ‘anger,’ or a lot of times kids will use ‘depression.’ We try to keep them away from using clinical words, like ‘depression,’ and ‘anxiety.’ We want them to talk about ‘scared,’ and ‘sad’ because ‘depression’ is actually the absence of feeling. We want them to be able to tap into what it is that's truly being experienced in the body. So we help them fine-tune that. Some of our kids also don't really know “feelings language.” So just learning, my go-to is: “mad, sad, glad, and scared.”

Let's start there. Those are four basic feelings. Then we can branch out after that. So they identify those feelings or maybe those thinking errors, you know, having self-harm thoughts or thoughts such as: “I don't feel like I have any worth.” Okay. Well now let's talk about you got the message that you don't have any worth, and where did you get that perception from? Or where have you felt sad before, where have you felt disrespected before? That typically lines them up with that core issue or that loss that was out of their control, that they have some really big feelings about.

Selina
So core issues actually drive. Certain core issues create feelings that drive behaviors.

Amy
Yes.

Selina
And then we can replace the behaviors with a more positive coping skill.

Amy
Yeah, exactly. And learn how to grieve those losses and deal with those feelings.

Selina
Now, is it good for parents to do their own Courage Circle?

Amy
Oh, for sure. For sure. I already talked about it. It'd be great for them to do the Courage Circle and be able to take to their therapist. Even if they feel like they have been through their own therapy and worked through all of that. If you've got a kid that's in treatment, that's a perfect opportunity just to go in for that “oil change,” so to speak, and get that tune-up in therapy and just make sure you've covered it.

Selina
Well, we can never learn too much, I can say that. Thanks for listening to On Air with Elk River Treatment Program, the residential program at Pinnacle Behavioral Health. And thank you, Amy for joining us today. To learn more about our residential program for teens, visit ElkRiverTreatment.com, or send an email to [email protected]. You can also call us directly at 866-906-8336. Thanks again. And we hope you'll join us next time, on air.