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Chandra Ghosh Ippen, Ph.D. - Guest
Chandra Ghosh Ippen, Ph.D. is a child trauma psychologist specializing in working with families with children under age 6. She is co-developer of Child-Parent Psychotherapy, the associate director of the Child Trauma Research Program at the University of California, San Francisco, and a member of the Board of Directors of Zero to Three. She has spent over 30 years conducting clinical work, research, and training in the area of childhood trauma and diversity-informed practice. She is also an award-winning children’s book author and has written 5 children’s books as well as the free Trinka and Sam disaster series, which has been translated and distributed to over 400,000 families around the world. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:32):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.Today I'll be speaking with Chandra Ghosh Ippen, Ph.D. who is a child trauma psychologist specializing in working with families with children under age six.
Keith Sutton, Psy.D. (02:28):
She's co-developer of Child Parent Psychotherapy, the Associate Director of Child Trauma Research Program at the University of California San Francisco, and a member of the board of Directors of zero to three. She has spent over 30 years conducting clinical work, research and training in the area of childhood trauma and diversity informed practice. She's also an award-winning children's book author and has written five children's books as well as the Free Trinka and Sam Disaster series, which has been translated and distributed to over 400,000 families around the world. Let's listen to the interview. Well, hi, Chandra. Welcome.
Chandra Ghosh Ippen, Ph.D. (03:04):
Thank you. Yeah, thank you for all
Keith Sutton, Psy.D. (03:06):
Me. Thanks so much for joining me today. So, uh, yeah, I was really interested in the work that you're doing and particularly, you know, I learned about child parent psychotherapy many years ago. I'm in the San Francisco Bay area, and I forget if I knew somebody that was training there or somebody had mentioned it. I had gotten some of the books and learned a little bit about it, but I, I really wanted to interview because, you know, I'm very interested in, you know, working with children and families, and you have such a unique program that's particularly addressing trauma and young children, very young children, and so would love to hear about your work and I know there's been a lot of great research and, and kind of what you all are doing now. Um, but I always like to start off and find out about your path and kind of how you got to doing what you're doing or your evolution of your thinking that got to doing this work with the child, child parent psychotherapy.
Chandra Ghosh Ippen, Ph.D. (04:03):
Um, I'm smiling because people often say, when did you start in the field? Hmm. And, um, I grew up in San Francisco with two parents who were both child welfare workers, and I am an only child and so if you can imagine, um, my dinner conversation, you know, they did ask me about my day. But I heard a lot about their day, and so I heard a lot about stress, trauma, and families who were experiencing a lot of difficulty. And I also heard some stories of hope and ways that they've been able to help people. Um, but I think that was a lot of my early learning around the dinner table. And then before the age of six, I grew up in San Francisco and Marin, six of my friends' parents had cancer. And three of them died and nobody talked about it.
Chandra Ghosh Ippen, Ph.D. (04:53):
Um, but I think we were, many of us were very significantly affected by this, just the idea that this could happen, um, that it could happen to people that you cared about, that it could happen to your own family. And so I grew up really wanting to be a cancer doctor. I wanted to find a cure for cancer, and I ended up being very driven. And at the age of 16, wound up at California Pacific Medical Center during an internship with a pathologist. On the first day they took me into see an autopsy, and then they had me to learn blood draws and other things. And then they ran outta things for me to do. And they said, why don't you go hang out on the units? And I did. And I ended up meeting the parents and the children, and I ended up talking to them, and I ended up seeing kind of a little bit of what they needed, just trying to be helpful in some ways. And some of the parents ended up pulling me aside, and I remember one said to me, she said, you know, you're the only one who treats her like a kid.
Chandra Ghosh Ippen, Ph.D. (05:50):
And that, that's so important. And that some of them were spontaneously talking about what it was like to have cancer as a teenager. And I was a teenager or a little kid about his fears and worries. And I became really interested in kind of the idea that we were helping people's health, but we weren't attuning to their emotional needs. So what was it like to grow up in that way? And I thought that at the very least, I would become a doctor who understood that and went to Berkeley and studied psychology. And as I was there, I think things took a turn. And that ended up being where I ended up. And I think as I did that, I went and I worked at Lincoln Child Center where it was, um, in Oakland. And I think what was interesting is, um, this was back in the 1980s
Chandra Ghosh Ippen, Ph.D. (06:39):
Um, we weren't trained a lot about trauma. Um, we were told that children were SED, which was severely emotionally disturbed. And I think I really wish, I wish they wouldn't label kids, but also if they are going to, I mean, I just think if they told us that they were significantly exposed to danger and that they might not trust me. And there would be some. So I think what I recognized is that as the person who was around the clock with these kids, six to 12 stories were pouring out of them. Inopportune times like bedtime bathtime when you're trying to go. So, and I wouldn't say that they're inopportune. Every, every moment that they share is opportune. Sure. But I recognize that I didn't know what I was doing. And so I said, let me get myself back to graduate school.
Chandra Ghosh Ippen, Ph.D. (07:24):
And I just kept moving younger and younger 'cause I think I remembered in myself, I knew from my own history, um, it's always funny, like we, we do end up very influenced by our experiences. I knew from my history, um, that young children, very little children have these stories inside them. You know, my friends who grew up with their parents with cancer that was inside them, one of my neighbors had a mental health breakdown, and I was the babysitter for her two kids who were at the time, you know, about four and six and maybe actually three and six. And so just, it seemed like the things that I was reading in the textbooks weren't quite right. About young children, about their ability to process about whether they could do therapy. And so I did all of the evidence-based models. I was very fortunate to study at USC and John Weiss was there, and we learned
Chandra Ghosh Ippen, Ph.D. (08:17):
Because he came, we learned a lot of evidence-based models. But I really was looking for something. Um, there was a lot of parenting that I studied. But I was what, what opens up to the emotional life of the child. And that, you know, Alicia's book is the emotional life of the toddler. Mm-hmm <affirmative>. I very fortunately got my pre-doc postdoc at UCSF. And when I saw what Alicia and Patricia were doing, that was in 1998, the program was newly formed in 1996. I said, wow, this is different than anything else I've learned. This really attunes to the, the, the kind of the, the lived and the fantasy experience of little kids, and also the wisdom that the people to help small children are their loved ones. And, and it really goes back to that they share things at what I would call, you know, the moment when like when therapists aren't around, we're not around at bad times, we're not around at, but we're not around at the park when the dog is barking and the child is scared.
Chandra Ghosh Ippen, Ph.D. (09:17):
And, you know, you really see how, you know, how does a parent, like most parents, like love their kids, wanna help their kids. Right. Even if they're the ones who have unfortunately even harmed their kids. That's sometimes the worst thing to happen to a parent. But I think we've been told that it could hurt the child if we bring it up. So we've actually been gagged in some ways from our instinct. And little kids, they share what's inside them. In code. Like it's this interesting mixture of fantasy and symbolism, metaphor, reality all mixed together. And so there is like, I think about there is a different language that they speak. Some kids are quite clear and transparent and other kids, like they'll bring three baby dolls and say, you know, the babies, you know, bad things are happening.
Chandra Ghosh Ippen, Ph.D. (10:16):
And you're like, but concretely, there aren't three baby dolls. Or they'll do it with cars. Like the little, the car falls off the cliff and Oh no, it got hurt and it's broken and nobody can help it. Right. And I think some parents completely understand that that could be a metaphor for them and for life crashing and whatnot. And they're not always, I'm sort of digressing all over the place, but I think, I hope what you get a sense of is there's, I think the need and the beauty of supporting repair. Um, especially we know this is what families really want and we can, we, I was also the associate research director. So I ran our randomized trial and was able to really be a part of looking at whether or not this was efficacious. And it was, there were, there have been five randomized trials of CPP and we can see all sorts of outcome measures changing.
Chandra Ghosh Ippen, Ph.D. (11:09):
And it's not just symptoms. Sure. It, it actually changes in the stories that children tell, which I think it changes in their, um, I mean, I wouldn't call it IQ, but in their testing scores. Actually we have new data out about their neurobiology and about cellular aging, cortisol levels. So we're seeing some, like, just the idea that a psychosocial treatment could have a biological impact is really amazing. And, and then we know that the brain is most rapidly developing in the zero to three and still, you know, three to five age range that it's not like I always say to people, 'cause they'll say, do young children remember? Part, part of me is like, yes, because I've seen what they've shown. But I would also say, um, that's probably the wrong question. It's not what they remember, it's what they learned.
Chandra Ghosh Ippen, Ph.D. (12:01):
And so you're learning like, am I safe? Am I lovable? Am I capable? Am I seen all of those things that form the template for what, you know, psychotherapists are also addressing later on. And that's developing a relationship. And so we just, you know, I think the whole notion of how important early childhood is. And how much stress and trauma can affect it and, and that repair is possible. And so, you know, I, I think that was sort of my evolution and that's why I've stayed here. 'cause I'm sure this is, it's kind of amazing and exciting and we need more and more people to understand this so that we stop saying that little kids are too little.
Keith Sutton, Psy.D. (12:43):
Yeah. Yeah. Right.
Chandra Ghosh Ippen, Ph.D. (12:44):
So like, some people will not work in this age range, but none of us should be saying little kids are too little. Or none of us should say that it, you know, they'll forget or they'll grow out of
Keith Sutton, Psy.D. (12:53):
It. Yeah. Or like, there's nothing you can do or they'll grow out of it. Exactly. Yeah. And it sounds like you're saying too, that there's this piece you're saying about the parents, right. Being there at those times, right. At bathtime, at bedtime, and the therapist isn't necessarily there at those moments. And so involving the parents in this and, and helping to have that repair as well as the kids having this their own emotional language. And, you know, I think that, you know, part of the work right. Is also helping the parents to learn this emotional language to, to how to be able to read what's going on or what the kids are communicating. Is that what's also part of the work in the CPP?
Chandra Ghosh Ippen, Ph.D. (13:34):
Yeah, we have many different ways of phrasing this, but we think about how do we enhance attunement. So how do we think about supporting the caregiver in noticing the child and where it might take them? How do we enhance a parent's reflective, functioning, thinking about the possible meaning of the, of the child's behavior and where it's coming from. So, and I think some parents walk through the door and they're already incredibly attuned and doing that. And other parents, maybe because of their own history and what they've been through, um, that's more challenging. And I think we believe in the parallel process. And so it's less me teaching you and more, you know, like Jury Paul, one of the, you know, grandmothers of infant mental health, she said, do unto others is you would have others do unto others. And so there's very much of the parallel process of how am I being with you? Am I being attuned to you? How might I be holding your suffering? How might I be seeing you? And there's a, there's a lived a lived kind of exchange between us. Sure. And I think, um, there's a great quote from Selma Fryberg of why does the parent not hear the baby's cries?
Chandra Ghosh Ippen, Ph.D. (14:49):
And the answer to this is perhaps because nobody heard her cries.
Keith Sutton, Psy.D. (14:54):
Mm-hmm.
Chandra Ghosh Ippen, Ph.D. (14:55):
And so it's, it's a, I think it, it puts us as therapists in a, I would say initially it can be a challenge if, if we came into the field as child people. Sure. Because we, like, for example, even just with a crying baby, we hear a crying baby. And our neurobiology is like, Ooh, do something about the crying baby. Right. So as, and as therapists we're often thinking, we must fix, we must jump, we must do. Yeah.
Keith Sutton, Psy.D. (15:18):
Yeah. Make it better.
Chandra Ghosh Ippen, Ph.D. (15:20):
Yeah. And if you have a parent where, you know, systems or life or society has sort of made them feel like they're not capable, they're not seen that they've sometimes been pushed down and I pick up your baby and your baby stops crying.
Keith Sutton, Psy.D. (15:34):
Yeah.
Chandra Ghosh Ippen, Ph.D. (15:35):
Or I do something, or I tell you what to do, and we don't have a connection that could be dreadful. M Like, there are some cases where parents like, please tell me what to do and it would be withholding of me not to support you.
Keith Sutton, Psy.D. (15:46):
Sure. Sure.
Chandra Ghosh Ippen, Ph.D. (15:47):
And there are other cases where it's like, oh dear, or Now I've just confirmed your belief that you are not capable. And then how does that help you in terms of stepping into the role of being, I love the words of circle of security is a good attachment figure is bigger, wiser, stronger kind. Right. But that, that comes from the inside out. Right. And so sometimes in our model, a little bit less is more. So like you catch these moments where the parent is attuned. And you sort of notice and you say, your mommy is looking at you. Right. Or your daddy or your uncle. Your uncle knew what you needed. And so, and then, and I think Linda Gilkerson, who's also another one of, you know, the grandmothers offa health, she says glow with them. Right. So just think about these very simple interventions where what behind that is I see you, I see, I see the beauty in you. I see what you're doing. Right. And do you see you,
Keith Sutton, Psy.D. (16:52):
Yeah. Right. Like the parent to kind of like to, to reflect them almost. Right. Like that looking glass theory of self, like kind of being able to see them and them even seeing you, seeing them.
Chandra Ghosh Ippen, Ph.D. (17:07):
Well, and that's actually like, you know, if you're ever with like a baby and you're watching a baby, and you're like, like, oh my God, they have the rattle. And they're like, I mean, and I'm not trying to put parents in that position. Yeah. But there's a feeling that transmits when you're watching it and there's a care and, and that's that attunement that is, it's very organic. It's not a skill. Like I would say that the gut is somehow involved when you're doing that.
Keith Sutton, Psy.D. (17:32):
Sure, sure. Yeah. Needing to kind of connect with that kind of initial reaction of that, that glow or whatever it might be that you're then able to go with maybe then overthink or intellectualize or something like that and trying to do a technique.
Chandra Ghosh Ippen, Ph.D. (17:49):
Yeah. Like sometimes we're bearing witness. Right. And, we also bear witness to struggle. So we see moments when things are not going well. I think, you know, I think I've just sort of segued into talking about the model. I think that where CPP is really different is that, um, you know, we have, we have a lot of mantras, but we say we speak the unspeakable. Which means that if you are working with a child and you know, you think about what are the experiences that they've been through. And so it wouldn't be a model, for example, where like a parent might come in and say, here's this child, they're misbehaving, we'd like you to do something about this. Three or four, they're tantruming way too much. And I think we would want to understand that, understand the parent's concerns, and then we really wanna understand their history.
Chandra Ghosh Ippen, Ph.D. (18:44):
And part of what we feel like we need to ask about is whether there have been stressful or traumatic experiences that have happened. And so we are, we're really starting alone with a caregiver in terms of some people are walking through the door, you know, calling because something has happened. Sure. Um, for some reason, like their child has seen violence or had a medical trauma or been in a car accident where something, you know, happened. And sometimes they're, you know, they're thinking more about the problem. Sure, sure. Um, and so I think we, I guess maybe the clearest way, hopefully I'm not all over the place, so I'm a very visual person. Sure, sure. I'm sort of guided by our visual, which is a triangle, but it's very different from other, like, I always, we always joke and say every other model had a triangle, so we wanted to.
Chandra Ghosh Ippen, Ph.D. (19:36):
So our triangle, we start with the right side, and on the right side of our triangle, if you draw it, we would put like symptoms and behaviors. And you could think about, you know, the child is hitting or not sleeping or tantruming. And on the left side, we start with curiosity. Mm. Um, 'cause we have a mantra, do not target for change what you do not yet understand. Okay. And so really thinking about what is the experience that might have connected, and I just wanna say the experience could be a genetic experience. It could be a prenatal experience, it could be, um, an experience of danger that the child has been through. Right. So it could be that people in the home are fighting. You know, and that's resulting in this because the kid is carrying a lot of angst inside and is also seeing that when people get angry, this is what happens.
Chandra Ghosh Ippen, Ph.D. (20:27):
And, um, and we also wanna understand like, what has the parent been through? And so what's the parent's experience? What is the cultural, you know, what in terms of, of the cultural group history and how does, how does that also contribute? And then once we have this, the bottom of the triangle is kind of our plan, and we make a much better plan. And so, and then around that we put protective steps and hope. Now this is sort of a simplified version of our triangle. It's always kind of connecting experience with functioning. So if somebody is walking in and they're only talking about like, Ugh, this problem and this problem, this problem, and some strengths.
Keith Sutton, Psy.D. (21:03):
Sure.
Chandra Ghosh Ippen, Ph.D. (21:04):
We would be curious and I would wanna earn the right to hear their story.
Keith Sutton, Psy.D. (21:09):
Yes. Yes.
Chandra Ghosh Ippen, Ph.D. (21:10):
Right. And then, you know, that's the parents' understanding of the story. And it's not, I, I wanna make sure that it's not event focused.
Keith Sutton, Psy.D. (21:20):
<affirmative>.
Chandra Ghosh Ippen, Ph.D. (21:21):
Like, because, you know, we really think about, like, so for example, um, if I'm a little kid and I had medical trauma. Then I had a car accident, and then I had my, my loved ones were fighting because they were stressed out. And then somebody left. It's not just about one event. It's about how these events kind of might form themes. That sometimes bodies get hurt. Sometimes people go away, sometimes we're not safe. Yeah. Does that make sense?
Keith Sutton, Psy.D. (21:55):
Yeah. So they, the, so when you're listening to the stories about what has happened, you're looking for those themes. Is that kind of what you're saying?
Chandra Ghosh Ippen, Ph.D. (22:05):
I'm looking both for themes and for like experiences. And I'm also looking, sometimes it depends on the, you know, the affect of state of the caregiver. Like, you don't want to, you don't wanna fry them. But if they're able to tell you about it, it can be really helpful. So, for example, and I remember a parent who was talking about her partner who was very violent. She talked about how, um, how scary it was and that they had to run to the bathroom and barricade themselves in the bathroom. Now everybody thought her kid was autistic because of the way he interacted and played. Right. And I wasn't sure what it would look like when he came into treatment. And I said, I started this whole story off by saying, we speak the unspeakable. So we don't bring the child in until after we've really met with the caregiver, got some sense of story, and really also thought about how can we begin treatment with a little one.
Chandra Ghosh Ippen, Ph.D. (23:04):
And when we begin, we begin by what I would say is opening the door and we use the elements of the triangle. So with this little boy, you know, I would've said, you know, I said, you know, mommy told me that when you were really little, things were really scary in your house. Right. And this was something that was known as a fact 'cause we don't like to plant things. And I said that mama told me that sometimes daddy had problems and he got really scary. And this kid turned away and he went away and he started like throwing furniture. He could just think, oh, he is really disruptive. But then he took all the furniture and he threw it in the bathroom.
Keith Sutton, Psy.D. (23:44):
Oh, interesting. Okay.
Chandra Ghosh Ippen, Ph.D. (23:45):
<laugh>. Yeah. Yeah.
Chandra Ghosh Ippen, Ph.D. (23:47):
Now if, if you don't know that little detail, yeah. You might have a very different interpretation. Right. And of course you can't know everything. So there are times when you, like, just yesterday I was in a session and I was with a grandfather and a child who's witnessed a murder, and that's ostensibly why they're there. But her mom had also had problems. And this child put a little figure all alone in the house and then said, A stranger is coming to the door. And then had the little figure hide. And that was not part of what she went through in witnessing the murder that we know of and so we were looking at this and, you know, he said, we don't have strangers coming, but he said, ah, but when she lived with her other family member, there were a lot of people who came in and out.
Keith Sutton, Psy.D. (24:37):
<affirmative>.
Chandra Ghosh Ippen, Ph.D. (24:37):
And so, and that's just one example of like, there's a way that we start with caregivers to think about what we might do together. Like, we're not clairvoyant. But we're not, like, we're not causing the child to play things. But we're opening the door and things might come out, and then as they come out, we might be thinking together about, huh, I wonder kind of how this might be connected to what they went through. Yeah. Does that, does that make sense?
Keith Sutton, Psy.D. (25:04):
Yeah. So you're meeting with the parents to kind of like, get the stories and understand so that when you are bringing the kids in, you might have something that helps make sense of, of how they're playing or how they're interacting. And you're also kind of speaking the unspeakable, whereas maybe other therapists who are just doing child play therapy, you know, where they might not bring up or talk about the trauma or so on, or kind of speak it, but instead kind of just be playing and play even though they're working on the trauma work. And tell me about that piece, about bringing up the unspeakable. Like how does that, I'm just curious about the flow of the session. Like where does that come in? Because I think that that is something that, you know, I do differently with children than I do with teenagers. It's like, you know, if I've got a child under 10, we'll have the, I have a parent session first, then I have the kid and the parents, and I kind of do some narrative kind of, you know, stuff with them, narrative therapy stuff. But then with a teenager, I'll have them all together in the first session. I'm curious about how you think about that in that first session where you bring that in and talk about the thing that happened.
Chandra Ghosh Ippen, Ph.D. (26:19):
Yeah. So in child parent psychotherapy, we have what we call a foundational phase. And so the foundational phase can be four to six. Sometimes it's a little bit longer, and we'll just start with when it's one parent and a child 'cause often it's two parents, or it's three caregivers, or, you know, because there's children with lots of people involved in their lives and sometimes they're siblings. So we'll just start with this simple case. And you know, I already walked you through a little bit of what we wanna know. We wanna understand that the kiddos symptoms, we wanna understand their history, we wanna understand how the caregiver is thinking and feeling about it. I also think that grownups deserve to have a place to fall apart. And so we're also providing a space where this is not the first telling for the grownup, like when the kid gets brought in.
Chandra Ghosh Ippen, Ph.D. (27:05):
Does that make sense? Yeah. Like grownups are not supposed to be robots when the kids come in. But I also really want them to know that like, I mean, I've worked in the area of sexual abuse and death and murders and kids are often bringing things up and it's hard for the grownup. And I want them to feel that I do know that it's hard for them, and we sometimes will have collateral sessions also where they can, you know, in between. But we do all of that pretty much with the grownup alone. Except for when they're billing things. And when they're billing things, we will, might have to start off 'cause in some systems you have to start by seeing the child. But you'll do an observation of the child and the caregiver together, and then you'll figure out a way to meet alone with the caregiver.
Chandra Ghosh Ippen, Ph.D. (27:48):
Does, does that make sense? So I think things get organized according to systems to be practical. Right. And then we typically are doing feedback along the way, but we also have a feedback session where we plan the introduction to the child. And, you know, normally there's no surprises. There are occasions parents where, um, they have, they have been mandated by the system or something, and there are some things on the table and other things that aren't on the table. And I think we then have to think about what does that mean and how might, given the circumstances Yeah. Like, there's some children, I mean, I remember a child who sat with me for about five minutes and said, you know, he was four. He said, my dad took a gun to my mom's head, and he looked at me and goes, that wasn't cool, was it?
Chandra Ghosh Ippen, Ph.D. (28:38):
No. And I said, no, it wasn't cool. And I was just the person sitting with him. Well, if his mom says he remembers nothing about it and I don't wanna bring it up, we wanna honor her wish that he doesn't hear. And we wanna go at a pace that makes sense for her. Yeah. But it wouldn't be kind of holding the child. We, we call it dia, we have many different aspects of fidelity, but, uh, but dynamic relational fidelity asks us to hold the perspective of the caregiver and the perspective of the child. And so we would be thinking about, well, we can't just kind of vote with the parent and leave the kid out there. But we do wanna hold the pain of the parent or the fear of the parent that we're part of a system that often moves kids if, and like, how do I help them to feel safe? So there's, there's nuance in that, but then we come to some kind of agreement of what can be spoken. And if it can't be spoken, what if the kid brings it up? Yes. Okay. We start off this way in. Now there's some children like that little boy who are gonna walk through the door and tell you all kinds of stuff.
Keith Sutton, Psy.D. (29:45):
Put it right out there.
Chandra Ghosh Ippen, Ph.D. (29:46):
Put it right out there at the age of four or three, sometimes even two. You know, just comes right out. And there are other kids, where there's a great article called by John Bowley called Unknowing, what you're Not supposed to Know and Feeling What you're Not supposed to Feel. Great title, great article. Yeah.
Chandra Ghosh Ippen, Ph.D. (30:04):
But where the gist is basically that very young children, they often know things that adults would prefer, they not know. They see things that adults would prefer that they not see. And that I have a choice because I'm a social referencing being. So when I hold the truth, I might try to communicate my truth to you. Now if as I do this, I fear that I'm going to lose you. Maybe because you become so sad or so overwhelmed, or maybe because you become so angry or you kind of like disappear for me. Or it could be that you physically disappear or like, whoa, where did my grandma go? She's not the same. Then what? Over the course of time, I have a dreadful choice. I can choose you, or I can choose my truth.
Keith Sutton, Psy.D. (30:52):
Yes.
Chandra Ghosh Ippen, Ph.D. (30:53):
Right. And that, that's where Bowlby says a lot of mental health challenges come from, is this, you know, I think this is the psychodynamic psychoanalytic roots of the challenge, but we see it happening in early childhood, and I've worked with parents who in not their best moment, they have screamed to their children to shut up and stop talking about things. Because they're talking about their sexual abuse and it's toxic and it hurts their parents' heart.
Keith Sutton, Psy.D. (31:19):
Yeah. Yeah.
Chandra Ghosh Ippen, Ph.D. (31:20):
You know, so and so how do we as therapists understand, support, hear the parent, and then support, repair. So even that speaking, the unspeakable, I just remember being with, you know, a father who said, I told you to shut up. I'm so sorry. Right. And then, and then the explanation of I was really mad at him because it hurt my heart. Yeah. He could hurt you because you were so precious. But I want you to be able to talk about this. Like, that's the, can you see like the door slammed shut on the conversation? Yeah. Yeah. And it needs to open because otherwise the child comes into therapy with zero permission. Right. And the same is true of like,
Keith Sutton, Psy.D. (32:07):
So sorry, you're starting, you're doing this early in this, in the therapy. Oh, yes. And okay, great. 'cause yeah, this is, uh, so I also and have done some training with attachment based family therapy, for depressed adolescents and have worked with trauma and parents that would get overwhelmed and then just say, well, what do you want me to do? And in part of the repair was helping the kid talk about how abandoning that felt and so on. And Yes. And the parent coming forward, and rather than the kid having to take care of the parent, the parent being able to share up and show up and repair that, that injury, that attachment rupture. And so, that's great. You're getting right into that in the very beginning to kind of make it okay to have that in the room.
Chandra Ghosh Ippen, Ph.D. (32:53):
Yeah. So that, that marks that session where you speak the unspeakable and you open the door, that's the beginning of what we call our core intervention phase.
Keith Sutton, Psy.D. (33:02):
How many sessions in is that with the kid present?
Chandra Ghosh Ippen, Ph.D. (33:06):
Um, so that's zero. I mean, observation, only observation of parent-child observation in the school, the work is with the parent. Sure. And then you bring in the child. So, you know, and that's the introduction to therapy
Keith Sutton, Psy.D. (33:21):
In that session. You, you speak the unspeakable and go right to it.
Chandra Ghosh Ippen, Ph.D. (33:24):
Yeah. And I wanna say that that's
Keith Sutton, Psy.D. (33:25):
Great. Yeah.
Chandra Ghosh Ippen, Ph.D. (33:26):
Just because I speak it doesn't mean I expect the kid's gonna go there. So some kids have turned their back to me, <laugh>.
Keith Sutton, Psy.D. (33:34):
Yeah.
Chandra Ghosh Ippen, Ph.D. (33:34):
And, and then we have, I mean, so we, we say that we do our work, not like, we don't have like a session checklist of this week. Yeah, of course. Except for maybe that one session where we're like, well, let's, you know, it can take the whole session, but you are opening the door, you're presenting what we call the CPP triangle to the child. Yep. Usually with toys and things. Um, but you know, other than that, we're not saying we, you need to get these things done because the kids are under age five. That doesn't work developmentally, right? So we work based on what we call ports of entry, which is a term from Daniel Stern, which is this idea of really a clinical moment. So you have a clinical moment, and then how do you enter, so when a child turns their back to you, that's a clinical moment.
Chandra Ghosh Ippen, Ph.D. (34:21):
And then the question is, what does the therapist do or say in that clinical moment? And so I might say, I guess I said a lot of things that might have been hard to hear. And, and I guess, you know, that he might need to get to know me better. So I'm saying this maybe to the child. Maybe to the parent, and then we might sort of simply play. Now what I've also learned is that some children, like, you know, this is very similar to other models, but, um, you, you think about the window of tolerance. Which is really important, right. In trauma work the metaphor that I use, which can be a little confusing to some people, but I say that our bodies are like cups and that there are times when your cup is full. And what I'm thinking is it's full of adrenaline and cortisol and stress hormones and what not, because, and what I'll say is that children, are smarter than adults because they know that you don't just sit there plowing through something hard. Right. They, they sort of intu because they haven't been socialized to do that. Okay. So they know like, oh, my cup is full. And, and they know they have to get the icky out.
Keith Sutton, Psy.D. (35:33):
Kinda
Chandra Ghosh Ippen, Ph.D. (35:33):
Right? Yeah. So boop yeah. You just did a, like a Right.
Keith Sutton, Psy.D. (35:37):
Yeah. Like turn off to the side and they're like, yep, okay. Like it's too much. So
Chandra Ghosh Ippen, Ph.D. (35:40):
Yesterday I was, yesterday I was in a session and the kid goes, we gotta clean these things up, <laugh> . And I had talked to her, her grandfather, about how this might happen. And so we went, okay, we're gonna clean stuff up. And then she cooked with food toys. We did nurturing play for like 20 minutes, right? And I think that is part of the model as well. 'cause what I would say is we're not a trauma focused therapy. I often say, I say we're trauma forward because we say we are the people with whom you can go there. Yes. But often you have to go there at the speed of the body. Right? So if, if somebody brings something up and your cup gets full, then you might see a kid just, you know, pivot, do something else. Yeah. And ideally that's, that's the attunement of the grownup. How does the grownup understand why the child is pivoting? Yeah. Right. And like, I often think about like, it's almost like playing poker. Where you read the person op opposite you and you think, what's your tell?
Keith Sutton, Psy.D. (36:38):
Yeah.
Chandra Ghosh Ippen, Ph.D. (36:39):
Right. And so some kids, they'll get really physical and start running around the room. Other kids will need to cuddle, other kids will regress and be like babies. But the way the grownup understands, ah, you know, this is hard for them. And to the degree that we let you, you know, again, very window of tolerance, you move away. You move back. And what they learn is you can touch a feeling state and not get stuck in it. You can touch the story and be okay with it. And so you are actually growing a bigger cup.
Keith Sutton, Psy.D. (37:14):
And whereas like a parent might be like, hey, you need to listen or you need to sit here, like, stay with that, rather than like seeing their kind of exit or their shutdown or their, like, you're irritated response as like the cup is too full.
Chandra Ghosh Ippen, Ph.D. (37:29):
Yeah. And, and I think when a parent does that, the first thing I wanna think about is, uh, how do I understand that the parent might be doing that. Right? Because parents want what's best for their children. Right. And so how do I, how do I hold that sense of urgency. Like the need, you know, for your kid to heal fast. You know, get it all out. Because I believe in this like, people who do this will get better, like, you know.
Keith Sutton, Psy.D. (37:58):
Well, and I think even the structure of the therapy, sometimes they want the kids to be good for the, for the doctor or whatever or so on, and doing what they're supposed to be doing and not realizing or, or you know, even embarrassed if the kid's not listening and trying to get them to be a good listener, whatever, rather than, you know, understanding that this is part of the regulation.
Chandra Ghosh Ippen, Ph.D. (38:19):
Yeah. And I mean, what I love about the model is that it's like, you know, when we think about, Alicia calls 'em the pillars, Alicia Lieberman the original developer. She calls 'em the pillars of a therapeutic attitude. And one of our, you know, core pillars is benevolence and the other one is curiosity. Right. And you don't just apply that to kids, you apply that to the grownups and you apply it to yourself. Because there are times when I'm like, oh, why am I doing this <laugh>? Yeah. Yeah. Right. And I come into supervision or into consultation and I'm like, yeah, that was not my best move. But again, that kind of being kind to yourself because we're touching trauma and we're touching very difficult. Like, we're hearing about things that are hard. And so it's only natural that we would have reactions. The parent would have reactions, the kid would have reactions.
Keith Sutton, Psy.D. (39:04):
Yeah. Is there any like, narrative or postmodern kind of elements that are influenced? 'cause I'm hearing things like the curiosity, the witnessing, the benevolence, the kind of that positive perspective. I don't know if that's, if there's any overlap there.
Chandra Ghosh Ippen, Ph.D. (39:22):
I think there's a tremendous amount. I think what you'll see is Alicia says that child parent psychotherapy is good clinical therapy manualized. And so you're gonna see a lot of overlaps with a lot of good therapeutic methods. I think where we differ is that we are wired for young children. And there's a lot of things that, you know, like you really, I mean, and you'll see this with adults, so it's not that it's not applicable, but I used to tell people that I do soundbite therapy. Right. Because little kids will bring things up and then, they're off to something else and they'll bring things up and then, they're off to something else. And that would happen in individual therapy, it would happen in dyadic. But when it's with, you know, I think when you're working with a parent, it doesn't matter how I understand it.
Chandra Ghosh Ippen, Ph.D. (40:05):
It matters how they understand it. And that's different. That's a diadic piece that doesn't always exist. Right. And then that changes what happens in the home, right. In terms of now the parent will come in and say, we were talking about this and she switched. Or, you know, uh, I recognize that this was a really hard day, so I took them to the park and we ran. And we did all these things. And that's where I really say that as I'm not, like, I have to remember that I'm not the key person.
Keith Sutton, Psy.D. (40:37):
Yes.
Chandra Ghosh Ippen, Ph.D. (40:38):
Right. I am not the person who comes in and sits with the child and is all, it's the parent. And so there are these micro interventions that we do. And often without thinking that really show that, like, you know, if a kid comes to us with a toy, very simple moment, I'm gonna say, I think grandpa knows how to fix it
Keith Sutton, Psy.D. (40:57):
Mm-hmm <affirmative>.
Chandra Ghosh Ippen, Ph.D. (40:58):
Right. I'm gonna pivot away from myself as being that person.
Keith Sutton, Psy.D. (41:02):
Yeah.
Chandra Ghosh Ippen, Ph.D. (41:03):
But I, you know. Yeah.
Keith Sutton, Psy.D. (41:04):
Yeah. I was gonna say, sometimes I think about it too is that, uh, of course we want a good relationship with the kids, but sometimes some people in recounting a case, they'll say, oh, and at the end of therapy, they were so sad to leave or so on. And the, and I had such a good relationship and part of it, I think the relationship with the kids is of course good, but my goal of a successful therapy is how well have I strengthened the relationship between the child and the parents 'cause Right. They're gonna be there the whole rest of the time. And, you know, the therapist is only gonna be there for, for some time in their life. So yeah that kind of turning them towards and bringing in the parent and helping strengthen that piece rather than necessarily being centralized on yourself, it sounds like.
Chandra Ghosh Ippen, Ph.D. (41:46):
Yeah.
Keith Sutton, Psy.D. (41:47):
Now there's the speaking, the unspeakable, and then what is the structure of the therapy of, you know, kind of from there, it sounds like there's some individual sessions, there's some didactic sessions, there's parent sessions.
Chandra Ghosh Ippen, Ph.D. (42:07):
I would say there's very little didactic sessions. There's
Keith Sutton, Psy.D. (42:10):
D or D, sorry, dyadic, yes.
Chandra Ghosh Ippen, Ph.D. (42:15):
Yeah this is probably that what you asked was the million dollar CPP question and the thing that frustrates people who are new to the model, because we would often like to know what's gonna happen. And I'm just gonna tell you the truth is that I, you know, I show up with the same toys. Uh, each week I try to make sure it's there if, if, if it's a child who's in the symbolic play range. 'cause we also work with babies, which we haven't touched as a conversation at all today. Um, but what's interesting is, um, you actually wanna leave empty space because you want to see what the child brings in. Yeah. Does that make sense? Where do they go? And, um, I often use the metaphor, um, of baseball. Where I'll say that we as grownups, we love to pitch, right?
Chandra Ghosh Ippen, Ph.D. (43:08):
So we'll say here, you know, this is how you behave. We socialize, we do things right. And that there are times when what is really needed is catching. You have a story and a reality inside you that is very confusing. And this is a space where it can come out. And so it's important that we not have toys that pull for like, I don't have electronics or things that are gonna pull certain games. Right. Because you wanna open the door to symbolism. Like in the empty spaces stuff comes out. And I think as it comes out, like, you know, I, I always describe the classic play that you often see. Is that a child will have like a character that is evil and destroys the home like it's a dinosaur. Like I'm looking at my dragon over there. And the dragon comes in and it destroys the house and burns fire, and nobody can help, nobody can help. And we like try to send in a helper. And sometimes they'll like, they'll be like, okay, yeah, someone can help and then someone can help and then they fall off the ledge. Even the helpers fall. And, and what you learn in a way is this is a child who is sharing that things felt really bad and scary and desperate and nobody could help.
Chandra Ghosh Ippen, Ph.D. (44:20):
They're not sharing. Yeah. It's not a cognitive reality. It's a gut reality. Right. And in a way, our task as grownups is to catch the suffering. Right. And to say, oh no, it was so scary, nobody could help. Now some children love it when you connect it to reality. Yes. And you say, you know, before when you lived with your mom, like if a parent was on drugs, you know, the mom might say, I used to be really scary, just like that dragon.
Chandra Ghosh Ippen, Ph.D. (44:49):
Right. And the kid will be like, yes. Or like, we'll, lean on the parent. And like, it's clear like, oh, and other kids like you interpret. And they're like, oh no, that was way too much. Like window of tolerance. Whoa. Too much. Yeah. And so this is also, we're learning about this little kiddo. Right. So you can't, and then, you know, clearly you start to learn. And then, what's interesting is the child changes over the course of time, <laugh> . Right. And so things shift, but like we see that as you hold their suffering, then actually one day what you'll find out is guess what? The helpers are able to come in.
Chandra Ghosh Ippen, Ph.D. (45:26):
And you're like, oh, today, isn't it interesting? And then, you know, what happens? The dragon is also nice. And then we start to explore, like we start to talk to the dragon and like, oh, why was the dragon so angry? <laugh>. And then, and then you realize that the dragon is not the parent. The dragon is many people, because the dragon could also be the child who was also in trouble at preschool. The dragon could be the parent, it could be the child, it could be somebody else in their environment who is also mad. It's a symbolic representation that destroys.
Keith Sutton, Psy.D. (46:04):
Yes. Yes.
Chandra Ghosh Ippen, Ph.D. (46:06):
So I think, yeah.
Keith Sutton, Psy.D. (46:08):
And the, um, so it's, so there's a, there's an interpretive element of it. There's kind of the classical kind of children working through in the play and the play evolving over time as they're working through and processing. And then there's also an element of weaving the parents in while and helping in them kind of being involved in that. Is it, I know, you know, most people I think oftentimes do a non-directive play therapy, just therapist and so on. And, um, so this is kind of somewhat non-directive and kind of using the interpret and involving the parent? Or is it, is it kind of different from the non-directive completely in a way? Yeah. I don't know how to, if that's an easy question or a question I explained.
Chandra Ghosh Ippen, Ph.D. (46:59):
Yeah. So I'm in the process of trying to write a book about this <laugh>. And I think one of the terms that I really like right now I'm very enamored of is the idea of catalytic play therapy. And so when you think of a catalyst, you're not non-directive. But you're not directive. So what you're doing is you're putting in enough to get something going. And the truth is, when you drop a little catalyst in, sometimes you don't know where it's gonna go, but you're putting in enough. So, you know, when we do the triangle, that's like a big jumpstart of the reaction that might happen, but then you back off and you wait and see where it takes you, and then you might put in a little bit more as is needed. Enough to, and what you're supporting is, you know, what we call meaning making.
Chandra Ghosh Ippen, Ph.D. (47:45):
Mm-hmm. How, like, you know, even with the dragon, the idea that some days the dragon is nice, and some days the dragon is like terrifying. And that's often a child's reality of their caregiver. Why is the caregiver that I love, also the caregiver who sometimes beats up my other caregiver and we have to hide from them. Right. And they're little children are struggling with deep meanings. Why did you leave me? Will you leave me again? Why did this happen? You know, little kids are putting babies in trash cans mm-hmm. Mm-hmm <affirmative>. Right. And, and it's like the throwaway baby, and like, they're trying to make sense of am I am, do people care about me? Right. So there's meaning making, and then there's also, you know, we really aren't trying to fraternize people or like dwell in bad histories. I believe that history is not destiny. It's about how you are helped to metabolize your history. And Selma Fryberg asked the question in her article goes in the nursery, 'cause she said, history's not destiny and what predicts whether the painful past of the parent will be carried forward in the next generation. And she said, people who connect, affect to experience are less likely to repeat. And so affect to experience in my mind is head to gut. It's the integration and metabolism of head to gut. But the way that kids connect to their feelings is actually through projective identification. It's through sharing feelings with another person. Right. So, and what's interesting is when you're in, and I love play as a modality. I think there's many other ways to do CPP, you're just getting a heavy dose of play. 'cause that's my thing. But like, when you're playing, you're playing with your gut. And, the caregivers like you feel it sometimes like when a kid has really been through what I would call an embedded really horrendous trauma, they take you to places in the play where you're like, oh God, everybody's dying. Nobody's surviving. Right. And there's like a feeling state where all of a sudden what you're recognizing is I'm sharing your affect. This is what it was like. But the beauty of that is, is if the caregiver and I hold that affect, the child is not alone with it. We see how bad it was. Yeah. And that actually means that it's not the same as when they were in it. Because when they were in it, they felt alone.
Keith Sutton, Psy.D. (50:22):
They were alone. Yeah. It's like, it's, it's empathy.
Chandra Ghosh Ippen, Ph.D. (50:25):
Right? Yeah.
Keith Sutton, Psy.D. (50:25):
Kind of connecting with that and them, them feeling seen or feeling felt. Not feeling alone.
Chandra Ghosh Ippen, Ph.D. (50:32):
Yeah. And then from that, normally what we get is, is, you know, so we're not coaching emotions. Does that make sense?
Keith Sutton, Psy.D. (50:38):
Yeah. Yeah.
Chandra Ghosh Ippen, Ph.D. (50:39):
But we are like, we're sort of experientially saying, oh, it was so sad. Right. And grandpa was sad and you were so sad.
Keith Sutton, Psy.D. (50:45):
You're like reflecting the emotions or like, yeah.
Chandra Ghosh Ippen, Ph.D. (50:48):
Yeah. And so like, you can't say, oh, you were sad 'cause <laugh>. Yeah, yeah,
Keith Sutton, Psy.D. (50:52):
Yeah. Right.
Chandra Ghosh Ippen, Ph.D. (50:53):
I be wearing creepy. Like there's a disconnection. So there's an authenticity and it's, and
Keith Sutton, Psy.D. (50:58):
Accurately empathizing in that way. This is so great and so interesting. I love the work that you're doing and it's just impressive. To speak the language or even see the language, you know, kind of played out in the metaphor, I think has gotta be such a skill, you know, that gets developed over time and such, to be able to really speak the language and see the language in the play the kids are doing. And I know that your program is helping so many kids that especially have been through some very difficult things and I know a lot of the researchers around domestic violence and such. It is such needed work because there's not a lot of people or therapists that, like you're saying, maybe even think about what is happening for those kids or what they're needing or, right. We work with so many oftentimes adults that have been through trauma or complex trauma and that nervous system has been affected. This is all affecting at a very young age. I know that you mentioned it for a moment, but I know there's also some research that's also found about the cellular aging and that actually this work has been seen to see differences in cellular aging, which is related to like disease cancers and so on in development and how trauma is related to increased cellular aging. And actually there's been some research with this finding that this is actually prevented or protected cellular aging?
Chandra Ghosh Ippen, Ph.D. (52:35):
Uh, yeah. So it wasn't a randomized control trial, so that's important to say. What it was is we had a group of children who went through CPP and they were compared to another group of children with similar traumas and looking at pre to post measures. And what you see is reduced that, that CPP reduced cellular aging. So it's a first step. And then now they're going to, I think, have another study that shows that CPP actually affects telomeres, where telomeres have little caps on the ends of the chromosomes in positive ways. It reduces I think, telomere degradation, but that study will be coming out, which is important 'cause it's a much harder biomarker to get.
Keith Sutton, Psy.D. (53:10):
Yeah. That's incredible.
Chandra Ghosh Ippen, Ph.D. (53:12):
I should also mention that CPP has been disseminated to about 37 states. And we are currently in order of dissemination. So we're in the us we're in Israel, we're in Sweden, Norway, Australia, and England. And we now also have folks joining us in our most recent learning collaborative. We also had folks in Hong Kong, and recently we have folks from Singapore and New Zealand joining as well. And so we're doing a lot of international dissemination of child parent psychotherapy through an 18 month learning collaborative process modeled off the National Child Traumatic Stress Network learning collaborative process.
Keith Sutton, Psy.D. (53:49):
That's great. Yeah.
Chandra Ghosh Ippen, Ph.D. (53:51):
To get more and more people to know about and do this model?
Keith Sutton, Psy.D. (53:54):
Yeah. And actually where, um, where do people go to learn more about, 'cause yeah, we that's great, the podcast has been downloaded in 137 different countries. So Yeah. For folks that are both local and also international, where do they, where would they go to learn more or get involved or get training?
Chandra Ghosh Ippen, Ph.D. (54:14):
Yeah, so you go to childparentpsychotherapy.com and you look up training and there'll be some information. And I think the training is intensive. What I often say is zero to five is a huge age span. Even today, I haven't talked at all about babies. And babies often come through medical trauma and have very difficult beginnings. And you can think about the danger embedded in a baby who has that so that they might flinch and pull away from their caregivers or have feeding aversions. And even there, like, how does the caregiver respond to the baby 'cause sometimes we're like so worried that we're gonna break the baby. And so we, we deserve to have support, right. In terms of what it's like for us, what we go through. And I think in many countries where they value early childhood intervention, you know, and maternal and early caregiver care, that support comes in very early and changes, you know, the developmental pathway like makes it much healthier, prevents problems. So we'd like to see more and more. And also there's perinatal, child parent psychotherapy, which is a newer development. Um, you know, not that we haven't done it, but I think we were thinking about how to disseminate it.
Keith Sutton, Psy.D. (55:22):
Wonderful.
Chandra Ghosh Ippen, Ph.D. (55:23):
Yeah, because you know, the number one time when domestic violence starts is in pregnancy.
Keith Sutton, Psy.D. (55:27):
Yeah. Yeah.
Chandra Ghosh Ippen, Ph.D. (55:28):
We should really work to better support people because it's a huge transitional period where lots of stuff gets kicked up. And we, I think if we are better supported in thinking of reflecting, like nothing brings back your childhood like having a kid.
Keith Sutton, Psy.D. (55:41):
I know, right? We are out of time, but <laugh>, that's a whole other piece too. Right. Because especially, you know, when, especially if there's trauma when the kids are that age, right. That also, and the interaction between the parents' experience and the kids is so huge. Thank you so much for taking the time today. This is really great. And I'm just Yeah. And I'll have the model I'm really interested in and looking forward to learning more. I really appreciate it. Thanks for the time. Thanks,
Chandra Ghosh Ippen, Ph.D. (56:06):
Keith.
Keith Sutton, Psy.D. (56:07):
Take care. Bye-bye. Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online One-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in person in the Bay Area, or throughout California online and our employment opportunities, go to SFIaap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area community counseling and family and PS of Berkeley, go to sfbcc.org and family institute of berkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BCCs [email protected]. BCC is a 501 C3 nonprofit, so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:32):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.Today I'll be speaking with Chandra Ghosh Ippen, Ph.D. who is a child trauma psychologist specializing in working with families with children under age six.
Keith Sutton, Psy.D. (02:28):
She's co-developer of Child Parent Psychotherapy, the Associate Director of Child Trauma Research Program at the University of California San Francisco, and a member of the board of Directors of zero to three. She has spent over 30 years conducting clinical work, research and training in the area of childhood trauma and diversity informed practice. She's also an award-winning children's book author and has written five children's books as well as the Free Trinka and Sam Disaster series, which has been translated and distributed to over 400,000 families around the world. Let's listen to the interview. Well, hi, Chandra. Welcome.
Chandra Ghosh Ippen, Ph.D. (03:04):
Thank you. Yeah, thank you for all
Keith Sutton, Psy.D. (03:06):
Me. Thanks so much for joining me today. So, uh, yeah, I was really interested in the work that you're doing and particularly, you know, I learned about child parent psychotherapy many years ago. I'm in the San Francisco Bay area, and I forget if I knew somebody that was training there or somebody had mentioned it. I had gotten some of the books and learned a little bit about it, but I, I really wanted to interview because, you know, I'm very interested in, you know, working with children and families, and you have such a unique program that's particularly addressing trauma and young children, very young children, and so would love to hear about your work and I know there's been a lot of great research and, and kind of what you all are doing now. Um, but I always like to start off and find out about your path and kind of how you got to doing what you're doing or your evolution of your thinking that got to doing this work with the child, child parent psychotherapy.
Chandra Ghosh Ippen, Ph.D. (04:03):
Um, I'm smiling because people often say, when did you start in the field? Hmm. And, um, I grew up in San Francisco with two parents who were both child welfare workers, and I am an only child and so if you can imagine, um, my dinner conversation, you know, they did ask me about my day. But I heard a lot about their day, and so I heard a lot about stress, trauma, and families who were experiencing a lot of difficulty. And I also heard some stories of hope and ways that they've been able to help people. Um, but I think that was a lot of my early learning around the dinner table. And then before the age of six, I grew up in San Francisco and Marin, six of my friends' parents had cancer. And three of them died and nobody talked about it.
Chandra Ghosh Ippen, Ph.D. (04:53):
Um, but I think we were, many of us were very significantly affected by this, just the idea that this could happen, um, that it could happen to people that you cared about, that it could happen to your own family. And so I grew up really wanting to be a cancer doctor. I wanted to find a cure for cancer, and I ended up being very driven. And at the age of 16, wound up at California Pacific Medical Center during an internship with a pathologist. On the first day they took me into see an autopsy, and then they had me to learn blood draws and other things. And then they ran outta things for me to do. And they said, why don't you go hang out on the units? And I did. And I ended up meeting the parents and the children, and I ended up talking to them, and I ended up seeing kind of a little bit of what they needed, just trying to be helpful in some ways. And some of the parents ended up pulling me aside, and I remember one said to me, she said, you know, you're the only one who treats her like a kid.
Chandra Ghosh Ippen, Ph.D. (05:50):
And that, that's so important. And that some of them were spontaneously talking about what it was like to have cancer as a teenager. And I was a teenager or a little kid about his fears and worries. And I became really interested in kind of the idea that we were helping people's health, but we weren't attuning to their emotional needs. So what was it like to grow up in that way? And I thought that at the very least, I would become a doctor who understood that and went to Berkeley and studied psychology. And as I was there, I think things took a turn. And that ended up being where I ended up. And I think as I did that, I went and I worked at Lincoln Child Center where it was, um, in Oakland. And I think what was interesting is, um, this was back in the 1980s
Chandra Ghosh Ippen, Ph.D. (06:39):
Um, we weren't trained a lot about trauma. Um, we were told that children were SED, which was severely emotionally disturbed. And I think I really wish, I wish they wouldn't label kids, but also if they are going to, I mean, I just think if they told us that they were significantly exposed to danger and that they might not trust me. And there would be some. So I think what I recognized is that as the person who was around the clock with these kids, six to 12 stories were pouring out of them. Inopportune times like bedtime bathtime when you're trying to go. So, and I wouldn't say that they're inopportune. Every, every moment that they share is opportune. Sure. But I recognize that I didn't know what I was doing. And so I said, let me get myself back to graduate school.
Chandra Ghosh Ippen, Ph.D. (07:24):
And I just kept moving younger and younger 'cause I think I remembered in myself, I knew from my own history, um, it's always funny, like we, we do end up very influenced by our experiences. I knew from my history, um, that young children, very little children have these stories inside them. You know, my friends who grew up with their parents with cancer that was inside them, one of my neighbors had a mental health breakdown, and I was the babysitter for her two kids who were at the time, you know, about four and six and maybe actually three and six. And so just, it seemed like the things that I was reading in the textbooks weren't quite right. About young children, about their ability to process about whether they could do therapy. And so I did all of the evidence-based models. I was very fortunate to study at USC and John Weiss was there, and we learned
Chandra Ghosh Ippen, Ph.D. (08:17):
Because he came, we learned a lot of evidence-based models. But I really was looking for something. Um, there was a lot of parenting that I studied. But I was what, what opens up to the emotional life of the child. And that, you know, Alicia's book is the emotional life of the toddler. Mm-hmm <affirmative>. I very fortunately got my pre-doc postdoc at UCSF. And when I saw what Alicia and Patricia were doing, that was in 1998, the program was newly formed in 1996. I said, wow, this is different than anything else I've learned. This really attunes to the, the, the kind of the, the lived and the fantasy experience of little kids, and also the wisdom that the people to help small children are their loved ones. And, and it really goes back to that they share things at what I would call, you know, the moment when like when therapists aren't around, we're not around at bad times, we're not around at, but we're not around at the park when the dog is barking and the child is scared.
Chandra Ghosh Ippen, Ph.D. (09:17):
And, you know, you really see how, you know, how does a parent, like most parents, like love their kids, wanna help their kids. Right. Even if they're the ones who have unfortunately even harmed their kids. That's sometimes the worst thing to happen to a parent. But I think we've been told that it could hurt the child if we bring it up. So we've actually been gagged in some ways from our instinct. And little kids, they share what's inside them. In code. Like it's this interesting mixture of fantasy and symbolism, metaphor, reality all mixed together. And so there is like, I think about there is a different language that they speak. Some kids are quite clear and transparent and other kids, like they'll bring three baby dolls and say, you know, the babies, you know, bad things are happening.
Chandra Ghosh Ippen, Ph.D. (10:16):
And you're like, but concretely, there aren't three baby dolls. Or they'll do it with cars. Like the little, the car falls off the cliff and Oh no, it got hurt and it's broken and nobody can help it. Right. And I think some parents completely understand that that could be a metaphor for them and for life crashing and whatnot. And they're not always, I'm sort of digressing all over the place, but I think, I hope what you get a sense of is there's, I think the need and the beauty of supporting repair. Um, especially we know this is what families really want and we can, we, I was also the associate research director. So I ran our randomized trial and was able to really be a part of looking at whether or not this was efficacious. And it was, there were, there have been five randomized trials of CPP and we can see all sorts of outcome measures changing.
Chandra Ghosh Ippen, Ph.D. (11:09):
And it's not just symptoms. Sure. It, it actually changes in the stories that children tell, which I think it changes in their, um, I mean, I wouldn't call it IQ, but in their testing scores. Actually we have new data out about their neurobiology and about cellular aging, cortisol levels. So we're seeing some, like, just the idea that a psychosocial treatment could have a biological impact is really amazing. And, and then we know that the brain is most rapidly developing in the zero to three and still, you know, three to five age range that it's not like I always say to people, 'cause they'll say, do young children remember? Part, part of me is like, yes, because I've seen what they've shown. But I would also say, um, that's probably the wrong question. It's not what they remember, it's what they learned.
Chandra Ghosh Ippen, Ph.D. (12:01):
And so you're learning like, am I safe? Am I lovable? Am I capable? Am I seen all of those things that form the template for what, you know, psychotherapists are also addressing later on. And that's developing a relationship. And so we just, you know, I think the whole notion of how important early childhood is. And how much stress and trauma can affect it and, and that repair is possible. And so, you know, I, I think that was sort of my evolution and that's why I've stayed here. 'cause I'm sure this is, it's kind of amazing and exciting and we need more and more people to understand this so that we stop saying that little kids are too little.
Keith Sutton, Psy.D. (12:43):
Yeah. Yeah. Right.
Chandra Ghosh Ippen, Ph.D. (12:44):
So like, some people will not work in this age range, but none of us should be saying little kids are too little. Or none of us should say that it, you know, they'll forget or they'll grow out of
Keith Sutton, Psy.D. (12:53):
It. Yeah. Or like, there's nothing you can do or they'll grow out of it. Exactly. Yeah. And it sounds like you're saying too, that there's this piece you're saying about the parents, right. Being there at those times, right. At bathtime, at bedtime, and the therapist isn't necessarily there at those moments. And so involving the parents in this and, and helping to have that repair as well as the kids having this their own emotional language. And, you know, I think that, you know, part of the work right. Is also helping the parents to learn this emotional language to, to how to be able to read what's going on or what the kids are communicating. Is that what's also part of the work in the CPP?
Chandra Ghosh Ippen, Ph.D. (13:34):
Yeah, we have many different ways of phrasing this, but we think about how do we enhance attunement. So how do we think about supporting the caregiver in noticing the child and where it might take them? How do we enhance a parent's reflective, functioning, thinking about the possible meaning of the, of the child's behavior and where it's coming from. So, and I think some parents walk through the door and they're already incredibly attuned and doing that. And other parents, maybe because of their own history and what they've been through, um, that's more challenging. And I think we believe in the parallel process. And so it's less me teaching you and more, you know, like Jury Paul, one of the, you know, grandmothers of infant mental health, she said, do unto others is you would have others do unto others. And so there's very much of the parallel process of how am I being with you? Am I being attuned to you? How might I be holding your suffering? How might I be seeing you? And there's a, there's a lived a lived kind of exchange between us. Sure. And I think, um, there's a great quote from Selma Fryberg of why does the parent not hear the baby's cries?
Chandra Ghosh Ippen, Ph.D. (14:49):
And the answer to this is perhaps because nobody heard her cries.
Keith Sutton, Psy.D. (14:54):
Mm-hmm.
Chandra Ghosh Ippen, Ph.D. (14:55):
And so it's, it's a, I think it, it puts us as therapists in a, I would say initially it can be a challenge if, if we came into the field as child people. Sure. Because we, like, for example, even just with a crying baby, we hear a crying baby. And our neurobiology is like, Ooh, do something about the crying baby. Right. So as, and as therapists we're often thinking, we must fix, we must jump, we must do. Yeah.
Keith Sutton, Psy.D. (15:18):
Yeah. Make it better.
Chandra Ghosh Ippen, Ph.D. (15:20):
Yeah. And if you have a parent where, you know, systems or life or society has sort of made them feel like they're not capable, they're not seen that they've sometimes been pushed down and I pick up your baby and your baby stops crying.
Keith Sutton, Psy.D. (15:34):
Yeah.
Chandra Ghosh Ippen, Ph.D. (15:35):
Or I do something, or I tell you what to do, and we don't have a connection that could be dreadful. M Like, there are some cases where parents like, please tell me what to do and it would be withholding of me not to support you.
Keith Sutton, Psy.D. (15:46):
Sure. Sure.
Chandra Ghosh Ippen, Ph.D. (15:47):
And there are other cases where it's like, oh dear, or Now I've just confirmed your belief that you are not capable. And then how does that help you in terms of stepping into the role of being, I love the words of circle of security is a good attachment figure is bigger, wiser, stronger kind. Right. But that, that comes from the inside out. Right. And so sometimes in our model, a little bit less is more. So like you catch these moments where the parent is attuned. And you sort of notice and you say, your mommy is looking at you. Right. Or your daddy or your uncle. Your uncle knew what you needed. And so, and then, and I think Linda Gilkerson, who's also another one of, you know, the grandmothers offa health, she says glow with them. Right. So just think about these very simple interventions where what behind that is I see you, I see, I see the beauty in you. I see what you're doing. Right. And do you see you,
Keith Sutton, Psy.D. (16:52):
Yeah. Right. Like the parent to kind of like to, to reflect them almost. Right. Like that looking glass theory of self, like kind of being able to see them and them even seeing you, seeing them.
Chandra Ghosh Ippen, Ph.D. (17:07):
Well, and that's actually like, you know, if you're ever with like a baby and you're watching a baby, and you're like, like, oh my God, they have the rattle. And they're like, I mean, and I'm not trying to put parents in that position. Yeah. But there's a feeling that transmits when you're watching it and there's a care and, and that's that attunement that is, it's very organic. It's not a skill. Like I would say that the gut is somehow involved when you're doing that.
Keith Sutton, Psy.D. (17:32):
Sure, sure. Yeah. Needing to kind of connect with that kind of initial reaction of that, that glow or whatever it might be that you're then able to go with maybe then overthink or intellectualize or something like that and trying to do a technique.
Chandra Ghosh Ippen, Ph.D. (17:49):
Yeah. Like sometimes we're bearing witness. Right. And, we also bear witness to struggle. So we see moments when things are not going well. I think, you know, I think I've just sort of segued into talking about the model. I think that where CPP is really different is that, um, you know, we have, we have a lot of mantras, but we say we speak the unspeakable. Which means that if you are working with a child and you know, you think about what are the experiences that they've been through. And so it wouldn't be a model, for example, where like a parent might come in and say, here's this child, they're misbehaving, we'd like you to do something about this. Three or four, they're tantruming way too much. And I think we would want to understand that, understand the parent's concerns, and then we really wanna understand their history.
Chandra Ghosh Ippen, Ph.D. (18:44):
And part of what we feel like we need to ask about is whether there have been stressful or traumatic experiences that have happened. And so we are, we're really starting alone with a caregiver in terms of some people are walking through the door, you know, calling because something has happened. Sure. Um, for some reason, like their child has seen violence or had a medical trauma or been in a car accident where something, you know, happened. And sometimes they're, you know, they're thinking more about the problem. Sure, sure. Um, and so I think we, I guess maybe the clearest way, hopefully I'm not all over the place, so I'm a very visual person. Sure, sure. I'm sort of guided by our visual, which is a triangle, but it's very different from other, like, I always, we always joke and say every other model had a triangle, so we wanted to.
Chandra Ghosh Ippen, Ph.D. (19:36):
So our triangle, we start with the right side, and on the right side of our triangle, if you draw it, we would put like symptoms and behaviors. And you could think about, you know, the child is hitting or not sleeping or tantruming. And on the left side, we start with curiosity. Mm. Um, 'cause we have a mantra, do not target for change what you do not yet understand. Okay. And so really thinking about what is the experience that might have connected, and I just wanna say the experience could be a genetic experience. It could be a prenatal experience, it could be, um, an experience of danger that the child has been through. Right. So it could be that people in the home are fighting. You know, and that's resulting in this because the kid is carrying a lot of angst inside and is also seeing that when people get angry, this is what happens.
Chandra Ghosh Ippen, Ph.D. (20:27):
And, um, and we also wanna understand like, what has the parent been through? And so what's the parent's experience? What is the cultural, you know, what in terms of, of the cultural group history and how does, how does that also contribute? And then once we have this, the bottom of the triangle is kind of our plan, and we make a much better plan. And so, and then around that we put protective steps and hope. Now this is sort of a simplified version of our triangle. It's always kind of connecting experience with functioning. So if somebody is walking in and they're only talking about like, Ugh, this problem and this problem, this problem, and some strengths.
Keith Sutton, Psy.D. (21:03):
Sure.
Chandra Ghosh Ippen, Ph.D. (21:04):
We would be curious and I would wanna earn the right to hear their story.
Keith Sutton, Psy.D. (21:09):
Yes. Yes.
Chandra Ghosh Ippen, Ph.D. (21:10):
Right. And then, you know, that's the parents' understanding of the story. And it's not, I, I wanna make sure that it's not event focused.
Keith Sutton, Psy.D. (21:20):
<affirmative>.
Chandra Ghosh Ippen, Ph.D. (21:21):
Like, because, you know, we really think about, like, so for example, um, if I'm a little kid and I had medical trauma. Then I had a car accident, and then I had my, my loved ones were fighting because they were stressed out. And then somebody left. It's not just about one event. It's about how these events kind of might form themes. That sometimes bodies get hurt. Sometimes people go away, sometimes we're not safe. Yeah. Does that make sense?
Keith Sutton, Psy.D. (21:55):
Yeah. So they, the, so when you're listening to the stories about what has happened, you're looking for those themes. Is that kind of what you're saying?
Chandra Ghosh Ippen, Ph.D. (22:05):
I'm looking both for themes and for like experiences. And I'm also looking, sometimes it depends on the, you know, the affect of state of the caregiver. Like, you don't want to, you don't wanna fry them. But if they're able to tell you about it, it can be really helpful. So, for example, and I remember a parent who was talking about her partner who was very violent. She talked about how, um, how scary it was and that they had to run to the bathroom and barricade themselves in the bathroom. Now everybody thought her kid was autistic because of the way he interacted and played. Right. And I wasn't sure what it would look like when he came into treatment. And I said, I started this whole story off by saying, we speak the unspeakable. So we don't bring the child in until after we've really met with the caregiver, got some sense of story, and really also thought about how can we begin treatment with a little one.
Chandra Ghosh Ippen, Ph.D. (23:04):
And when we begin, we begin by what I would say is opening the door and we use the elements of the triangle. So with this little boy, you know, I would've said, you know, I said, you know, mommy told me that when you were really little, things were really scary in your house. Right. And this was something that was known as a fact 'cause we don't like to plant things. And I said that mama told me that sometimes daddy had problems and he got really scary. And this kid turned away and he went away and he started like throwing furniture. He could just think, oh, he is really disruptive. But then he took all the furniture and he threw it in the bathroom.
Keith Sutton, Psy.D. (23:44):
Oh, interesting. Okay.
Chandra Ghosh Ippen, Ph.D. (23:45):
<laugh>. Yeah. Yeah.
Chandra Ghosh Ippen, Ph.D. (23:47):
Now if, if you don't know that little detail, yeah. You might have a very different interpretation. Right. And of course you can't know everything. So there are times when you, like, just yesterday I was in a session and I was with a grandfather and a child who's witnessed a murder, and that's ostensibly why they're there. But her mom had also had problems. And this child put a little figure all alone in the house and then said, A stranger is coming to the door. And then had the little figure hide. And that was not part of what she went through in witnessing the murder that we know of and so we were looking at this and, you know, he said, we don't have strangers coming, but he said, ah, but when she lived with her other family member, there were a lot of people who came in and out.
Keith Sutton, Psy.D. (24:37):
<affirmative>.
Chandra Ghosh Ippen, Ph.D. (24:37):
And so, and that's just one example of like, there's a way that we start with caregivers to think about what we might do together. Like, we're not clairvoyant. But we're not, like, we're not causing the child to play things. But we're opening the door and things might come out, and then as they come out, we might be thinking together about, huh, I wonder kind of how this might be connected to what they went through. Yeah. Does that, does that make sense?
Keith Sutton, Psy.D. (25:04):
Yeah. So you're meeting with the parents to kind of like, get the stories and understand so that when you are bringing the kids in, you might have something that helps make sense of, of how they're playing or how they're interacting. And you're also kind of speaking the unspeakable, whereas maybe other therapists who are just doing child play therapy, you know, where they might not bring up or talk about the trauma or so on, or kind of speak it, but instead kind of just be playing and play even though they're working on the trauma work. And tell me about that piece, about bringing up the unspeakable. Like how does that, I'm just curious about the flow of the session. Like where does that come in? Because I think that that is something that, you know, I do differently with children than I do with teenagers. It's like, you know, if I've got a child under 10, we'll have the, I have a parent session first, then I have the kid and the parents, and I kind of do some narrative kind of, you know, stuff with them, narrative therapy stuff. But then with a teenager, I'll have them all together in the first session. I'm curious about how you think about that in that first session where you bring that in and talk about the thing that happened.
Chandra Ghosh Ippen, Ph.D. (26:19):
Yeah. So in child parent psychotherapy, we have what we call a foundational phase. And so the foundational phase can be four to six. Sometimes it's a little bit longer, and we'll just start with when it's one parent and a child 'cause often it's two parents, or it's three caregivers, or, you know, because there's children with lots of people involved in their lives and sometimes they're siblings. So we'll just start with this simple case. And you know, I already walked you through a little bit of what we wanna know. We wanna understand that the kiddos symptoms, we wanna understand their history, we wanna understand how the caregiver is thinking and feeling about it. I also think that grownups deserve to have a place to fall apart. And so we're also providing a space where this is not the first telling for the grownup, like when the kid gets brought in.
Chandra Ghosh Ippen, Ph.D. (27:05):
Does that make sense? Yeah. Like grownups are not supposed to be robots when the kids come in. But I also really want them to know that like, I mean, I've worked in the area of sexual abuse and death and murders and kids are often bringing things up and it's hard for the grownup. And I want them to feel that I do know that it's hard for them, and we sometimes will have collateral sessions also where they can, you know, in between. But we do all of that pretty much with the grownup alone. Except for when they're billing things. And when they're billing things, we will, might have to start off 'cause in some systems you have to start by seeing the child. But you'll do an observation of the child and the caregiver together, and then you'll figure out a way to meet alone with the caregiver.
Chandra Ghosh Ippen, Ph.D. (27:48):
Does, does that make sense? So I think things get organized according to systems to be practical. Right. And then we typically are doing feedback along the way, but we also have a feedback session where we plan the introduction to the child. And, you know, normally there's no surprises. There are occasions parents where, um, they have, they have been mandated by the system or something, and there are some things on the table and other things that aren't on the table. And I think we then have to think about what does that mean and how might, given the circumstances Yeah. Like, there's some children, I mean, I remember a child who sat with me for about five minutes and said, you know, he was four. He said, my dad took a gun to my mom's head, and he looked at me and goes, that wasn't cool, was it?
Chandra Ghosh Ippen, Ph.D. (28:38):
No. And I said, no, it wasn't cool. And I was just the person sitting with him. Well, if his mom says he remembers nothing about it and I don't wanna bring it up, we wanna honor her wish that he doesn't hear. And we wanna go at a pace that makes sense for her. Yeah. But it wouldn't be kind of holding the child. We, we call it dia, we have many different aspects of fidelity, but, uh, but dynamic relational fidelity asks us to hold the perspective of the caregiver and the perspective of the child. And so we would be thinking about, well, we can't just kind of vote with the parent and leave the kid out there. But we do wanna hold the pain of the parent or the fear of the parent that we're part of a system that often moves kids if, and like, how do I help them to feel safe? So there's, there's nuance in that, but then we come to some kind of agreement of what can be spoken. And if it can't be spoken, what if the kid brings it up? Yes. Okay. We start off this way in. Now there's some children like that little boy who are gonna walk through the door and tell you all kinds of stuff.
Keith Sutton, Psy.D. (29:45):
Put it right out there.
Chandra Ghosh Ippen, Ph.D. (29:46):
Put it right out there at the age of four or three, sometimes even two. You know, just comes right out. And there are other kids, where there's a great article called by John Bowley called Unknowing, what you're Not supposed to Know and Feeling What you're Not supposed to Feel. Great title, great article. Yeah.
Chandra Ghosh Ippen, Ph.D. (30:04):
But where the gist is basically that very young children, they often know things that adults would prefer, they not know. They see things that adults would prefer that they not see. And that I have a choice because I'm a social referencing being. So when I hold the truth, I might try to communicate my truth to you. Now if as I do this, I fear that I'm going to lose you. Maybe because you become so sad or so overwhelmed, or maybe because you become so angry or you kind of like disappear for me. Or it could be that you physically disappear or like, whoa, where did my grandma go? She's not the same. Then what? Over the course of time, I have a dreadful choice. I can choose you, or I can choose my truth.
Keith Sutton, Psy.D. (30:52):
Yes.
Chandra Ghosh Ippen, Ph.D. (30:53):
Right. And that, that's where Bowlby says a lot of mental health challenges come from, is this, you know, I think this is the psychodynamic psychoanalytic roots of the challenge, but we see it happening in early childhood, and I've worked with parents who in not their best moment, they have screamed to their children to shut up and stop talking about things. Because they're talking about their sexual abuse and it's toxic and it hurts their parents' heart.
Keith Sutton, Psy.D. (31:19):
Yeah. Yeah.
Chandra Ghosh Ippen, Ph.D. (31:20):
You know, so and so how do we as therapists understand, support, hear the parent, and then support, repair. So even that speaking, the unspeakable, I just remember being with, you know, a father who said, I told you to shut up. I'm so sorry. Right. And then, and then the explanation of I was really mad at him because it hurt my heart. Yeah. He could hurt you because you were so precious. But I want you to be able to talk about this. Like, that's the, can you see like the door slammed shut on the conversation? Yeah. Yeah. And it needs to open because otherwise the child comes into therapy with zero permission. Right. And the same is true of like,
Keith Sutton, Psy.D. (32:07):
So sorry, you're starting, you're doing this early in this, in the therapy. Oh, yes. And okay, great. 'cause yeah, this is, uh, so I also and have done some training with attachment based family therapy, for depressed adolescents and have worked with trauma and parents that would get overwhelmed and then just say, well, what do you want me to do? And in part of the repair was helping the kid talk about how abandoning that felt and so on. And Yes. And the parent coming forward, and rather than the kid having to take care of the parent, the parent being able to share up and show up and repair that, that injury, that attachment rupture. And so, that's great. You're getting right into that in the very beginning to kind of make it okay to have that in the room.
Chandra Ghosh Ippen, Ph.D. (32:53):
Yeah. So that, that marks that session where you speak the unspeakable and you open the door, that's the beginning of what we call our core intervention phase.
Keith Sutton, Psy.D. (33:02):
How many sessions in is that with the kid present?
Chandra Ghosh Ippen, Ph.D. (33:06):
Um, so that's zero. I mean, observation, only observation of parent-child observation in the school, the work is with the parent. Sure. And then you bring in the child. So, you know, and that's the introduction to therapy
Keith Sutton, Psy.D. (33:21):
In that session. You, you speak the unspeakable and go right to it.
Chandra Ghosh Ippen, Ph.D. (33:24):
Yeah. And I wanna say that that's
Keith Sutton, Psy.D. (33:25):
Great. Yeah.
Chandra Ghosh Ippen, Ph.D. (33:26):
Just because I speak it doesn't mean I expect the kid's gonna go there. So some kids have turned their back to me, <laugh>.
Keith Sutton, Psy.D. (33:34):
Yeah.
Chandra Ghosh Ippen, Ph.D. (33:34):
And, and then we have, I mean, so we, we say that we do our work, not like, we don't have like a session checklist of this week. Yeah, of course. Except for maybe that one session where we're like, well, let's, you know, it can take the whole session, but you are opening the door, you're presenting what we call the CPP triangle to the child. Yep. Usually with toys and things. Um, but you know, other than that, we're not saying we, you need to get these things done because the kids are under age five. That doesn't work developmentally, right? So we work based on what we call ports of entry, which is a term from Daniel Stern, which is this idea of really a clinical moment. So you have a clinical moment, and then how do you enter, so when a child turns their back to you, that's a clinical moment.
Chandra Ghosh Ippen, Ph.D. (34:21):
And then the question is, what does the therapist do or say in that clinical moment? And so I might say, I guess I said a lot of things that might have been hard to hear. And, and I guess, you know, that he might need to get to know me better. So I'm saying this maybe to the child. Maybe to the parent, and then we might sort of simply play. Now what I've also learned is that some children, like, you know, this is very similar to other models, but, um, you, you think about the window of tolerance. Which is really important, right. In trauma work the metaphor that I use, which can be a little confusing to some people, but I say that our bodies are like cups and that there are times when your cup is full. And what I'm thinking is it's full of adrenaline and cortisol and stress hormones and what not, because, and what I'll say is that children, are smarter than adults because they know that you don't just sit there plowing through something hard. Right. They, they sort of intu because they haven't been socialized to do that. Okay. So they know like, oh, my cup is full. And, and they know they have to get the icky out.
Keith Sutton, Psy.D. (35:33):
Kinda
Chandra Ghosh Ippen, Ph.D. (35:33):
Right? Yeah. So boop yeah. You just did a, like a Right.
Keith Sutton, Psy.D. (35:37):
Yeah. Like turn off to the side and they're like, yep, okay. Like it's too much. So
Chandra Ghosh Ippen, Ph.D. (35:40):
Yesterday I was, yesterday I was in a session and the kid goes, we gotta clean these things up, <laugh> . And I had talked to her, her grandfather, about how this might happen. And so we went, okay, we're gonna clean stuff up. And then she cooked with food toys. We did nurturing play for like 20 minutes, right? And I think that is part of the model as well. 'cause what I would say is we're not a trauma focused therapy. I often say, I say we're trauma forward because we say we are the people with whom you can go there. Yes. But often you have to go there at the speed of the body. Right? So if, if somebody brings something up and your cup gets full, then you might see a kid just, you know, pivot, do something else. Yeah. And ideally that's, that's the attunement of the grownup. How does the grownup understand why the child is pivoting? Yeah. Right. And like, I often think about like, it's almost like playing poker. Where you read the person op opposite you and you think, what's your tell?
Keith Sutton, Psy.D. (36:38):
Yeah.
Chandra Ghosh Ippen, Ph.D. (36:39):
Right. And so some kids, they'll get really physical and start running around the room. Other kids will need to cuddle, other kids will regress and be like babies. But the way the grownup understands, ah, you know, this is hard for them. And to the degree that we let you, you know, again, very window of tolerance, you move away. You move back. And what they learn is you can touch a feeling state and not get stuck in it. You can touch the story and be okay with it. And so you are actually growing a bigger cup.
Keith Sutton, Psy.D. (37:14):
And whereas like a parent might be like, hey, you need to listen or you need to sit here, like, stay with that, rather than like seeing their kind of exit or their shutdown or their, like, you're irritated response as like the cup is too full.
Chandra Ghosh Ippen, Ph.D. (37:29):
Yeah. And, and I think when a parent does that, the first thing I wanna think about is, uh, how do I understand that the parent might be doing that. Right? Because parents want what's best for their children. Right. And so how do I, how do I hold that sense of urgency. Like the need, you know, for your kid to heal fast. You know, get it all out. Because I believe in this like, people who do this will get better, like, you know.
Keith Sutton, Psy.D. (37:58):
Well, and I think even the structure of the therapy, sometimes they want the kids to be good for the, for the doctor or whatever or so on, and doing what they're supposed to be doing and not realizing or, or you know, even embarrassed if the kid's not listening and trying to get them to be a good listener, whatever, rather than, you know, understanding that this is part of the regulation.
Chandra Ghosh Ippen, Ph.D. (38:19):
Yeah. And I mean, what I love about the model is that it's like, you know, when we think about, Alicia calls 'em the pillars, Alicia Lieberman the original developer. She calls 'em the pillars of a therapeutic attitude. And one of our, you know, core pillars is benevolence and the other one is curiosity. Right. And you don't just apply that to kids, you apply that to the grownups and you apply it to yourself. Because there are times when I'm like, oh, why am I doing this <laugh>? Yeah. Yeah. Right. And I come into supervision or into consultation and I'm like, yeah, that was not my best move. But again, that kind of being kind to yourself because we're touching trauma and we're touching very difficult. Like, we're hearing about things that are hard. And so it's only natural that we would have reactions. The parent would have reactions, the kid would have reactions.
Keith Sutton, Psy.D. (39:04):
Yeah. Is there any like, narrative or postmodern kind of elements that are influenced? 'cause I'm hearing things like the curiosity, the witnessing, the benevolence, the kind of that positive perspective. I don't know if that's, if there's any overlap there.
Chandra Ghosh Ippen, Ph.D. (39:22):
I think there's a tremendous amount. I think what you'll see is Alicia says that child parent psychotherapy is good clinical therapy manualized. And so you're gonna see a lot of overlaps with a lot of good therapeutic methods. I think where we differ is that we are wired for young children. And there's a lot of things that, you know, like you really, I mean, and you'll see this with adults, so it's not that it's not applicable, but I used to tell people that I do soundbite therapy. Right. Because little kids will bring things up and then, they're off to something else and they'll bring things up and then, they're off to something else. And that would happen in individual therapy, it would happen in dyadic. But when it's with, you know, I think when you're working with a parent, it doesn't matter how I understand it.
Chandra Ghosh Ippen, Ph.D. (40:05):
It matters how they understand it. And that's different. That's a diadic piece that doesn't always exist. Right. And then that changes what happens in the home, right. In terms of now the parent will come in and say, we were talking about this and she switched. Or, you know, uh, I recognize that this was a really hard day, so I took them to the park and we ran. And we did all these things. And that's where I really say that as I'm not, like, I have to remember that I'm not the key person.
Keith Sutton, Psy.D. (40:37):
Yes.
Chandra Ghosh Ippen, Ph.D. (40:38):
Right. I am not the person who comes in and sits with the child and is all, it's the parent. And so there are these micro interventions that we do. And often without thinking that really show that, like, you know, if a kid comes to us with a toy, very simple moment, I'm gonna say, I think grandpa knows how to fix it
Keith Sutton, Psy.D. (40:57):
Mm-hmm <affirmative>.
Chandra Ghosh Ippen, Ph.D. (40:58):
Right. I'm gonna pivot away from myself as being that person.
Keith Sutton, Psy.D. (41:02):
Yeah.
Chandra Ghosh Ippen, Ph.D. (41:03):
But I, you know. Yeah.
Keith Sutton, Psy.D. (41:04):
Yeah. I was gonna say, sometimes I think about it too is that, uh, of course we want a good relationship with the kids, but sometimes some people in recounting a case, they'll say, oh, and at the end of therapy, they were so sad to leave or so on. And the, and I had such a good relationship and part of it, I think the relationship with the kids is of course good, but my goal of a successful therapy is how well have I strengthened the relationship between the child and the parents 'cause Right. They're gonna be there the whole rest of the time. And, you know, the therapist is only gonna be there for, for some time in their life. So yeah that kind of turning them towards and bringing in the parent and helping strengthen that piece rather than necessarily being centralized on yourself, it sounds like.
Chandra Ghosh Ippen, Ph.D. (41:46):
Yeah.
Keith Sutton, Psy.D. (41:47):
Now there's the speaking, the unspeakable, and then what is the structure of the therapy of, you know, kind of from there, it sounds like there's some individual sessions, there's some didactic sessions, there's parent sessions.
Chandra Ghosh Ippen, Ph.D. (42:07):
I would say there's very little didactic sessions. There's
Keith Sutton, Psy.D. (42:10):
D or D, sorry, dyadic, yes.
Chandra Ghosh Ippen, Ph.D. (42:15):
Yeah this is probably that what you asked was the million dollar CPP question and the thing that frustrates people who are new to the model, because we would often like to know what's gonna happen. And I'm just gonna tell you the truth is that I, you know, I show up with the same toys. Uh, each week I try to make sure it's there if, if, if it's a child who's in the symbolic play range. 'cause we also work with babies, which we haven't touched as a conversation at all today. Um, but what's interesting is, um, you actually wanna leave empty space because you want to see what the child brings in. Yeah. Does that make sense? Where do they go? And, um, I often use the metaphor, um, of baseball. Where I'll say that we as grownups, we love to pitch, right?
Chandra Ghosh Ippen, Ph.D. (43:08):
So we'll say here, you know, this is how you behave. We socialize, we do things right. And that there are times when what is really needed is catching. You have a story and a reality inside you that is very confusing. And this is a space where it can come out. And so it's important that we not have toys that pull for like, I don't have electronics or things that are gonna pull certain games. Right. Because you wanna open the door to symbolism. Like in the empty spaces stuff comes out. And I think as it comes out, like, you know, I, I always describe the classic play that you often see. Is that a child will have like a character that is evil and destroys the home like it's a dinosaur. Like I'm looking at my dragon over there. And the dragon comes in and it destroys the house and burns fire, and nobody can help, nobody can help. And we like try to send in a helper. And sometimes they'll like, they'll be like, okay, yeah, someone can help and then someone can help and then they fall off the ledge. Even the helpers fall. And, and what you learn in a way is this is a child who is sharing that things felt really bad and scary and desperate and nobody could help.
Chandra Ghosh Ippen, Ph.D. (44:20):
They're not sharing. Yeah. It's not a cognitive reality. It's a gut reality. Right. And in a way, our task as grownups is to catch the suffering. Right. And to say, oh no, it was so scary, nobody could help. Now some children love it when you connect it to reality. Yes. And you say, you know, before when you lived with your mom, like if a parent was on drugs, you know, the mom might say, I used to be really scary, just like that dragon.
Chandra Ghosh Ippen, Ph.D. (44:49):
Right. And the kid will be like, yes. Or like, we'll, lean on the parent. And like, it's clear like, oh, and other kids like you interpret. And they're like, oh no, that was way too much. Like window of tolerance. Whoa. Too much. Yeah. And so this is also, we're learning about this little kiddo. Right. So you can't, and then, you know, clearly you start to learn. And then, what's interesting is the child changes over the course of time, <laugh> . Right. And so things shift, but like we see that as you hold their suffering, then actually one day what you'll find out is guess what? The helpers are able to come in.
Chandra Ghosh Ippen, Ph.D. (45:26):
And you're like, oh, today, isn't it interesting? And then, you know, what happens? The dragon is also nice. And then we start to explore, like we start to talk to the dragon and like, oh, why was the dragon so angry? <laugh>. And then, and then you realize that the dragon is not the parent. The dragon is many people, because the dragon could also be the child who was also in trouble at preschool. The dragon could be the parent, it could be the child, it could be somebody else in their environment who is also mad. It's a symbolic representation that destroys.
Keith Sutton, Psy.D. (46:04):
Yes. Yes.
Chandra Ghosh Ippen, Ph.D. (46:06):
So I think, yeah.
Keith Sutton, Psy.D. (46:08):
And the, um, so it's, so there's a, there's an interpretive element of it. There's kind of the classical kind of children working through in the play and the play evolving over time as they're working through and processing. And then there's also an element of weaving the parents in while and helping in them kind of being involved in that. Is it, I know, you know, most people I think oftentimes do a non-directive play therapy, just therapist and so on. And, um, so this is kind of somewhat non-directive and kind of using the interpret and involving the parent? Or is it, is it kind of different from the non-directive completely in a way? Yeah. I don't know how to, if that's an easy question or a question I explained.
Chandra Ghosh Ippen, Ph.D. (46:59):
Yeah. So I'm in the process of trying to write a book about this <laugh>. And I think one of the terms that I really like right now I'm very enamored of is the idea of catalytic play therapy. And so when you think of a catalyst, you're not non-directive. But you're not directive. So what you're doing is you're putting in enough to get something going. And the truth is, when you drop a little catalyst in, sometimes you don't know where it's gonna go, but you're putting in enough. So, you know, when we do the triangle, that's like a big jumpstart of the reaction that might happen, but then you back off and you wait and see where it takes you, and then you might put in a little bit more as is needed. Enough to, and what you're supporting is, you know, what we call meaning making.
Chandra Ghosh Ippen, Ph.D. (47:45):
Mm-hmm. How, like, you know, even with the dragon, the idea that some days the dragon is nice, and some days the dragon is like terrifying. And that's often a child's reality of their caregiver. Why is the caregiver that I love, also the caregiver who sometimes beats up my other caregiver and we have to hide from them. Right. And they're little children are struggling with deep meanings. Why did you leave me? Will you leave me again? Why did this happen? You know, little kids are putting babies in trash cans mm-hmm. Mm-hmm <affirmative>. Right. And, and it's like the throwaway baby, and like, they're trying to make sense of am I am, do people care about me? Right. So there's meaning making, and then there's also, you know, we really aren't trying to fraternize people or like dwell in bad histories. I believe that history is not destiny. It's about how you are helped to metabolize your history. And Selma Fryberg asked the question in her article goes in the nursery, 'cause she said, history's not destiny and what predicts whether the painful past of the parent will be carried forward in the next generation. And she said, people who connect, affect to experience are less likely to repeat. And so affect to experience in my mind is head to gut. It's the integration and metabolism of head to gut. But the way that kids connect to their feelings is actually through projective identification. It's through sharing feelings with another person. Right. So, and what's interesting is when you're in, and I love play as a modality. I think there's many other ways to do CPP, you're just getting a heavy dose of play. 'cause that's my thing. But like, when you're playing, you're playing with your gut. And, the caregivers like you feel it sometimes like when a kid has really been through what I would call an embedded really horrendous trauma, they take you to places in the play where you're like, oh God, everybody's dying. Nobody's surviving. Right. And there's like a feeling state where all of a sudden what you're recognizing is I'm sharing your affect. This is what it was like. But the beauty of that is, is if the caregiver and I hold that affect, the child is not alone with it. We see how bad it was. Yeah. And that actually means that it's not the same as when they were in it. Because when they were in it, they felt alone.
Keith Sutton, Psy.D. (50:22):
They were alone. Yeah. It's like, it's, it's empathy.
Chandra Ghosh Ippen, Ph.D. (50:25):
Right? Yeah.
Keith Sutton, Psy.D. (50:25):
Kind of connecting with that and them, them feeling seen or feeling felt. Not feeling alone.
Chandra Ghosh Ippen, Ph.D. (50:32):
Yeah. And then from that, normally what we get is, is, you know, so we're not coaching emotions. Does that make sense?
Keith Sutton, Psy.D. (50:38):
Yeah. Yeah.
Chandra Ghosh Ippen, Ph.D. (50:39):
But we are like, we're sort of experientially saying, oh, it was so sad. Right. And grandpa was sad and you were so sad.
Keith Sutton, Psy.D. (50:45):
You're like reflecting the emotions or like, yeah.
Chandra Ghosh Ippen, Ph.D. (50:48):
Yeah. And so like, you can't say, oh, you were sad 'cause <laugh>. Yeah, yeah,
Keith Sutton, Psy.D. (50:52):
Yeah. Right.
Chandra Ghosh Ippen, Ph.D. (50:53):
I be wearing creepy. Like there's a disconnection. So there's an authenticity and it's, and
Keith Sutton, Psy.D. (50:58):
Accurately empathizing in that way. This is so great and so interesting. I love the work that you're doing and it's just impressive. To speak the language or even see the language, you know, kind of played out in the metaphor, I think has gotta be such a skill, you know, that gets developed over time and such, to be able to really speak the language and see the language in the play the kids are doing. And I know that your program is helping so many kids that especially have been through some very difficult things and I know a lot of the researchers around domestic violence and such. It is such needed work because there's not a lot of people or therapists that, like you're saying, maybe even think about what is happening for those kids or what they're needing or, right. We work with so many oftentimes adults that have been through trauma or complex trauma and that nervous system has been affected. This is all affecting at a very young age. I know that you mentioned it for a moment, but I know there's also some research that's also found about the cellular aging and that actually this work has been seen to see differences in cellular aging, which is related to like disease cancers and so on in development and how trauma is related to increased cellular aging. And actually there's been some research with this finding that this is actually prevented or protected cellular aging?
Chandra Ghosh Ippen, Ph.D. (52:35):
Uh, yeah. So it wasn't a randomized control trial, so that's important to say. What it was is we had a group of children who went through CPP and they were compared to another group of children with similar traumas and looking at pre to post measures. And what you see is reduced that, that CPP reduced cellular aging. So it's a first step. And then now they're going to, I think, have another study that shows that CPP actually affects telomeres, where telomeres have little caps on the ends of the chromosomes in positive ways. It reduces I think, telomere degradation, but that study will be coming out, which is important 'cause it's a much harder biomarker to get.
Keith Sutton, Psy.D. (53:10):
Yeah. That's incredible.
Chandra Ghosh Ippen, Ph.D. (53:12):
I should also mention that CPP has been disseminated to about 37 states. And we are currently in order of dissemination. So we're in the us we're in Israel, we're in Sweden, Norway, Australia, and England. And we now also have folks joining us in our most recent learning collaborative. We also had folks in Hong Kong, and recently we have folks from Singapore and New Zealand joining as well. And so we're doing a lot of international dissemination of child parent psychotherapy through an 18 month learning collaborative process modeled off the National Child Traumatic Stress Network learning collaborative process.
Keith Sutton, Psy.D. (53:49):
That's great. Yeah.
Chandra Ghosh Ippen, Ph.D. (53:51):
To get more and more people to know about and do this model?
Keith Sutton, Psy.D. (53:54):
Yeah. And actually where, um, where do people go to learn more about, 'cause yeah, we that's great, the podcast has been downloaded in 137 different countries. So Yeah. For folks that are both local and also international, where do they, where would they go to learn more or get involved or get training?
Chandra Ghosh Ippen, Ph.D. (54:14):
Yeah, so you go to childparentpsychotherapy.com and you look up training and there'll be some information. And I think the training is intensive. What I often say is zero to five is a huge age span. Even today, I haven't talked at all about babies. And babies often come through medical trauma and have very difficult beginnings. And you can think about the danger embedded in a baby who has that so that they might flinch and pull away from their caregivers or have feeding aversions. And even there, like, how does the caregiver respond to the baby 'cause sometimes we're like so worried that we're gonna break the baby. And so we, we deserve to have support, right. In terms of what it's like for us, what we go through. And I think in many countries where they value early childhood intervention, you know, and maternal and early caregiver care, that support comes in very early and changes, you know, the developmental pathway like makes it much healthier, prevents problems. So we'd like to see more and more. And also there's perinatal, child parent psychotherapy, which is a newer development. Um, you know, not that we haven't done it, but I think we were thinking about how to disseminate it.
Keith Sutton, Psy.D. (55:22):
Wonderful.
Chandra Ghosh Ippen, Ph.D. (55:23):
Yeah, because you know, the number one time when domestic violence starts is in pregnancy.
Keith Sutton, Psy.D. (55:27):
Yeah. Yeah.
Chandra Ghosh Ippen, Ph.D. (55:28):
We should really work to better support people because it's a huge transitional period where lots of stuff gets kicked up. And we, I think if we are better supported in thinking of reflecting, like nothing brings back your childhood like having a kid.
Keith Sutton, Psy.D. (55:41):
I know, right? We are out of time, but <laugh>, that's a whole other piece too. Right. Because especially, you know, when, especially if there's trauma when the kids are that age, right. That also, and the interaction between the parents' experience and the kids is so huge. Thank you so much for taking the time today. This is really great. And I'm just Yeah. And I'll have the model I'm really interested in and looking forward to learning more. I really appreciate it. Thanks for the time. Thanks,
Chandra Ghosh Ippen, Ph.D. (56:06):
Keith.
Keith Sutton, Psy.D. (56:07):
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