Richard Jacobs: This is Richard Jacobs with the Finding Genius Podcast now part of the Finding Genius Foundation. My guest today is Dr. Lisa Machoian, she’s an Author and a Psychologist. We’re going to talk specifically about teenagers that engage in what’s called self-harm, cutting and other behaviors.
Would you tell me a bit about your background? How did you become a Psychologist and an Author? How did you get to where you are today?
Dr. Lisa Machoian: The work began as a teacher of children and adolescents. One of the kids said to me, as I was thinking about going to graduate school back in the day. Ms. Machoian, you would be a really good counselor. How come you’re not one of the counselors, you’re easy to talk with? I had always been interested in psychology as my work and an educator. Also, it was related to kids that had trauma histories and kids that had trouble reading with dyslexia. So that’s how my career began. What led me into psychology and counseling, and writing my book on teenage girl’s depression was that right on the cusp of heading into graduate school. I had a cousin who I loved dearly, she committed suicide. It was somewhat changed the course of my work going into graduate school.
Richard Jacobs: Today we’re going to talk about cutting and self-harm. Is that a major offshoot of counseling or did you decide to focus in an area and why?
Dr. Lisa Machoian: What happened, I was doing research on girls that had depression and had attempted suicide or had made suicidal gestures. I was also simultaneously doing my clinical training for Psychology and to be a Psychotherapist at the Trauma Center. In both of these situations, there was quite a bit of cutting going on. It’s not like, I set out initially to explore cutting, but there it was, in the girls that I was working with as a Therapist in my training. Also, when I stayed on as a Staff Clinician, the girls that I was interviewing for my book. At that time, my dissertation research as a Doctoral Student, they were suicidal, depressed, and anxious. A lots of them have post-traumatic stress and some of them didn’t, but they were all cutting and engaging in self-harm. So I led into it naturally, because of what was going on with the girls at that time.
Richard Jacobs: What is self-harm versus cutting? What is cutting just for people that don’t understand?
Dr. Lisa Machoian: Self-Harm can take the form of things beyond cutting. There’s cutting, picking, and there are other ways that kids and adults as well can hurt themselves. Burning high risk behaviors to hurt themselves. Cutting is when they specifically take something, whether it be a scissor, a paperclip, a knife, a razor, or a piece of glass. There’s a number of things youth can cut with, somewhere on their body. Also, there are other ways kids can self-injure, but cutting it in and of itself is you take some type of an object and they’ll cut a spot on their body.
Richard Jacobs: Why do teenage seems to do this and resort to this behavior?
Dr. Lisa Machoian: There’s two things that are going on. They’re often trying to shift negative or awful feelings that are unbearable. In a sense, it’s a coping strategy. It’s a way they’re trying to regulate and change how they feel. It’s just hurtful, harmful and unhealthy coping strategy. I take a Non-pathology model in that. It’s kids trying to cope or what’s called Self-regulate. They’re trying to change how they feel because they are either overwhelmed and flooded with negative feelings and they don’t know any other way to change how they feel, where they’re feeling extremely numb and don’t feel anything. There are cutters that girls have cut that are secret cutters. In case of boys, they might cut their hair. It’s more prevalent in girls. They’re called Secret Cutters that really hide it and don’t want anyone to see it. Also, there are girls that I would call more help-seeking cutters that do want someone to see it because they are seeking help.
Richard Jacobs: How people find out how cutting affects people and why people do it? Have you personally interviewed a lot of people that have done this? Do they give the explanations that you’re giving? How was your experience with this? What did it look like to you when you talked to some patients that do it?
Dr. Lisa Machoian: I can actually read you a couple of quotes from some girls. What happens, when somebody cuts, their body releases a flood of Endorphins. It’s what happens, if we get injured. Endorphins can also get released when we’re exercising and running. Endorphins make you feel good. Endorphins can bring off a flood of calming, sedating and feel good hormones. So when you cut, you get an endorphin release. It changes the way a girl feels. You feel that she will feel better or if she’s feeling completely numb and doesn’t feel anything, then she does heal something. What happens, a lot of times the kids don’t know this initially, but it’s become so mainstream right now, and the rates of cutting are extremely high during the pandemic because of COVID has increased it. At the end of August, the Mental Health America did a survey and found that nearly 54% of 11 to 17 year olds who were either feeling like killing themselves, suicidal or had actually cut or self-injured themselves in some way within the past two weeks, when the school was starting. It’s a way kid self-regulate. It also is a way that adults take notice.
I’ll read you a quote from a girl. “I did it when my mom was there because she wouldn’t listen to me. I was so aggravated, so I cut to prove a point. Then they be like, ‘Don’t cut, talk to me.’ I’ll be like, ‘Okay, cutting gives me a reason for people to listen to me.’ I don’t think it’s conscious. Its subconscious, if I cut, I’m not saying, ‘Gee, I want them to talk to me.’ So I cut when people don’t listen. If people should not listen to me, obviously, I just feel frustrated, numb, or upset, and then people do listen.” Another young woman said, “It’s an actualization of pain. There are several levels. The most basic is, even if you tell people that something is wrong, a lot of times they don’t know how wrong, but all they’ll do see a cut along the vein and they basically get the message right away.”
It’s also becomes a way that kids who are suffering parents take heed. A lot of times, kids and girls voices may not be listened to, but if a parent sees a cut — I can’t tell you how many kids have been referred to me because of cutting. There’s a lot of shame and stigma related to it, but usually that’s makes parents take notice. Many parents would notice signs of depression and anxiety prior to that, but if they haven’t noticed or listened, a lot of things get dismissed as teen angst. Hopefully now people are a lot more alert to the mental health issues because of the pandemic. A lot of times kids get dismissed, “Oh, its normal teenage angst or teen turbulence.” So that’s something that stood out to me, both as a Clinician and working with girls, but also in the research I did interviewing girls was a way that people listened to them. Unfortunately, in our culture, people take notice of violence. It’s self-inflicted violence, but nonetheless, it’s act of violence against one self.
Richard Jacobs: How serious is cutting? If a kid is doing it, could that be a good thing that they’re at least getting their feelings out in that way or is it always a very bad thing?
Dr. Lisa Machoian: It’s a very bad thing. It’s sad that it takes that to get noticed. Parents are all doing the best they can and they don’t know. People just don’t know enough signs and signals about mental health issues, depression, anxiety, or post-traumatic stress. The reason it’s a bad thing is, it’s highly addictive. It’s like a drug because of the Endorphin release. What happens is, a girl will cut once, but then the flood of Endorphins and the feeling good, they want to feel that way again. So they’ll cut again and again. What happens is, it’s like a drug where you need more of the drug. One cut, just won’t do it. They’ll have to do several more cuts and cut deeper, more frequently. It goes from one cut to a bunch of cuts and deeper cuts. The frequency of cutting will increase. It’s very dangerous and it’s just like any other addiction. It’s very hard for kids to stop. So it’s important to listen to kids and notice the signs and symptoms of other mental health red flags, but this has become extremely common and the norm. So many girls are engaging in cutting. The most important thing is, if someone is cutting or starting to cut because they need intervention right away as soon as possible. So it doesn’t continue.
Richard Jacobs: What kind of interventions seem to work?
Dr. Lisa Machoian: The most important is certainly therapy, a trusting therapeutic relationship and teaching other forms of self-regulation. There’s quite a few groups out there that have very highly structured formats to work with cuttings. There’s DBT, which has found to be helpful, but teaching other ways to self-regulate and change the way that they’re feeling becomes really important.
Richard Jacobs: What is DBT?
Dr. Lisa Machoian: Dialectical Behavior Therapy, often that’s in a group or can be done individually, but that’s certainly a way to bring in some mindfulness of what are you thinking? What are you feeling? What’s going on that particular moment when you’re feeling these particular feelings? So those are the ways. Somebody who’s cutting needs to be in therapy and they need to really learn to coping strategies.
Richard Jacobs: What are some of the coping strategies that can work to replace cutting?
Dr. Lisa Machoian: Certainly bringing kids into the present moment or finding other ways, such as are they exercising on a regular basis? I always go to very basic needs with all kids, regardless of what they’re struggling with mental health wise. It means, are they getting enough sleep? Are they eating properly? Are they hydrating? Are they exercising? Exercise can release the same amount of Endorphins. If you get your cardiovascular system up as cutting does, you get what’s called “A Runner’s High.” It’s the same thing as an endorphin release as you would get from cutting. So that’s one huge coping strategy.
There are so many more you can do, when you’re not feeling. It’s about other ways to regulate how they’re feeling, such as listening to music, making a playlist of songs that make them feel better engaging in social interaction, or having somebody to talk to. It’s about learning how to shift the way that they’re feeling, shift their emotional state without doing it in a harmful way.
Richard Jacobs: Is there a difference between people that cut because they’re emotionally numb versus people that are actively depressed or anxious?
Dr. Lisa Machoian: Numbness can be from depression as well as feeling overwhelmed emotionally. I don’t think there’s a huge difference. It also can go back to if there’s a trauma basis as well, because post-traumatic stress, people can feel extremely numb. It’s by phasic PTSD, especially if it’s developmental, meaning they can feel very hyper-aroused, hyper-vigilant and highly activated, but that can also shift into feeling extremely numb in a sense the body’s trying to balance itself. If it’s from just chronic post-traumatic numbing, then that could be a little bit different, but there can also be a bit of a shift.
I work with a teenage girl once and she was extremely numbed out. I was in training. It was years ago. When she began to cry in therapy, I remember my supervisor saying to me, she’s sighing out, she’s unnumbing, she could actually feel versus not feeling so numb. There are cutters that are completely numb and then ones that are depressed or extremely anxious. Anxiety is high right now. So there can be a differentiation, but they can also be completely overlapped. One person can feel numb at sometimes and also at other times feel overwhelmed with sad, anxious, scared, angry, and frustrated feelings
Richard Jacobs: There are medications for depression and anxiety, they may not work very well in some places. Are there any medications for cutting that could be redeployed for this and is it effective or is it a manifestation that really is untouchable by medication?
Dr. Lisa Machoian: I’m not a huge advocate for putting young kids on drugs unless they really need for depression. Often, anxiety and depression overlap. Medication has saved a lot of people’s and kids’ lives. I would really want a child, an adolescent to be fully evaluated. Per se there isn’t a drug or medication for cutting. The release of the Endorphins is like a sense of a drug for them. I would want someone to be really evaluated. If it’s severe depression, then an antidepressant may be indicated, but per se, there isn’t a medication for cutting. Usually, kids that are cutting are also suffering with depression and anxiety, which are much overlapped as well or post-traumatic stress disorder.
Richard Jacobs: In kids, where the PTSD come from? Does it come from bad home environment or not being able to go to school and socialize, like for past one and a half year? What do you think the root is?
Dr. Lisa Machoian: There’s a lot of roots of post-traumatic stress. Post-Traumatic stress can be caused by physical and sexual abuse violence in the home or in the community, witnessed to violence, violence towards children, domestic violence, community violence, severe traumatic loss, severe alcoholism where there might be violence. So there’s a lot of causes of childhood post-traumatic stress. Also, kids that live in war, there’s many causes of post-traumatic stress, even there’s emotional abuse that can traumatize kids as well. Those would be very much in developmental trauma where it’s chronic complex and it’s been part of their childhood, it really impacts their developing brain. Not that anything’s wrong with brain, but the brain gets impacted and the brain is very plastic. We must remember. With the right treatment, it can help. There’s also what can be one-time acute trauma or one-time trauma, where there’s witness to one thing versus ongoing trauma. Both can lead to post-traumatic stress that severity of developmental trauma is certainly more concerning because it’s ongoing.
Richard Jacobs: How it is correlated with puberty in boys and girls? At a time where this tends to happen and how does it happen?
Dr. Lisa Machoian: No kids can have post-traumatic stress from a young age. Depending on the environment that they’re living in, both home and community. To shift a bit specifically, to depression, there’s a difference. During childhood boys tend to have higher rates of depression than girls do in early adolescents, which dramatically shifts and the rates of depression rapidly rise for girls. It’s part of the research that I did because I was curious as to why a lot of people will very quickly attribute it to the hormonal changes of adolescence for girls with the onset of menses. But that’s not the cause of fact, there’s been research that has drawn blood and had shown its psychosocial factors.
It’s a social factors that cause it, because in early adolescents, girls experienced an increase in estrogen, which actually should make you feel better. So it’s not caused by puberty per se. Girls get a lot of messages, even younger and younger, about how they’re supposed to be and how they’re supposed to behave to fit in to the world. They get bombarded. Now, it’s even younger and what may be called the Tween Years. The premise of my book, which is “Hearing Girl,” is it girls begin to not really say what they’re thinking and feeling. They have to change who they are, they have to behave differently to fit in with the peer group.
Now, we’ve got all of this with the overlay of a pandemic, which is creating massive uncertainty, isolation and social isolation. They are a huge risk factor for mental health issues where we’re tribal beings and being kids, having to be isolated is very hard. The remote learning has been hard. We need to think of ways we can help kids and girls with connecting in ways that are safe, whether it be distancing, the kids are going back to school and wearing masks, but at least they can be around other kids. So we need to encourage safe ways of connection because the lack of connection and living in uncertainty is very hard. A lot of kids are very lonely right now. Its along-winded answer to the question about puberty, but it’s important for people to know that the rates of depression really go up for girls in the early adolescent years. About age 15, they’re mirroring the adult population, where you have twice as many girls depressed as boys. Women out-number men in depression and anxiety through the adult years.
I also want to say that boys and men may have depression and anxiety, but it may manifest differently because they have been socialized to keep things in and not express it as much. On some of the standardized ways of finding out about these things, boys and men just may not be showing up quite as much, but what the research shows is higher rates for girls. Girls engage in a lot more suicidal behaviors during the teenage years, but boys are more likely to actually kill themselves during the teenage years.
Richard Jacobs: If you have, let’s say a 12 year old girl that’s cutting versus a 16 year old. Is there any difference? It’s worse if it starts earlier or it’s worse, if they’re older? What’s the difference between the two?
Dr. Lisa Machoian: It’s not good at any point, but the younger it starts and if it goes unnoticed and untreated, it’s going to be more severe. It doesn’t mean that if someone starts at 15 and they don’t get help, it isn’t going to be severe. We know that girls and boys that start drinking at a younger age, 13 or 14 are much more prone to develop alcoholism. So anything that starts younger can be worrisome, but I wouldn’t dismiss the severity. It could evolve into if it started at 15 or 16, but a little 12 year old cutting, which is unfortunately common. Now it’s very concerning. Any kid that’s cutting themselves, any girl that’s cutting herself really needs to get help right away, because as I’ve said, it’s going to escalate. It’s not going to go away by it.
Richard Jacobs: What are some of the protocols that are successful? Is it group therapy individual therapy, or exercise?
Dr. Lisa Machoian: I would certainly say, Individual therapy. Finding what are other ways they can regulate and how they’re feeling. Also knowing and naming the emotions, linking what they’re thinking to. What’s the thought and, then what’s the action? What was your thought for your feeling? What did you do with it? Did you go out and take a run? Did you call a friend? Did you Face Time a friend? Did you listen to music? Did you find something to cut yourself with?
“What are other ways that youth can regulate themselves?” The sooner it’s addressed the better they might not need the intensity of a particular treatment program or a therapist that might have specialty and know how to work with it. Anything the sooner, like the intervention, the better. Also if there are ways to prevent it by making sure kids are learning healthy, coping strategies, and keeping lines of communication open
Richard Jacobs: Does girls with the siblings feel better or it make no difference?
Dr. Lisa Machoian: I haven’t seen that it makes really that much of a difference. An interesting question, I’ll have just kind of look into that research wise. I haven’t noticed that it makes a difference. Historically, I’ve worked as a therapist for a lot of girls for a lot of years because we really depend on their relationship with their sister. Some girls have strong and healthy relationships with their sisters and others have more strained and difficult relationships with their sisters. So I think it would depend on the sibling relationship with their sister.
Richard Jacobs: Does it matter if they’re the older one or the younger one, and the older one warn younger girls that they have an older sibling?
Dr. Lisa Machoian: I haven’t in my own work. I haven’t noticed any trends with regard to that. Certainly what can happen is, I’ve worked with girls with younger sister and girls with the older sister. There’s a lot of sibling competition and parental attention isn’t balanced. It can cause a problem for the sibling that may not be the one getting as much attention. There was a girl with I’ve worked, her mom brought her right in at the first sign of one cut or maybe two cuts. She didn’t become a cutter. Now I’ve worked with her for a number of years, but she now has a sister who gets a lot more attention. I’ve had a situation that was reversed, where the girl was the older sister and had more difficulties because the younger sister had more mental health issues and was getting focused upon.
There might be a little bit of a trend in my own work, it’s the younger sister, but again, it’s not definitive research wise, at least in my own work. So trying to balance out parental attention is another important factor for parents. Especially, now parents are extremely overloaded. If you have one child that has more challenges or mental health struggles than the other one, it’s only a matter of time before something is going to manifest in the other child that doesn’t have as many showing they may fare, but there are implications for that.
Richard Jacobs: The kid starts cutting and all of a sudden they’re going to have a lot of attention focused on them, not in all families, but in a lot. Does that intensify and make it worse? Does it make them withdraw because now all of a sudden their problem is known to their family?
Dr. Lisa Machoian: Once they’re secret cutters, it can go a long time without it being known. They wear long sleeve shirts to cover their hands, they cut on their inner thighs, on their stomach, and in ways that it can’t be seen. It also depends on the siblings age, whether parents revealed to the entire family or to a sibling.
Richard Jacobs: I just wonder, because all of sudden, heightened attention to the person that’s cutting. How will they react? Do they react well to withdraw? Are there any patterns you see?
Dr. Lisa Machoian: If they feel like they haven’t been heard, and they’re needing help and are finally getting it, it could be a bit of relief. It can be very specific to circumstances. It can also be on the subjective experience of the grill. It can become stressful because, now their parents are watching them like a Hawk, trying to remove things that they may cut with. It can help, but it doesn’t work because they’ll always find something, if they’re hooked on cutting, which is what happens. It becomes their way of coping and their way of self-regulating.
On one hand, a lot of the girls that I interviewed, it was a relief because they finally were getting help and they wanted help. In the long run, that is how they feel, but in the beginning, when the parent(s) first discover it, they’re trying to cut because that’s the only way they know how to shift their effective and emotional state. It can be disturbing and frustrating because they don’t know how else to self-regulate, that’s how they’ve been doing it. It’s like somebody who can’t get their drug. It’s very much like a drug. So the withdrawal and trying to find something —
There was an emergency, it was over a holiday weekend and I got called to do a consult. The mom had to run out and do an errand with the younger daughter because the other girl had got sent home from school or camp because she was cutting. They thought she was okay and they tried to remove things. I got a text and we have a call to an emergency that she was cutting again. It didn’t surprise me because now she was addicted to it. So just because things get removed and the child’s found out, doesn’t mean they can’t. They really need help to stop.
Richard Jacobs: How do you averse someone that become addicted? How do you break the link?
Dr. Lisa Machoian: Treatment, working on what are you thinking and feeling? What’s the thought or the feeling when you start to cut and what else can they do? There’s other ways to get your endorphins. It’s just fast, quick and easy. It’s just like, I’ve said many times that I would get these kids on a physical activity, whether it’s running, getting on a trampoline doing something for other people, or helping others can make you feel good about yourself. This one particular girl, they got her treatment and they had her volunteering to help other children. So having kids help building their efficacy, their sense of self-esteem is all important. Finding other ways to change how they’re feeling comes highly important.
Richard Jacobs: The disappearing girl, does it cover cutting only? What is it focus on?
Dr. Lisa Machoian: The focus of the book is on girl’s depression. It’s actually the first and still only book specifically devoted to girl’s depression. It’s based on in-depth clinical interviews of teenage girls and their case studies where you can actually hear the girl’s voices. The theory and the basis of it is what girls had to say. I interviewed lots of girls. It’s also based on my work as a therapist with teenage girls. So it’s fun to girl’s depression, but there are certainly a lot about anxiety because of the coexistence. I have a chapter dedicated to trauma in there as well, but it’s the stories of girls and a lot of them are just everyday girls and things start to go haywire in those early adolescent years, their spirals into depression, which could be prevented. Something that really stood out to me in doing the research, it was highly pronounced the power of the peer group and the social group for kids. There’s a lot to do with parents and parenting, but what was so pronounced was what lengths that girls have to go to maintain friends, fit in, look a certain way, have the right clothes, listened to the right music, and the inclusion and exclusion of girls, they’re called groups now, but they used to be called cliques.
It was really pronounced for me that a lot of girls in more recent years are trying to fit in and have a peer group. I know because I did some recent research for a chapter in my colleague’s book. Also, the girls, they’re experiencing more sexual harassment in schools. It is also a precursor to depression, anxiety and cutting themselves. If they don’t look a certain way, there’s a massive social media and immediate images. Now that the bombardment. In my little bit more recent research that’s also stood out for me, but both their immediate friends and the larger peer group that’s something that has really stood out. It’s also important for people to know and to ask, “How school was? Who did you sit with in the lunchroom? What were your classes like? Was anybody nice today? Was anybody not?” It is because girls have a lot of shame about all of this, if they’re not in a group. It’s kind of bullying, actually, it’s a severe form of bullying for girls.
In general, girls tend to be more socialized to sometimes keep things in, not all girls. This can certainly vary, but they may be a bit less direct and it can be certain things that they do that are just basically unkind to one another. It can really lend itself to girls feeling depressed and anxious. A lot of girls that I’ve worked with recently, things have really shifted for them with the pandemic and remote learning, and some girls are feeling like their friend groups have changed. Not because they couldn’t always be with them, but just because of the pandemic. For the older teenage girls, it’s been a little eye opening. What’s most important in a friends, is it more important to have a lot of friends or to have a few quality friends that are loyal and that you can trust, but that tends to be more for 16 and 17 year olds, where the younger girls, 12 to 14, it’s very imperative to have a friend group to fit in. You can see some differences between early adolescence, middle adolescence, and the later, such as the 11 to 13 year olds, and the 14 to 16 years old group.
Richard Jacobs: What are some of the warning signs that a child is headed for emotional trouble and possibly cutting?
Dr. Lisa Machoian: Certainly loneliness, there’s a lot of that right now. The repercussions of this pandemic, we’re looking at years. I used to say that they’re always in their room, but now they’re in their room a lot because they were remote learning. If you notice, it increased anxiety, irritability, agitation, a drop in grades, and losing interest in what they once liked to do. If they start to act out or pulling away negative comments about the self is to be a huge red flag for depression. A lot of people think depression is more emotional, but it’s also very cognitive, negative self-talk, negative comments about the self, self-deprecating remarks, and pessimism. Those can also be sense, such as if there crying and moping, but also anger and agitation.
Some kids, even girls, we used to be called Mask Depression, but they psychology toss that term out, which I think is too bad because it was helpful. Some girls get very angry, defiant and oppositional, which can be a sign of depression, but it can often get missed. A well-known psychiatric hospital constructed a study where they looked at girls who were angry and defiant. They looked at two groups of girls;
The clinicians rated the sad and crying girls as depressed, but not the angry and oppositional girls. But on a self-report inventory, the angry oppositional girls were just as depressed as the sad and crying girls. It’s something to look out for if a girl’s acting out that can be a sign of depression that often gets missed, such as their sleep gets disrupted, changes in behavior and eating habits, become more bitter, sad writing drawings, can’t get out of bed, having trouble with just basic self-care, getting up, brushing their teeth, getting into the shower, lethargic, tired, or low energy.
There’s also a lot of physical symptoms related to depression, as well as anxiety. Kids can get stomach aches, headaches, or muscle tension. Adolescents are much less likely to connect a feeling, say of anxiety to a bodily symptoms. As an adults, you might say, “My shoulders are tense or I’m feeling stressed right now,” but teenagers are less likely to make that link. There’s also, headaches, stomach aches, nausea and problems like that you always want to rule out any medical health concerns. There are often physical signals of depression as well as anxiety and cognitive. It’s not all of emotional. If they’re feeling of worthlessness, having trouble sleeping (insomnia) or excessive sleeping, low frustration level, loads of crying, or not participating in activities they used to. Some of that can be curtailed now because of the pandemic, but that’s still something to keep an eye on including physical symptoms, which we often miss.
Richard Jacobs: It’s a good list and a lot more than I thought. It would be good for parents to look out for those warning signs.
Dr. Lisa Machoian: There could be more, but I am glad that we’ve gotten a few out there.
Richard Jacobs: What’s the best way for people to get your book and to find out more about your work? Where can they go?
Dr. Lisa Machoian: My book is available on Amazon and Barnes & Noble, The Disappearing Girl: Learning the Language of Teenage Depression. There’s also a website for the book, www.thedisappearinggirl.com, which will link to mine. I’m very accessible by phone and email, and anyone’s welcome to call or text if they need consultation or help. I also do a lot of work with not just teens and girls, but also parents, such as parents support, parents’ guidance, parent coaching, as well as self-care for parents. As for working with the parent, I don’t work specifically with the team. I keep a boundary here, but I do both. I can also be reached 6172858198, and lisamachoian@gmail.com as well.
