Attachment and the Impact of Early Childhood Trauma - Daniel A. Hughes, Ph.D

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Attachment and the Impact of Early Childhood Trauma - Daniel A. Hughes, Ph.D.

All Nations Centre, Cardiff, UK - 5 November 2010

- www.Danielhughes.org

Dyadic Developmental Psychotherapy

DDP is a treatment approach to trauma, loss, and/or other dysregulating experiences, that is based on principles derived from attachment theory and research and also incorporates aspects of treatment principles that address trauma. It is a specialized form of Attachment-Focused Family Therapy which is utilized for all families.

DDP involves creating a safe setting in which the child can begin to explore, resolve, and integrate a wide range of memories, emotions, and current experiences, that are frightening, shameful, avoided or denied. Safety is created by insuring that this exploration occurs within an intersubjective context characterized by nonverbal attunement, reflective dialogue, acceptance, curiosity, and empathy. As the process unfolds, the client is creating a coherent life-story which is crucial for attachment security and is a strong protective factor against psychopathology. Therapeutic progress occurs within the joint activities of co-regulating affect and co-creating meaning.

Primary intersubjective experiences between a parent and infant contain shared affect (attunement), focused attention on each other in a way such that the child’s enjoyable experiences are amplified and his/her stressful experiences are reduced and contained, and a congruent intention to understand the other/be understood by the other. This is done through contingent, nonverbal (eye contact, facial expressions, gestures and movements, voice prosody and touch) communications. These same early parent-child experiences, fundamental for healthy emotional and social development, are utilized in therapy to enable to the child to rely on the therapist and parents to regulate emotional experiences and to begin to understand these experiences more fully. Such understanding develops further through engaging in affective/reflective (a/r) dialogue about these experiences, without judgment or criticism. The therapist will maintain a curious attitude about past and present events and behaviors, facilitating the client’s ability to explore them to better understand their deeper meanings in his life and gradually develop a more coherent life-story. This process may be stressful for the client, so the therapist will frequently “take a break” from the work, go slower, provide empathy for the negative affect that may be elicited, and repair the treatment relationship.

The primary therapeutic attitude demonstrated throughout the sessions is one of playfulness, acceptance, curiosity, and empathy (PACE).

For the purpose of increasing the child’s psychological safety, his readiness to rely on significant attachment figures in his life, and his ability to resolve and integrate the dysregulating experiences that are being explored, a person who is a primary attachment figure to the client will be actively present. The role of the parent—or other attachment figure—in her child’s psychotherapy is the following:

1. Help him to feel safe.

2. Communicate PACE, both nonverbally and verbally.

3. Help him to regulate any negative affect such as fear, shame, anger, or sadness.

4. Validate his worth in the face of trauma, loss, and shame-based behaviors.

5. Provide attachment security regardless of the issues being explored.

6. Help him to make sense of his life so that it is organized and congruent.

7. Help him to understand the parents’ perspective and intentions toward him.

Frequently a person’s symptoms are his unsuccessful ways of regulating frightening or shame-based memories, emotions, and current experiences. Confronting a child to stop engaging in these symptoms may actually increase their underlying causes. In helping the child in therapy and at home to regulate the affect associated with the symptoms, and to understand the deeper meanings of the symptoms, we are increasing the likelihood that the symptoms will decrease. At the same time it may certainly be necessary to address the symptoms through increased daily structure and supervision or through applying natural consequences for them. Again, however, the issues will be addressed more effectively when done with PACE rather than routine anger, rejection, harsh discipline, or other shame-inducing actions.

When we are asking a child to address frightening or shame-based memories, emotions, and current experiences, we are asking him to engage in an activity that will be emotionally stressful. In do so it is crucial that we maintain an attitude characterized by PACE in order to insure that the client is not alone while entering that painful experience. The child has developed significant symptoms and defenses against that pain, most often because he was alone in facing it. When we help to carry and contain the pain with him, when we co-regulate the affect with him, we are providing him with the safety needed to explore, resolve, and integrate the experience. We do not facilitate safety when we support a child’s avoidance of the pain, but rather when we remain emotionally present when he is addressing and experiencing the pain.

For a caregiver and therapist to remain present for a child during periods of dysregulation, it is important for them to have resolved any similar issues from their own attachment histories. The significant adults in the child’s treatment need to address—in their own lives—any areas of fear or shame that are similar to what they are asking the child to address. Individual or joint treatment for the parent(s) may be necessary prior to, instead of, or during this family-focused treatment.

The following statements reflect routine features of DDP:

1. Playful interactions, focused on positive affective experiences, are never forgotten as being an integral part of most treatment sessions, when the client is receptive. When the client is resistant to these experiences, the resistance is met with PACE.

2. Shame is frequently experienced when exploring many experiences of negative affect. Shame is always met with empathy, followed by curiosity about its development, organization, exceptions, management, and impact on the narrative.

3. Emotional communication that combines nonverbal attunement and reflective dialogue and is followed by relationship repair when necessary, is the central therapeutic activity. All communication is “embodied” within the nonverbal.

4. Resistance is addressed and met with PACE, rather than being confronted.

5. Treatment is directive and client-centered. Directives are frequently modified, delayed, or set-aside in response to the child’s response to the directive.

6. The therapist is responsible for insuring the rhythm and momentum of the session. The therapist insures the development of a coherent story line through his matched, regulated, affect, accepting awareness, and clear intentions.

DEVELOPMENTAL TRAUMA DISORDER

Toward a rational diagnosis for children with complex trauma histories

Bessel van der Kolk, MD

Psychiatric Annals 35:5 May 2005, Pp.401-408

“Traumatized children rarely discuss their fears and traumas spontaneously. They also have little insight into the relationship between what they do, what they feel, and what has happened to them.” P.405

“The PTSD diagnosis does not capture the developmental effects of childhood trauma:

The complex disruptions of affect regulation;

The disturbed attachment patterns;

The rapid behavioral regressions and shifts in emotional states;

The loss of autonomous strivings;

The aggressive behavior against self and others;

The failure to achieve developmental competencies;

The loss of bodily regulation in the areas of sleep, food, and self-care;

The altered schemas of the world;

The anticipatory behavior and trauma expectations;

The multiple somatic problems, form gastrointestinal distress to headaches;

The apparent lack of awareness of danger and resulting self endangering behaviors;

The self-hatred and self-blame;

The chronic feelings of ineffectiveness.” P. 406

Treatment Implications “Treatment must focus on three primary areas:

1. Establishing safety and competencies. 2. Dealing with traumatic re-enactments

3. Integration and mastery of the body and mind.” P. 407

“Unless this tendency to repeat the trauma is recognized, the response of the environment is likely to replay the original traumatizing, abusive, but familiar, relationships. Because these children are prone to experience anything novel, including rules and other protective interventions as punishments, they tend to regard teachers and therapists who try to establish safety as perpetrators.” Pp.407-408.

COMPLEX TRAUMA IN CHILDREN AND ADOLESCENTS

Alexandra Cook, Joseph Spinazzola, Julian Ford, Cheryl Lanktree, et al

Psychiatric Annals, Vol. 35, Iss 5 May, 2005, pg390-398.

Domains of Impairment in Children Exposed to Complex Trauma

1. Attachment 2. Biology 3. Affect Regulation 4. Dissociation

5.Behavior Control 6.Cognition 7. Self-Concept

Six Core Components of Complex Trauma Intervention:

1. Safety 2. Self-Regulation 3. Self-Reflection 4. Traumatic Experience Integration

5. Relational Engagement 6. Positive Affect Enhancement

ATTACHMENT-FOCUSED CARE WITH TRAUMATIZED, DISORGANIZED CHILDREN

ATTITUDE

1.Accepting 2. Curious 3. Empathic

4. Loving 5. Playful (PLACE)

To Facilitate the CAPACITY FOR FUN AND LOVE:

1. Reciprocal Intersubjective Experiences

2. Stay physically close.

3. Integrate and resolve own issues from own attachment history.

4. Eye contact, smiles, touch, hugs, rocking, movement, food.

5. Emotional availability in times of stress

6. Safe Surprises

7. Playful, nurturing, holding your child

8. Make choices for him and structure his activities.

9. Reciprocal communication of thoughts & feelings, shared activities

10. Humor and gentle teasing

11. Basic safety and security

12. Opportunities to imitate parents

13. Spontaneous discussions of past and future

14. Routines & Rituals to develop a mutual history

To Facilitate EFFECTIVE DISCIPLINE (Shame-Reduction and Skill Development):

1. Stay physically close.

2. Make choices for him and structure his activities.

3. Set & Maintain your favored emotional tone, not your child’s

4. Accept thoughts, feelings, wishes, intentions, and perceptions of child

5. Provide natural and logical consequences for behaviors

6. Be predictable in your attitude, less predictable in your consequences

7. Reattunement following experiences he experiences as shameful

8. Interrupt cycles of resistance: “mom time”

9. Use paradoxical responses

10. Use permission, thinking, practicing, having limits, being supervised.

11. Employ quick, appropriate, anger, not habitual anger or annoyance

12. Convey with empathy that you are not overwhelmed by your child’s problem

13. Use the child’s anger to build a stronger connection

14. Reciprocal communication of thoughts and feelings

15. Be directive and firm, but also be attuned to the affect of your child

16. Greatly limit your child’s ability to hurt you, either physically or emotionally.

17. Integrate and resolve own issues from own attachment history.

Dan Hughes

PHYSICAL PRESENCE

Once they know how to crawl, toddlers have the ability to touch, bite, pull, or climb on everything within their reach. Parents immediately begin to socialize them, for their safety and the safety of others as well as the protection of the family’s assets.

Maintaining Physical Presence is the primary way that parents discipline toddlers. Parents are aware of their toddler. They “keep an eye on her” and “an ear on him” constantly throughout the day. They are near their child, so that the child takes their presence for granted and gradually comes to rely on their knowledge about what to do. Their child also constantly engages in “social referencing” whereby (s)he watches her/his parents’ nonverbal reactions to know whether or not someone or something is a danger or is safe. The develop their primary knowledge of self, other, and the world through relying on their parents’ minds and hearts. The parents’ presence gives the child the sense of safety necessary to be able to explore and learn about her/his world.

Children lacking a secure attachment need physical presence just as much as does the toddler. They do not have the skills needed to internalize rules, control impulses, remember consequences of their actions, have empathy for others or feel safe. Allowing them to be outside of the parents’ presence, to make the “right” choice unsupervised, is a blueprint for disaster and failure.

Physical Presence Involves:

Structure &Containment (The following is applied to the degree that the child requires.)

1. Supervision. The parent is aware of the child at all times when (s)he is not sleeping. If the parent is out of visual contact briefly, the child is confined to an area (with a door alarm if necessary) where (s)he cannot hurt her/himself, others, or destroy something important.

2. The child sits, plays, works, or rests near her/his parent. The parent enjoys her/his company frequently with brief engagements.

3. There is a well defined routine, alternating active and quiet activities, work and play, solitary and interactive activities

4. The parent chooses the activities, as well as much of the food, clothing, toys, etc. for the child, giving him/her the ability to choose only when she/he shows some readiness to be able to make choices, that lead to contentment and success.

5. The home is “child-proof”.

Fun and Love

The parent provides numerous activities to become engaged with her/his child with reciprocal fun and love. The parent is attuned to the child’s emotional state and is engaged with her/her in positive emotional, nonverbal communication throughout.

1. Feed, prepare food together 6. Wash, dress and comb hair.

2. Hold, rock, hug, touch, massage 7. Read and tell stories

3. On the floor: roll, crawl, rest among pillows. 8. Quiet, extended bedtime routines.

4. Songs and games for babies and toddlers. 9. Go for a walk, holding hands.

5. Habitual background music 10. Periods of “baby talk”, “small talk”.

Dan Hughes

Parenting Profile for Developing Attachment©

Respond from 1-5. 1 represents very little; 5 a great deal of the characteristic/skill.

Focus on adult’s abilities, not whether or not the child is receptive to the interaction.

My Perception My Perception of

Of Self Spouse/Friend

____________________(1 =very little 5 =very much)__________________________

1. Able to maintain a sense of humor- - - - - - - - - - - - - _____ _____

2. Comfortable with giving physical affection- - - - - - - _____ _____

3. Comfortable receiving physical affection - - - - - - - - _____ _____

4. Ready to comfort child in distress - - - - - - - - - - - - - _____ _____

5. Able to be playful with child - - - - - - - - - - - - - - - - _____ _____

6. Ready to listen to child’s thoughts and feelings - - - - _____ _____

7. Able to be calm and relaxed much of the time.- - - - - _____ _____

8. Patient with child’s mistakes- - - - - - - - - - - - - - - - - _____ _____

9. Patient with child’s misbehaviors - - - - - - - - - - - - - _____ _____

10. Patient with child’s anger and defiance- - - - - - - - - - _____ _____

11. Patient with child’s primary two symptoms- - - - - - - _____ _____

12. Comfortable expressing love for child - - - - - - - - - - _____ _____

13. Able to show empathy for child’s distress- - - - - - - - _____ _____

14. Able to show empathy for child’s anger - - - - - - - - - _____ _____

15. Able to set limits, with empathy, not anger - - - - - - - _____ _____

16. Able to give consequence, regardless of his response- _____ _____