Attachment therapy for children who have experienced family trauma

29/10/2013 12:00am

 

I am frequently asked by other professionals about what I do and what to do when referred a child who has experienced family trauma. What follows is a brief description of my work with these children. It is written with professionals in mind and assumes a basic knowledge of Attachment Theory and psychological approaches to treatment.
Children who have experienced gross deficiencies in care during their early formative years (preschool) are increasingly spoken about as having suffered from complex developmental trauma. Gross deficiencies in care incorporate physical, emotional and/or sexual abuse of the child and/or a persistent failure or inability of the child’s main caregiver or caregivers to consistently offer physical and emotional comfort in times of distress, such that the child is frequently left in a state of prolonged and severe physical and emotional distress. The developmental aspect incorporates the impact complex trauma has on developmental processes and outcomes for the child, which is increasingly being tied to impacts on the developing brain. However, the very nature of the aetiology of complex developmental trauma allocates a central role to the child’s primary attachment relationships and their impact on attachment security.
Children who have experienced complex developmental trauma frequently exhibit insecurity. Many are diagnosed with Reactive Attachment Disorder (RAD). Children diagnosed with RAD typically exhibit gross disturbances in social and emotional relatedness and behaviour. These disturbances are considered to stem from maladaptive beliefs about self, other and the world (attachment representations), hyperarousal (and associated arousal dysregulation), and a pervasive and enduring preoccupation with access to core needs provision (including the need to feel safe, accepted and to be physically nourished). 
Psychological interventions for complex developmental trauma, and its common associate Reactive Attachment Disorder, are often grouped under the general heading Attachment Therapies. As the name suggests, Attachment Therapies typically seek to repair the traumatised child’s attachment relationships and/or promote attachment security. The provision of reparative attachment experiences in therapy has a central role. With references often being made to such terms as transference and counter-transference, Attachment Therapies are often placed in the psychoanalytic tradition.                                                                                    
My own approach to Attachment Therapy focuses on promoting adaptive beliefs about self, other and the world (secure attachment representations), lower and improved regulation of arousal, and reduced preoccupation with access to basic needs. Therapy is experiential, just as early attachment relationships are formed through experiences. Children referred to me are offered sustained, consistent and intense experiences of structure, direction, guidance, mastery, deep understanding of their inner world, emotional connectedness and access to needs provision. This is achieved through therapeutic activities (e.g. Theraplay) and a stream of interpretations of the child’s thoughts, feelings, perspectives and intentions (i.e. verbalising understanding – a.k.a. validation).
As to what psychotherapy school or tradition my approach to Attachment Therapy sits in, it is possible to argue one way or another. There is no doubt that I am managing transference and counter-transference to achieve desired therapeutic outcomes for traumatised, attachment disordered children on a daily basis. However, it is also my practice to explore and name the child’s maladaptive beliefs about self, other and the world and take the child on a journey whereby they experience themselves, others and the world in a different, more helpful way. In doing so, my intent is to reorganise and restructure attachment representations and expose the traumatised, attachment disordered child in a systematic and sustained manner to the very source of their trauma: the dependency relationship. Desired outcomes include cognitive change and lowered arousal through habituation to the trauma stimulus; although arousal management techniques are also an important component of intervention. Hence, my therapeutic approach sits easily in the cognitive-behavioural tradition.
In addition, successful outcomes for traumatised, attachment disordered children rest in no small way on the promotion of a supportive care environment outside of the therapy setting. Engagement with the child’s caregivers in the home and educational contexts is an important aspect of the intervention process. Successful caregiver psychoeducation rests on the therapists ability to achieve understanding and acceptance of required approaches to the care and management of the traumatised, attachment disordered child. Wholesale changes in care and management approach are rarely accepted and implemented in a consistent and sustained manner; if at all. Even if they were implemented, the potential effectiveness of wholesale changes are likely to be quickly dismissed as traumatised, attachment disordered children are highly reactive to changes in caregiving practices. More subtle changes to care and management practices are more likely to be accepted, by the child and his or her caregivers alike. My own practice is to identify those aspects of common caregiving that facilitate the child’s experience of their caregiver as being accessible, understanding and emotionally-connected; such as is the infant’s experience when he or she is forming their first (secure) attachment relationships. As caregivers can rightfully assert “I do that anyway” they feel validated for the positive contribution they are making to the remediation of the child’s trauma and attachment difficulties and, having been made aware of what caregiving practices help, might be expected to do them more often.
For the reader who requires additional information about Attachment Theory and Attachment Disorder, please refer to my book:
Pearce, C. (2009). A Short Introduction to Attachment and Attachment Disorder.  London: Jessica Kingsley

I am frequently asked by other professionals about what I do and what to do when referred a child who has experienced family trauma. What follows is a brief description of my work with these children. It is written with professionals in mind and assumes a basic knowledge of Attachment Theory and psychological approaches to treatment.

Children who have experienced gross deficiencies in care during their early formative years (preschool) are increasingly spoken about as having suffered from complex developmental trauma. Gross deficiencies in care incorporate physical, emotional and/or sexual abuse of the child and/or a persistent failure or inability of the child’s main caregiver or caregivers to consistently offer physical and emotional comfort in times of distress, such that the child is frequently left in a state of prolonged and severe physical and emotional distress. The developmental aspect incorporates the impact complex trauma has on developmental processes and outcomes for the child, which is increasingly being tied to impacts on the developing brain. However, the very nature of the aetiology of complex developmental trauma allocates a central role to the child’s primary attachment relationships and their impact on attachment security.

Children who have experienced complex developmental trauma frequently exhibit insecurity. Many are diagnosed with Reactive Attachment Disorder (RAD). Children diagnosed with RAD typically exhibit gross disturbances in social and emotional relatedness and behaviour. These disturbances are considered to stem from maladaptive beliefs about self, other and the world (attachment representations), hyperarousal (and associated arousal dysregulation), and a pervasive and enduring preoccupation with access to core needs provision (including the need to feel safe, accepted and to be physically nourished). 

Psychological interventions for complex developmental trauma, and its common associate Reactive Attachment Disorder, are often grouped under the general heading Attachment Therapies. As the name suggests, Attachment Therapies typically seek to repair the traumatised child’s attachment relationships and/or promote attachment security. The provision of reparative attachment experiences in therapy has a central role. With references often being made to such terms as transference and counter-transference, Attachment Therapies are often placed in the psychoanalytic tradition.          

My own approach to Attachment Therapy focuses on promoting adaptive beliefs about self, other and the world (secure attachment representations), lower and improved regulation of arousal, and reduced preoccupation with access to basic needs. Therapy is experiential, just as early attachment relationships are formed through experiences. Children referred to me are offered sustained, consistent and intense experiences of structure, direction, guidance, mastery, deep understanding of their inner world, emotional connectedness and access to needs provision. This is achieved through therapeutic activities (e.g. Theraplay) and a stream of interpretations of the child’s thoughts, feelings, perspectives and intentions (i.e. verbalising understanding – a.k.a. validation).

As to what psychotherapy school or tradition my approach to Attachment Therapy sits in, it is possible to argue one way or another. There is no doubt that I am managing transference and counter-transference to achieve desired therapeutic outcomes for traumatised, attachment disordered children on a daily basis. However, it is also my practice to explore and name the child’s maladaptive beliefs about self, other and the world and take the child on a journey whereby they experience themselves, others and the world in a different, more helpful way. In doing so, my intent is to reorganise and restructure attachment representations and expose the traumatised, attachment disordered child in a systematic and sustained manner to the very source of their trauma: the dependency relationship. Desired outcomes include cognitive change and lowered arousal through habituation to the trauma stimulus; although arousal management techniques are also an important component of intervention. Hence, my therapeutic approach sits easily in the cognitive-behavioural tradition.

In addition, successful outcomes for traumatised, attachment disordered children rest in no small way on the promotion of a supportive care environment outside of the therapy setting. Engagement with the child’s caregivers in the home and educational contexts is an important aspect of the intervention process. Successful caregiver psychoeducation rests on the therapists ability to achieve understanding and acceptance of required approaches to the care and management of the traumatised, attachment disordered child. Wholesale changes in care and management approach are rarely accepted and implemented in a consistent and sustained manner; if at all. Even if they were implemented, the potential effectiveness of wholesale changes are likely to be quickly dismissed as traumatised, attachment disordered children are highly reactive to changes in caregiving practices. More subtle changes to care and management practices are more likely to be accepted, by the child and his or her caregivers alike. My own practice is to identify those aspects of common caregiving that facilitate the child’s experience of their caregiver as being accessible, understanding and emotionally-connected; such as is the infant’s experience when he or she is forming their first (secure) attachment relationships. As caregivers can rightfully assert “I do that anyway” they feel validated for the positive contribution they are making to the remediation of the child’s trauma and attachment difficulties and, having been made aware of what caregiving practices help, might be expected to do them more often.

For the reader who requires additional information about Attachment Theory and Attachment Disorder, please refer to my book:

Pearce, C. (2009). A Short Introduction to Attachment and Attachment Disorder.  London: Jessica Kingsley

You can read the full article written by Colby Pearce here.