Chapter Eight
Trauma Therapy
If
the purpose of therapy is to support the client in managing the effects of
changes and challenges on everyday life then identifying those specific events
is necessary. For many people and many
problems staying in the present and moving forward will work just fine. For others including children early life
experiences have an impact and we ignore this brain science at their
peril. Unplanned pregnancy, in utero
drug exposure, separation from birth mother, and removal from parents count as
much or more than multiple moves and physical or sexual abuse. A family history or other documentation can
supply information to construct genograms, timelines, and placement maps. A genogram, like a family tree, identifies
multiple generations of family members, the quality of their relationships, and
conditions like mental illness and substance abuse. A timeline lays out major developmental
milestones along with both major and minor positive and negative events in a
person’s life. A placement map shows
where and with whom a child may have moved and what happened in each home. The process of physically drawing out these
on paper is just as important as the finished products. It allows parents to really investigate
family life and to focus on details they may have forgotten or wish to
deny. In the hearing, the child is
educated about important events held in implicit or body memory and validated
for experiences held in explicit and verbal memory.
Many parents feel
uncomfortable sharing very scary information with children; if the child was a
product of rape, if a parent is in prison, if serious mental illness or
substance abuse is involved. They fear
hurting the child more, they fear dealing with the emotional consequences, they
fear the child will adopt the same behaviors, they feel ashamed of the behavior
or to be associated with people who make such decisions or hurt their
children. I acknowledge all of that to
parents. Yet, in most cases, the child
is the one associated with “those” people, “that” behavior. The nature of attachment trauma is that abuse
and neglect happen in the context of what is supposed to be a nurturing
relationship. Humans hurt each other,
sometimes on purpose, usually by accident.
We are most often hurt by people we count on and love. That is the nature of the work. Parents may take themselves off the hook for
hurting the child but they must take responsibility for helping the child heal
because children cannot heal on their own.
They are also self-centered and egotistical because they are supposed to
be. Everything is about them. That means what they don’t know, they make
up, what they make up is worse than the truth, and what they make up that is
worse than the truth is their fault.
Children need to be taken off the hook for causing their own
trauma. So, children need to know the
truth as soon as they are able to handle it, and that is usually at a very
young age. Parents of infants and
toddlers can practice the story. “You
were a very beautiful baby when you were born.
You have eyes likes your biological mother. We don’t know who your biological father is,
but he must have great hair, because you do.
But your mother was taking methamphetamines which made her forget about
taking care of you. That’s why the child
welfare worker came and took you to a foster home because you needed bottles
and diapers just like every other baby.”
It is not the details of the story a small child will grasp but the
parents’ tone in telling it. They may
not understand the details, but this story will be repeated for the rest of the
child’s life as they grow older and ask more questions requiring
elaboration. It is their story. It becomes the parents’ story as the family
grows and acceptance of these facts demonstrates acceptance of the child and
those connected to them. If we reject
biological parents, we reject the child.
Talking about “something bad that happened”, “mistakes the parents
made”, or “they were smoking bad stuff” is a cop-out and damages the trust
parents want their children to have in them.
Children deserve to hear the whole truth.
Again, a book like
The Little Flower (McAndrew, 1999) normalizes traumatic events and the emotions
that go with them. After the parent
reads the book I have the child draw a flower that represents themselves and
then we list the basic needs of flowers and children. It reinforces that the child deserves
care. Life events laid out on a timeline
provide a roadmap to healing. Both
positive and negative developments need to be included: “This is the house
where you learned to walk,” “this is the house where you ate dry Top Raman
because they did not feed you.” Sometimes
just seeing all of the events lined up on paper is enough to put the pain in
perspective; separations, divorces, deaths, moves, and more. Then we use colored pencils to highlight
happy, stressful, and neutral events. I
ask the client to scale the level of current stress associated with each
traumatic event and to prioritize the traumatic events for processing. I do the same for veterans and others with
Post-Traumatic Stress Disorder. When we
pick a triggering traumatic event we identify the thoughts, emotions, and
situations associated with each. We look
at the impact on the client’s life and what the client is doing to cope,
behaviors that are working or not working, normalizing the experience. For example, “if you heard adults fighting at
nighttime, no wonder you are scared to go to bed.” This is the format for trauma-focused
cognitive behavior therapy used with adults as well as children. The client is
supported in challenging automatic negative thoughts and cognitive distortions,
to learn and practice more effective coping skills, and to develop a narrative
of their life that focuses on surviving and thriving. For children it requires the active
participation of parents focusing on relational safety, co-regulation of emotion,
and intersubjectivity; the ideas that the parent provides acceptance and
commitment in the face of difficult experiences and behavior, can manage their
own emotions and lend the child support in managing theirs, and can accept the
child’s interpretation of events while guiding them to mastery of the material.
Role play is an
excellent way to bring events to life especially with children because of their
interest in fantasy and make believe and their visual learning styles. Role play can be very effective with adults
as well. I start by establishing a sense
of safety by emphasizing that role play is just that, play, we are playing
parts and we can make up the characters and script, which is often empowering
to the client. I give the client the
power to end the role play if it becomes overwhelming or uncomfortable by
practicing a hand signal like “time out” or simply saying, “Mike, can we please
stop.” For example, adopted children
will often like to revisit the court hearing at which the judge decided to
terminate parenting rights and order the child adopted. In this case, the child plays the judge, the
one in charge, and I take the roles of attorney, biological parent, or child
welfare worker, depending upon whom the child would like to hear from or “cross
examine”. The “bailiff” calls the
hearing to order, the judge pounds the “gavel”, and the witnesses take “the
oath” and “the stand”. The attorney asks
“biological mother or father” why their children were removed and whether they
have completed services to fix their problems.
The child “judge” will often ask about their living situations and
whether they miss the child showing their deep concerns. When the real adoptive parents take “the
stand” the attorney asks about their preparation and commitment to adopt. The child “judge” most often asks about food
showing their interest in basic needs.
The attorney gives a “closing argument” and the judge is asked to decide
whether the child will be “adopted”. The
child acting as judge signs the order along with the parents creating a
relationship agreement the child did not make the first time.
The results are
sometimes as cathartic when the child wants to talk with a biological family
member or even their perpetrator who are not available or safe enough to see in
person. This comes after several
sessions in which we have developed a safe therapeutic relationship and a
practice of emotional expression and soothing coping skills to which to
return. Orlans and Levy, (2006)
demonstrate this in their trainings.
Again, this requires some preparation and set-up, “Remember, you’ll
really have to use your imagination because I’m pretending to be your
bio-mother and I am Mike.” The other
preparation that makes this intervention more than mastering the trigger event
is the role of the parent in demonstrating intersubjectivity with the
child. The client is encouraged to ask
questions or talk with the “parent or perpetrator”. They might even prepare questions or a letter
to read. But if they cannot or do not speak,
the parent is encouraged to speak for them in “I statements” as the voice of
the child which demonstrates they share the child’s concerns and
interests. At the very least the
client’s experience is validated. At
most a moment of connection as when a “biological parent” suggests the child
“come to visit” and the child pulls back into the arms of the adoptive parents
whom he has seemed to reject. Another
time, a five year old boy faced his “uncle” who favored him over his jealous
siblings while molesting him. The
nonchalant “uncle” asked, “What do you want me to do?” The boy, who had scary tantrums daily in his
adoptive home said firmly, “I want you to apologize.” The nurturing mother pulled us both out of
that most real role play by having us play together again.
When role play is
too intrusive and triggering to tolerate, narrative therapy helps people
process traumatic life events. Nichols,
Lacher, and May (2002) describe constructing narratives that review a child’s
developmental stages and traumatic experiences.
Like bibliotherapy, third party story telling allows the person to take
a new perspective on events similar to their own in a way that reduces resistance
and dissociation. We heal by hearing
stories of people who have overcome problems like our own. With parents children can be engaged in
creating characters, plot, challenges, conflict, and resolution which can be
empowering and satisfying. I start with
a story of a prince or princess who leave their ill parents, the king and queen,
on a journey to find a family, going through a scary forest, meeting strange
animals, listening to magic birds, until they employ special powers to find a
home in which there are rules but also lots of love and care. I ask children with their parents to create
their own story in words and pictures. I
often provide an outline that includes chapters for the child’s birth, traumatic
events, moving, settling in, and growing up.
Some children enjoy drawing pictures that represent events, others write
poems illustrated with drawings. Their
reading of their creation validates their experiences and reviewing it over
time helps them master their trauma. Similar
to the birth narrative I lead parents through telling the child’s developmental
and trauma narrative placing themselves at pivotal moments to support the
child’s growth; “and we would hold your hands as you begin to walk”, “and if we
saw you walking on the street in your diaper we would call the police and get
you some clothes and food.” Parents
often bring props like blankets, bottles, pictures, toys, food, and clothes
that bring the stories to life in a way that emphasizes nurturing and safety.
Trauma
Metaphors
Psychoeducation in the form of
examples, stories, and metaphors can be helpful for children, adolescents,
and adults. Two metaphors that may not
be scientifically based still help me conceptualize trauma and therapy. First, there is the analogy of airline
luggage. Sometimes we carry around a
lot of baggage that is heavy and expensive to check. Our whole lives are dumped into the
suitcase and it is not particularly organized. In therapy we unpack the big bag, take a
look at what is important, get rid of what we do not need, and organize it
in a smaller bag that is easier to wheel around and cheaper to carry
on. We put it up in the overhead
compartment or on the shelf in the closet and we can have access to it
whenever we need to recall, refresh, and update the contents. The second metaphor is about the brain as
computer. We are working along when
we get an error message or everything slows down or stops. Our computer has a virus and files may be
infected. The repair opens each
document saved on our hard drive, brings it up to the desktop, editing and
refreshing, resaving with a new name, organizing documents into the correct
file folders, deleting unwanted material, and emptying the recycle
bin. Each time we open and look at a
file we change it even if the content stays the same. Reviewing thoughts,
beliefs, and memories changes them.
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