Tuesday, June 28, 2016

Trauma Therapy

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.