Dr. Kathy Seifert k.seifert@espsmd.com

Developmental and Systems Approaches to

the Treatment of TraumaJune 1, 2011

Dr. Kathy Seiferthttp://preventbullyingnow.info

k.seifert@espsmd.com

The nature of the trauma The severity and chronicity of the

trauma

The Effects of Trauma on the Individual Depend on:

The Inability to Escape Trauma Leaves one Trapped in Fight or Flight or Freeze Mode

Trauma

Fight/Flight /Freeze

Numb – unable to act

Frontal Cortex Not in Use

New Stressor - High Arousal -

Excitability

Hyper- Vigilant – Poor

executive function

In the days of dinosaurs this reaction to stress was a survival strategy and led to safety.

Trauma Staying stuck

Taking Action

Taking Effective Action (learning to cope)Takes a Trauma Survivor from “Frozen - Deer in the Head Lights” to Feeling Competent and “Moving On.” This can be done in several ways.

Feeling Incompetent

Feeling Competent

Leaves a person in constant fear Freezes Normal developmental

sequences and does not allow them to progress.

Does not allow person to defend herself Reinforces the inevitability of

revictimization

Frozen Mode of Complex Trauma

• Complex Trauma is different than traditional ideas of PTSD:

• Child abuse, neglect, domestic violence and attachment trauma happens in the context of family and other intimate relationships .

• The victim is psychologically and physically immature and dependant on others.• His or her development is often seriously compromised by repetitive abuse and inadequate response at the hands of family members or others on whom he or she relies for safety and protection.

The individual’s strengths and vulnerabilities within himself,

his history and his environment.

The Effects of Trauma on the Individual Depend on:

Strengths Easy going

temperament Good problem

solving skills Good self-

management skills Good interpersonal

skills Strong genetics

Vulnerabilities Rigid or irritable

temperament Unresolved trauma

that negatively affected development

Developmental Delays

Mental illness Vulnerable genetics

Individual

History

Strengths Vulnerabilities

No history of trauma Caregivers stress

respect for all people and communication

No history of assaulting others

No history of bullying or being bullied

School success

History of trauma Chaotic household

with domestic violence

History of assaulting others

Is a bully or is being bullied.

Not successful in school

Environment

Strengths Vulnerabilities

Family and Community does not support crime and drug use

Sufficient school supports for youth to be successful

Family is supportive and nurturing with good boundaries and appropriate and effective disciplinary practices

Family or Community supports crime and drug use

Insufficient support for youth to be successful in school.

Family is unsupportive and hostile with poor boundaries and inappropriate and effective disciplinary practices

The Developmental Level of the Individual

When the Trauma Occurs

The Effects of Trauma on the Individual Depend on:

Brain still developing throughout childhood.

Make a fist with thumb sticking down – Thumb is brain stem, inside of fist is limbic system (emotions), fingers are cerebral cortex or thinking part of brain.

Over proliferation of synapses is followed by use it or loose it trimming.

Amygdala – emotional regulation – may be smaller and less effective

Brain development may be delayed Cortisol may be in over abundance causing

a constant state of arousal

Brain changes caused by trauma

• Babies, children and adolescents are more vulnerable to the long term effects of trauma when it interferes with the developmental process.

• The availability of a support system that can help an individual build strengths to manage the trauma and its effects will, in part, determine the severity and length of time effects will last.

• Permanency of the changes in the brain and neurochemical systems due to the trauma and support systems is more likely in infancy and childhood.

The Developmental Level of the Individual When the Trauma Occurs

Attachment problems are often Part of the trauma picture. What is attachment?

Attachment is the heart to heart, 2 way, emotional connection between the primary caregiver and a child. It is a survival mechanism for the child.

It makes the caregiver want to be close (babies’ smell, round heads and big eyes, maternal instinct)

The caregiver then, meets the child’s needs. It prompts the child to call for help from the

caregiver. It forms the basis of all future relationships for

the child. It supports healthy brain and skill development It forms the core of self concept and how others

are perceived.

Attachment

Child Development & Attachment

Caregivers build warm, loving, protective relationships with their babies. When a baby is well cared for, she learns to trust her mother and then others and then the outside world. From this she will learn what she needs to know to develop in a healthy manner.

Skill development Interpersonal relatedness Self concept Self management Theory of mind Emotional regulation Development of pro-social values Brain development Family cohesiveness and relationships

When attachment bonds are disrupted, there can be problems with

1. Secure - Mom is safe base; forms new relationships somewhat cautiously, but can form deep relationships with others after building trust.

2. Inhibited (ICD 10)a. Anxious - I am afraid of (not sure I can

trust) mom and other relationships.b. Ambivalent - I think I want a relationship

with mom, but then I don’t; I do and I don’t; sometimes I do and sometimes I don’t; Borderline Personality Disorder. I hate you; don’t leave me.

3/4 Attachment styles

4. Disinhibited (ICD 10) - Disorganized /Dismissive - I am angry with mom; I must defend myself against everyone; No one is safe. Don’t mess with me; I will hurt you.

Baby has needs

Baby cries to get Mom’s attention

Mom attends to his needs

He feels safe, relaxed, &

happy

He is good, his mom is good, the

world is good.

Secure Attachment

arousal

satisfaction

Not able to form trusting, reciprocal relationships after age 10 or 11

Severe relationship problems with parents and others

Has not developed empathy or compassion after age 10 or 11

Does not have effective coping skills and improved behavioral regulation after age 10 or 11.

Is not academically or behaviorally successful in school

Disrupted attachment patterns - relationships

Stage I – Ages 0-2. Immediate Gratification

Stage II – Ages 2 -7. Reciprocity begins to develop

Stage III – Ages 8 – 11. Empathy Develops. More organized , less impulsive.

Trauma Negatively Affects Moral Development, Kohlberg, 1969

Stage IV (12-18) Learning the importance of group membership and the “Golden Rule”

Can be blocked by Trauma

Can be blocked by Trauma

Can be blocked by Trauma

Difficulty regulation affect, impulses, and emotions (risky behaviors)

Alterations in attention and consciousness (dissociation, amnesia, depersonalization)

Alterations in self perception (chronic guilt & intense shame)

Alterations in perception of the perpetrator (incorporating his or her belief systems)

Alterations in relationships to others (not able to feel intimate)

Somatization and/or medical problems Alteration in systems of meaning (despair of ever

recovering or being understood)CPTSD is another way to Understand the

Symptoms of Several Other Disorders

Criteria for Complex PTSD (What else could these symptoms represent?)

Attachment disorders/CPTSD/Developmental Trauma Disorder may be the Youthful presentation of Adult Personality Disorders.

87% of those with adult Borderline personality disorder have experienced childhood sexual abuse and 25-71% have been physically abused.

The perception and interpretation of the trauma by the individual and those around her.◦ Sexual behavior between parents and children is

normal◦ Abuse in the name of discipline

The Effects of Trauma also depend on

Alcohol abuse (2.5X more likely)

Drug abuse (4X) Violence, criminal

behavior, and personality disorders, particularly BPD and antisocial PD (4X),

Depressive disorders (3.4X).

Outcomes for ineffectively treated trauma

Assessment of all strengths and vulnerabilities of the individual and her environment◦ Use CARE2 or CANS as a broad based assessment

Assess the developmental level of basic life skills for all people that have experienced childhood trauma and are having difficulty forming relationships or coping with life.◦ For children and teens, us the Behavioral Objective

Sequence (BOS) by Sheldon Braaten, research press.com

◦ For adults with personality disorders, there is no developmental tool. The BOS can be used as a guide.

◦ At the least, use corrective developmental experiences involving trust and immediate gratification may be needed.

Assessment

Consult with teachers and other service providers when assessing youth and family to get other perspectives.

General Assessment Principles

Attachment/trauma history Awareness of Emotional & Environment Triggers Parenting Attitudes and Competencies

◦ The child needs a loving home with nurturing, affection, routine, structure and boundaries.

◦ There are skills to learn about anger management, reframing the meaning of behaviors, teaching, rather than punishing

Parent Mental Health & Stability◦ Parents must take care of their mental health to do this job

effectively Parenting knowledge and style

◦ Parents need to learn about attachment and trauma and skills to help their children

Assessment of Parents

Marital Relationship & Co-ParentingThe child will do best if the caregivers take care of their relationship health, as wellAdults will recover best in the context of a supportive relationship – relative or friend. Include them in the therapy when appropriate.

Treatment which addresses all of the above

Treat how the trauma affect the persons whole life

Treat the effects of trauma on an individual’s development

Treatment

Build relationships Rapport building Encourage significant

others to be included Employ Routines and

Rituals Discourage isolation. Respect the person’s

background. Focus on the positive. Offer

encouragement. Positive

reinforcement 4:1 Take pleasure &Laugh

together.

Creating a Sense of Belonging

Those were important skills (tools) at one time (fighting, sneaking, taking care of your own needs)tool. They probably saved your life, so you want to keep them safe in case you ever need them again. Put them in your tool belt.

Have you noticed how they don’t work in every situation?

Now it is time to learn new tools and when it is best to use which tools.

Are you up for that? Alright! Lets go!

“Tool belt” analogy

Reframing Oppositional and Defiant Behavior as Survival in a Dangerous Environment.

I. Safety and stability II. Skill Building III. Emotional /Mental Health IV. Relationship Building V. Holistic Treatment VI. Acceptance of self VII. Attachment /relationship/trust work VIII. Processing Trauma

The 8 Treatment Components of C-PTSD/DTD/RAD

Use Trauma to Build Strengths

The Sword

In the days of knights, your survival depended on the strength of your sword. Do you know how swords were made?

The parents / significant others (SO’s) create an environment that is safe, nurturing, without violence or aggression, and with good problem solving and anger management where children can heal and learn to cope.

The label you place on a child’s /adults behavior guides what you do about it. Parents and SO’smust learn to reframe “bad behavior,” a negative trait, int o “survival behavior,” a strength that is only to be used in certain circumstances.

Don’t take away their survival skills, add new ones to the tool belt, so they only need “survival skills in extreme circumstances.

Balance love and limits Parents should be proactive rather than

reactive.

Create a healing environment

I know that in the past fighting was a way to survive and you were good at it. You survived.

I want you to learn other ways to solve your problems and only use fighting when you life is in danger.

Now, why are you and Johnny fighting. What is the problem and how do we solve it?

You also have to go tell Mrs. Jones what happened.

Someone may need to apologize.

Reframing and coaching through an alternative response (teaching not Punishing

Change the dance, change the child. Child upsets parent (distancing behavior); parent punishes child in angry tone – Go to your room (distancing behavior); child becomes more angry and defiant – throwing toys around(distancing behavior).

Poopy stomping story Child attempts to make parent angry (distancing

behavior); Parent verbalizes child’s behavior and doesn’t take the bait, but makes a game or joke out of it (connection behavior); parent teaches through natural consequences in a calm tone (connection, communication, teaching behaviors); Child responds by accepting limits, feeling closer to parent and learning something.

The Goal is communication, teaching and connection

By Sheldon Braatan A developmentally sequenced group of

skills in 6 Domains. Age is not the determiner of skill level Youth must learn skills in appropriate

developmental sequence. Find out at what level they have

mastered skills (can do it 90% of the time without prompting)

The Behavior Objective Sequence

Adaptive Self-Management Communication Interpersonal Behaviors Task Behaviors Personal Behaviors

BOS Domains

Adaptive: Responds appropriately toroutine and new expectationsrespond independently to materials for amusementappear alert and able to focus attentionbring no weapons to schooluse amusement materials appropriatelywait for turn without physical interventionuse and return equipment without abuseaccept positive physical contacttouch others in appropriate waysrefrain from stealingrespond when angry without hittingrecognize and show regard for possessionsaccept verbal cue for removal from a situationrespond when angry without abuse of propertyrespond appropriately to substituterespond when angry without threatswalk to timeout without being moved by an adultwork or play without disrupting othersrefrain from inappropriate behavior when otherslose controlrespond to provocation with self-controlrespond when angry with self-removal

Stay for the long haul Stay calm Understand where the behavior is

coming from Don’t take it personally Reframe, reframe, reframe Use love, boundaries, and humor Caregivers need respite

7 Basic Principles of Treatment - Advice for Parents and Treatment Providers

Attachment concepts are not understood by the majority of people.

To correct this, other professionals must be educated in a very gentle and respectful way

As you can see from this workshop, it is complex with voluminous information.

Change is not easy Changing beliefs is extremely hard to do. You must be patient and always teaching

Teaching about attachment to all parties

Child Family Family Relations Community Systems

Focus of Intervention

Safety and stability are the first priority. Use CPS, if needed. (Ford &Courtois; Herman, 92; Seifert)

This is true whether child or adult.

I. Safety

BOS – 1 - Braatan Measure where the child is in each domain Start where the child is. The goal is to build on successful experiences

to learn new skills It must be everyday by everyone working

with the child. Choose one skill that is almost mastered and

one that will take a little work ( 2’s & 3’s). Everyone, including the child works on those

2 skills until mastered. Give the child multiple opportunities to

practice the skill and coach him through the appropriate response

Skill teaching Methods –BOS

Every 8 skills mastered gets a certificate

I give kids a binder for certificates. You will see skills mastered without

working on them. Give a certificate and lots of praise.

Show the child on a chart how he is mastering the skills.

Never say this is an elementary school skill. Say, “These are skills that we must all learn to be successful.”

This is a reinforcement program. You are building competence and confidence.

BOS -2 (Behavior Objective sequence) Braatan, Researchpress.com

◦ CBT – CBT is based on the Cognitive Model of Emotional Response. Cognitive-behavioral therapy is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that we can change the way we think to feel / act better even if the situation does not change. (http://www.nacbt.org/whatiscbt.htm)

◦ DBT – Marsha Linehan. CBT with validation and dialectics added. (http://www.behavioraltech.com/resources/whatisdbt.cfm)

◦ Positive reinforcement outweighs consequences by 4 to 1 (Seifert)

◦ Relaxation exercises (Seifert) Guided imagery (Seifert) Deep breathing when stressed or upset

(Seifert) Do the “three step.” (Seifert)

Programs

Someone reading to a child or adult who is sitting near you

Playing simple games and laughing Roller skating Walking in the park Building a snowman/snowwoman Swimming Dancing Drumming

Corrective developmental experiences if you are dealing with early childhood trauma (Seifert)

Therapist uses self to build relationship with parents and child . (Ford & Courtois; Herman,92)

Maximize relationships between child and family. ( Ford & Courtois; Levy & Orlans)

Reconnect to self and others. (Herman, 92)

Maintain healthy relationships (Levy & Orlans)

IV. Relationship building (Ford & Courtois; Seifert; Levy & Orlans; Herman)

Multimodal treatment with CARE2 (Seifert)

Whether you're an educator, social worker, mental health professional, juvenile services professional, or a concerned parent, you have the power to provide at-risk children and teenagers with the nurturing, support, and treatment that will give them a second chance at life.

You start by identifying the strengths, problems, and stressors of each "at promise" youth.

You continue by creating an intervention plan to provide the care, support, and treatment that counteract risk factors and trauma and promote a youth's strengths.

You move toward success by executing the intervention plan and by following up.

Multi-systemic Therapy (http://mstservices.com/)

Multisystemic Therapy (MST) is an intensive family-and community-based treatment program that focuses on the entire world of chronic and violent juvenile offenders — their homes and familes, schools and teachers, neighborhoods and friends. MST works with the toughest offenders. They are adolescents, male and female, between the ages of 12 and 17 who have very long arrest histories.

V. Holistic Treatment (Seifert)

Experience secure attachment in safe environment over a substantial period of time (Seifert, Becker-Weideman)

Reframe the view and working model of the youth, others and the world from “bad”, negative and unsafe to a more realistic view with positives and negatives, self-esteem, and hope. (levy & Orlans)

VII. Attachment work (Levy & Orlans, Becker-Weideman)

STORY TELLING – Tell a story, but let the character solve the problem and change the ending to one of competence and confidence . (Seifert) Every child can become involved in

story telling First let the child make up a “once upon

a time” story. Remind her that stories have characters, a beginning, a middle, and an end, and a problem to solve.

For smaller children, I write down or type the story. The child illustrates it and we start a book of stories.

VIII. Processing Trauma (Seifert; Courtois & Ford; Herman; Levy & Orlans)

When ready, they can tell some real stories about their lives. (when child is very stable and has some self soothing skills and family is stable.)

The therapists guides the story so that in solving the problem the hero/heroin (the child) gains skills to solve the problem and go happily on with his/her life.

Children have to move to learn. They also have to experience some level of emotion to rid themselves of old traumas.

When the story level is mastered, the child, parents and therapist can act out one of the stories. Let the child direct. The therapist directs behind the scenes.

I kept dress up clothes in my office to help with scenes.

Processing Trauma (Story telling - 2)

Spend a minor amount of time in the past You must change the end of the story. If this happened today, what could you do and

who could help you? Let’s act that out. You teach: I am stronger than I was then; I can

call for help; My parents now can be trusted to help me.

Let child and parents spend time relaxing and sitting quietly with each other after this.

They will likely be exhausted. Only use it if you have a supervisor to help you

or you have some training in psychodrama.

Psychodrama & Role Play (Seifert; Levy & Orlans)

Visualization Inner child Deep breathing Relaxation exercises Safe place

Other Methods

Helping Parents be effective

Reframing behaviorStaying CalmSkills – Mindful parentingA Healing EnvironmentProviding a secure baseReducing conflicts

These children adults need relationships that last longer than 2 years. (Examples - Will you be here when I have children of my own? I am leaving for college and I wanted to say thanks.

Relationships must be appropriate and loving, with good limits and attachment informed therapy.

Sometimes the therapist has to be the attachment figure.

Longevity and relationships if there are attachment problems

Several Theoretical Bases Any will be effective Attachment therapy is family therapy,

even if it is foster parents Cannot ignore this part

Family Therapy

What is the Child’s Goal – What is one thing you would like to be different in your life. Let him write down 3. (not have my parents yell at me so much.)

If the Parent’s could change one thing, what would it be. Have them write down 3. (Have Trevon go to bed at 9 PM without a fuss.)

What is the therapist goals. (Help the family have 1 more happy time during the week.)

Building Reciprocity - Contracting

Neighborhood Schools Juvenile

services Social services Law

enforcement Recreation

centers Peers Businesses

Coordinate Community systems

Treatment Foster Care, Departments of Social and Juvenile Services, Acute Care and Residential Treatment, Outpatient settings with multiple agency involvement

Educate all agencies Coordinate services; meet on regular

basis Work as a team Set up an email list for frequent

communication

How to Apply These Principles to:

Complex PTSD, Developmental Trauma Disorder, and Disrupted Attachment Patterns or RAD all have strong similarities (May be different forms of same disorder) leading to substance abuse, personality disorders ,criminal behavior, and violence in adulthood when not effectively treated.

Trauma negatively affects child development in many areas

The quality of early attachment bonds forms the basis of all future relationships for the child.

The balance between healthy and unhealthy biology, environment and experiences will determine the health of development.

In families, all members interact with and affect each other in continuing patterns that can be understood as a dance. Change the pattern of the dance.

Take Home Points

Assess youth, parents, family systems, community systems

Be thorough, take a holistic view Developmental assessment is essential Background information on all is

essential Assessing parents mental health is

essential

Take home points - assessment

I. Safety and stability (Ford &Courtois; Herman, 92; Seifert)

II. Skill Building (Braatan, seifert, Linehan, Ford & Courtois, Levy & Orlans; Van der Kolk)

III. Emotional Health (Levy & Orlans) IV. Relationship Building (Ford & Courtois; Seifert;

Levy & Orlans; Herman) V. Holistic/ Multi-dimensional Treatment (Seifert) VI. Acceptance of self (Herman; Levy & Orlans)

VII. Attachment work (Levy & Orlans) VIII. Processing Trauma (Seifert; Courtois & Ford;

Herman) IX. Coordination of Agencies

Take home points – 8 components of treatment