Developmental Trauma Disorder. Margaret Blaustein, Ph.D. DTD Criterion B: Affective/Physiological Dysregulation. Developmental Trauma Disorder

Transcription

1 Applications of the Attachment, Regulation and Competency (ARC) Framework with youth exposed to developmental trauma Annual Trauma Center Conference Boston, MA May 31, 2017 Margaret Blaustein, Ph.D. The Trauma Center at Justice Resource Institute Developmental Trauma Disorder Criterion A A1. Traumatic victimization + A2. Attachment Disruption Criterion B Affective/Physiological Dysregulation Criterion C Attentional/Behavioral Dysregulation Criterion D Self/Relational Dysregulation Developmental Trauma Disorder Criterion A A1. Traumatic victimization + A2. Attachment Disruption Criterion B Affective/Physiological Dysregulation Criterion C Attentional/Behavioral Dysregulation Criterion D Self/Relational Dysregulation DTD Criterion B: Affective/Physiological Dysregulation B. 1. Inability to modulate or tolerate extreme affect states B. 2. Inability to modulate/recover from extreme bodily states: aversion to (a) touch, (b) sound; (c) unexplained bodily problems DTD Criterion D: Self and Relational Dysregulation D. 2b. Attachment insecurity: attempt to care for caregivers, or difficulty tolerating reunion after separation from primary caregiver(s) Feeling angry or upset when reunifying with caregivers D. 3b. Extreme persistent distrust, defiance or lack of reciprocal behavior in close relationships: Feeling like other people are trying to push you around or take advantage of you D. 5b. Psychological boundary deficits (excessive seeking of intimate contact or reliance on peers/adults for safety/reassurance): Needing a lot of reassurance or attention when upset Briefly what is ARC 1

2 Competency Regulation Attachment ARC Framework Relational Connection Identification Caregiver Affect Management Trauma Experience Integration Executive Functions Attunement Self-Development & Identity Modulation Effective Response What is Trauma Experience Integration TEI for complex developmental trauma involves the sequential development of capacity to first survive and tolerate moments of overwhelming distress and arousal; to build ability to engage curiosity and reflect upon those states; and ultimately to shift and transform them allowing active engagement in the present moment. Engagement Education Routines & Rituals How are ARC Skills Used to Support TEI? Throughout treatment, the 8 core skills are applied to the work in support of regulation (of the child, the caregiver, and the system); curious reflection (by the child, the caregiver, and the system); and eventually present engagement (the ultimate goal of TEI). Applications of skills vary by stage (of the work) and by state (of the child and caregiver) Some assumptions of ARC relevant to DTD Criterion in B and D 1. Children develop in the context of relationship, and developmental trauma takes place in the context of relationship. Therefore treatment that does not directly address current relationships and the caregiving system will be limited in its impact Assumption 1b: Trauma affects not just the child, but the entire system. Some assumptions of ARC relevant to DTD Criterion in B and D 2. Understanding state-based treatment is crucial to supporting TEI; the Observe-modulate / Modulate-observe / Do sequence guides effective intervention Some assumptions of ARC relevant to DTD Criterion in B and D 3. Behavior makes sense, and behavior may be thought of as a type of communication. Behavior driven by dysregulation is a clue about the child s experience in the world, their needs, their lens, their goals, and their adaptations. Therefore Addressing behavior is far less effective than addressing the underlying need. 2

3 How do we understand regulation? Regulation is a complicated skill set that is not just about maintaining status quo Individual differences: Comfort zone (I like to be here) vs. safety zone (I NEED to be here) and danger zone (I can t TOLERATE being here) How do we understand regulation? Comfort zone: I like to live here Regulatory capacity: The capacity to tolerate entering a range of arousal states; have strategies or resources to manage those states; and tools that help you return to baseline Uncomfortable but manageable Tolerable arousal states Comfort zone: Preferred arousal state Tolerable arousal states Uncomfortable but manageable How do we understand dysregulation*? Safety zone: I NEED to live here to remain regulated Regulation in a safety zone: Exerting extreme efforts to remain in a narrow band of arousal to maintain felt safety, and becoming disorganized and distressed when out of that band Danger zone: highly distressing arousal states leading to disorganization Tolerable but uncomfortable arousal state Safety zone: where I need to live *Option 1 0 How do we understand dysregulation*? Almost NO Safety zone: Very slim band that allows functional engagement Very few organized regulation strategies, leading to easy cycling among hypo- and hyper-aroused states *Option 2 Rapidly triggered / cycling arousal response Functional state Slim safety zone Functional state Rapidly triggered / cycling arousal response Back to DTD Criterion B: Affective/Physiological Dysregulation Addressing Dysregulation B. 1. Inability to modulate or tolerate extreme affect states B. 2. Inability to modulate/recover from extreme bodily states: aversion to (a) touch, (b) sound; (c) unexplained bodily problems A core goal in any developmental trauma intervention is therefore to address regulation The challenge: relationships (a key normative developmental resource for regulation) are often one of the primary triggers for dysregulation. For children who have experienced developmental trauma, relationships may increase disorganization rather than increasing safety 3

4 DTD Criterion D: Self and Relational Dysregulation D. 2b. Attachment insecurity: attempt to care for caregivers, or difficulty tolerating reunion after separation from primary caregiver(s) Feeling angry or upset when reunifying with caregivers D. 3b. Extreme persistent distrust, defiance or lack of reciprocal behavior in close relationships: Feeling like other people are trying to push you around or take advantage of you D. 5b. Psychological boundary deficits (excessive seeking of intimate contact or reliance on peers/adults for safety/reassurance): Needing a lot of reassurance or attention when upset How do we try to address this in ARC? Key goals: Increase safety in the surrounding environment: a caregiving system that can see, tolerate, and understand the child s affective and physiological arousal (attunement); manage its own affective response (caregiver affect management); and provide support for (co-) regulation Support child capacity to initially tolerate distressing states, and to over time understand and regulate them (identification / modulation) Meet Joey 8-year-old boy of mixed ethnicity (Latino/ Caucasian) referred by his father History of early physical and emotional abuse by biological mother, compounded by a recent move and felt loss of community Currently struggling with intense episodes of emotional dysregulation and behavioral acting out, leading to triggered /frozen response in mother Father struggling with trying to support both child and mother, and minimize risk for physical abuse Joey s regulation presentation Shifting states, all marked by high arousal: General presentation: hyperaroused, disorganized, highly active and difficult to contain Explosive and inconsolable sudden surges of arousal leading to aggressive and impulsive behaviors, often directed at parents and younger sister, followed by sadness/distress Overwhelmed with worry, often at night Foundational work: Child and caregiver engagement and cultivation of relationship Establishing child-specific goals (1) Increase Joey s awareness of emotion and arousal level; (2) Increase Joey s capacity to modulate arousal and emotion at age-appropriate level; build range of coping strategies (3) Increase caregiver-child attunement; (4) Increase appropriate child-caregiver expression and communication. Build child-specific therapy routine to facilitate goals and support modulation in-session Structure included both individual / dyadic / familial child sessions as well as separate parent-child coaching sessions Why a session routine? Session Routine Our goals: to support rhythm and safety in the treatment, and to provide structure to support goals Joey s routine: Modulation activity Check-in Goal activity Free play Dyadic / familial time Clean-up 4

5 The Check-in Goals: Organize and provide rhythm to session Support Relational Connection: create opportunity for invited child expression Support Basic Identification: Reflection and curiosity about internal experience A window into relationships Building relationship Goals: Engagement: cultivating stake and connection Identity: getting to know the whole child **Strong emphasis in ARC on integrating Self and Identity work at all stages of treatment Surface Identity Likes and Dislikes Identity shield More vulnerable self 5

6 Modulation Goals Setting the foundation for modulation Modulation goals: To build understanding of the concepts of comfort and effectiveness To build awareness of the range of energetic states in the body, and the link with emotions To experiment with a range of strategies, integrating effective and comfortable tools into a purposeful toolbox To develop a proactive regulation plan, integrating caregiver and systemic support as needed Engaging the Body From the beginning, physical activity and experimentation was built into session Organization of physiology allowed more active engagement in the work Importance of modulating toward, rather than away from, his energy state initially Gradually increasing role of reflection: how does this activity influence his experience of his body? Setting the Foundation for Identification Identification: Affect and Physiology General goals of Identification: building awareness of internal experience, including: Language for emotions and arousal Understanding connections feelings, body, behavior, thoughts Understanding context Why do I feel this way? Use of: Reflection and mirroring by adults Cultivation of curiosity Early Identification Work 6

7 Displaced Feelings Direct Feelings Detective Work Deepening Identification Depicting the funny feeling Development of an energy scale Developing a shared understanding of energy 7

8 Incorporation of energy scale into check-in The bridge from Observe to Modulate Dual early focus: Building a shared language for internal experience and energy / arousal (Identification) Supporting routine for engaging in modulation activities / experimenting with physiology (basic Modulation) Building the bridge: Beginning to link awareness of internal experience with cause, context, and tools for building comfort and addressing needs Engaging ARC caregiver - Blaustein & Kinniburgh supports 2010; Kinniburgh in this & Blaustein, process 2005 Linking emotion to physiological sensation Linking physiological arousal and behavior ARC - Blaustein & for Kinniburgh self 2010; Kinniburgh and & Blaustein, mother 2005 Linking specific states to specific tools Bridging therapy room to real world practice Physiological organization depends on capacity to modulate in-the-moment ; however, the hardest time to access modulation skill is in the moment you need it Our general sequence: Supported experimentation in calm states (Supported) practice in calm states Supported modulation in targeted moments Independent modulation in targeted moments Generalized access to strategies 8

9 Key Challenges In this Case Addressing Relational Dysregulation Role of mutual disorganization: child triggered parent, parent triggered child Goal of simultaneously increasing each individual s capacity to regulate experience independently, while building positive experiences and eventually supporting coregulation Very different relationship with each caregiver Joey s Perception: Core ARC Caregiver Targets Caregiver affect management: Supporting adults in understanding and having the resources to address their own felt experience as caregivers Attunement: Increasing caregivers capacity to accurately read and effectively respond to children s needs and communications; building rhythm in relationship Effective Response: Building safe and effective responses to child behavior that are purposeful and incorporate an understanding of the origin of those behaviors Caregiver coaching and support Parents and parent-child unit were engaged in a separate weekly session to support increasingly attuned responses; these meetings included direct parent coaching and support for dyadic positive play experiences Importance of providing mother separate (less vulnerable) space to learn strategies and to feel successful, and to build positive felt experiences for both mother and child Engaging Caregiver in Session At each child meeting parent (primarily father, but sometimes mother) would join for some portion Dyadic meeting time included: Reflection on the week Identification of positive moments Dyadic practice of modulation / co-regulation Eventually, setting homework goal for supported modulation practice 9

10 Linking identified in-session tools to caregiver-supported home practice Clinical Course and Outcomes Core treatment period lasted ap. one year, with separate dyadic sessions lasting ap. 6 months. Final sessions were gradually spaced out until parents and child felt confident in progress Family brought many resources to the table: Willingness to engage in treatment Generally stable environment and neighborhood Education / intelligence level..coupled with multifaceted trauma exposure: caregiver mental health issues, physical and psychological abuse, separation, and (stressful) loss of community Clinical Course and Outcomes Perception by all involved of a successful treatment : Sharp decrease in physiological dysregulation Increase in parents confidence in capacity to coregulate Improved relationship between mother and child The Flow of Treatment Treatment is both sequential and simultaneous: Multiple targets addressed at one time (i.e., attunement in support of identification in support of modulation, held in the context of identity) Deepening (and at times shallow-ing) of intervention according to child and family state: gradually increasing capacity to be curious, reflect, harness inthe-moment modulation capacity, and to use this in service of active engagement in present life Full Circle: Defining Trauma Experience Integration TEI for complex developmental trauma involves the sequential development of capacity to first survive and tolerate moments of overwhelming distress and arousal; to build ability to engage curiosity and reflect upon those states; and ultimately to shift and transform them allowing active engagement in the present moment. Competency Regulation Attachment ARC Framework Relational Connection Identification Caregiver Affect Management Trauma Experience Integration Executive Functions Attunement Self-Development & Identity Modulation Effective Response Engagement Education Routines & Rituals 10