Treating Complex Childhood Trauma: Targeting the Building Blocks of Resilience

1. Treating Complex Childhood Trauma: Targeting the Building Blocks of Resilience Presentation by: Kati Taunt June 2017 Day 1 ARC Developed By: Margaret E. Blaustein, Ph.D. Kristine M. Kinniburgh, LICSW The Trauma Center at JRI

2. Introductions Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

3. Check Yourself

4. +10 +5 0 -5 Let’s talk about energy How high (or low) is your energy right now?

5. Totally comfortable Really uncomfortable Let’s talk about energy How comfortable does that energy feel in your body?

6. Great match (Very effective) Terrible match (Not at all effective) Let’s talk about energy How good a match is your energy level for what you are doing?

7. Great match (Very effective) Totally comfortable +10 +5 Terrible match (Not at all effective) 0 Really uncomfortable -5

8. Trauma is not the event itself: rather trauma reside in the nervous system… • Levine and Kline

10. Human Stress Response • Perception is more important than reality • Human beings are biologically primed for survival • When threat is perceived: Activation of ‘survival centres’ • Recognition of fear/danger • Activation of fight/flight/freeze response Shutting down of non-essential tasks

11. Multi-layered nature of trauma • Discrete experiences of danger (i.e., physical/sexual abuse) • Failures of need fulfillment (i.e., neglect) • Interpersonal context (i.e., betrayal of caregiving expectations; loss, abandonment; working models) • Interference with developmental tasks Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

12. Multiple Layers Lead to Complex Outcomes • Expectations of harm (from the world and from others) • Difficulty forming relationships • Difficulty managing, understanding, and regulating feelings and behavior • Damaged sense of self/fragmented sense of self • Developmental challenges (problem-solving, agency, imagination, academic performance, etc.) Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

13. What helps the child survive? Assumption of danger Rapid mobilisation in the face of perceived threat Self-protective stance Development of alternative strategies to meet developmental needs

14. Trauma’s Dual Influence on Development • Prioritization of those domains of skill / competency / adaptation which help the child survive their environment and meet physical, emotional, and relational needs • De-emphasis of domains of development which are less immediately relevant to survival Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

15. Trauma is Complex: Dimensions of Traumatic Experience Type of exposure • Age/developmental stage during exposure • Origin of exposure • Public versus private • Chronicity • Lasting impact • Social support • Contextual issues (culture, family, community) • Presence/absence of additional resources • Presence/absence of additional vulnerabilities • Individual differences (cultural factors, coping style, cognitive, temperament)

16. Sophie and Angela • Sophie is 14 years old • Living with Maternal Aunt Angela last 2 years • Self harms • 2 serious overdoses in last 12 mths • Non school attender • Sexually active (at risk of CSE) • Poor peer relationships • Aggressive outbursts (violent to Aunt)

17. Sophie and Angela • Non involvement with CAMHS • Diagnosis over the years: ADHD, Conduct Disorder, Oppositional Defiance • Currently considered diagnosis: Depression, Emerging severe personality disorder)

18. Using the Trauma Lens: Understanding Sophie What has Sophie experienced in her life? How might her experiences have affected her? What has she learned about herself? About relationships? How has she learned to manage her internal experience? In what ways are her behaviors adaptive? How has she learned to survive his world? Where were the opportunities to intervene?

19. “Sophie’s” Adverse Experiences: • Exposure to domestic violence • Parental mental health (Bipolar? BPD) • Impaired caregiving • Sexual abuse • Neglect • Poverty • Chaotic environment • Multiple attachment losses (parents, siblings) • Caregiver hospitalization • Multiple placements • School moves

20. Impact of Sophie developmental trauma Difficulty trusting others (“I don’t trust much”) Heightened arousal system – frequently on edge and jumpy Trouble managing internal experience – constriction and explosion (use of self harm, drugs and sex to modulate) Lack of agency / felt control – no sense of future or current possibilities Impacted sense of self (“I’m really stupid”)

21. Diagnostic Issues PTSD is the single diagnosis currently in the DSM-IV to capture chronic adaptations to trauma PTSD is not the most common diagnosis for youth who have experienced more chronic adversities Youth (and adults) who have experienced chronic adversities frequently meet criteria for a range of other diagnoses, and individuals with PTSD experience frequent comorbidity There is currently a proposal for inclusion of Developmental Trauma Disorder in the DSM-V

22. PTSD A: Exposure to a traumatic event B: Persistent re-experiencing C: Persistent avoidance and emotional numbing D: Persistent symptoms of increased arousal not present before E: Duration of symptoms for more than 1 month

23. Developmental Trauma Disorder – Proposed Criteria A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including: A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse

24. Developmental Trauma Disorder – Proposed Criteria B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following: B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization B. 2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions) B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states B. 4. Impaired capacity to describe emotions or bodily states

25. Developmental Trauma Disorder – Proposed Criteria C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following: C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation) C. 4. Habitual (intentional or automatic) or reactive self-harm C. 5. Inability to initiate or sustain goal-directed behaviour

26. Developmental Trauma Disorder – Proposed Criteria D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following: D. 1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behaviour in close relationships with adults or peers

27. Developmental Trauma Disorder – Proposed Criteria • D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other adults • D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance • D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness

28. Developmental Trauma Disorder – Proposed Criteria E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D. F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months. G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at two of the following areas of functioning: Scholastic Familial Peer Group Legal Health: Vocational

29. “In addition to the conditioned physiological and emotional responses to reminders characteristic of PTSD, complexly traumatised children develop a view of the world that incorporates their betrayal and hurt, They anticipate and expect the trauma to recur and respond with hyperactivity, aggression, defeat or freeze responses to minor stresses.” • Bessel A. van der Kolk, MD

30. Developmental Trauma, explaining it to kids • The bruise you cant see, but it hurts when it gets touched and then you react.

31. The Problem of Treating Complex Trauma Need for intervention that: Can address continuum of exposures (layers of chronic and acute), including ongoing exposure Is embedded in a social/contextual framework Is sensitive to individual developmental competencies and vulnerabilities, and flexible in its approach Addresses individual, familial, and systemic needs and strengths

32. “Treatment” therefore involves… • Building / enhancing / supporting surrounding environment and relationships in capacity to support healthy child development • Supporting youth (and their systems) in recognizing survival “strengths”, and reorganizing these toward present, goal-oriented active engagement • Support in building / enhancing normative developmental competencies Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

33. The ARC Framework

34. ARC – a framework for intervention Core principles Trauma derails healthy development Trauma happens in a context, and service provision has to address the context 3 Core Domains to address: A safe caregiving system (Attachment) The ability to regulate and tolerate experience (Self-Regulation) Support in the mastery of an array of tasks crucial to resilient outcome (Competency)

35. 3 Primary Domains • Attachment • Regulation • Competency Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

36. 2 Integrating Strategies • Routines • Psychoeducation Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

37. Executive Functions Modulation Expression Identificat. Attunement Consistent Response Caregiver Affect Mgmt. 8 Primary Skills: Building Blocks Self Dev’t & Identity Competency Routines Regulation Psychoed Attachment Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

38. 8 Primary Skill Targets • Support Caregiver Affect Management • Support Caregiver Attunement • Support Caregiver Consistent Response • Increase Self Awareness (Identification) • Increase Modulation Skills • Support Child Relational Engagement • Improve Problem Solving • Enhance Self and Identity Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

39. Each skills target is built in layers Main / Overarching Domain Concept: Build safe / trauma-informed caregiving systems and safe relationships that support children / adolescents Attachment Core Target / Goal: Help caregivers to better understand and respond to children / adolescents Attunement Key Sub-skills: -Parallel attunement to caregivers -Support active curiosity -Build and support mirroring skills -Use attunement skills in support of youth regulation -Build pleasure / positive engagement Techniques: i.e., Dyadic check-ins, feeling charades, etc. Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

40. 1 Overarching Goal • Trauma Experience Integration Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

41. 1 Overarching Goal • The Main Idea: Work with children to actively explore, process, and integrate historical experiences into a coherent and comprehensive understanding of self in order to enhance children’s capacity to effectively engage in present life.

42. Breaking it down… Actively explore: Engaging in curious reflection Process: to go beyond observation – moving toward attuned and realistic understanding and meaning-making Integrate into a coherent and comprehensive understanding of self: Building an age-appropriate understanding of self that incorporates many aspects of experience Enhancing capacity to engage in present life: Harnessing the above in order to shift from “reaction” mode to thoughtful action and engagement

43. To curiously explore in order to make sense of and understand (age appropriately) who they are. Making sense of the things that have happened to them and how this may affect them. So that they can fully get on with all aspects of their lives.

44. So how do we get there? Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

45. TEI for a child is embedded in their larger world • TEI relies on curious observation; ideally, this curious observation is held in layers: by the child, the caregiver, and the provider team. Keep in mind that a caregiver may also be integrating his or her own experiences. Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

46. How are ARC Skills Used to Support TEI? • Throughout treatment, the 8 core skills are applied to the work in support of present engagement (the ultimate goal of TEI). • Applications of skills vary by stage (of the work) and by state (of the child and caregiver) Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

47. FLUID PHASIC APPLICATION OF SKILLS: Surviving and Tolerating the Moment In the Moment Goal Intervention Emphasis Caregiver Core Goals Child Core Goals Surviving and Tolerating Present-focused distress tolerance Recognize and support coping with current perceived experience Support caregivers’ tolerance of their own experience as well as youth experience, and engage in strengths Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

48. FLUID PHASIC APPLICATION OF SKILLS: Recognizing and Addressing the Moment In the Moment Goal Intervention Emphasis Caregiver Core Goals Child Core Goals Recognizing and Addressing Self / Other Attunement Recognize and build understanding of patterns; understanding triggers and behavioral functions Build a caregiving system that accurately sees and understands youth experience Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

49. FLUID PHASIC APPLICATION OF SKILLS: Shifting and Transforming the Moment In the Moment Goal Intervention Emphasis Caregiver Core Goals Child Core Goals Shifting and transforming Meaning Making and Future Orientation Identify and explore past experiences, expand on self in the present, and engage links to the future Support caregiver’s own meaning-making and expand family identity Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005

50. FLUID PHASIC APPLICATION OF SKILLS In the Moment Goal Intervention Emphasis Caregiver Core Goals Child Core Goals Surviving and Tolerating Present-focused distress tolerance Recognize and support coping with current perceived experience Support caregivers’ tolerance of their own experience as well as youth experience, and engage in strengths Recognizing and Addressing Build a caregiving system that accurately sees and understands youth experience Self / Other Attunement Recognize and build understanding of patterns; understanding triggers and behavioral functions Shifting and transforming Meaning Making and Future Orientation Identify and explore past experiences, expand on self in the present, and engage links to the future Support caregiver’s own meaning-making and expand family identity Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005