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Complex trauma in children and adolescents can interfere with the capacity to integrate sensory, emotional, and cognitive information into a cohesive whole and sets the stage for unfocused and irrelevant responses to subsequent stress. Fisher &Van Der Kolk (2000)
The immediate and long-term consequences of children exposed to maltreatment and other traumatic experiences are multifaceted. Emotional abuse and neglect, sexual abuse, and physical abuse as well as witnessing domestic violence, ethnic cleansing, and war, can interfere with the development of a child having secure attachment within the caregiving system.
Complex trauma results in a loss of core capacities for self-regulation and interpersonal relatedness. Children often experience lifelong problems that put them at risk for addiction. Impairments like psychiatric and addictive disorders, chronic mental illness, and legal, vocational, and family problems. These problems can carry into adulthood. Cook, (2005)
In a study on the effects of early childhood trauma, Fischer &Van Der Kolk (2000), conclude that childhood abuse and neglect are responsible for costly long-term psychiatric disabilities, chronic medical problems, substance abuse, learning problems with unemployment, risk of developing HIV and other serious social and health problems. Early comprehensive intervention may be effective in reversing some of these changes. If not prevented or treated early these children are likely to grow up to lead traumatized and traumatizing lives. Leading to impulsive behavior, drug abuse, and interpersonal violence. Fischer &Van Der Kolk (2000)
The domains of impairment in Children exposed to Complex Trauma are as follows.
- Attachment, problems with boundaries, distrust, social isolation interpersonal difficulties difficulty attuning to other peoples emotional states, and perspective-taking.
- Biology, sensorimotor developmental problems, Analgesia, problems with coordination, balance, body tone, somatization, and increased medical problems across the lifespan. (pelvic pain, asthma, skin problems, autoimmune disorders pseudo seizures).
- Affect regulation, difficulty with emotional self-regulation, labeling and expressing feelings, problems knowing and describing internal states, difficulty communicating wishes and needs.
- Dissociation, distance alteration in states of consciousness, amnesia, depersonalization, and de-realization, two or more distinct states of consciousness, and impaired memory for state-based events.
- Behavior control, poor modulation of impulses, self-destructive behavior, aggression toward others, pathological self-soothing behaviors, sleep disturbances, eating disorders, substance abuse, excessive compliance, oppositional behavior difficulty understating and complying with rules reenactment of trauma in behavior or play.
- Cognition, difficulties in attention regulation and executive functioning, lack of sustained curiosity, problems with processing novel information, and problems focusing on completing tasks. Problems with object constancy, difficulty planning and anticipating, problems in understating responsibility, learning difficulties, problems with language development, and orientation in time and space.
- Self-concept, lack of continuity, predictable sense of self, poor sense of separateness, disturbances of body image, low self-esteem, shame, and guilt.
The other model that is important to understand when treating trauma is the Six Core Components of Complex Trauma Intervention.
Safety, self-regulation, self-reflective information processing, traumatic experiences integration, relational engagement, positive affect enhancement. Cook (2005)
Identify what you see as the core components of effective treatment in working with survivors of trauma.
In treating survivors of trauma, it is important to take into consideration the whole person. Keeping in mind their past, present, and future. Understanding the role that trauma has played in the clients life. It requires an in-depth knowledge and understanding and being able to identify dissociation. The clinician must have a strong understanding of the effects the traumatic events have on the clients and use the best practices when treating trauma to avoid, therapeutic misadventures . Levers, (2012)
In treating trauma survivors trauma therapy typically covers three phases. Safety is the first stage. Using an accurate assessment is critical. Establish a framework in which the therapy will proceed with the discussion of boundaries and limits. Discuss frequency and stress the importance of the therapeutic relationship is not a friendship. A discussion needs to happen on how to manage a crisis and develop a crisis team if needed.
During this phase, it would be important to check for harm to self and harm to others. Check to see if the client is suicidal or experiencing homicidal ideation and see if they have a plan. If either one of these is present then the client needs to go to an emergency facility or in-patient facility so they are not in danger of harm to self and danger to others. Administer a suicide assessment test to determine if the client is suicidal.
Danger to others- plan an inpatient facility, or have them check into the local ER by calling emergency contact on their intake paperwork.
Safety and stabilization is the second phase. Building relationships by using unconditional positive regard. Often this can be a challenge with trauma survivors due to their lack of feeling safe in their bodies and personal relationships. This phase can take as long as the client needs. Safety refers to the physical safety of the environment where the therapy occurs as well as the emotional safety of the client. This phase includes psychoeducation. Explaining the effects of traumatic stress, including the biological and psychosocial ramifications. This can help reduce fear and normalize the clients symptoms and reactions. Helping the client recognize that some of their responses are due to their trauma can be so helpful.
In this phase, educating the client on self-soothing techniques is key. Teaching them emotional regulation. I would use the container and safe space exercises from EMDR Phases 1, 2, and 3. Emotional regulation and stabilization are key. I would also use EFT tapping, acupuncture pressure points, and education on techniques to help regulate. Weighted blanket, putting legs up on the wall, deep box breathing, and as many tools as it takes to find what works for the individual client.
The second phase is processing trauma. This phase begins only when the relationship is established and the client has the necessary coping skills for grounding and containment and they feel safe to be able to process the traumatic memory. The client is in charge of this process and can stop at any time. Attunement with the client allows for adjustments during this phase. The therapist offers support and guides the therapeutic process with the client If the client becomes hyper-aroused or experiences intense trauma symptoms the session needs to slow down and stabilize with previously learned skills such as a peaceful place or container. I would use EMDR for this. History taking, container, safe space, and emotional regulation. During the history taking 8 phase three prong phase, the client has discovered their negative core belief about themselves due to the trauma they experienced. They have also identified a past, present, and future memory where this negative core belief is causing them emotional and often physical distress. It is important during this process that the client moves through the traumatic memory. Using tapping and breath to help them process the trauma. I would also assess the clients ability to regulate and decide what specific memory to work on. Often if they have a lot of trauma it is good to start with EMDr prime. Focusing on just one memory and not allowing the client to go into the body connection. Starting small and reducing the change of hyperarousal.
The third phase is Reconnection and integration. The focus is to help the client see that they are not their trauma or what happened to them. Trauma survivors have a difficult time being in the present moment and future. In this phase, the client will focus on formulating a new relationship with themselves, relationships, intimacy, and be able to identify their strength-based narrative. I love to add Narrative Therapy into this phase because often trauma survivors havent thought about their future. Clients begin to feel a new-found sense of self. Often making meaning out of their trauma and developing a sense of purpose. I often find that during this phase service and advocacy, can be a big part of a survivor’s healing. Levers, (2012)
Basics of assessment for survivors I would use the ACES and Resilience test. I think this gives a good idea of a clients early childhood trauma and it also offers a narrative around survival and the strength-based narrative needed to go through trauma.
Responding to the safety concerns of survivors is key. The therapist needs to anticipate a crisis may arise. The goal is to give the client a clear direction on how a crisis needs to be handled between sessions and outside of therapy. Review the boundaries and limits of the therapeutic relationship. The therapist can expect transference issues within this phase. Supervision is key during this phase and all phases. Some clients can act in self-inflicted harm. There needs to be a safety plan in place that is talked about and agreed on what to do if this happens. Call the support team or 911.
To stabilize urges to self-injure and manage suicidal thoughts, eating disorders, and substance abuse Engaging in the client writing a safety plan and having both the client and the therapist sign is a helpful way to engage both in promoting safety. Include in the plan high-energy activities, like exercising, biking, jogging, walking, dancing and kicking or throwing a ball. Also, less intense like who they call on their support team or list. Journal writing, drawing, taking a bath, or listening to music. The contact spells this out. Including calling 911 in case of emergency.
Neurobiology refers to how neurons work, how the brain functions and develops, and the developmental aspect of Interpersonal relationships with the developing brain. The infant-caregiver relationship is a gene-environmental relationship where the mother mediates the external environment of the child. This happens in a dyadic affective transaction psychobiological influences the infants production of hormones and neurohormones in the infant’s developing nervous system. Researchers have identified a variety of neurobiological abnormalities in traumatized children and teens. Often, they are unaware of their emotions because they are stored in their bodies. They also found abnormalities in the corpus callosum a thick cord made up of fibers that connect the left and right hemispheres of the brain. They noted that in children who have endured longer periods of abuse the cerebral volume in the brain was smaller and they displayed more trauma symptoms such as hyperarousal, avoidance, disassociation, and intrusive images and thoughts. Other researchers found that chronic trauma results in affect dysregulation, sleep disorders, startle reactions, sensory-motor dysfunction, dissociation, learning problems, relationship issues, anxiety, and panic attacks, and avoidance of specific situations or events. They can negatively affect a childs development.
Self-care for survivors is so important. Trauma survivors often dont connect their minds and bodies. Mindfulness Stress Reduction Techniques can help survivors be in the present moment and get into their bodies. In concluding an article done on mindfulness in trauma survivors we find many positive changes. Mindfulness emphasizes non-judgmental acceptance of ones experience, including unwanted thoughts or emotions, and evidence of its impact on attention control and physiological arousal is accruing. Changing autonomic arousal may be integral to reducing the effects of trauma reactivity, hypervigilance and attentional control may reduce intrusive thoughts. Lang (2017) Its also important to note that mindfulness can be moving meditation, or walking your dog, sometimes still meditation can trigger trauma survivors because it is another thing they feel that they failed at. It isnt comfortable for them to be still in their bodies.
Transference is defined as a phenomenon in which a person transfers to someone in the present, the responses and feelings that he or she has had for someone in the past . This happened to me when I was doing neurofeedback to a patient who had a stroke. The situation was so familiar to me and I had no idea what was happening. I began caretaking the client and thankfully my supervisor was with me. She looked at me and suddenly I was aware of what I was doing. I excused myself and was able to process it with her afterward. I also became aware of my limits. It is probably not the best idea for me to do that technique on stroke survivors. Since then I have had a client who is a stroke survivor and have been able to separate my experience from hers and stay present with my emotions and supervision around this client. Levers, (2012)
Countertransference is something I witnessed when I was doing an EMDR session with my supervisor. The client had a similar trauma to my supervisor and she had a physical reaction during her treatment. Started coughing and tearing up. Thank goodness, the client didnt realize and I took over but later after processing with my supervisor, she shared how this countertransference happened due to the similarities in their traumas. I have also experienced this with some motherless daughters I work with. When their story is, similar I find, myself getting a bit teary. I have learned that when this happens to wiggle my toes and grab onto the rock in my pocket to bring me back to the present moment. I find that most often clients appreciate the empathy. Thank goodness, I have never got to the point where it triggers me and I have been able to make sure the client doesnt feel responsible for my emotions. I work hard at this in supervision and therapy weekly.
In the future, I will work with the issues as they arise by remaining vigilant in my self-care and therapy. Seeking out supervision, mindfulness, grounding techniques, self-care, and trauma processing with my therapist.
This changed for you over this year working with clients. Not really this term. I have been working on this since last January and will continue to do so.
References
- Cook, A. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390-398.
- Lang, A. J. (2017). Mindfulness in PTSD treatment. Current Opinion in Psychology 14, 40-43.
- Ling, J., Hunter, S. V., & Maple, M. (2013). Navigating the challenges of trauma counseling: How counselors thrive and sustain their engagement. Australian Association of Social Workers, 67(2), 297-310.
- Lopez Levers, L. (2012). Trauma counseling: Theories and interventions. New York, NY: Springer. Meyer, D. & Ponton, R. (2006).
- Streeck-Fischer, A. & van der Kolk, B. A. (2000). Down will come baby, cradle and all: Diagnostic and therapeutic implications of chronic trauma on child development. Australian and New Zealand Journal of Psychiatry, 34, 903918.
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