Working with Traumatized Parent-child Dyads: Challenging the Internal Working Model

1. Working with Traumatized Parent-child Dyads: Challenging the Internal Working Model Douglas Goldsmith, Ph.D. Executive Director The Children’s Center

2. Overview • Understanding secure attachment • Understanding the impact of trauma • Assessment of the internal working model • Challenging/Repairing the internal working model in treatment

5. Secure Attachment • The caregiver is perceived as a reliable source of protection and comfort

6. Secure Attachment • When I am close to my loved one I feel good, when I am far away I am anxious, sad or lonely • Attachment is mediated by looking, hearing, and holding • When I’m held I feel warm, safe, and comforted • Results in a relaxed state so that one can, again, begin to explore Holmes (1993)

7. Secure Attachment • Promote exploration of the environment • Expand mastery of the environment • “I can explore with confidence because I know my caregiver will be available if I become anxious.” • The infant gains confidence in his or her own interactions with the world Weinfield et al (1999)

8. Attachment is a reciprocal relationship The parent offers caregiving behavior that matches the attachment behavior of the child The child, using social referencing, checks in with the mother “looking for cues that sanction exploration or withdrawal” Holmes (1993) Secure Attachment

9. Anxious Attachment • Lack experience with consistent availability and comfort • Attachment behaviors are responded to with: • Indifference • Rebuffs • Inconsistency

10. Anxious Attachment • Anxious about caregiver’s availability • Afraid that the caregiver will be unresponsive or ineffective in providing comfort • Experience anger about caregivers unresponsiveness

11. Anxious Attachment • Shows overt aggression toward the inconsistent mother • “Don’t you dare do that again!” but has to cling because he knows from experience that she will. Holmes (1993)

12. Impact of maltreatment • Peer relations are disturbed • More withdrawal and avoidance • Physically abused children are more aggressive toward peers • Display unusual or aggressive behavior in response to distress of peers • More depressive symptoms

13. Impact of maltreatment • School functioning is compromised • Representational models of self are more negative • Experience distorted ongoing parent-child interactions • More negative family relationships • Poorer developmental outcomes Lyons-Ruth & Jacobvitz 1999

14. Impact on the parent-child relationship • “A frightened or frightening attachment figure presents an inherent conflict for an infant. Fear of the parent activates the attachment system, and the infant feels compelled to seek proximity; however, proximity seeking increases the infants fear, and he or she then contradicts the approach.” Lyons-Ruth & Jacobvitz, 1999

15. Relational PTSD • Parents may be traumatized even if not present at the trauma: • Withdrawn/Unresponsive/Unavailable • Emotionally and functionally unavailable • May have suffered trauma in the past • Overprotective/Constricting • Preoccupied about the trauma re-occuring • Reenacting/Endangering/Frightening • Repeatedly ask about the event Scheeringa & Zeanah (2001)

16. Parental Response to Trauma • Parents experience: • Helplessness • Frustration with inability to protect their children Osofsky ( 1995)

17. Impact of Parental Anxiety • Unable to hear their children’s distress • Withdraw to protect themselves emotionally • Difficulty tolerating children’s anxiety and aggression Osofsky & Fenichel, (1994, 1996, 2000)

18. Children’s Response to Trauma • Loss of sense of basic trust • Loss of security • Destabilized “Secure Base” Compromised emotional development

19. Infants and Toddlers • Following violence in their home or community: • Increased irritability • Immature behavior • Sleep disturbances • Emotional distress & crying • Fears of being alone • Physical complaints • Loss of skills – regression in toileting and language • Increased separation distress Appleyard & Osofsky (2003)

20. Young Children • Re-experiencing of the traumatic event • Avoidance • Numbing of responsiveness • Increased arousal • Fear going to sleep to avoid nightmares • Restricted range of emotion in play • Serious, disorganized, somber Appleyard & Osofsky (2003)

21. Parental Response to Trauma • How does the parent make sense of the child’s new behaviors? • Is the child perceived as understandably anxious? Or too clingy? • Is the parent able to be patient and supportive? Or is the parent pushing the child too hard to resolve the trauma? • How is the “Circle of Security” impacted?

23. Internal Working Model • “Through a history of responsive care, infants will evolve expectations of their caregivers’ likely responses to signs of distress or other signals of the desire for contact” • Bowlby believed that, “What infants expect is what happened before.” Weinfield et al (1999)

24. The model governs how children feel toward each parent and about themselves, how they expect to be treated and how they plan their own behavior toward their parent Impact of the Internal Working Model

25. Internal Working Model • Anxious infants learn to see the world as: • Unpredictable • Insensitive • The self does not deserve better treatment • These beliefs are carried forward to new relationships and new experiences Weinfield et al (1999)

26. Internal Working Model • “When the expectation of being hurt, disappointed, and afraid is carried forward to new relationships, the anxious infant becomes an angry, aggressive child.” Weinfield et al (1999)

27. Bowlby • The IWM governs how he feels toward each parent and about himself, how he expects each of them to treat him, and how he plans his own behavior towards them. They govern too both the fears and the wishes expressed in his day dreams

28. Bowlby • The IWM of a parent and self in interaction tend to persist • The IWM comes to operate at an unconscious level • As child grows older and parents treat him differently there is a gradual updating of the IWM

29. Bowlby • But for the anxiously attached child • Updating is obstructed through defensive exclusion of discrepant experience and information • Patterns of interaction are habitual, generalized, and largely unconscious • They persist uncorrected and unchanged even when dealing with persons who treat him differently from his parents

30. Maintaining Proximity • When attachment behaviors such as searching, calling, and crying persistently fail to regain the figure, the child is forced to marshal defensive strategies that exclude this painful information from consciousness. Solomon & George

31. Response to Trauma • When a child feels unwanted and unlovable (mirrored by representations of the attachment figure as one who cannot care for or rejects the child), representational models reflect a complex interplay of multiple representations of self and other that are to some degree incompatible and difficult to integrate Solomon & George

32. Understanding the Post-trauma IWM • How has the trauma impacted the child’s view of the parent? Others? Sense of safety? • How has the trauma impacted the parent’s view of the child? • Permanently damaged? • Needing extra care and nurturing? • Fears getting close?

33. Cooper, Hoffman, Marvin &Powell , 2000

34. Assessment of Parent’s Point of View • Interview questions: • Could you give me a thumbnail sketch of your child? • Tell me about a time in the past two weeks when you and your child really clicked. • Tell me about a time when you didn’t. • What gives you the most joy in your relationship? • What gives you the most pain? • Where do you turn for emotional support? Steele (2003)

35. Assessment – Secure Base • Over the past two weeks can you think of a time when your child was: • Hurt? • Frightened? • Separated from you? • What did your child do? • How did you respond?

36. Assessment of the Child • Utilize narratives to gain an understanding of the child’s view of adults • Clinical interview

37. Treatment - Bowlby • A therapist applying attachment theory sees his role as: • Providing the conditions in which the patient can explore his representational models of himself and his attachment figures • Helping the patient reappraise and restructure the models in the light of new understanding

38. Treatment - Bowlby Five therapeutic roles Provide a secure base Help the patient consider ways in which he engages with significant relationships Encourage exploration of the therapist-patient relationship Consider how perceptions are a product of childhood relationships Recognize that past images may no longer be appropriate

39. Challenging the Parent’s IWM • Parental Insightfulness • What do you think was going through your child’s mind? • Gain a comprehensive understanding of the parental point of view • Gently challenge the point of view

40. Challenging the Child’s IWM • Utilize play therapy to understand the child’s world view • Gently challenge the child’s perception by intervening within the child’s play • Utilize empathy to challenge the child’s expanded world view that may include adults outside of the family circle e.g. “Adults are never helpful” “No one understands”

41. Challenging the Child’s IWM • Use observation and interview to understand how the child’s perception of peers has been impacted • Group therapy may be instrumental in helping the child view peers less negatively or defensively

42. Parent-Child IWM • Parent-child therapy is utilized to: • Help the parent respond empathically • Interpret the child’s play • Confirm/correct child’s view of trauma • Practice nurturing skills • Learn to set limits • Help child with emotion regulation

43. Supportive Parent Intervention to address PTSD • Increase protection for highly anxious children • Temporarily change sleeping arrangements • Actively demonstrate safety • Allow child to maintain closer proximity when possible • Decrease toileting demands on very young children • Increase use of transitional objects

44. Supportive Parent Intervention • Increase structure for acting out behaviors • Remind children that rules haven’t changed • Continue with consequences • Increase communication and help child understand their response to trauma

45. Secure Base Interventions • Nurturing • Concept of good grandparenting • Anticipating needs • Helping child regulate emotions • Parental emotional availability • Structure and consistency • Experience of being in one’s mind