Transcript Child-Parent Psychotherapy for Young Children Exposed to

Trauma- Focused
Child-Parent Psychotherapy
In Infancy and Early
Childhood
Alicia F. Lieberman, Ph. D.
Professor of Medical Psychology
University of California San Francisco
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Defining Trauma
in the Early Years
• Child’s direct experience or witnessing
of an event or events that involve:
Actual or threatened death or serious
injury to child or others
Threat to psychological or physical
integrity of child or others
(DC:0-3R, Zero to Three, 2004)
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Violence As Paradigm of Trauma
In the Early Years
• Child abuse is leading cause of death in the first
year of life
• Half of child abuse victims are under age 7
• 85% of abuse fatalities are under age 6
• U. S. ranks THIRD among 27 industrialized
countries in child deaths due to maltreatment
(Gentry, 2004; UNICEF, 2003; HHS
Children’s Bureau, 2003)
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Convergence of Types of
Violence
• Children exposed to domestic violence
– 15 times more likely to be abused than the
national average
– 30-70% overlap with child abuse
– At serious risk of sexual abuse
• Battered women
– Twice more likely to abuse their children than
comparison groups
(Osofsky, 2003; Edleson, 1999; Margolin & Gordis, 2000; McCloskey, 1995)
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Impact of Trauma in the Early
Years
• Loss of developmental expectation of
protection from the parent
• Disrupted mental representations
• Affect Dysregulation
• Impairment in Readiness to Learn
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Impact of Trauma on Parents
• Loss of internal security
• Changes view of self/other
– Victim
– Persecutor
– Non-helpful bystander
• Traumatic reminders
• Traumatic expectations
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Changes in Child-Parent
Relationship after Trauma
• Impaired affect regulation
• Negative Mutual Attributions
• Traumatic Expectations
• Parent and child may serve as traumatic
reminders for one another
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Domestic Violence in Infancy
and Early Childhood
• Shattering of developmental expectation of
protection from the attachment figure
• The protector becomes the source of danger
• “Unresolvable fear”: Nowhere to turn for help
• Contradictory feelings toward each parent
(Pynoos, 1993; Main & Hesse, 1990; Lieberman & Van Horn, 1998)
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Maternal Attributions
• Fixed beliefs about the child’s existential core
• Perceived as objective truth
• Reflect maternal fantasies, including fears,
conflicts, and wishes about the child
(Lieberman, 1997)
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Maternal Attributions and Child
Sense of Self
• Mother attunes selectively to the child’s
feelings
• Maternal responses shape the child’s
sense of what he/she is permitted to
feel
• Child internalizes the maternal
attribution
(Lieberman, 1997, 1999)
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Young Children Need to Be Seen in
the Context of Their Relationships
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Treating Young Children
• Young children develop in relationships
• Young children use relationships with
caregivers to
– Regulate physiological response
– Form internal working models of
relationships
– Provide secure base for exploration and
learning
– Model accepted behaviors
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Caregiver as Protective Shield
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Child-Parent Psychotherapy
Theoretical Target
• The system of jointly constructed meanings in
the child-parent relationship.
• These meanings emerge from each partner’s
representations of themselves and each
other.
• These representations are expressed through
individual or interactive language, behavior,
and play.
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Child-Parent Psychotherapy
Goals
• Encouraging normal development:
engagement with present activities and future
goals
• Maintaining regular levels of affective arousal
• Establishing trust in bodily sensations
• Achieving reciprocity in intimate relationships
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Child-Parent Psychotherapy
Trauma-related Goals
• Increased capacity to respond realistically to
threat
• Differentiation between reliving and remembering
• Normalization of the traumatic response
• Placing the traumatic experience in perspective
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Balancing Trauma Treatment
with Other Goals
• Trauma lens: Trauma reminders,
expectations and affects
• Attachment lens: Protection and safety
• Developmental lens: Age-appropriate
pursuits
• Cultural lens: Ecological context
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Integration of Theoretical
Approaches
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Developmentally Informed
Attachment
Trauma
Psychoanalytic theory
Social learning theory
Cognitive Behavioral Interventions
Culturally Informed
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ASSESSMENT
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Multidimensional Approach
to Assessment
• Child’s Individual Functioning
• Family Context
• Community and cultural values
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“Best Practices” For Assessment
• 3-5 45-minute assessment sessions
• Developmental history before/after
trauma
• Observation of child
• Observation of child-parent relationship
• Child’s trauma narrative
• Collateral information
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Assessment as Form of
Treatment
• “Psychological first aid”
- Developmentally appropriate intervention
- Immediate emotional relief
• Information gathering
• Assessment-treatment feedback loop
• Incorporates developmental changes
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Assessment Domain:
Child’s Trauma Experience
• Circumstances and Sequence of Trauma
What
Who
How
When
Where
• Nature of Child’s Involvement
• Each Parent’s Presence and Participation
• Events Following the Trauma
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Can Young Children Remember
Trauma?
• Implicit Memory
- Engages early-maturing brain regions
- Non-verbal
- Functions outside awareness
- Experimentally shown in infants
• Explicit Memory
- Focal attention for encoding
- Subjective recollection for retrieval
- Verbal recall
(Schachter, 1987)
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Can Young Children Remember
Trauma?
• “Memorability”
Unique, dramatic, eliciting intense emotion
• Retrieval
Verbal children narrate traumatic events that
occurred when they were pre-verbal
• Accuracy versus misunderstanding
(Nelson, 1994; Gaensbauer, 1995; Terr, 1988)
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Assessment Domain:
Child’s Functioning
• Biological rhythms:
Eating, sleeping, somatic complaints
• Emotional regulation:
Age-appropriate anxieties and coping
• Social connectedness:
Quality of attachment, peer relations
• Cognitive functioning:
Developmental milestones, readiness to learn
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Assessment Domain:
Child-Parent Relationship
• Trauma shatters child’s trust
Parental failure to protect
Parent as attacker
• Trauma disrupts parent’s mental health
Traumatic response
Self-blame
• Trauma disrupts family bonds
Mutual blame
Emotional alienation
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Assessment Domain:
Traumatic Reminders
• Neutral stimuli trigger traumatic memories
• Intrusive imagery and sensory experiences
• Operating outside consciousness
• Associated with secondary stresses
• Parent as traumatic reminder
• New fears
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Assessment Domain:
Continuity of Daily Routines
• Predictability supports emotional
regulation
• Trauma disrupts daily routines
• Secondary adversities add new stress
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Assessment Domain:
Family Ecological Niche
• Family Circumstances
Primary caregiver
Who holds the holding environment
Concrete supports
• Family Belief Systems
• Cultural Values
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Making a Clinical Diagnosis
Traumatic Stress Response
• Re-experiencing the trauma
Post-traumatic play; distress at reminders;
recollections outside of play; flashbacks;
dissociation; nightmares
• Numbing
Social withdrawal; loss of milestones;
play constriction
• Increased arousal
Hypervigilance, attentional problems, startles
• New symptoms
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Making a Clinical Diagnosis:
Co-Morbidity
• Prevalent in traumatic response
across development
• In young children, related to immature
expressive repertoire
• The same behavior can signify different
experiences
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Treatment
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Child-Parent Psychotherapy
Intervention Modalities
1. Promote developmental progress
through play, physical contact, and
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language
Unstructured/reflective developmental
guidance
Modeling protective behaviors
Interpretation: linking past and present
Emotional support
Concrete assistance, case management,
crisis intervention
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Ports of Entry
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Possible Ports of Entry
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Child’s or parent’s behavior
Parent-child interaction
Child’s representation of self or of parent
Parent’s representation of self or of child
Mother-father-child interaction
Inter-parental conflicts
Child-therapist relationship
Parent-therapist relationship
Child-parent-therapist relationship
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Ports of Entry
• Immediate object of clinical attention
• Chosen on basis of emotional
immediacy and clinical need
• Not driven by a priori theory, but by
therapist’s assessment of potential for
positive change
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Ports of Entry
• Begin from simplicity
• Safety and trust as organizing concepts
• Developmental guidance may suffice
• If unsuccessful, explore resistance
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TRAUMATIC BEREAVEMENT IN
INFANCY AND EARLY
CHILDHOOD
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Traumatic Bereavement in
Infancy and Early Childhood
“There are no peaceful deaths for
parents of young children. Whenever
we say ‘his parent died’, we leave out
the inevitable horror and tragedy that
such a death entails”
(Furman, 1974)
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Dual Lens: Grief and Trauma
The child cannot mourn successfully
when traumatic reminders interfere with
the memory of the parent. The child’s
work of mourning is facilitated when
the traumatic circumstances of the
death recede in the child’s mind.
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Factors Affecting the Child’s
Response to Parental Death
• Child’s developmental stage:
understanding of death
• Circumstances of the death:
Sudden? Violent? Witnessed by child?
• Quality of parent-child relationship
• Availability of another parental figure
• Emotional support
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Is Parental Death Always
Traumatic for the Young Child?
Continuum of traumatic experience:
Milder: Increased child maturity
Anticipatory guidance
Child is not witness
Severest: Sudden, violent
Witnessed by child
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Developmental Impact of
Parental Death
Disruptions in:
• Regulation of bodily rhythms
• Modulation of emotion
• Formation and socialization of relations
• Learning from exploration
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Manifestations of Grief and
Mourning
• Protest
Crying, searching, rejecting comfort
• Sadness and emotional withdrawal
Lethargy; awaiting reunion
• Anger at self and others
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Manifestations of Grief and
Mourning
• Intensification of normative anxieties
• Regressions in development
• New fears
• Denial, self-blame, idealization
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Responses to Witnessing Violent
Death
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Horror
Powerlessness
Intrusive mental images
Fear for personal safety
Dissociation
Responses to traumatic reminders
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Assessment Guidelines
• Circumstances of the death
What the child witnessed
What the child knows
Traumatic reminders
• Current family circumstances
• Child’s functioning: before and after
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Assessment Guidelines
• Child’s Relationship with Dead Parent
• Current Caregiver & Continuity of Routines
• Family Response to the Death
• Cultural and family traditions and beliefs
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Does Child Have a Clinical
Diagnosis? Using DC:0-3
Prolonged Bereavement/Grief Reaction
• Crying, calling, searching
• Emotional withdrawal with lethargy
• Disruption of biological rhythms
• Developmental regression
• Restricted affective range
• Detachment
• Extreme sensitization to loss reminders
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Does Child Have a Clinical
Diagnosis? Using DC:0-3
Traumatic Stress Disorder
• Re-experiencing
• Numbing of emotional responsiveness
• Increased arousal
• New fears
• Aggression
• New symptoms
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Primary Treatment Goals
• Creating a Safe, Consistent Environment
• Supporting Child’s New Attachment
• Child’s Acceptance of Physical Reality of
Parental Death
• Emotional Regulation to Reminders
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Longer Term Treatment Goals
• Promote Adjustment to Changes
• Enhance Problem Solving and Conflict
Resolution
• Integrating the Dead Parent into the
Child’s Ongoing Sense of Self
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The Treatment Process
• Creating a Safe Treatment Frame
Identify Surrogate Primary Caregiver
Preserve Reassuring Reminders
Decide on Attendance to Funeral/Wake
Help Maintain Predictable Routines
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The Treatment Process
• Alleviating Children’s Fears
“Will other people I love leave me?”
“Will I die also?”
“ Who will take care of me?”
“ Did I cause the death?”
“ I want to die too to be with mommy”
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The Treatment Process
• Addressing Traumatic Reminders
Remove upsetting reminders
Reassure child of safety
Explain the meaning of reminders
Teach to anticipate traumatic response
Teach self-soothing strategies
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Everything Can Help
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Therapeutic Toys
Play
Games: hide-and-seek, peek-a-boo
Movement: Jumping, dance, yoga
Putting feelings into words
Practicing prosocial behaviors
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Balancing Focus on Trauma and Loss
with Continuity of Daily Living
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REFLECTIVE SUPERVISION
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Therapist, Heal Thyself!
• Working with intensely bereaved and
traumatized young children evokes
strong feelings in the therapist,
including hopelessness and rescue
fantasies.
• Self-care is essential to help the child.
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Reflective Supervision
• Non-judgmental
• Gives the therapist a setting to reflect
on the process of the treatment and on
the process of individual sessions
• Permits reflection on the therapist’s role
in the inter-subjective field with the
dyad
• Helps prevent therapist burn-out
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Conflicts of Interest/Disclosures
• Professional Advisory Board,
Johnson & Johnson Pediatric Institute
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Disclosure
• No medications are discussed in this
presentation
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