Creative Therapies for Complex Trauma

Helping Children and Families in Foster Care, Kinship Care or Adoption

Joy Hasler, Anthea Hendry

• Publisher: Jessica Kingsley Publishers
• Year: 2017
• Print ISBN: 9781785920059
• eBook ISBN: 9781784502423
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

A burgeoning evidence base supports that arts, play and other creative therapies have potential to help children in foster care, kinship care or adoptive families to recover from complex trauma.

Written by contributors working at the cutting edge of delivering effective therapeutic interventions, this innovative book describes models for working with children in foster care, kinship care or adoption. Covering how to assess needs and contextual considerations for working with children and families, this book presents a range of creative therapeutic approaches spanning art psychotherapy, music therapy and dance therapy. It emphasizes the necessity of working with caregivers and other significant adults, as well as the child, to facilitate recovery. The theoretical foundations of attachment, developmental psychology and neurobiology are embedded in each chapter showing how they underpin each of the recommended creative therapies.

This book will be suitable for professionals directly employing creative approaches in their practice, such as arts therapists and play therapists, as well as those working with children who are interested in creative alternate approaches, such as psychologists, counsellors, therapists and social workers.

PART 1

MAPPING OUT
THE TERRITORY

Chapter 1

COMPLEX TRAUMA IN CHILDREN

An Overview of Theoretical Developments

FRANCA BRENNINKMEYER

Trauma really does confront you with the best and the worst. You see the horrendous things that people do to each other, but you also see resiliency, the power of love, the power of caring, the power of commitment, the power of commitment to oneself, the knowledge that there are things that are larger than our individual survival.

Bessel van der Kolk

This chapter will give an overview of the theoretical developments with regard to the concept of ‘complex trauma’ in children. By way of introduction a summary of where this concept has emerged from will be presented.

Trauma, post-traumatic stress disorder and the DSM

‘That was awful, really traumatic…’ – a spontaneous expression that can often be heard in relation to taxing events in everyday life. Thankfully, many of these exclamations will not relate to psychological trauma in a clinical sense, but they indicate that there is a popular understanding of ‘trauma’ referring to psychological upset following distressing events.

The word ‘trauma’ stems from the Greek language and means ‘injury’ or ‘wound’. The use of the word ‘trauma’ for a ‘psychological injury/wound’ only appeared at the end of 19th century (Weisaeth 2014). However, it was not until the late 1970s that an official consensus emerged around what a ‘psychological trauma’ consisted of. This led to the diagnostic category of ‘post-traumatic stress disorder’ (PTSD), which was first included in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (APA 1981). The enormous number of Vietnam War veterans who were struggling with severe psychological distress helped to advance this development in considerable measure (Friedman, Resick and Keane 2014; Turnbull 1998).

The DSM generally defines mental health conditions by their symptoms and not their causes. In an exception to this, the DSM defines PTSD explicitly with regard to both cause and effect (Greenberg, Brooks and Dunn 2015). The cause of the disorder is a traumatic event and the effects are the ensuing PTSD symptoms. The traumatic event is termed the ‘stressor criterion’ or criterion A. After some revisions, criterion A was defined in the DSM-IV (APA 1994) as having two parts: criterion A1 is specified as ‘the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others’; criterion A2 became ‘the person’s response involved intense fear, helplessness, or horror’ (APA 1994). The subsequent possible effects of such a traumatic event were defined in the DSM-IV (APA 1994) as three symptom categories or criteria: criterion B describes recurrent and intrusive re-experiencing symptoms (such as dreams, flashbacks), criterion C describes avoidance symptoms (including numbing, detachment) and criterion D describes arousal symptoms (such as hypervigilance, increased startle). Two further criteria, E and F, respectively stipulated that the symptoms had to last for at least one month and that the distress or ‘functional impairment’ had to be significant (Friedman et al. 2014).

The symptom categories B, C and D each had a subset of symptoms of which a specified minimal number had to be present for PTSD to be diagnosed. Criterion D (arousal symptoms) would, for example, be met if at least two of the following were present: 1) difficulty falling or staying asleep; 2) irritability or outbursts of anger; 3) difficulty concentrating; 4) hypervigilance; 5) exaggerated startle response; and 6) ‘physiological activity upon exposure to events that symbolize or resemble an aspect of the traumatic event’ (APA 1994). The details regarding the three symptom categories highlight the potentially varying PTSD presentations. These are further added to by the DSM-IV (APA 1994) describing ‘specifiers’ (acute, chronic and delayed-onset PTSD) as well as possible ‘associated features’ (e.g. survival guilt, marital problems, loss of job) and ‘associated disorders’ (e.g. panic disorder, phobias, depression). PTSD was initially classified under the broader category of ‘Anxiety Disorders’, but this changed in the DSM-5 (see below).

PTSD in the ICD

The International Classification of Diseases (ICD) is published by the World Health Organization (WHO). It covers all known medical diseases and includes mental health conditions. PTSD was added in 1992 and defined in a similar manner to how it appeared in the DSM (Turnbull 1998).

PTSD and children

The initial DSM-III criteria for PTSD in adults were also meant to be used for children and adolescents. It soon appeared, however, that PTSD presented differently in children and therefore the criteria needed to be adjusted. This led to a small number of age-specific features gradually being included (Cohen 1998). With regard to criterion A, the DSM-IV specifies that children may react with ‘disorganized or agitated behavior’ when first exposed to the traumatic event. Criterion B, event re-experiencing, could be expressed through ‘trauma related repetitive play’, ‘re-enactment’ and ‘frightening dreams that may have non-recognizable contents’. Criterion C remained the same as for adults. It was furthermore mentioned that children may express having physical ills (e.g. stomach pains and headaches) and that there may be ‘omen formation’ (a belief that warning signs must have preceded the trauma and need to be looked out for to prevent future traumas). As it is difficult for children to verbalize their symptoms, the DSM-IV stated that the evaluation of symptoms in children must include reports from parents, teachers and other observers (APA 1994).

Traumatized children, especially very young children, continued to be under-diagnosed with PTSD, however, resulting in a number of researchers voicing that the criteria for children needed to be more ‘behaviourally anchored’ and ‘developmentally sensitive’ (Friedman and Resick 2014, location no.1084). Kaminer, Seedat and Stein (2005) drew renewed attention to the issue that ‘eight of the eighteen PTSD criteria require a verbal description of internal states and experiences, a task beyond the cognitive and expressive language of young children’ (p.121–122). PTSD symptoms in young children could therefore easily be missed. Instead, the focus could end up on a co-morbid disorder, such as oppositional defiant disorder and separation anxiety disorder, when these may in fact be ‘part and parcel of the PTSD’ (Cohen and Scheeringa 2009, p.93). It was advocated to move away from the concept of frequency of a certain number of symptoms, towards considering intensity of symptoms and the ensuing level of impact on the child’s functioning and development. It was also pointed out that a number of trauma-related manifestations in children were not included in the criteria, such as regressive behaviours, new fears or re-emergence of old fears, increased carelessness, attention deficit hyperactivity disorder-like (ADHD) behaviours, depression and complex grief symptoms (Cohen 1998, 2010; Frem 2013; Kaminer et al. 2005). However, Cohen and Scheeringa (2009) concluded that although in need of revision, PTSD was ‘a well-validated disorder and the most useful construct of child and adolescent post-trauma psychopathology for research and clinical purposes’ (p.98). These authors stressed that professionals must improve their knowledge of PTSD, as well as their assessment skills, before arguing that PTSD criteria are not suitable for children, especially chronically traumatized children.

Complex trauma

The concept of ‘PTSD’ was undoubtedly groundbreaking when first formalized in 1980. Voices questioning it could soon be heard though. Judith Herman, in her seminal book Trauma and Recovery (1997, first published 1992), argued that the PTSD criteria were based too much on the experiences and symptoms of war veterans. Traumatic experiences were actually happening closer to home and in significant numbers, especially with regard to domestic and sexual violence. Herman also argued that extreme forms of psychological traumatization were not sufficiently covered by the PTSD criteria. These severe psychological traumas typically occurred in situations where the victim was held in physical or emotional captivity whilst under the permanent, harsh or cruel control of another human being (such as in concentration/prisoner-of-war camps, brothels, long-term domestic violence and in various forms of child abuse). It was thought that the personal, repeated and prolonged nature of these traumas resulted in chronic helplessness (inability to escape), chronic dissociation (detachment from events/others/self in order to survive), as well as a chronic loss of trust and sense of self. The most significant consequences of functioning in this highly compromised manner were a fragmented self and an inability to relate to others. In addition, there was a heightened chance of being re-victimized and thus a consolidation of symptoms. It was for this altogether more complex and deeper-seated presentation that Herman proposed a new diagnosis of ‘complex PTSD’.

Rather than a variation of PTSD, Herman thought of complex PTSD as a separate disorder with its own (seven) diagnostic criteria. The first, stressor criterion (1) was defined as prolonged (months’ to years’) exposure to ‘totalitarian control’ that often includes physical and/or sexual abuse/exploitation. The ensuing symptoms were clustered into six criteria defined as ‘alterations’ in: 2) affect regulation; 3) consciousness; 4) self-perception; 5) perceptions of the perpetrator; 6) relations with others; and 7) systems of meaning. Each of these clusters had two to five symptoms, some of which were traditionally associated with borderline personality disorder (Herman 1997, p.121).

The concept of ‘complex PTSD’ seemed to resonate with clinicians and researchers, who recognized the symptoms in many of their traumatized clients/study subjects. Bessel van der Kolk (2001), for example, describes how ‘over the years, it has become clear that in clinical settings the majority of traumatized treatment seeking patients suffer from a variety of psychological problems that are not included in the diagnoses of PTSD’ (p.2).

Research results with regard to complex PTSD – temporarily also known as ‘disorders of extreme stress not otherwise specified’ (DESNOS) – led to proposals for complex PTSD to be included in the DSM-IV and the DSM-5 as a separate disorder to PTSD (van der Kolk et al. 2005). Although to date the proposals have not been successful, the symptoms of complex PTSD were included under the previously mentioned ‘associated features’ of PTSD in the DSM-IV, and a long list of symptoms it is (APA 1994).

Emerging recognition of complex trauma in children

Already in 1991 Terr suggested two subtypes of PTSD in children. The first subtype (I) related to one-off, sudden traumas that resulted in PTSD symptoms as per the DSM-III. The second type (II) related to chronic, multiple traumas (e.g. physical or sexual abuse) that led to symptoms of ‘denial and numbing, self-hypnosis and dissociation, and rage’; ‘considerable sadness’ could also occur. Terr notes that ‘crossover conditions’ (a combination of type I and type II) were possible too (Terr 1991, p.10). It would take a few years before these ideas were progressed (by others). The growing research with regard to complex PTSD in adults advanced this development as it increasingly pointed to the significance of early childhood trauma such as ongoing sexual, physical and emotional abuse (van der Kolk et al. 2005). One of the important, large-scale studies (17,337 participants) in this regard is the ‘Adverse Childhood Experiences’ (ACE) study, which showed strong correlations between the extent of prolonged childhood trauma and the extent of both physical and mental health problems in adulthood (Anda et al. 2005; Felitti et al. 1998).

Other studies focused on the significant effects of complex trauma on children themselves: persistent difficulties in the children’s relational, em...

Table of contents

• Cover
• Title Page
• Contents
• Foreword by Colwyn Trevarthen
• Introduction
• Part 1: Mapping Out the Territory
• Part 2: Clinical Applications of Creative Therapies for Complex Trauma
• Part 3: Complex Trauma and Creative Practice in Education
• About the Editors
• About the Contributors
• Organizations
• Subject Index
• Author Index
• Join Our Mailing List
• Acknowledgements
• Copyright
• Of Related Interest
• Endorsements