Attachment-Based Milieus for Healing Child and Adolescent Developmental Trauma

A Relational Approach for Use in Settings from Inpatient Psychiatry to Special Education Classrooms

John Stewart

• Publisher: Jessica Kingsley Publishers
• Year: 2017
• Print ISBN: 9781785927898
• eBook ISBN: 9781784507398
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

This book presents an innovative relational and community based therapeutic model to ensure children's essential attachment needs are catered for in intensive mental health care.

The text combines an overview of theory relating to attachment and trauma before laying out a model for working with children and adolescents in an attachment-informed way. The approach applies to a diverse range of settings - from in-patient psychiatric settings, through to schools-based programs, and provides the reader with the knowledge and guidance they need to introduce the approach in their own service. It also addresses the complexities of working with specific clinical populations, including children with ADHD, ASD, RAD and psychosis.

Accessible for entry level clinical caretakers, yet sophisticated enough for clinical supervisors, this book is essential reading for professionals looking to improve the effectiveness of child and adolescent treatment programs.

Section II

SUPPORTING HEALING
ATTACHMENTS IN THE
TREATMENT MILIEU

How Is an Attachment-Informed Approach Used
in a Child and Adolescent Treatment Milieu?

Chapter 5

HOW ARE ATTACHMENTS FORMED
AND HOW IS THIS APPLIED IN
THE TREATMENT MILIEU?

As suggested within our definition, attachments develop within the context of relational experience and become a part of our emotional and cognitive make-up on both a conscious and an unconscious level. The ability to enjoy strong or positive attachments throughout life is significantly linked to the nature of our connections during childhood, with the heaviest loading for impact during the first three years. This is not to suggest that early attachment difficulties are irreversible but rather, if unresolved, they point social and emotional development in a highly problematic direction. A child’s early experiences shape both the development of their brains and the nature of their expectations and openness to attachment. Again, this is not to suggest that early life experiences leave an immutable stamp on a child’s capacity to form and use relationships; but it is to say that what happens in those first years is profoundly important and may take many years of compassionate and attuned connections to correct and “rewire” if things have not gone well.

In that childhood is our principle focus and childhood experiences are critical to attachment style and/or capacity, we will direct most of our attention to early life attachment development. It is, however, important to acknowledge that most insights with respect to attachment apply equally to adults and children. For those interested in the adult-to-adult side of attachment, I recommend the works of Sue Johnson, Daniel Siegel and Lou Cozolino.

As we attempt to understand how attachments are formed in the child–adult dyad, our attention must first turn to understanding the profound degree of dependency on the part of the human infant upon their caretaker. From a developmental perspective our species’ maturation towards self-sufficiency lags dramatically behind that of all others, resulting in a profound human need for a durable and mutually reinforcing relationship between the infant and their caretaker. In the absence of such a bond both the infant and in time our species would perish.

So what is it that the infant does for the parent, and the parent for the infant that promotes and preserves attachment and the adult’s commitment to caregiving? From the moment a woman becomes aware of her pregnancy, the typical mother begins to form an empathic and protective relationship with her unborn child. The mother, if secure in her own attachments and not overwhelmed by other variables, begins to feel a profound commitment to protect the child from harm and promote its growth. In the fulfillment of this commitment, the mother is afforded a sense of purpose, pride and competency as she is guided by her empathic caring for the child and the child’s growth.

At birth the dance of attachment between mother and infant typically, when not impeded by factors such as maternal mental illness and environmental stress, fully launches as the mother is overwhelmed with wonder at what she has created and the child shows a significant preference for the smell, sight and touch of mom. When this process goes well, the attuned care of the infant rewards mom with everything from pride in the child’s thriving to the glow and warmth associated with the flow of oxytocin (a hormone promoting a powerful sense of well-being) within the mom as she cuddles and feeds her little one. For the child, food, safety, warmth and perhaps their own boost of oxytocin drives a longing for the attachment forward.

As time passes, if all goes well, the child begins to understand their ability to impact the parent and draw the parent into supportive behaviors. The parent smiles back when the child smiles, frowns when the child is sad, and feeds, changes, comforts or plays with the child when the child is crying or acting cranky. This dance carries on in one form or another over the course of childhood, when things go well.

In this developmental process the child develops a secure and safe sense when the parent is present. Over time, however, due to exper-iences of optimal frustration (see below), children begin to develop an increasing belief in their own competencies and the ability to soothe themselves through reliance upon the emotional memories of their caretaker and an evolving set of self-soothing strategies. In other words, the child develops from a sense of safety based upon the competent caretaker’s physical presence and care, to safety associated with trust in their own evolving capacities and the ability to feel safe in accessing the emotional memory of the competent caretaker.

In short, attachments within a young child’s life evolve as the child and caretaker experience (for the most part or “good enough”) a mutually gratifying process of connection; both feeling a secure sense of well-being within the relationship. As we try to understand more specifically how it is that attachments deepen over time and use this understanding to direct our work with children, we will draw from many developmental theorists and researchers.

We will start this discussion with a brief overview of three core concepts concerning attachment development largely taken from the work of Dan Hughes (2007). The first of these is intersubjectivity, the second represented in the acronym PACE (playful, accepting, curious and empathic) and the third in the attachment-strengthening process of Connect–Tear–Repair.

Note: Again, please be aware that throughout this text the term “caretaker” is used in a generic sense to describe anyone in the position to care for a child, including but not limited to: parents, foster-parents, older siblings, extended family, teachers, therapists and even law enforcement personnel.

Intersubjectivity

At the core of supporting the attachment process is a highly intimate shared experience referred to in the attachment literature as intersubjectivity (Stern 1985). In simple terms, this shared experience is a deep, albeit transient, sense of “feeling felt” or lost together for a moment in a common feeling and experience. This shared sense of the moment is largely non-verbal and reflects a non-hierarchical connection of oneness in focus, thought and feeling. These moments come and go, yet build upon one another over time to provide a transcendent sense of shared self, deep connection and caring.

Intersubjective moments can occur in the context of a wide variety of experiences. They can evolve early in a courtship relationship as a young couple stays up all night talking, losing sense of time and feeling more at home with one another than alone. They can occur in a moment of play between a father and a son as the milkweed stalks become light sabers and they vanquish the frog king living in the pond. They can occur in the sharing of deep sorrow over the loss of a loved one, as wordless embraces allow two mourners to collapse into a hug. They can occur in the joyful laughter of a little one playing peek-a-boo, or a particularly well acted-out story of “This little pig went to market.” They can occur between a mother and a daughter in the gentle hug offered as they take a last look at a home they have loved and are leaving. They can occur between an infant and his mother as they settle into each other’s arms for a last snuggle before being laid in bed for the night. And so on and so on...

At the core of the intersubjective moment is connection without hierarchy, without purpose (aside from that of connecting), experienced within and between both individuals equally. So often in the lives of our more complicated children, struggling on so many fronts, the number and quality of intersubjective moments is quite limited. In recognizing this fact and the importance of these experiences in wiring the brain for connection, emotional regulation and well-being, we are compelled as caretakers and caretaking institutions to seek, value and promote opportunities for intersubjectivity. Sadly, the pace and demands of our current world, as well as our reluctance to value that which cannot be easily measured, serve to undermine our culture’s value and provision of this deeply human capacity and need for moments of all-encompassing connection.

Intersubjective connection, whether between a parent and a child or a clinician and a child, requires a deep commitment to supporting the child in “feeling felt,” whether this be in joyfulness or sadness. Dan Hughes, who writes as eloquently as anyone on this topic, describes intersubjectivity as demanding three shared components: shared attention, shared affect and shared intention. In the sharing of these domains there evolves a transient “oneness” that virtually defines intimacy and connection.

It is additionally important to recognize that a child’s evolving sense of self is largely created by the caretaker–child experiences of intersubjectivity. When the caretaker experiences the child with delight, they experience themselves as delightful; but conversely, the opposite experience can also be true: If your parents are bored with you, you are boring; if they are often angry with you, you are bad. For the most part the children served in intensive treatment settings have selves they largely perceive as negative, given that they have evolved from negative caretaker–child experiences. In turn, these negative selves entrench and block the child from the very openness to care and intersubjectivity that could allow for healing of their disturbed self and the rewriting of their relational stories.

PACE

The PACE model offered by Dan Hughes (2007) for facilitating attachment between caretaker and child prescribes an adult stance of Playfulness, Acceptance, Curiosity and Empathy. Hughes suggests that it is through this stance that critical moments of intersubjectivity and deepening attachment evolve. These moments are void of power differentials or any clear agenda on the adult’s part to teach, or direct, in deference to the far more important effort to simply be present and connect. It is the caretaker’s ability to walk beside the child, to be with them in their inner world in a safe and accepting manner, that allows the adult the capacity to support the child through periods of powerful emotional upheaval or stress. The caretaker’s attunement and acceptance of the child’s inner world allows them to support emotional co-regulation (see Chapter 2) and ultimately promote the critical capacity to self-regulate in a manner that facilitates learning and higher-level adaptive functioning.

Within the PACE directive there is no implied hierarchy or sequence for these modes of interaction. The PACE stance simultaneously reflects all four modes of interaction with some degree of primary focus vacillating among them dependent upon an attuned sense of what is needed to further the connection within the moment. In other words, the situation in which one finds oneself and the child’s response to our efforts to connect will dictate whether playfulness, acceptance, curiosity or empathy is utilized. The fact is that one may move between these avenues for connection in a fluid, non-sequential manner; in essence, PACE describes a stance towards the child, requiring the adult to seek the avenue that best fits the child and the moment. This PACE stance is critical to all aspects of caretaking; in short, it is useful to think of PACE as an interactional posture for which we strive within all situations, particularly when needing to set a behavioral limit or dealing with a dysregulated child.

Offered below is an overview of the PACE model to introduce the concept and to apply it within clinical settings. The reader is encouraged to see Hughes (2009) for a more in-depth discussion of PACE.

Playfulness within the treatment milieu

Playfulness, or the “P” of the PACE acronym, is an often overlooked, yet extremely powerful aspect of the attachment-enhancing process. In being playful, caretaker and child enter into a highly intimate, intersubjective or jointly created experience of the moment. As we pretend together that the game of peek-a-boo surprises us each time that the other reappears; that the family dog is speaking with us, sharing human-like thoughts and feelings; as we share ...

Table of contents

• Cover
• Title Page
• Appreciations
• Contents
• Foreword by Dan Hughes
• Preface
• Introduction
• Section I: Introduction to Attachment Theory
• Section II: Supporting Healing Attachments in the Treatment Milieu
• Conclusion
• References
• Subject Index
• Author Index
• About the Author
• Join Our Mailing List
• Dedication
• Copyright
• Of Related Interest