For therapists working with clients with complex or developmental trauma, advances of the last decade in understandings of attachment theory and early childhood development have important implications. Guided by these insights, a therapist can develop a strategy of treatment that more accurately addresses the symptoms and underlying needs of a client. Without them, a lot of time, effort, and resources can be wasted.
From Attachment to Regulation Theory
An important advance is found in the work of Allen Schore, applying findings of neuroscience to attachment theory. Starting in the 1990s, Schore published essays expanding previous understandings of attachment.
While respectful towards the pioneering work of John Bowlby, whose theories of attachment shaped practitioners since the 1960s, Schore demonstrated the need for updates in attachment theory and application.
In the words of Schore and Schore (2008): “Bowlby stated that attachment behavior was based on the need for safety and a secure base. We have demonstrated that attachment is more than this; it is the essential matrix for creating a right brain self that can regulate its own internal states and external relationships. Attachment intersubjectivity allows psychic structure to be built and shaped into a unique human being. Our task as therapists is to understand and facilitate this developmental process with our clients.” (p17).
Key to Schore’s contribution is the awareness that a therapist interacts with an existing right brain formation of a client, formed long ago in early childhood, in response to the child’s attachment experience of caregivers, as well as to the environment and the unique responses of the child’s body to the world around.
This formation is intuitive, non-verbal, and pre-rational. Schore and Schore (2008) describe it as the result of an unconscious process rooted in physical interactions between a mother (or other caregiver) and infant, in an exchange from the right brain of the mother to the right brain of the infant. These experiences shape the nascent organization of the right brain, which is the core of human consciousness (p. 10).
These early life experience provide the foundation for infants to interact with and form attachment to parents, and eventually to build relationships with others. This includes the relationship with the therapist, whose goal is to become a “co-regulator” with the client of emotional responses. Attunement is vital for a therapist to become a co-regulator of a client.
On Attunement
Attunement is a nonverbal process of being with another person in a way that attends fully and responsively to that person. A key aspect of attunement is that it is a joint activity, experienced in interaction with a caregiver. In the first years of its life, a baby is fully dependent on others. The early brain formation described above emerges in response to largely non-verbal interaction with another human being, including eye contact, vocalization, speech, and body-language (Wylie & Turner, 2011. p. 8).
Parents are never able to anticipate all of a child’s needs, so an infant inevitably gets upset from time to time. Schore and Shore (2008) call this “misattunement”. Well-functioning parents respond appropriately to sooth the baby, which Schore calls “reattunement” (2008). In the beginning, a baby is fully dependent on parents for calming and soothing, but through repeated cycles of attunement, misattunement, and reattunement, babies internalize the ability to cope with inputs of their senses from within and from the external world, both rewarding and frustrating. From this emerges a sense of self and ability to control emotions, or emotional regulation.
Attunement is managed by the structures of the right brain, which leads the way for development of other elements of the brain. Since brain development is hierarchical, if infants are unable to engage in cycles of attunement, misattunements, and reattunement, later development of other brain functions is affected. Anda and Felitti et al., (2006) have documented the long-lasting effects of adverse childhood experiences (ACE) and linked them to changes in brain structures and stress response mechanisms of the brain.
Difficulties come when attunement is obstructed. If an infant does not receive enough stimulus, sustained attention, love, caring and warmth on an on-going basis, or if the latter are available only in unpredictable ways, developmental trauma can result. “The brain needs patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort and hunger keeps a baby’s stress system on high alert.” (Perry, 2007 p. 113) The consequence is reduced ability to manage emotions, cope with stress, sustain close relationships, and more.
Emotional Regulation and Sensory Integration
A common symptom for trauma survivors, of course, is difficulty in controlling emotions, even in response to things with no apparent connection to the traumatic events. Therefore, emotional regulation is a key in trauma therapy. How then to help a child, teen or adult client who has experienced developmental trauma to form a secure attachment and develop self-regulation?
What Does Occupational Therapy Have to Do with Trauma?Several personal experiences had a big impact on my understanding of trauma treatment. One is that I have Sensory Integration (SI) issues (read blog here), something I was able to name as such only in my 30s. I experienced pre-verbal trauma in infancy, which may or may not be related to the SI issues. Although I knew that I was loved by my parents and family, circumstances around me did not feel safe. As far back as I can remember, life did not seem safe to me.
These life-altering personal realities have kept me constantly on the lookout for concepts and strategies that might help. I learned not to accept the standard orthodoxies as the final word and found helpful things in unexpected places.
As an adult, at a time when I was trying to learn about my own newly uncovered SI issues, I observed an occupational therapist working with a toddler in a sensory integration session. I was amazed by how relaxed this child - who began the session hyper-alert - became by the end, because of a process of repetitive SI physical movements.
This was an “aha” moment for me. As a therapist trying to help traumatized clients cope with chronic hypo- and hyper-alertness and self-regulation issues, I was surprised to witness an occupational therapist readily achieve through strategic use of repetitive movements the same state of relaxation I sought with my clients using other modalities, mostly expressive therapies.
So I read extensively about sensory integration and learned about protocols used by occupational therapists for treating children with sensory processing issues. For several decades, a growing number of occupational therapists have been focusing on sensory integration. They have developed a wide variety of SI activities, for small children, older children, and adults. Since developmental trauma affects brain development specific to the age at which the trauma took place, the experience of OT practitioners is a gift for trauma therapists who want to guide a client or parents in sensory integration work appropriate to the age of traumatization.
Encouraged by the results I was seeing with clients, I soon made sensory integration a pillar of my work. Gradually I was able to assemble a theoretical framework to explain why this unusual approach to trauma treatment was effective. Perry, whose Neurosequential Model of Therapeutics (NMT) is particularly insightful, captures key elements in his 2007 book. In reference to developmental trauma survivors, he writes "...these children need patterned repetitive experiences appropriate to their development needs, needs that reflect the age at which they missed important stimuli or had been traumatized, not their current chronological age” (Perry, 2007. p. 138).
Not just any sensory integration activity will do. Each must be chosen in response to a client’s needs and history. A key goal is to engage the client’s “survival brain”, the part of the brain that is dominant before age three, and facilitates sensory integration. This supports improved emotional regulation and, in work with a therapist who understands attachment, it opens the possibility of developing secure attunement.
A Framework for Building Secure Attunement
Expectations and PurposeFrom the beginning of and throughout therapy, I describe its goal as “integration”. Though this may seem long mere semantics, I consider it a disservice to clients and their families to use words like healing, recovery, or reversal. Such terms imply erasure of things that cannot be erased and suggest a conclusive process of limited length.
Living with developmental trauma is a lifelong journey. There can be many lifegiving moments in the journey, but integration is an on-going process. I find that trauma survivors respond better when they understand this from the beginning.
Trauma integration for developmental trauma survivors involves internalization of a sense of safety, predictability, and connection to the self and others. We work for this through a process of secure attunement designed to:
(1) help clients improve self-regulation;
(2) help clients develop a more organized and secure attachment.
In my experience, the following elements provide an effective therapeutic framework for creating secure attunement*:
Experiential psychoeducation – see this blog post.
Use action in safe space to achieve enhanced safety (more below).
Use SI activities adapted for the age of the client when the trauma took place to improve emotional regulation.
Facilitate safe-regression (see below) to take place, leading to possibilities integration, using the first three elements above.
Develop and implement an Individualized Sustainability Plan (ISP**) for continued stability (more in this blog post).
Action in a Safe Space
Safety as a quality of the therapeutic relationship is a core goal in therapy. However, with trauma clients in general, and complex and developmental trauma in particular, it is especially important. For an extended period early in therapy, the main focus of therapy must usually be engaging in activities that foster safety. A variety of techniques and tools facilitate this.
As an expressive therapist, I most often use “imaginal space”, also known in psychodrama as “surplus reality”. This creates an abstract creative space of play, fantasy, and spontaneity in which a client is able to explore and engage with different aspects of her experiences through art, play, movement, dance, drama, music and so forth.
Any type of activity that involves creativity and movement that the therapist feels comfortable using is likely to be effective. This could include things as simple as taking a walk, jumping together on a trampoline or in a room, dancing, singing together, etc.
The point is for the client to be engaged in something that involves multi-sensory inputs and-
is light and relaxing for the client,
allows for interaction with the therapist, usually on topics of what feels safe and, later in the process, what does not feel safe.
These activities foster creativity, playfulness and spontaneity while allowing for slowly introducing things that involve some element of risk and autonomy, yet not too much and not too early. Because it is a drawn out process of interacting around topics fraught with danger for the client but carefully modulated to protect the client’s sense of safety, I call it safe attunement.
Interaction with the client about an activity emerges from the client’s experience. A therapist might start by asking the client to pick different colors of crayons/markers and draw with these on paper. If this is too big a task, begin with just drawing lines or dots.
The experience deepens when it moves from creating something on paper to creating something in imaginal space. You can facilitate this by inviting the client to next select from a pile of fabrics those that relate to the colors on paper. Invite the client to lay the fabrics on the floor to reflect the lines on the paper (as if the floor is the paper). Then invite the client to walk together with the therapist around or over or along the fabrics. Have her stand close to them for a few seconds, then far from them. Invite her to walk next to them on the floor and notice how it feels.
Exercises like this enable the therapist to guide a client into embodied play and sensory integration, and into conversation about what the client is experiencing. But don't go too far too quickly. Building a sense of safety is paramount.
If the client finds it hard to engage, start with any activity that the client would feel comfortable to join, even as simple as talking while walking in the therapy room instead of sitting and talking.
Repetition leads to safe regression. Survivors of developmental trauma need more than an experience of attunement, they need repetition of it. You can witness this easily in playing with a two year old. Let a child run away, then chase her and snatch her into your arms. Your reward will be loud laughter and a command, “Again!”
Activities repeated over a number of sessions build a sense of safety, enabling the client to enter what I call safe regression. Perry suggested that patterned repetitive experience in a safe environment has an impact on the child's brain (Perry. 2007 p. 134).
Safe regression is therapist-assisted exploration of an attachment-related developmental phase that did not advance due to trauma.
When a child is ready to enter this phase, often we begin to notice some ordinary regression in overall behavior, usually outside of the therapy room and reported by parents. When this happens I increase the frequency of therapy to more than once a week.
Much of the focus up to this point has been about containment in therapy. Now comes a more demanding phase and this necessitates a more intensive pace of therapy. In part this is to ensure that the therapist can respond adequately to whatever regression marked entry into this phase.
The primary focus of the phase is a combination of sensory integration creative activities that are playful and spontaneous, and selected to be appropriate to the age at which the trauma took place. Repetition is a defining mark of the phase. Some clients do the same or similar activity in every session for weeks. Therapist-client communication for extended parts of sessions is often similar to that used with a pre-verbal child. This is the case for some adult clients as well.
To illustrate the above sequence: One of my clients spent several months in sessions that were play and SI based activities. Then he began to show signs of regression at home and in therapy, so I increased sessions to twice a week.
He had shown particular interest in singing. I invited him to sing along with me. The first time we sang together, he sang a few words, though I could barely hear his voice. In the next session, he sang loudly along with me. This continued for several weeks. One day he asked to sing a song to me by himself. A few sessions later, he sat and sang by himself for the entire session, glancing up at me often to make sure I was listening. This reflects a predictable trajectory of content, moving from SI activities to performance for the therapist.
At about the same time that the boy began to do more performance in sessions, his parents began to notice improved behaviors and emotional regulation at home.
An adult client at this stage showed interest in drawing. For months we had a routine format in sessions. He would draw and I would sit with him in the most supportive (attuned) way I could without distracting him. Every few minutes he would glance at me to make sure I was looking at him. I would smile, or nod; he would continue drawing with a contented look on his face.
Clients can work with clay, dance, reading aloud, poetry, etc., as a medium of expression. Some clients are ready for a change in the nature of the activity sooner than others, but overall the need for safe regression activities supported by an attuned therapist takes a while.
At some point things change, often quite suddenly, like a growth spurt. What felt like a comfortable, appropriate activity may suddenly seem out-of-place. This is a sign that the client is ready for activities appropriate to a more advanced developmental phase.
Integration emerges when the client begins to display improvement in self-regulation and is able to demonstrate openness - in relationships outside of the therapy room - to the possibility of secure attunement that was first experienced in the therapy room. Integration does not mean a perfectly secure attunement. Clients will experience movement throughout their lifetime between a sense of attunement, misattunement, and reattunment. ***Find out more on the ETI approach upcoming workshops Footnotes
*When working with children who suffer from developmental trauma I always have an additional session one-on-one with at least one of their caregivers on a weekly basis as well.
**When there is a need, I refer my clients to other professionals who work closely with me to address other aspects of the integration process, such as nutrition, physical therapy, neurofeedback, functional medical doctor, occupational therapy, massage therapy, acupuncture and so forth.
References:
Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C. H., Perry, B. D., ... & Giles,
W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood. European archives of psychiatry and clinical neuroscience, 256(3), 174-186.
Perry, B., & Szalavitz, M. (2007). The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist's Notebook Child Psychiatrist's Notebook--What Traumatized Children Can Teach Us About Loss, Love, and Healing.
Schore, J. R., & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36(1), 9-20. Wylie, M. S., & Turner, L. (2011). The attuned therapist. Psychotherapy Networker, 35(2), 19-27.
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