A framework for building secure attunement.
Trauma therapists inevitably work with children and adults suffering from developmental trauma. The effects of this can be devastating. (See this description by a parent of adopted children suffering from early childhood trauma.) Working with developmental trauma requires a different framework of treatment than work with trauma experienced later in life. Unfortunately, not all therapists appear to be up-to-date with current research and practice essential for effective treatment. In this post I review concepts and strategies every parent and caregiver of traumatized child should have, as should therapists working with adults who were traumatized as children.
What Is Developmental Trauma?
In the first years of life, infants and toddlers need safe, predictable, accessible, and loving caregivers. In this environment the brain is able to develop in a healthy, normal sequence of growth.
The brain develops from the bottom upwards. Lower parts of the brain are responsible for functions dedicated to ensuring survival and responding to stress. Upper parts of the brain are responsible for executive functions, like making sense of what you are experiencing or exercising moral judgement.
Development of the upper parts depends upon prior development of lower parts. In other words, the brain is meant to develop like a ladder, from the bottom-up. When stress responses (typically due to consistent neglect or abuse) are repeatedly activated over an extended period in an infant or toddler, sequential development of the brain is disturbed. The ladder develops, but foundational steps are missing and many things that follow are out of kilter.
Developmental trauma (DT) (or reactive attachment disorder) can manifest in a variety of ways: sensory processing disorder, ADHD, oppositional defiant disorder, bi-polar, personality disorders (especially borderline personality disorder), PTSD, cognitive impairment, speech delay, learning disabilities and more.
Interventions for Developmental Trauma
Among the various approaches to developmental trauma, I find the work of van der Kolk and Perry particularly useful.
van der Kolk in his 2017 essay identifies phases of intervention for developmental trauma. Similar to Hermann’s 1992 phasic framework, van der Kolk’s approach breaks down trauma integration into three phases, each with its own dynamics and requirements for treatment:
Establishing a sense of safety and competence – engage with survivors in activities that do not trigger trauma responses and that give them a sense pleasure and mastery while facilitating self-regulation (van der Kolk, 2017);
Dealing with traumatic re-enactment. Survivors may re-play their original trauma with other people. This can include perceiving people who try to help them, such as therapists, as perpetrators (van der Kolk, 2017);
Integration and mastery. Engaging survivors in “neutral, ‘fun’ tasks and physical games can provide them with knowledge of what it feels like to be relaxed and to feel a sense of physical mastery."
Perry’s Neurosequential Model of Therapeutics (NMT) provides a framework of brain development for work with developmental trauma. By using Perry’s framework, therapists can precisely target their work to whatever stage a child was in when trauma took place.
Traumatized children, Perry writes (2007), “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.”
Following assessment, a therapist uses activities selected to address the area of the brain impacted by trauma. The goal is to bridge gaps in development that have been identified. For example, if assessment indicates gaps related to brainstem and midbrain functioning, therapeutic activities will include expressive arts, yoga, massage, etc. After these functions have improved, activities progress to facilitate further sequential development of the brain.
My interest in developmental trauma is rooted, among many other things, in my own childhood as a trauma survivor. My study of van der Kolk, Perry, and others was enormously illuminating for me personally and professionally. Yet I felt less than satisfied with my own journey of integration and that which I observed in clients until I eventually added several concepts that I’ve found transformative personally and professionally. I’ve combined these in what I call an Expressive Trauma Integration (ETI) Secure Attunement Framework. (See this post for a description of the different stages of this framework.)
Attunement is Key In Developmental Trauma Integration
Attunement is a process of giving complete, non-judgemental, responsive attention to another person through eye contact, and other more-or-less nonverbal forms of attention and response. Though many parents do attunement so naturally they are not even conscious they are providing it for their children, frequent and extended experiences of attunement are one of the most important requirements for children to develop sequentially.
In the first years of its life, a baby is fully dependent on caregivers to meet her needs. Experiencing frequent attunement is a basic need, essential to support healthy development in particular brain development.
However, even in the best of circumstances, parents are not 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).
Misattunement is unavoidable and not damaging so long as it is followed by prompt reattunement. But ongoing stress (misattunement) without proper reattunement deeply disrupts an infant’s ability to experience being in the center – being attuned to. Infants, toddlers, and children who experience this disruption on an ongoing basis grow physically (although even physical growth can be stunted). But emotionally, the foundations for forming relationships, feeling safe and at rest in the world, and self-regulation are deeply damaged.
These are the missing steps in development I referred to above. The ladder (brain) continues to develop, but without a foundation in attunement, and the sense of ongoing secure footing in the world it provides, all the higher order functions (logic, concentration, retention and ability to respond and not react) that follow develop above these missing steps.
Children who do not frequently experience attunement are unable to form secure attachments (stable relationships). This applies not only to others but also to being able to be attuned to themselves, to their own needs.
Inability to attune to self and others is a precursor, of course, to a variety of destructive symptoms. Underlying many, if not all of these, is the perception of survivors, that relationships are not predictable or safe and that life itself is not safe. Beneath the chaos and struggle that often seem to churn around these individuals is a determined effort to connect with others in the only way they know how, reactive engagement.
Expressive Trauma Integration (ETI) Secure Attunement Framework
Trauma integration in the context of developmental trauma aims to help trauma survivors internalize a sense of safety, predictability, and connection to self in relationship to someone else, starting with the therapist.
This work is done by:
Strategic use of activities that facilitate self regulation;
The therapist functioning as a co-regulator with the client (using the framework of attunement-misattunement-reattunement) until the client is able transfer this role elsewhere and self-regulate.
In my experience, elements of an effective therapeutic framework for creating secure attunement include:
1. Experiential psychoeducation. Educate the survivor and family members, in ways that fit their developmental capacity, about what happens when the child is triggered emotionally, afraid, and stressed. For adults clients, this includes understanding how developmental trauma affects them today. (Learn more in this post.)
2. Enhanced sense of safety. I consider use of action in a safe space the preferred strategy for this, since in developmental trauma the damage took place in an age when imagination and playfulness were supposed to be dominant and essential to facilitate brain development. The therapist uses activities that involve playfulness, imagination and spontaneity appropriate to the child’s current age to trigger bottom-up brain develop corresponding to the age when the developmental trauma took place. For adults clients, this also include activities that enhance playfulness and spontaneity.
3. Improved self-regulation. Since our body detects stress (real or perceived), self-regulation relies on sensory integration. (Learn more in this post). For this we use sensory integration activities adapted to the age of the client when the trauma took place.
4. Safe regression. The first three elements above together lay the groundwork for this phase. The activities in the therapy room foster creativity, playfulness and spontaneity while allowing for slowly introducing things that involve some risk and autonomy. It takes time. But not too much, and not too early! Repetition of these activities in many sessions builds a sense of safety, enabling the client to enter what I call safe regression.
When a client is ready to enter this phase, often we begin noticing some ordinary regression in overall behavior, usually outside of the therapy room and reported by the client or family members. This is a sign to increase the frequency of therapy sessions, usually to more than once a week.
Clients can work with any medium of expression. The therapist, just like parents, cannot be perfectly attuned to the client. This provides opportunities for misattunement to take place for the therapist to model how to re-attune to the client in times of stress/trigger/withdrawal (stage 3 in the ETI trauma response roadmap).
Most of my clients with developmental trauma display reactive behaviors and difficulties in self-regulations at home and other settings (school, work etc.). In this stage the clients show expanded ability to take risk and display more reactive behaviors in the therapy room as well.
The therapist models different responses to the reactiveness, first by calming down the reactive stress response (experiential self-regulation). Then by modeling reattunmenet and reconnecting to the client, and providing psychoeducation to why he/she was reacting like this or that, in that moment.
In most situations, when clients, even the young ones, come to understand that they react instinctively in certain situations, they gain an important new insight: “This is not me, this is a result of something that happened to me."This is followed by an equally important realization: now we are doing something about it.
5. Develop and practice an Individualized Sustainability Plan (ISP**) for continued stability. (Read more about this in my previous post.) An individualized sustainability plan should take into account all aspects of well-being and rely on the client’s specific resources and vulnerabilities (genetics, traumatic past, condition of immune system, age when trauma took place, intergenerational trauma, etc.).
Developmental trauma requires a complex response. It is not realistic to expect results with such an injury on all aspects of well-being without addressing the many aspects of life impacted by it (emotional, cognitive, physical, spiritual and social).
It is also unrealistic to expect that seeing a therapist once a week would be enough. After any injury when we want to help someone heal we make sure they eat well, get enough rest, support their immune system and metabolism, improve their cognitive abilities, engage socially as much as they are able and so forth.
Trauma therapy in general requires daily routines that facilitate long-term sustainability. Without these, we may see some progress, but it won’t be as long-lasting as if we address all of them at once. For developmental therapy this is even more true.
Living with developmental trauma is a lifelong journey. Survivors who are able to integrate their trauma can expect, like everyone else, to experience movement throughout their lifetime between a sense of attunement, misattunement, and reattunement.
Without adequate neurodevelopmental intervention they will spend more time in misattunement and find reattunement more difficult. With proper intervention and greater integration comes less time in misattunement and greater fluidity in returning to attunement.
I have been tremendously encouraged by the results I have witnessed in clients when therapy is guided by a neurodevelopmental trauma therapy framework that includes targeting all aspects of well-being. The quality of life for both clients and their families is often significantly improved.
*When working with children who suffer from developmental trauma I have come to consider it essential to have an additional session one-on-one with at least one of their caregivers on a regular 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.
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.
Perry, B. D., & Hambrick, E. P. (2008). The neurosequential model of therapeutics. Reclaiming children and youth, 17(3), 38.
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.
Van der Kolk, B. A. (2017). Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric annals, 35(5), 401-408.