By Patrick Tomlinson
Date Posted: December 18 2013
This article was published first in the goodenoughcaring Journal in December 2013 and is the text of a lecture delivered to foster and residential worker in Japan in October, 2013.
Patrick Tomlinson’s work with traumatised children spans from 1985, as a residential care worker, operational manager, organisation director, clinician, consultant and author. He began his career at the Cotswold Community in the UK, a ‘therapeutic community for emotionally disturbed boys’. He spent fourteen years there, the last six as Assistant Principal.
Following a two-year period working with Young Options (UK) as Head of Therapy and Regional Director, he joined SACCS (UK) as a Director in 2002. SACCS provides an integrated treatment program for traumatised children, in residential and foster care. Working with Mary Walsh, he was central to the development of the SACCS Recovery Program.
Since 2008 he has been working independently with organisations and individuals. His main interest is in the development of therapeutic models of care for children and young people who have been traumatised by abuse and neglect. In recent years Patrick has provided services in UK, Japan, Australia, Ireland and Romania.
Patrick is the author, co-author and series editor seven books and numerous papers, including – Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for Practice (2011), co-authored with Rudy Gonzales and Susan Barton from the Lighthouse Foundation, Melbourne. Visit Patrick’s website at http://www.patricktomlinson.com
Communicating with Traumatised children
Author’s Note: For the sake of economy the words child and children are used throughout, though the terms are also inclusive of young people. The male gender is also used purely for economy.
The Impact of Trauma on Child Development
It is important to understand the nature of trauma, how it impacts on child development and the kind of approaches in the work with a child that can enable him to begin recovery. Trauma is like an emotional shock – an experience that is too overwhelming for the person to process. Normally, with support and over time the person naturally recovers from trauma and is able to integrate their experience of trauma as part of their personal history. In childhood, trauma can be particularly damaging because the child’s brain is not fully developed – therefore the natural development process can be disrupted and become distorted. Trauma alters patterns in the brain, chemicals such as adrenaline and cortisone are produced in excess, initially as a necessary survival response i.e. to prepare a person to take flight from the threat. Trauma that is repeated over time, often in many different forms, such as physical, emotional and sexual abuse, as well as neglect – becomes complex trauma.
Providing therapeutic care for children who have suffered complex trauma is an extremely challenging and difficult job. Enabling these children to recover can also be very rewarding, as Kolk and McFarlane (2007, p.573) have said, “This struggle to transcend the effects of trauma is among the noblest aspects of human history.” If trauma is repeated over time, the changes in the brain become permanent rather than a temporary response. When this happens the brain becomes unbalanced – development goes on hold as the brain is constantly in survival mode. For example, if someone is hypervigilant, constantly anxious, ready to fight or take flight, or alternatively ‘watchfully frozen’ to become invisible – the person is unable to receive nurturing experiences, which foster development.
The Importance of Safety
The first thing traumatised children need is to be safe and secondly to feel safe. Being safe and feeling safe are not always the same thing. For instance, we might be ensuring that a child is safe from harm but he might not trust us. For the child to feel safe we will need to ensure that he is actually safe over a long period of time. His negative experiences of adults over many years can only change through new consistent positive experiences. We cannot expect something that been learnt over such a long time to change quickly. Until this happens a traumatised child is likely to be highly anxious, hypervigilant and mistrustful. They will keep others at a distance by using various defensive strategies, which have been adopted as a survival mechanism,
- behaving in a hostile, rejecting manner
- becoming withdrawn to keep others at a distance
- becoming manipulative to maintain a sense of control – sometimes this may be by adopting a compliant and pleasing exterior protecting the real and vulnerable self
All of these behaviours, which are really attempts to survive and protect the self, prevent people from feeling connected with the child in a meaningful way. Trauma based behaviour is functional at the time in which it develops as a response to threat. The strategies may be effective in causing adults to give up and stop trying to form an attachment – in this sense the child’s strategy is effective in protecting him from what he feels is the likely outcome of closeness to an adult – hurt, rejection and abuse. However, in the long term the strategy is dysfunctional as the child cannot grow and develop without forming close relationships with adults.
Safety is created by being reliable and consistent, with firm but non-punitive boundaries. This approach must be maintained, however difficult and challenging the child’s behaviour. A child may try to push us away or provoke us into rejecting him in a punitive way, by being aggressive and very challenging. This needs responding to with firm and clear management, to ensure the child and others are safe. Clear boundaries and expectations can be put in place in a way that also has empathy for the child. Keeping the child safe without hurting or punishing is an essential part of helping him to feel secure. Feeling secure and being able to trust adults, creates a sense for the child that asking for help and trusting may be worthwhile and beneficial. An important part of the approach is to make it clear that it is the behaviour we are responding to – we are ‘challenging the behaviour not the person’ (Barton, et al, 2011). We might say, ‘I don’t like that behaviour because it hurts people’, rather than ‘I don’t like you because you hurt people’. Empathy can be shown with statements like, ‘I know you are feeling very upset but it isn’t ok to hit someone’. However, a simple message like this may be confusing to a child, who has been abused by his own parents. If we are saying it isn’t ok to hurt someone, then it raises the question, ‘why did my parents hurt me then?’
Internal Working Models
What we think of as normal may be quite the opposite in the world of the child. Therefore we are challenging the child’s view of the world and potentially helping him to change his view to a healthier one. These views of the world have been internalised during the early formative years as inner working models (Levy and Orlans, 1998, p.46). Examples of negative and positive inner working models(IWMs) are,
- I am good/bad, lovable/unlovable, competent/helpless.
- Caregivers are responsive/unresponsive, trustworthy/untrustworthy, caring/hurtful.
- The world is safe/unsafe; life is worth living/ not worth living.
These early attachment experiences become internalised as core beliefs and anticipatory images that influence later perceptions, emotions and reactions to others. IWMs are not entirely conscious but, once established are resistant to change. However, with appropriate experiences the child’s IWM can change and become modified.
Creating a Therapeutic Home Environment
As well as our direct interactions with children, everything we do in the home communicates a message to them. In this sense, every detail of daily living is a therapeutic opportunity. The child needs to see that this is a home for him, where his needs are given a priority and where he has a say in how things are done. His experience may have been that a home is just a place where things happen (sometimes traumatic things) with little or no regard for his needs. Simple matters in daily living can make a difference, for example,
- the way we allow children to have their own personal space with their own belongings
- how we look after the home
- the care we take over basic needs, such as cooking, cleaning and laundry
- the kind of toys, books and other child related resources that are available
- how adults work together, demonstrating respect, kindness and thoughtfulness – all of which might be quite alien to the child
A child will only communicate something important in a straightforward way when he believes and trusts that there may be a positive and caring response. Until he has experienced this from us consistently over time he has no reason to believe that we are any different from adults who have hurt and failed to protect him in the past.
One of the realities of the daily living situation is that important communication often happens in a spontaneous rather than planned way. When a child has been abused and neglected in their family home all aspects of daily life may have associations with trauma. Mealtimes may have especially powerful associations for one child, while for another it may be bedtimes. This means that often children’s emotions and memories are triggered by different events in daily living. This provides an opportunity to respond to the child and potentially work through a traumatic experience. Ward (1996) has called this ‘opportunity led’ work.
One example I had was a morning when we were getting children ready to go to school. One of the boys was slow in finishing his breakfast, so I asked him to hurry up. He immediately became highly anxious and ended up in an out of control panic. Researching his history we discovered that his mother had once asked him to eat his breakfast, he refused and she hit him on the head with a stick so hard he had to be taken to hospital. We were then able to talk together about this distressing and traumatic memory associated with breakfast. It would have been better if I had been attuned to this part of his history and able to anticipate the potential difficulty. However, in the context of his life this was just one incident among many.
The Daily Routine and Regulating Emotions
To begin with, rather than being concerned too much with communication at a deep level the focus should be on basic matters like,
- letting the child know what will be happening during each day
- how the daily routine will work
- the expectations around all aspects of living together
- what time meals, bedtimes and other daily events happen
- who will be looking after him today and anything else that will take place, during the day
Children may need reminding of these things on a daily basis, as they may not be familiar with anything remaining consistent. Traumatised children are very wary about unpredictable things happening, so the more they know what to expect the better. The reliable daily routine and communication helps to reduce their anxiety and improves their ability to regulate their emotions.
Traumatised children have often had their development disrupted in early life and so do not function at a chronologically age appropriate level. For example, a 10 year old may have a similar level of emotional regulation as a 2 year old. It is not realistic to expect a child like this to be able to think much about his feelings and to put them into words, when so much of his energy is used to manage overwhelming feelings and impulses. An important task for adults working with such children is to co-regulate their emotions, by anticipating potential difficulties, explaining to a child in a calm way what is happening and by taking actions to reduce the stress for him. To help frightened and anxious children to feel calm, first of all the adults need to feel and act calm themselves (Perry and Szalavitz, 2006, p.67). To maintain a calm and emotionally containing approach it is essential that carers support each other and talk together about the difficulties in their work with the children.
Carers Communicating and Working Together
Before we can expect children to communicate, the adults who are looking after them need to become effective at communicating with each other. If we believe it is helpful for a child to communicate and that this might help him understand and mange himself better – we need to role model our belief in this by doing it for ourselves. If we communicate with each other it will make a difference in our ability to work with the children. Sometimes we can do this together as a team, or couple, when we are working and other times it may be in a special context, such as a team meeting. Sometimes because the work with traumatised children can be so difficult, leaving us with complicated, strong and confusing feelings, we may need help to communicate effectively. Such help may be offered by a supervisor, manager or consultant.
All Behaviour has Meaning
All behaviour has meaning and can be considered as a form of communication. Babies and infants let us know what they are feeling and what they need without using words. An emotionally attuned parent can distinguish subtleties in the infant’s communication e.g. tired, uncomfortable, scared, hungry, contented, etc., based on the infant’s actions. It is only the parent’s attuned and reliable response to the infant’s actions that enable him to begin the process of thinking about his feelings and needs, and then to find words to communicate with. “It is almost a truism that children learn to think by being thought about; that an infant’s essential learning about him or herself takes place in the encounter of one mind with another from the very moment of birth.” (Margot Waddell (2004, p.22), Child and Adolescent Psychotherapist)
Developing the Capacity to Think
A child who is traumatised may either have never developed the capacity to think about and communicate his feelings, or he may have lost this ability temporarily due to the impact of trauma. A common symptom of shock is not being able to communicate. We often think of a person who is in shock as appearing to be in a ‘frozen’ state. So we don’t push them to talk before they are ready or capable. We offer reassurance and simply be with the person, providing a sense of security and continuity – during a time which is also one of loss and insecurity. Sometimes we help soothe the person through our physical presence, the tone of our voice, etc. In the more extreme cases we may manage things for the person and we are not too concerned if his level of functioning has temporally regressed. We might refer to the person as ‘not being himself’. We might even see behaviour that is completely ‘out of character’. Therefore a traumatised child who in many ways is in a prolonged state of shock – may for many reasons not be able to talk about important things. Van der Kolk and Newman (2007, p.18) point out that premature attempts to talk about matters related to the trauma may only make things worse. The most helpful approaches include,
- Reducing stress – providing a reliable healthy routine, regular eating, sleeping, waking patterns are important for general health and also relieving stress.
- Providing nurture and care without being too pushy or intrusive. The child may be very anxious about physical closeness with an adult.
- Explain things clearly throughout the day – prevent anxiety about what will be happening later by reminding the child.
- Pay attention to the child and listen carefully to his communication – verbal and non-verbal.
- Show a healthy interest in the child, find out what he likes, what he enjoys doing, what is important to him, etc.
- Where possible offer the child choices. Having a sense of some control can be very important to traumatised children who have felt out of control and unable to escape frightening and possibly abusive experiences.
- Don’t just focus on the child’s history, but do things in the present that are normal, fun, and enjoyable – just as you would with a child who hasn’t experienced trauma. It has been said that trauma can take a child’s childhood away – we need to enable the children to be children.
Reminding us of this, Mary Walsh whoI worked with at SACCS used to say that traumatised children are ordinary children to whom extraordinary things have happened.
Physical Mastery and a Sense of Normalcy
Traumatised children often feel stigmatised as if they are different to other children – they need a ‘sense of normalcy’ (Anglin, 2002) of doing normal, ordinary things like all children. If they have been abused for example, they have experienced something extraordinary that a child should not experience. The traumatic experiences can dominate the child’s sense of who they are and they need ordinary experiences to create a more balanced and healthy identity. Play games with children and let them develop interests, where they can use their bodies in a healthy way. For example,
- playing ball
- playing an instrument, singing
- riding a bike
- using hands to paint, draw and make things
This can also help the child develop a sense of physical mastery, which stimulates development and self-confidence, as well as the ability to relate to others. Activity that involves exercise also helps to reduce stress and depressive feelings. However, careful judgment of what the child is capable of and will be able to manage is important. For example, some children may need to learn how to play with an adult before they can play with another child.
Communication through our Actions
All of what I have discussed so far, is necessary before we can focus on communication. In a sense, we are already communicating with the children, through our actions. We are demonstrating that we care, that we are concerned about them and that they are worthy and deserving. The hundreds of little caring things that we do over and over again gradually enables children to develop trust. “I also cannot emphasize enough how important routine and repetition are to recovery. The brain changes in response to patterned, repetitive experiences: the more you repeat something, the more engrained it becomes.” ( Perry and Szalavitz, 2006, p.245) However, as I have said we cannot expect that the child will necessarily accept our efforts – often it will be quite the opposite. We may feel as if we getting it wrong and failing, that it is a hopeless situation and a waste of time. Sometimes just as things seem to be getting better they will get worse. Recovery from trauma is very much, two steps forward and one step back, or two steps back and one step forward! Long periods of time, months or even years can pass by where it seems like little progress is being made. For a traumatised child a little step forward can be the equivalent of a huge leap. We need patience and to continually try and understand why things are so difficult. Sometimes we may not be able to understand. Early in my career, when I felt overwhelmed and useless, and like giving up – our consultant Barbara Dockar-Drysdale said to me that sometimes surviving is the most important thing we can do – if we survive and are still there the next day, this can be more important to the child than we can imagine.
Before we consider, how we communicate with children using words it is important to also consider other forms of communication. Young children often communicate using symbols, for example, through play or through drawing. Using puppets can also be an excellent way of enabling children to communicate. As I have said, traumatised children may be functioning at an age that is younger than their chronological age. A child may tell us how he feels by showing us the feeling in a symbolic way. For example, children who have a teddy may tell us that ‘teddy’ is feeling sad, or teddy isn’t feeling well, or the child may draw a picture of a person with an angry face. When a child does this we should respond with the same symbolic language. For example, ‘it can’t be very nice for teddy to be feeling so sad – I wonder what has made him feel like that’, or ‘what can we do to help him feel better’. If the child likes drawing, we can play drawing games with him. Winnicott (1971) the British Child Psychoanalyst used to play a game with children that he called ‘Squiggle’. He and the child would take it turns to draw a squiggle and the other would turn the squiggle into a picture of something. Often what the child would draw would tell a lot about him. Winnicott used this to help him understand the child he was seeing – it was also something the child would engage with and often enjoy. For some children this is a much more useful technique than asking, ‘what are you feeling or thinking’. Here are some examples,
All of these pictures that started off with a simple line of squiggle are quite revealing, and communicate something that can be responded to in words or further drawings. For example, in diagram 2 we might say, ‘that snake looks very big and the cat looks very small’. It is important not to make too many assumptions about what the picture might mean to the child. For instance, we might feel the cat is frightened of the snake, which looks like it is going to hurt the cat. The child might respond to our initial, less directive comment by saying that ‘the snake is looking after the cat’ – we might then say something like, ‘I wonder if the cat feels safe being looked after by a snake’, etc. In the first picture we might say something simple like, ‘the person seems sad, I wonder why?’ and in the third picture we might remark ‘what big teeth the dog has’. We don’t need to feel too concerned about having a discussion with the child as the child might not want to talk – the act of drawing something is in itself a form of communication, often unconscious and it may be helpful to the child just to draw the picture.
Sometimes in life story work children draw pictures of their family, with expressions on their faces, and position each family member close or distant to the child. This can tell us a lot about how the child has experienced life in his family. This kind of communication, which might take place in the daily living situation should not be seen as therapy but as communicating with the child in a way that is engaging and enjoyable for him. Making interpretations or strong links between what a child draws and what the drawing might mean could provoke anxiety, causing him to shut down and withdraw.
Play and the Language of the Child
It is important to work at the pace of the child, using the child’s language. Play has been called the language of the child. If a child does draw something let him take control of what he would like to do with the drawings afterwards. He might want to keep the drawing, ask you to look after it for him, or to throw the drawings away. Having this sense of control will help the child feel less anxious about what he has communicated.
This is just one example of engaging children in communication without primarily using words. Similar approaches can also be adopted to other forms of play, using toys, play animals and figures, music and dance. All of these can be used creatively and provide ways for children to express themselves. For instance, play figures may be used by a child to create domestic scenes. Toy animals might be organised in different ways – like some animals taking on protective or aggressive roles. I saw some children recently put on a drumming and dancing performance – the adult who had been working with them told me that much emotion had been expressed.
All of this kind of play and non-verbal communication, which as well as being enjoyable for the child, enables us to gain insights and to understand him better. In terms of understanding the child’s play it can be helpful to have discussions in team meetings or supervision. As said, thinking about the child in this way, provides him with an experience of being thought about in a way he might not have experienced before. However, being thought about, while our intentions are benign and helpful, might not be experienced by the child in the same way. The child may not be used to an adult thinking about him in the healthy way a caring and protective parent would think about their children. The child may be very suspicious of why an adult may be thinking about him – he might expect that it will lead to an abusive or hurtful situation. The child may try to stop us thinking about him by giving us nothing to think about – withdrawing, or by being difficult to fill our heads with different thoughts like how we are going to manage his behaviour.
Working with Difficult Behaviour and Strong Feelings
Difficult behaviour can be used by the child as a way of controlling others. This type of control, which can cause us significant concern is often how the child tries to deal with his fears and anxieties related to trauma. To us the behaviour may seem like a major nuisance – to the child it might be how he survives and copes with his fear of being out of control. We might find ourselves feeling suddenly angry or punitive towards the child. It is very important that we think about our own feelings, how they change when we are with the child and what we might learn by thinking about our feelings and thoughts. For instance, one child I worked with used to try and provoke me into hurting him – thinking about this it was clear that this was what he expected me to do and in some ways wanted me to do, so his fears could be confirmed. Being with people who didn’t hurt him and beat him was unfamiliar and therefore threatening to his sense ‘normality’.
Other children would try to disrupt adults who were talking together – from their experience adults talking together might mean something bad would happen next. Sometimes a child would feel that the adults were more interested in each other rather than him – in his world this might feel like being neglected. This doesn’t mean that we shouldn’t think or talk together about a child, but we need to be sensitive to what this might mean to him. We role model a healthy alternative to their previous experiences. Some children might become extremely anxious when they know an important meeting about them is going to take place. Adults meeting together, might mean to the child that they are making a plan for him – such as to be moved to another placement. It is not surprising that a child with this kind of fear may try to stop the meeting from happening.
Now to consider verbal communication. Research has shown that parents who talk a lot with children during the normal routine of the day, tend to have children who also talk more and develop bigger and more elaborate vocabularies (Hart and Risley, 1995). Talking is built into daily life by,
- explaining what is happening
- commenting on things the child does
- asking questions
- exploring things together
- linking cause and effect
- naming feelings
A healthy child is biologically programmed to respond and interact with this,
“Ultimately, genes…..create needs which can be satisfied only by particular environments. Fish genes create organisms that need water. Monkey genes create organisms that need mothers to teach them how to behave. Human genes make organisms that need adults around in order to learn how to talk.” (Glantz and Pearce, 1989)
Children who are traumatised however, may not be used to talking or have become defensive and wary of what they say. They may have very little vocabulary that can be used to express their needs and feelings. When we talk with these children they might not respond, or if they do respond it might be in ways we don’t expect, for example by becoming aggressive. It is important to persevere and to talk about things in a way that isn’t too challenging. For instance, if a child says something that we don’t agree with or understand – rather than disagree, we can ask a question and explore things. If a child makes a statement, such as ‘Peter hit Paul’, we can say something like, ‘I wonder how that made Paul feel’, or ‘I wonder why Peter did that’. The child might not have an answer, but we are making the link between cause and effect, between actions and emotions. We are also encouraging the development of empathy. Perry and Szalavitz emphasised the importance fpr traumatised children of learning about cause and effect,
“…children who develop severe behavior problems often lack this ability to link cause and effect. The early chaos of their environments doesn’t make these connections clear and visible. There are too many anomalies, too many inconsistencies. A child of average or below average intelligence won’t be able to learn without constant repetitions.”
If a child is acting as if he is angry, we can begin to help him name feelings, ‘I wonder whether when you behave like this you are feeling angry’, or ‘you seem to be feeling angry today’. This gradually helps the child to find ways of expressing feelings through words rather than by acting out. A child who can begin to say things like, ‘I feel so angry with Peter that I could hurt him’ is making significant progress. We can then help the child begin to anticipate things and take responsibility for managing emotions and behaviour, ‘Remember last time when you felt like this and you had a big fight, what can do to prevent that from happening’. Often traumatised children, feel that if they say something it won’t be listened to or that they might even be punished, so they think that communicating is a waste of time or even dangerous. We need to provide a lot of support to help give children the confidence to communicate. For example, if a child is angry with another child, we can say that ‘we will help you talk about this and if the other child gets angry with you, we won’t allow you to be hurt’.
Listening to Children and Different Kinds of Communication
Really listening to children can be difficult. We might be distracted by other things and not paying full attention or we might feel anxious about what we are hearing. If we can really listen and be receptive to a child’s communication he is more likely to tell us important things. As well as listening to children we need to pay attention to the non-verbal communication and the feelings evoked in us. This may tell us as much about the child as the words he uses. We also need to be open to children saying critical and difficult things to us as adults. We need to be careful not to be defensive. It is important to remember that many children who have been abused, have experienced denial from adults who they have talked to. Some children who have been abused may have been threatened with serious consequences, even death, if they tell anyone. Whenever a child says anything significant to us we need to show that we take the communication seriously and not be dismissive. This is empowering for the child who may begin to believe that he can make a difference by communicating. If we believe communication is important we need to show children the positive benefits. Feeling listened to, understood and taken seriously is a vital part of building self-esteem and resilience. We all talk in a variety of ways,
- chatter – where we are just talking about everyday matters without much feeling attached
- talking about everyday matters with feeling – ‘I really enjoyed our time together today’, or ‘that story made me feel really sad’
- talking about important personal matters, but in a matter of fact way without feeling, ‘when I was young my dad used to hit me’
- talking about important personal matters with feeling, ‘when I was young my dad used to hit me and it made me feel really scared
- talking about important personal matters with feeling and insight, ‘when I was young my dad used to hit me and it made me feel really scared and now sometimes I am still scared of men’
A healthily developed person will be able to communicate on all these different levels and knows the appropriate context for different levels of communication. Traumatised child may be very limited in their communication. They may only tend to chatter or if they are able to communicate about more personal and intimate matters, they may not know how to do this appropriately. For example, instead of making social chatter with someone they don’t know very well, they may say something too personal or intimate. So as well as helping traumatised children learn how to communicate we also need to help them understand the social function of communication. Most young children know the difference between things they would talk about with their parents, with friends, teachers, strangers, etc.
Communication and the Child’s Stage of Development
When thinking of our expectations regarding children’s communication and the way we communicate with them we need to consider this alongside their stage of emotional development and not just their chronological age. So for example, we would not expect a child who is functioning as a young infant, whether he is actually 2, 7, 10, or 14 years old, as being capable of communicating important personal matters, with feelings and insight. As Bruce Perry (2006a) has shown the brain develops in a neurosequential way. A child cannot move to one stage of development until the last has been completed. During early infancy communication is primitive, through actions such as crying, then words are used to express feelings and needs, then this is done with some recognition that others also have needs and feelings. Finally the ‘executive function’ of the brain develops, enabling complex abstract concepts to be understood and communicated. This ability may only be fully realised in later childhood and continues to develop into adulthood. So if a child seems to be constantly chattering or saying very little, our response to this needs to be guided by understanding the child’s actual ability. If the child is very young emotionally it might be unrealistic to expect that much can be achieved by in-depth discussions. As discussed earlier, it might be better to focus on other ways of communicating and to focus on developing physical mastery rather than talking. A young child may feel better by playing a game rather than by ‘talking about his problems’. On the other hand if the child is reasonably well developed but always seems to chatter rather than talk about anything more meaningful, he may be avoiding something. This may be due to the potential distress involved, feeling unsafe or afraid of what might happen. Our task here is to help remove the block rather than push the communication. If the child doesn’t feel safe, help him to feel safe and then he is more likely to communicate. It is also important to recognise that whilst it may seem a child is chattering endlessly if we listen carefully there may be details of what he says that have significant meaning. The meaning may not be immediately obvious but through careful attention we may begin to make connections. If we think that there are important things a child is potentially able to communicate, but is holding back we need to be thoughtful and gentle in our approach. It may be extremely difficult for a child to communicate about painful and distressing issues, for example abuse and neglect in their family. Once the child begins to communicate, as well as the painful memories being activated, other feelings will be brought to the surface, such as anger, shame, guilt and sadness.
Trauma also involves loss and this can be very difficult to acknowledge. Rather than accept the loss involved in realising that a parent hurt him, a child may deny the reality and be protective of the parent. The child’s feelings might be very confused and distorted. For instance, feeling guilt about the abuse, as if it was the child’s responsibility. Communicating and working through these issues, requires time, understanding and patience. As well as the communication being potentially distressing for the child we need to be aware that some of things we hear may also be distressing for us. It is very important that we talk about our own feelings with colleagues so we can process our experience. Otherwise we are more likely to prevent a child from communicating due to our own fear of the feelings it will raise for us.
Research has shown that how children relate and get on with each other plays a vital role in child development (Shonkoff and Phillips (2000), Anglin (2002)). Young children from infancy upwards, who are able to get along well with their peers tend to develop more healthily than those who don’t. Positive peer relationships is one of the strongest indicators of positive long term outcomes for children (Shonkoff and Phillips, ibid). Therefore the way we enable children to relate to each other is one of the most important parts of our work. Traumatised children often have great difficulty with this, so initially a great deal of support needs to be provided. We need to be careful to ensure that children are not left in situations, which they are unlikely to manage well. At the same time we need to provide the space for children to play and talk with each other. The level of support and supervision can be reduced as children mature. Some children will need adults to show them how to get on with each other and to intervene when difficulties arise. As well as informal situations throughout the day providing opportunities for children to relate to each other, more formal opportunities such as group meetings can also be provided. A group meeting can be used to,
- discuss how we are getting on with each other
- discuss interesting matters, such as achievements children have made
- plan things we would like to do
- discuss general matters related to daily living
The group meeting provides an excellent opportunity for adults to role model thoughtful and respectful communication, ensuring that everyone feels listened to. Sometimes if a child has something difficult to talk about, an adult can talk with the child beforehand so that he knows he will be supported. It is very important for children to experience that difficulties can be resolved without leading to people falling out. They may be very familiar with differences leading to arguments, leading to violence, etc. In a therapeutic community I worked in we also used to have ‘talking groups’ where a group of 3-4 children, would have half an hour with an adult just to talk about anything they wanted to (within reasonable boundaries). This was especially helpful for children who found talking in a larger group difficult. In one group one of the boys suggested we had a ‘teddies talking group’, for each of the boys’ teddies to talk to each other. This turned out to be a very creative idea, providing an opportunity for playful symbolic communication.
The Context for Therapeutic Communication – Residential Care, Therapy and Life Story Work
While this paper is mainly about therapeutic communication that can take place in the daily living situation, especially in residential care and to some extent foster care, much of it is also relevant to other contexts such as therapy and life story work. Many of the basic principles are relevant to any kind of therapeutic work with traumatised children. For children who have suffered complex trauma, abuse and neglect in their family environment – the therapeutic care environment is an essential part of the therapeutic approach. All aspects of the home environment are associated with abuse, therefore a home environment is the natural setting for therapeutic work to take place in. As Farragher and Yanosy (2005, p.100) have said,
“Recovery from injuries perpetrated in a social context must occur in a social context.”
In this sense those adults who are looking after the traumatised child are not just parenting the child. Ordinary parenting provides children with healthy development, whereas traumatised children need a kind of parenting that enables them to recover from trauma as well as to resume normal development. Recognising the important therapeutic nature of this work the term Therapeutic Parenting has been used in organisations such as SACCS in the UK, The Lighthouse Foundation in Australia and previously Browndale in Canada. In many ways the ‘therapy’ takes place in the daily living situation. If this is the case, it then leads us to the question of what is the role of other specific forms of therapeutic work, such as therapy and life story work.
Often children are provided therapy or counselling in relation to specific difficulties that may be related to issues that are not as far reaching as complex trauma. For example, working through a one-off traumatic event, or dealing with an aspect of mental health disorder. However, as long as a traumatised child’s complex needs are being addressed within the 24 hour a day group living situation, individual therapy and life story work can also play a useful part in the recovery process. Therapy provides a regular session with a qualified therapist, usually once or twice a week with a clear focus on working through the child’s difficulty so that it no longer hinders his functioning and development. Different forms of therapy may be used – talking, play, art, drama, etc. The therapy space and relationship provides a process with clear boundaries, separate from the daily living environment. Some children find they can really engage with a therapist and use the home and therapy for different purposes. It can be a relief to some children to take their ‘issues’ or ‘muddles’ to therapy and leave them there, while they might use home more to receive nurture. In reality the separation is usually not as clear as that, but it can work well for some children. Others may prefer not to see someone outside of the home and this may be influenced by their past experiences and individual disposition.
Life story work (Rose and Philpot (2005), (Rose (2012)) may be provided for children who have especially complex life histories. A child who has had numerous placements, maybe many people in parental roles, with lots of siblings, half siblings, etc. may have a very confused sense of his own history and identity. This is one of the reasons why it is so important for everyone who works with the child to have a thorough knowledge of his history. The daily living situation can be used to work through many aspects of a child’s history, leading to a more realistic sense of history and also identity. However, for children whose histories are especially complex and where the child’s perception is very confused and distorted, the work in the living environment may not be sufficient. Life Story Work provides a focused and methodological approach to working on the child’s history. The work not only involves clarifying the child’s history but more importantly enabling the child to work through their feelings and distorted views related to their history. Some children may know what has happened in their lives, but are very confused about the reasons. For instance, a child who has been abused but believes he is responsible for what happened and not the adult. Some children believe they are in care because they have done ‘bad’ things. The life story worker will be trained in the detail of the work and as with the therapist not be someone who is involved in the therapeutic parenting work. As with therapy some children benefit from having different places where they can work on things and the separation it provides. Life story work typically takes place with a session every 1-2 weeks and it normally take around 18 months to complete. At the end the child will have his own life story book, which serves as a valuable record of his history.
Whether a child has therapy or life story work or not, should not be an arbitrary decision, but one based on an assessment of the child’s needs. When a child does have therapy or life story work, or both, it is important that the therapeutic parents, therapist and life story worker, work together in an integrated or ‘joined up’ (Cant, 2002) way, holding the whole of the child’s experience together. The 3 therapeutic domains of therapeutic parenting, therapy and life story work can all play an equally important part in supporting a traumatised child’s journey to recovery. The communication that takes place between everyone who works with the child is often as important as that which takes place directly with him.
The following points which I have discussed are central to work with traumatised children and the importance of communication,
- Trauma has an impact on child development so that a child’s ability to function and communicate may be significantly diminished. A 10 year old child may have the functioning ability normally expected of a 2 year old.
- Therapeutic work with traumatised children can be extremely difficult and challenging, and it can also be very rewarding.
- Being and feeling safe is the beginning of therapeutic work and recovery.
- Managing behaviour in clear, firm but non-punitive way is important. Clear boundaries and expectations are necessary.
- The daily living environment in all of its detail gives children messages about our attitude towards them.
- A reliable, child centred, healthy and consistent daily routine plays a crucial role in enabling children to feel cared for and in making the world a more predictable and less stressful place.
- Regulating emotions is necessary before a child can be expected to think about communication. A consistent daily routine helps to regulate emotions.
- Communicating and working together a team. We can’t expect children to communicate unless we do it ourselves. This also provides a role model for children.
- While we might not think of behaviour as communication it does tell us something about the child and all behaviour has meaning.
- The capacity to think is a pre-requisite of communication. Trauma disrupts the capacity to think. We help children to think by thinking about them.
- Traumatised children will not easily accept our efforts to communicate with them and to think about them. Lots of patience and understanding are required and sometimes we might just need to survive the children’s difficulties.
- Some children may not be able to communicate easily with words but may be able to communicate using symbols. We need to be open to using other methods such as play and drawing.
- Play is the language of the child. As well as being a normal and enjoyable part of childhood, we can also learn a lot about a child through play and it can be an excellent way of building relationships.
- Traumatised children may be anxious and fearful in relation to all forms of communication. The work might be very difficult and we need to be thoughtful about the strong feelings that can be evoked in us.
- The ability to communicate verbally is a vital part of child development. The way we listen to and respond to children is very important in enabling them to develop. Really listening to children can be difficult and we also need to pay attention to the feelings evoked in ourselves. It is important to recognise the different levels and quality of communication and to understand that children at different stages of development will communicate differently.
- Communication can open up very difficult and potentially distressing memories and feelings. We need to be aware of this for the child and for ourselves.
- Peer relationships are a vital part of child development and we need to support children in the way they get along and communicate with each other.
- Some children may also benefit from life story work and therapy as well as therapeutic parenting. When this happens it is important that the therapeutic parents, therapist and life story worker, work together in an integrated way, holding the whole of the child’s experience together.
Anglin, J. (2002) Pain, Normality, and the Struggle for Congruence: Reinterpreting Residential Care for Children and Youth, New York: The Haworth Press Inc.
Barton, S., Gonzalez, R. and Tomlinson, P. (2011) Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for Practice, London and Philadelphia: Jessica Kingsley Publishers
Cant, D. (2002) “Joined up Psychotherapy: The Place of Individual Psychotherapy in Residential Therapeutic Provision for Children’, Journal of Child Psychotherapy 28, 3, 267-281
Hart, B., and Risley, T.R. (1995) Meaningful Experiences in the Everyday Experiences of Young American Children, Baltimore, MD: Paul H. Brookes Publishing Co., Inc.
Levy, T.M. and Orlans, M. (1998) Attachment, Trauma and Healing: Understanding and Treating Attachment Disorder in Children and Families Washington, DC: CWLA Press
Perry, B.D. and Szalavitz, M. (2006) The Boy who was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook New York: Basic Books
Perry, B.D. (2006a) “Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized Children: The Neurosequential Model of Therapeutics,” in Boyd, N. (2006) (Ed)Traumatized Youth in Child Welfare, New York: Guilford Press
Perry, B.D. and Szalavitz, M. (2010) Born for Love: Why Empathy is Essential and Endangered, New York: HarperCollins
Rose, R. and Philpot, T. (2005) The Child’s Own Story: Life Story Work with Traumatized Children, London and Philadelphia: Jessica Kingsley Publishers
Rose, R. and Philpot, T. (2012) Life Story Therapy with Traumatized Children: A Model for Practice, London and Philadelphia: Jessica Kingsley Publishers
Shonkoff, J.P. and Phillips, D.A. (Eds) From Neurons to Neighborhoods: The Science of Early Childhood Development, Board on Children, Youth, and Families National Research Council and Institute of Medicine, Washington, D.C.: National Academy Press, This PDF is available from the National Academies Press at: http://www.nap.edu/catalog/9824.html,
van der Kolk, B.A. and McFarlane (2007) Conclusions and Future Directions, in Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society New York: The Guildford Press
van der Kolk, B.A. and Newman, A.C. (2007) “The Black Hole of Trauma”, in Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society New York: The Guildford Press
Waddell, M. (2004) “Attachment Anxiety”, Young Minds Magazine 72 September /October, London: Young Minds
Ward, A. (1996) “Opportunity led work part 2: the framework”, in Social Work Education, 8 (1), 67–78
Winnicott, D.W. (1971) Therapeutic Consultations in Child Psychiatry, London: Hogarth Press and the Institute of Psycho-Analysis