Working with Traumatized Parentchild Dyads: Challenging the Internal Working Model

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Working with Traumatized Parent-child Dyads
Challenging the Internal Working Model

• Douglas Goldsmith, Ph.D.
• Executive Director
• The Childrens Center

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Overview

• Understanding secure attachment
• Understanding the impact of trauma
• Assessment of the internal working model
• Challenging/Repairing the internal working model
  in treatment

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Secure Attachment

• The caregiver is perceived as a reliable source
  of protection and comfort

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Secure Attachment

• When I am close to my loved one I feel good, when
  I am far away I am anxious, sad or lonely
• Attachment is mediated by looking, hearing, and
  holding
• When Im held I feel warm, safe, and comforted
• Results in a relaxed state so that one can,
  again, begin to explore
  

Holmes (1993)
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Secure Attachment

• Promote exploration of the environment
• Expand mastery of the environment
• I can explore with confidence because I know my
  caregiver will be available if I become anxious.
• The infant gains confidence in his or her own
  interactions with the world
• 
  
  
  Weinfield et al (1999)

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Secure Attachment

• Attachment is a reciprocal relationship
• The parent offers caregiving behavior that
  matches the attachment behavior of the child
• The child, using social referencing, checks in
  with the mother looking for cues that sanction
  exploration or withdrawal
• Holmes
  (1993)

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Anxious Attachment

• Lack experience with consistent availability and
  comfort
• Attachment behaviors are responded to with
• Indifference
• Rebuffs
• Inconsistency

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Anxious Attachment

• Anxious about caregivers availability
• Afraid that the caregiver will be unresponsive or
  ineffective in providing comfort
• Experience anger about caregivers unresponsiveness

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Anxious Attachment

• Shows overt aggression toward the inconsistent
  mother
• Dont you dare do that again! but has to cling
  because he knows from experience that she will.
• 
  Holmes (1993)

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Impact of maltreatment

• Peer relations are disturbed
• More withdrawal and avoidance
• Physically abused children are more aggressive
  toward peers
• Display unusual or aggressive behavior in
  response to distress of peers
• More depressive symptoms

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Impact of maltreatment

• School functioning is compromised
• Representational models of self are more negative
• Experience distorted ongoing parent-child
  interactions
• More negative family relationships
• Poorer developmental outcomes
• 
  
  Lyons-Ruth Jacobvitz 1999

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Impact on the parent-child relationship

• A frightened or frightening attachment figure
  presents an inherent conflict for an infant.
  Fear of the parent activates the attachment
  system, and the infant feels compelled to seek
  proximity however, proximity seeking increases
  the infants fear, and he or she then contradicts
  the approach.
• Lyons-Ruth
  Jacobvitz, 1999

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Relational PTSD

• Parents may be traumatized even if not present at
  the trauma
• Withdrawn/Unresponsive/Unavailable
• Emotionally and functionally unavailable
• May have suffered trauma in the past
• Overprotective/Constricting
• Preoccupied about the trauma re-occuring
• Reenacting/Endangering/Frightening
• Repeatedly ask about the event
• Scheeringa Zeanah (2001)

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Parental Response to Trauma

• Parents experience
• Helplessness
• Frustration with inability to protect their
  children
• Osofsky ( 1995)

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Impact of Parental Anxiety

• Unable to hear their childrens distress
• Withdraw to protect themselves emotionally
• Difficulty tolerating childrens anxiety and
  aggression
• Osofsky Fenichel, (1994, 1996, 2000)

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Childrens Response to Trauma

• Loss of sense of basic trust
• Loss of security
• Destabilized Secure Base
• Compromised emotional development

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Infants and Toddlers

• Following violence in their home or community
• Increased irritability
• Immature behavior
• Sleep disturbances
• Emotional distress crying
• Fears of being alone
• Physical complaints
• Loss of skills regression in toileting and
  language
• Increased separation distress
• Appleyard Osofsky (2003)

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Young Children

• Re-experiencing of the traumatic event
• Avoidance
• Numbing of responsiveness
• Increased arousal
• Fear going to sleep to avoid nightmares
• Restricted range of emotion in play
• Serious, disorganized, somber
• Appleyard Osofsky (2003)

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Parental Response to Trauma

• How does the parent make sense of the childs new
  behaviors?
• Is the child perceived as understandably anxious?
  Or too clingy?
• Is the parent able to be patient and supportive?
  Or is the parent pushing the child too hard to
  resolve the trauma?
• How is the Circle of Security impacted?

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Internal Working Model

• Through a history of responsive care, infants
  will evolve expectations of their caregivers
  likely responses to signs of distress or other
  signals of the desire for contact
• Bowlby believed that, What infants expect is
  what happened before.
• Weinfield et al (1999)

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Impact of the Internal Working Model

• The model governs how children feel toward each
  parent and about themselves, how they expect to
  be treated and how they plan their own behavior
  toward their parent

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Internal Working Model

• Anxious infants learn to see the world as
• Unpredictable
• Insensitive
• The self does not deserve better treatment
• These beliefs are carried forward to new
  relationships and new experiences

Weinfield et al (1999)
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Internal Working Model

• When the expectation of being hurt,
  disappointed, and afraid is carried forward to
  new relationships, the anxious infant becomes an
  angry, aggressive child.
• Weinfield et al (1999)

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Bowlby

• The IWM governs how he feels toward each parent
  and about himself, how he expects each of them to
  treat him, and how he plans his own behavior
  towards them. They govern too both the fears and
  the wishes expressed in his day dreams

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Bowlby

• The IWM of a parent and self in interaction tend
  to persist
• The IWM comes to operate at an unconscious level
• As child grows older and parents treat him
  differently there is a gradual updating of the IWM

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Bowlby

• But for the anxiously attached child
• Updating is obstructed through defensive
  exclusion of discrepant experience and
  information
• Patterns of interaction are habitual,
  generalized, and largely unconscious
• They persist uncorrected and unchanged even when
  dealing with persons who treat him differently
  from his parents

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Maintaining Proximity

• When attachment behaviors such as searching,
  calling, and crying persistently fail to regain
  the figure, the child is forced to marshal
  defensive strategies that exclude this painful
  information from consciousness.

Solomon George
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Response to Trauma

• When a child feels unwanted and unlovable
  (mirrored by representations of the attachment
  figure as one who cannot care for or rejects the
  child), representational models reflect a complex
  interplay of multiple representations of self and
  other that are to some degree incompatible and
  difficult to integrate

Solomon George
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Understanding the Post-trauma IWM

• How has the trauma impacted the childs view of
  the parent? Others? Sense of safety?
• How has the trauma impacted the parents view of
  the child?
• Permanently damaged?
• Needing extra care and nurturing?
• Fears getting close?

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Cooper, Hoffman, Marvin Powell , 2000
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Assessment of Parents Point of View

• Interview questions
• Could you give me a thumbnail sketch of your
  child?
• Tell me about a time in the past two weeks when
  you and your child really clicked.
• Tell me about a time when you didnt.
• What gives you the most joy in your relationship?
• What gives you the most pain?
• Where do you turn for emotional support?
• Steele (2003)

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Assessment Secure Base

• Over the past two weeks can you think of a time
  when your child was
• Hurt?
• Frightened?
• Separated from you?
• What did your child do?
• How did you respond?

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Assessment of the Child

• Utilize narratives to gain an understanding of
  the childs view of adults
• Clinical interview

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Treatment - Bowlby

• A therapist applying attachment theory sees his
  role as
• Providing the conditions in which the patient can
  explore his representational models of himself
  and his attachment figures
• Helping the patient reappraise and restructure
  the models in the light of new understanding

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Treatment - Bowlby

• Five therapeutic roles
• Provide a secure base
• Help the patient consider ways in which he
  engages with significant relationships
• Encourage exploration of the therapist-patient
  relationship
• Consider how perceptions are a product of
  childhood relationships
• Recognize that past images may no longer be
  appropriate

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Challenging the Parents IWM

• Parental Insightfulness
• What do you think was going through your childs
  mind?
• Gain a comprehensive understanding of the
  parental point of view
• Gently challenge the point of view

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Challenging the Childs IWM

• Utilize play therapy to understand the childs
  world view
• Gently challenge the childs perception by
  intervening within the childs play
• Utilize empathy to challenge the childs expanded
  world view that may include adults outside of the
  family circle e.g. Adults are never helpful
  No one understands

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Challenging the Childs IWM

• Use observation and interview to understand how
  the childs perception of peers has been impacted
• Group therapy may be instrumental in helping the
  child view peers less negatively or defensively

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Parent-Child IWM

• Parent-child therapy is utilized to
• Help the parent respond empathically
• Interpret the childs play
• Confirm/correct childs view of trauma
• Practice nurturing skills
• Learn to set limits
• Help child with emotion regulation

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Supportive Parent Intervention to address PTSD

• Increase protection for highly anxious children
• Temporarily change sleeping arrangements
• Actively demonstrate safety
• Allow child to maintain closer proximity when
  possible
• Decrease toileting demands on very young children
• Increase use of transitional objects

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Supportive Parent Intervention

• Increase structure for acting out behaviors
• Remind children that rules havent changed
• Continue with consequences
• Increase communication and help child understand
  their response to trauma

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Secure Base Interventions

• Nurturing
• Concept of good grandparenting
• Anticipating needs
• Helping child regulate emotions
• Parental emotional availability
• Structure and consistency
• Experience of being in ones mind