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RAISING CHILDREN WHO REFUSE TO BE RAISED: PARENTING
AND THERAPY INTERVENTIONS FOR THE MOST DIFFICULT CHILDREN - BY DAVE ZIEGLER, PH.D. ALL MATERIAL COPYRIGHT
2000.
Chapter 2 - Childhood Trauma and the Aftermath
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Childhood trauma is one of the most insidious disabling experiences a human being can experience. At a time when
a child experiences complete dependence and vulnerability, they reach out for protection and nurturance and find
the opposite. For the rest of their life, vulnerability will be associated with terror. Trauma inflicted by a primary
care provider, usually a parent, appears to produce the most lasting scars. After nearly three decades of working
with abused children, it seems that neglect and other types of abuse by a parent are far more lasting and serious
for a child than more substantial abuse by most anyone else. I have found it odd that neglect seems to play a disproportionate
role in behavioral and emotional disturbances when compared to substantial physical and at times even sexual abuse.
But from one perspective, this makes some degree of sense. Physical abuse is scary and painful, but neglect can
be more emotionally damaging in that it creates the ongoing question of whether one's basic survival needs will
be met. Faced with a bruise or burn and survival itself, what would you prefer? Neglect appears to be a betrayal
of confidence in a care provider that can have intense long term impact on an individual's ability to truly count
on or have confidence and belief in another human being.
It is likely that as far back as one can go in the history of humans, trauma has been an important factor. It is
hard to imagine that an unexpected encounter with a saber tooth tiger did not leave a lasting impression on Homo
Erectus, that is if the human was lucky enough to get the better of the encounter. It appears clear from physiology
that the internal stress response was important for survival enabling the "fight or flight" response.
It also appears that as long as humans have been on the planet, they have been busy warring with other humans.
Undoubtedly war also made lasting impressions on at least some warriors, although the understanding of trauma produced
by war is a relatively recent occurrence. At the same time, it appears to have always been the case that some external
experiences may produce little lasting trauma for one person, but may incapacitate another person. The study of
trauma and its effects on people first began due to pervasive effects of world wars. But after decades of study,
it is still somewhat of a mystery how some soldiers are able to come through the horrors of war with little or
no significant trauma, while others have been forever scarred by the experience. One potential explanation for
this is how the individual cognitively processes the experience. One of the essential clinical criteria for traumatic
stress is the experience of a profound or life threatening event. Therefore it appears that if the individual does
not define and thus experience the event as traumatic, it may not produce the same stress response, or be stored
in the mid brain in the way we now know traumatic experiences are remembered. The ability of humans to use their
cognitive abilities to define their external and internal experience can literally define their reality. For example,
thrill seekers or proponents of "extreme" sports pursue the rush of experiences others would be traumatized
by. The experience of whitewater rafting can be very frightening to one person and thrilling to another. Although
the same physiological experience, the cognitive process defines the meaning and long term significance of the
situation.
A number of years ago Michael Reaves, a psychiatrist with significant experience with post traumatic stress disorder
in war veterans, and I collaborated in a review of the similarities and the differences in PTSD in war veterans
and in young sexually abused children. The results were shared at the annual conference of the Society for Traumatic
Studies in Los Angeles. We were somewhat surprised that there were far more similarities than differences between
veterans and children. However, there was one defining difference, most of the children did not have a cognitive
paradigm to define their experience, where most of the veterans did. This tended to result in children viewing
their experience as random and unpredictable and from an egocentrist position (they were the personal target of
the abuse). Therefore since the event could reoccur at anytime, the experience as never really over, times of non-abuse
were merely interludes before the next episode. The child had an experiential open wound. As bad as war can be,
the veteran at least to some degree has a context to place the experience and cognitively knows that they leave
the war behind when they return home. But where does the child go to escape trauma that occurs in their home, often
at the hands of a parent? Unlike veterans who had life experiences before the experience in war to compare it with,
some young children know only a world with trauma ever present.
The point being made here is that the ability of an individual to be aware of their physiological and emotional
state, and more importantly to cognitively define the meaning of external and internal experience, are keys to
solving the puzzle of trauma and its effects on children.
The Challenge for Therapists
With a few exceptions the potent aspect of psychotherapy is the therapeutic relationship with the client. When
working with children who have experienced trauma, a relationship is very important. However, knowing how to form
a bond with a traumatized child and knowing when a bond has been formed can be more complex than may be anticipated.
A relationship can be defined as a mutual connection between two people where social and emotional needs are met
and no one is used or abused. With this definition in mind, forming a relationship with a traumatized person, particularly
a traumatized child, can be a mine field. The most common mistake of inexperienced therapists is to believe a relationship
has rapidly developed, when they are actually far from it. Forming a bond with a traumatized child is actually
not the first rung of the therapeutic ladder like most others therapeutic alliances. It is actually one of the
top rungs. Keeping in mind the fact that traumatized children remain in the "war zone" of potential abuse
in their minds, a number of steps must occur to form the foundation of a true relationship. In my work I have found
the Building Blocks of Treating Emotional Disturbance a useful road map.
Safety
The internal question of the child is "will I be safe in a non-violent environment where my basic needs are
unconditionally met?" Of course the child is seldom consciously aware of this question. They more likely assume
they are not safe and thus are hypervigilant and suspicious of the people around them and the next potential source
of abuse. Even if the child believes that you will not be the next abuser, they must determine that you will be
able to protect them from their former or future sources of abuse.
An environment that communicates safety to an abused child has several essential characteristics:
Non-violence - all aspects of the environment must be free of signs or hints of violence. This includes
the presence of someone who wants to take you where you don't want to go (how a child might view a prying therapist).
The energy from individuals must be for the most part calm, supporting and understanding. The child must experience
room to be him or herself, the space and time to share what they want to share, and in the way they choose to share
(seldom initially with words).
A suggestion I make is to consider the physical environment of your therapy space. Most therapists are aware of
child friendly signs such as furniture that is comfortable and sized for children, as well as pictures, objects,
and games that interest the child. Less often do therapists consider that closing the door to the office during
the initially stages of therapy can be very threatening to the child. It can also make a difference if the therapist
sits or stands between the child and the door, perhaps viewed by the child as blocking an escape route. I suggest
that doors remained open at least a crack, and insure that the child knows they can exit the room even though they
may never feel a need to.
A non-violent environment lets the child know that being who they are is not upsetting to the adults around them,
because they know what happens when adults get upset. Although this may not be obviously, an abused child will
carefully read the energy of the therapist and his/her hypervigilance will signal if the therapist is pleased or
displeased with what is going on. This will then be personalized to the therapist being displeased with him/her.
Touching the child client is a complex issue and one that must always be considered individually. I would not say
to avoid touch, but how and when you touch the child is important. Often abused children have an approach avoidance
reaction to touch. On a deep level they like touch and it fulfills a basic need. On a protective level, they are
weary of touch and often attribute incorrect meaning to it. The best course of action is to signal the meaning
of supportive friendly touch with your energy. Your words will mean very little, so always communicate the fact
that you are a safe person with your energy not your words. Abusers often tell the child one thing and the abuser's
actions tell a very different story. Do not be reluctant to set some physical boundaries using physical touch.
For example, if the child becomes destructive of property in the office, calmly and firmly step in and stop the
behavior. Or if the child begins to hurt himself or herself, again calmly hold the child to prevent any harm. It
is through this physical touch that the child learns that you are powerful enough to protect them from others and
from themselves.
These children will be looking for any inconsistency in you and may react strongly when they find it. This can
come as a surprise when the child is very upset when you see them at 9:05 when you said "I will see you at
9." Therapist often wonder how such a minor issue becomes major, and one of the answers is that the child
is looking for the next characteristic of a safe environment--predictability.
Predictability - To an abused child, when things happen that they did anticipate and do not understand,
their reaction is generally negative. Knowing their world and anticipating events are one of the few factors that
reduces hypervigilance, which takes a great deal of stressful energy. A person cannot be safe if they are anticipating
something bad happening at any time. In therapy predictability means having a routine: not changing appointments
frequently, having a familiar and consistent place, and greeting the child with consistent supportive energy. If
the process is going to change, leave sufficient time to help the child understand the change. Remember, to many
of these children, if it is different, it is bad. Having a session opening and closing 'ritual' of some kind may
help with predictability. In this way, the child is reminded at the beginning of the session that this is the place
where good things have happened, and at the end they are warned that we are about to finished for this time.
Boundaries - Physically and sexually abused children have experienced that their most basic boundaries have
been violated. Adults have not respected limits on physical punishment by inflicting pain and injury. Sexual abuse
has violated their most intimate and private spaces. Establishing boundaries does not just mean that you respect
the child's space by asking for a hug or asking permission to touch them. It also means that you require the child
to respect your space and follow basic rules in the office. Being open and supportive as a therapist does not mean
letting the child do what they want. The child learns that there are rules that will be enforced, and this provides
an important element of safety. The child may intrude on the therapist's space and in a counterintuitive way, unless
the therapist establishes and maintains his/her space, the child will not feel safe. Some sexually abused children
have been taught to offer themselves sexually and to act seductively. If you do not establish this boundary, you
are not protecting the child's space which adults have taught the child not to protect for themselves.
There should always be rules in the therapy office. An essential one is no violence, which includes targeting people
or things. There is a difference between and child expressing anger by pounding a doll identified as an offending
parent, and the child trying to destroy the doll as an aggressive act. There will probably be places in the office
that are off limits, such as client files on your desk. There will often be items in the office that are not available
to play with or even touch, such as art work or the therapist's personal property like a purse or brief case. Unlike
some who suggest not having items in the therapy room that are off limits, I would suggest having such items to
show that there are limits that will be enforced. Limits and rules that are respected and taken seriously provide
a sense of boundaries to an abused child.
Security
The next step in the journey toward relationship is being secure in the people and the environment around the child.
In therapy, building security means having consistent aspects of the counseling process the child can count on.
Change will often be met with resistance and usually with suspicion. If there is a change in the day you are to
meet the child or even the time of day, it is generally best to let the child know well in advance. Circle the
new date on a calendar and let the child take it with them. Just the fact that you take the time to let him or
her know helps with the need for security.
The other essential aspect of security is structure. As a general rule, the more anxious the child, the more structure
he or she needs. Structure is important not only for children but for adults in the therapy process. Part of the
structure of therapy are the rules. Overall, the best way to enhance security is through consistent structure in
the therapy process.
Acceptance
Hypervigilant children are extremely aware of the reaction adults have to them. They know that as a therapist,
you are an important person in their life. How you respond to them in large and small ways will be greatly amplified
by them. It is not unusual for the child to believe that anytime you are displeased with something they have done
and you mentioned it, you were "yelling at them." The important point of acceptance is that there is
a differentiation between the behavior and the child. Do not assume the child understands this distinction if,
for example, you correct the child's behavior for perhaps violating one of the therapy rules. It is important each
time to correct the behavior but letting the child know that you believe in him/her and his/her ability to abide
by the rule in question.
Consider your therapy style. Do you reward children when they easily share with you, and subtly punish those who
withhold from you? Many years ago, I was asked to meet individually with an eleven year old female who was having
problems with family members, peers and her teacher. She managed to go the entire first session without saying
a word to me and in fact would not look in my direction. This became a challenge for me, and the next session I
was prepared for the silent treatment. However, after several weeks of all my tricks to even have the child look
at me, I received the same response from her--no response. I met with her parents and told them nothing was working.
Shocked at my assessment, they had just the opposite point-of-view. They explained that from the first session,
the vast majority of the problem behaviors had disappeared and they pleaded with me to keep doing exactly what
it was that was making such a huge difference. I nodded knowingly, and agreed to continue despite being confounded
by such a strange therapeutic relationship. Over the next ten sessions, I continued a variety of strategies and
on one occasion I even brought in a newspaper and began to read it to the child. After fifteen sessions, that in
my experience were all one way communication, we terminated the therapy a huge success with all problem behaviors
gone at both home and school. However no matter what I did, this child never once acknowledged my presence in the
room, said not a word to me, or even said good-bye when we terminated. To this day, if I can believe that our time
together had anything to do with her behavioral turn around, my only theory is that she felt accepted by me even
though she ignored me the whole time. Despite this, and I continued to be there for her. To her, our time was hers
to do with what she wanted, even if that was ignoring me. I thought about calling it newspaper therapy and going
on the lecture circuit, but I knew some graduate student would ask how it worked and I wouldn't know how to answer.
Abused children always have dark secrets about the abuse. You may think you know from the file what they have been
through, but at best you know some of the external facts. There is always more that the child went through, not
to mention how they experienced it on the inside. Part of the therapy process is providing the child a place to
communicate their experience in their own way. If they chose to let you in on their dark secrets, it is essential
that you hear them out without strong reaction on your part. Unless you can hear about terrible abuse without reacting,
the child may not sense that you can handle and accept what they have been through. Some children provide small
details and gauge your reaction. If you have a strong reaction, "O you poor thing, that must have been terrible,"
the child will assume you can't handle the rest. Other children may exaggerate some details to see if you can handle
it. The best course of action is to remain interested but not emotionally react. To the child, if you cannot handle
their secrets, how can you accept "what they have done." One of the aspects of abuse that weighs on children
is that they have been involved. Their behavior caused mommy to hit them, or it was their body that made daddy
come in late at night. To many children, they were actively involved in the abuse, even if the opposite is true.
Throughout the process of therapy, continue to reflect to the child the strengths you see in them. Do not ask them
to acknowledge these strengths, it is likely that they will not agree with you. However, this is a way that you
can mirror back to the child aspects of him/her that you value. This process can strengthen the child feeling your
acceptance.
Belonging
To a child who does not feel that they belong anywhere, the challenge is to help them feel like they belong in
your office. You will need to find individualized ways to accomplish this. It may mean that the child keeps one
of their belongings in your office while you work together, or it could be that the child likes the toys placed
in certain ways. You may ask to put some of their art on your wall, or ask if they would like to make any changes
in the room while they are there. Whenever possible, I attempt to externalize the goal I am trying to achieve in
therapy. In this case, the interpersonal experience of belonging can be externalized by a tangible symbolic representation
that has meaning to the child.
Trust
By this point in the relationship building process, you may be thinking that surely the child knows you are there
for them and a relationship has been established. But consider that some sexually abused children were the objects
of grooming by the offender for six months or even longer. It only makes sense that many of the methods you use
to gain a child's trust may have also been used by an offender to gain trust as well. Once I was facilitating a
group for children who had been sexually abused. It was the first session and afterward I noticed an upset parent
ushering her two children who were new to the group into their car. I intercepted them to hear the mother's angry
tears that the children's offender had said and done many of the same things we were doing in group, and how was
she to know if this would have a different result. I simple said, you will know because you can be here the entire
time. Unlike some children's groups, I have always made it available to parents. Knowing they can come is often
enough security that they don't feel a need to be there the whole time. In the therapy process, trust is not only
an issue with the child, it is also important between therapist and parents as well.
Other aspects of trust can be enhanced by giving the child straight information. It may seem odd but trust can
be built particularly by being honest in giving bad news to the child. Trust is built by being firm and enforcing
boundaries previously discussed. Trust is also strengthened when the child experiences you as consistently the
same person each time they meet with you. Abused children are used to adults who are unpredictable, which raises
their stress and often spells trouble for them because they cannot anticipate when they may be hurt next. To build
trust, accept the child's reactivity and let them know you expect them to need reassurances along the way.
I am often asked how long this process takes to develop a relationship, managed care does not give you fifteen
sessions to form a relationship and thirty more to address the problem areas. It is difficult to put time frames
on such a complex process, but the relationship building and therapy are not separate steps. In the graph of Building
Blocks of Treating Emotional Disturbance, there are time lines mentioned that I have found in my work. You will
quickly see that in fact the time mentioned (for relationship it make take six months) does not fit into the managed
care paradigm. Some medical and psychological issues can be addressed with Band-Aids, others cannot. Trauma work
does not easily fit the managed care mind set.
And Finally... Relationship
Now that you have taken this journey with the child and sufficient time has expired that each of the building blocks
have been climbed by both of you together, in my mind the word relationship can begin to be accurately used to
describe what you have with your young client. If you are saying to yourself, I can do it much quicker with my
kids, I would ask you to reconsider your position. Does the child give you what they think you want to hear? Does
he act the way you let him know you want him to act? Does she comply out of anxiety? Does she share scary things
when she would rather not? If any of this is true then what you have does not meet the definition of relationship
where there is a mutual bond, with room for both people and no one is used, not even for therapeutic reasons. This
is much of therapeutic value that you have accomplished on the way to a relationship, but don't believe you have
arrived at a relationship until you actually have.
Other Issues In Treating Traumatized Children
We come from a culture that measures everything. Even psychology gives more credence to measurement or quantitative
rather than qualitative analysis. In this culture of measuring everything, we attempt to quantify trauma with less
than helpful results. The nature of trauma is not in the external event but in the internal meaning and experience
of the event. A common mistake of professionals in law enforcement and psychology is to consider the seriousness
of the external event. Unless you know the meaning of the event to the child, you will not know the level of the
trauma. It is common to have one child go through profound abuse and at times be less haunted by it than another
child who's abuse appears on the surface to be much less significant. Do not attempt to measure the seriousness
of abuse, it will only predispose you to a belief about how the abuse has translated into trauma. The problem with
your belief is that you may be accurate 50% of the time, which could be achieved by guessing. The importance of
a traumatic event is solely in the eyes of the person who went through it. Put your energy into learning how traumatized
children tell you about their pain, and pain is an internal experience with at times little to do with external
events.
Some therapists confuse support with emoting for the child, or confuse sympathy for empathy. As in medicine, the
first dictum is "Do no harm." In trauma therapy this starts with don't make the problem worse with mistaken
signs of emotional support through sympathy. Remember the child's trauma is in part based on the meaning they ascribe
to the event. Don't make statements that are very appropriate in other therapy situations, such as "that must
have been terrible for you," or "I bet you felt very alone." Let the child let you know by words
or symbolic communication what it was like for them. As a therapist, your words are not the only important communication
to the child, your energy and your non-verbal messages are very important as well. You must learn to hear about
abuse and not let your face tell the child it is hard for you to listen to his/her story. Many abused children
will protect you from further details if they believe it is difficult for you. Particularly in the early stages
of treatment, learn to listen to the child as you were listening to the weather report, and leave your meanings
of the event to yourself. This can help avoid the child learning to consider the abuse more impactful than they
first thought.
It should be clear by now that it is important not to rely on words as the primary communication. Children often
do not have words to describe events or experiences even if they wanted to let you know in words. There are many
symbolic methods of communication that children are more comfortable with and may even enjoy. These include play,
art, stories,
movement, sand tray work, and puppets. There are professional trainings offered for these methods, which can be
important aspects of the therapist's bag of tricks. One of the roles I played for years was to work with children
who would not open up to child protective service workers, and particularly to law enforcement officers. I quickly
learned that if I approached the child as the investigators did, I would likely end up with the same results. So
my first job when meeting the child was to establish a method of play. When young children interact with peers
and adults, they often do so with toys. One of the most effective toys in my office turned out to be a large plastic
alligator, which had a mouth that opened. Seldom did the child hold back when I spoke through the alligator as
I opened its mouth. The children were usually fascinated and spoke freely to "Ally." I would not have
chosen this rather fierce looking toy, but it was the only toy handy one time and it was just odd enough that it
worked very well, so I used it often.
There is no question that law enforcement and child protective service workers have difficult an unenviable jobs.
However, I do have a problem with some aspects of typical investigations, and that is the goal is not to help the
child, it is to get something from the child, in this case information. Many investigators belief that putting
together a good forensic case does help the child. My clinical experience is that investigations and court cases
do as much harm as good for the child. Don't confuse what we in our society want (justice or revenge, depending
on your perspective) from what the child wants, which is generally to be left alone and to forget bad experiences.
Done poorly an investigative interview can definitely be further traumatizing, and be experienced by the child
as just another adult using him or her for their own purposes. Actually the investigator is in fact using the child
for information. Some would defend investigators by saying their job is to get the facts. Perhaps so, but it is
important that therapists not go in search of facts and miss the child. Seldom are facts important in trauma therapy.
For this reason it is very important that therapists not do what investigators do, which is to ask the child to
open ,up and be vulnerable when it is not clear the child feels protected and supported when you aren't around.
We should never ask the child to let down her defenses if she will need them when we leave. It may take you some
time to determine how supported the child feels in their living situation before beginning to encourage them to
open sensitive doors to personal trauma.
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