Thursday, January 30, 2020

Creative Psychotherapy with Developmental and Complex Trauma

It is my pleasure to introduce this guest blog by Carol Duffy. Based in Mayo, Ireland, Carol is a child and adolescent psychotherapist specialising in play. She is also a clinical supervisor and trainer. She has over 15 years’ experience working with attachment disruptions, trauma, and sensory regulation. Carol is also married and mum of three vibrant and wonderful children. As this blog shows, she fully understands the importance of safety, regulation, attunement and repair after ruptures in relationships. It also shows the value of play as a healing process. Carol describes beautifully how play and safety are so connected in therapeutic work. I hope you enjoy this thoughtful and insightful blog and please do share.
Patrick Tomlinson

Part 1
The deceptive simplicity of psychotherapy using play and creative approaches is quite paradoxical to explain. In many instances, it must be seen, felt and experienced to be fully understood. There is a wealth of science available to us now to consolidate what we as creative psychotherapists experience and contemplate so frequently and fluently in our work. Play and creativity are often cited as having transformative, therapeutic, healing and reparative potential, amongst many other qualities. However, when does playfulness become therapy? When does creativity, joy and spontaneous laughter become healing and reparative?  
There is an abundance of research that indicates what we need to pay attention to. There are evidence-based strategies that tell us what to do. But none of these matter unless we pay close attention to the ’how’ of what we do and realise that our greatest ’tool’ is the use of ourselves. While we can describe a symphony of wonderful play ideas that are designed to activate wellbeing and interrupt trauma-induced behaviours - if we are not playful, then it’s not play. It becomes more of the same...another intervention full of good intentions, that is not useful to the client. The intervention becomes part of the story of origin and cannot possibly interrupt it.

In the ninetieth session with my teenage client, I was simply brushing her hair while she imagined her future. Her future had hope, realism, and possibility attached to it. She imagined me in her future as our relationship had become something that mattered. She casually referred to it without flinching and without hints of fantasy. After 70 sessions a level of trust had developed, and she asked me to brush her hair. After ten more sessions, she engaged with me in thinking about her future. In the beginning of her therapy, notions of the future didn’t exist, or at least when they did, they sounded fantastical and impossible. The past sounded rosy, which of course it wasn’t.
Everything felt fragmented, disjointed and at times it was very difficult for me to stay awake. I think this was due to her deeply embedded dissociative coping style. Our clients don’t tell us how they coped and survived unspeakable terror; they show or project it into us.

In many cases having creative approaches available and a permissive environment is all they need. Their coping becomes visible in how they approach the play and/or you. But dissociation is more difficult to describe. The more entrenched it has become the more automatic it can be for the client. I noticed a heavy energy in the room, a sleepiness and a pressure so great that staying present in the moment seemed almost impossible. I imagined that for this client, staying present in her pain was simply unbearable and so she shut down. She had to shut down so much that now the coping had become automatic. This feeling of shutting down can also be felt by the therapist when they are truly attuned to their client. This has been a common experience of mine with those clients that have suffered profound and/or early relational trauma.  

Early in the therapy, my energy and therapeutic presence were entirely focused on trying to just stay with her.  Expanding her ability to even tolerate my presence, was underpinned by a visceral drive in me to pull away and a belief that I was useless. But none the less I stayed present, interested and tried to engage and communicate safety through my eyes, my voice, my body, and my self. I used my prosody, eye contact, body language and facial expressions to communicate interest. A desire to be with her and that she was deserving of unconditional positive regard.
Above all, I tried to communicate safety.  Through my reflective presence, I tried to give her an experience of herself that felt whole.

This is what we do when babies are born. We reflect back to them their being. We look at them with interest and joy, and we balance it, so to not over stimulate. We watch for excitement, interest and fear and we respond in kind. We tend to do this automatically and often without conscious awareness. It comes naturally to many of us. But for those of us who never received this, the need to have the experience replaced somehow, is fundamental. This work requires a conscious and deliberate focus. Play also offers an invitation to engage that can disarm or bypass habituated defence/coping mechanisms like dissociation.  I tried to be an external regulator and container for her experiences. This took work, hearty supervision, energy and a type of focus that is quite difficult to explain or fathom.

This is the work when we try to engage with young people who have suffered developmental trauma and attachment disruptions. The success of the therapeutic models we use rests heavily on how we deliver them. Or rather how we embody them. We use our selves, much like I described above. We give our undivided attention. We try to communicate a felt understanding and reflect back interest, validation, understanding and at times an invitation to go a little further in our journey together. It is new ground for us both. As the therapist, you must exude and communicate that this is a safe terrain. Just like any parent of more than one child will tell you, it’s a different journey with each child.

I saw my first movie in a movie theatre back in 1987. It was “Three men and a baby”. I remember my young eyes seeing Tom Selleck cradle the little baby he was suddenly responsible for after he found her on his doorstep. The tragedy bearable within the comedy. He was reading to her from an architecture magazine. His friend criticised him for his choice of reading material and I distinctly remember him saying “it’s not what I am reading, it’s the way I am reading it that matters”. My child’s brain imprinted on that message, but it is only now that science has fully explained the resonance. Porges (2017, p.187) captures this very well,
Also, we need to remember that we live in a culture where people say, “It is really what I say and not how I say it that’s important.” But our nervous system is telling something different to us: It says, “It is not really what you say – it is how you say it”.

Our nervous system responds more to the tone and physical expressions than the words. 

The work of Bessel van der Kolk (2014) and his aptly titled book, ‘The Body Keeps the Score’, illuminates the way our bodies hold the memories of our trauma, as felt physical sensations rather than conscious memories. The work of Allan Schore, Bruce Perry, Daniel Siegal, and many others on the significance of regulation and a significant “other” acting as an external regulator highlights the potential power of the attuned therapeutic relationship.

When someone engages with us playfully and communicates warmth, interest, and safety, their tone of voice and facial expression can communicate a type of felt safety. When this is paired with the fun and joy of play it creates a potent combination of both safety and connection. This enables regulation by the “other” and in turn, begins coregulation and the beautiful tapestry of social engagement. The pleasure it brings causes our bodies to crave it again. As it patterns it can then become an alternative and healthy habituated response as opposed to an automatic defensive response.

From my perspective, this also closely matches what Jaak Panksepp taught us about the importance of play as one of our emotional circuits in the brain. The joy play brings counteracts the effects of stress and fear. And of course, others such as Donald Winnicott have for a long time emphasized the importance of play in childhood development and therapeutic work. Winnicott (1971, p.44) stated the centrality of play in therapy,
Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible, the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.

Play amplifies our capacity to engage positively with others. This is a crucial therapeutic power of play (see Schaefer & Drewes, 2016). Play can generate positive emotions and promote bonding. Play is a creative, imaginative process. It happens in the space between two or more people.  It is a shared experience, which also acknowledges separation and the boundaries between those involved. Play is a way in which feelings and experience can be expressed symbolically. Symbols and creative expression can communicate what cannot be put into words.

To describe the work of a psychotherapist these days who specialises in trauma or attachment, one will unavoidably be ensconced in the work of such amazing pioneers. However, the complexity and intricacies of the collective works of these people will only bring us so far. For again, it is not the ’what’ we play or how brilliantly we can describe it for that matter, that will ultimately reach our harder to reach clients…it is the ’how’ we play. Play and playfulness are felt experiences, that must feel ‘real’ to be meaningful. The simple description of finally reaching a place where I could brush the hair and nurture the adolescent child who now sat before me, did not and could not reflect the painfully slow at times pace that it took for such safety, regulation and trust to develop. Upon this, all other areas of her healing took place. This is where play and creativity became healing and reparative.

I once was asked, how do we explain what is happening, when it appears we are not really doing anything? My answer is that what may appear simplistic and ’nothing’, reflects a vitally important interpersonal process.
To support such wounded people to tolerate your very presence and to experience safety and co-regulation is the essence of complexity, and yet is deceptively simple in many ways. It is at the root of trauma recovery and attachment repair.

Good relationships can heal and repair and are the foundation of good mental, physical and indeed social health. For ordinary child development and recovery from trauma, an attachment relationship is necessary. And what facilitates attachment is attunement. An attuned ‘other’ is necessary for regulation to take place. Once external regulation has happened over and over again, the capacity for co-regulation and subsequent self-regulation grows. This is now cited across the literature and indeed, as above, in popular fiction. Relationships are portrayed as the answer to so many of life’s difficulties. Relationships can buffer, mitigate against stress already endured and protect against potential traumas. I often describe healthy relationships as being nature’s own antibiotic and vaccination all rolled up into one.

The reason for the volume of documentation and publicity is because it’s true. Relationships are that powerful and they can heal and transform the potential of people’s lives in ways that can be unfathomable. Recently Hambrick et al. (2018) highlight that the wealth of our current relational health is the most powerful predictor of our future outcomes. This even surpasses the impact of any adversities we may have experienced. This warrants much optimism. We must harness the positive and powerful regulating effects of healthy relationships, which will undoubtedly lend themselves toward the capacity to thrive following adversity.

Part 2
What happens when relationships are the very thing that we fear? What happens when the greatest danger experienced by someone is also the vessel of the healing potential?
Nature’s cure, sadly, is often also nature’s cause.

For so many people, who have experienced the harsh environments of childhood trauma where the very people they turned to for protection were the source of their terror and pain, the idea of a relationship being the answer to their problems may seem absurd and dangerous. It may feel as terrifying as it would be to stand in front of an oncoming truck. Can you imagine that feeling? The pulsing of your heart, the beating in your ears, irregular breathing, the cold panic, the desire to run, kick, and scream, or the out of control impulses that may take over? The fear may take such a hold of you that you collapse and lose consciousness. Now apply that terrified state to the seemingly attractive and benign qualities that one may perceive about the relationships we offer to those impacted by complex trauma. This sadly is the lived experience that many traumatized people have for much of their life. The tragedy is that they crave and fear the connection they so greatly need. The Shakespearean irony here often results in a classic Shakespearean tragedy. We may even hear narratives such as, ’they were offered every support going’ or ’they didn’t want the help’ or ’they couldn’t be helped’.

It is this intersection we now must turn our unrelenting attention to. The intersection of where we attempt to support another through a relationship, and they are very scared of it. This is where and when, that the ’how’ of what we do really becomes important. We know that when the body has been hijacked by overwhelming events, it becomes primed for defence, not for connection.
When trauma happens repeatedly it patterns as Perry et al. (1995) showed us, and our, “States become Traits”.

The connections in our brain that fire up in response to fear and threat, get used repeatedly and strong neural connections develop there. These essentially form the go-to patterns of behaviour in our brains. Areas of the brain which are not getting used, for example, areas that are better able to think, reason, feel joy and gentle pleasures, become a little more barren and less populated. The more populated areas become our driving seat and our ‘government’ will reside there. They direct our behaviours.

If the areas primed for defence or threat become most populated, they are also the least able to think, the least able to rationalise or contextualise. Unintegrated traumas from the past will feel present. Benign experiences that are happening presently, such as, a person offering a secure, helpful, and possibly even transformative relationship, will unavoidably remind that person of their previous other relationships. The overused and by now overactive defence mechanisms will kick in. They now have the most seats in power. They will overrule and shut down the parts of our brain that could actually help them contextualise and set this relationship apart. Without that capacity, this new relationship will melt into the same pot as all the others. Without ability to contextualise it, the threat is very real and present. The person will do what nature intended in response to a threat – run, defend, attack or collapse – all of which are designed to enable one thing and one thing only…survival.

These responses are very important and protective in the context of a real threat but become unhelpful when they are habitually re-acted. We need to be respectful to these protective reactions and help the client feel safe in the therapy context.  
Porges (2017, p.87) goes as far to say, “Feeling safe is the treatment”. 

Safety is certainly the first stage and lays the foundation upon which all therapeutic work takes place.   Kezelman and Stavropoulos, (2012) referring to the pioneering work of Pierre Janet, the French Psychologist and Psychotherapist, in the field of dissociation and traumatic memory, in the nineteenth century, state, 
Phased treatment is the `gold standard’ for therapeutic addressing of complex trauma, where Phase I is safety/stabilisation, Phase II processing and Phase III integration.

And so, we must use ourselves to externally regulate and to communicate safety above all else. We cannot do this by trying to engage the parts of the brain that have been overruled. The parts that relate to rational thoughts and reason. We harness the curative and transformative powers of play to regulate nervous systems and engage the right, emotional brain with non-verbal emotional transactions that exude calm, consistency and safe presence. Presence that doesn’t seek to change or alter the frightened self in front of us. But presence that seeks only to engage and to engage safely. Presence that recognises that if we can manage a shared smile or moment of joy together then we are on the path. Presence that remains available even in the mix of confusion and doubt. Many times, we will feel that confusion and doubt as strongly as our clients. Presence must externally regulate long before there is co-regulation and even longer before there is self-regulation. Presence that communicates, “I’ve got you. I am here. I will not leave you in this alone. I want to be with you no matter what. You will be okay because in this moment, right here and right now, I will paddle for us both and keep us both afloat.” We use our supervision, self-care and support networks in the same way, so that we can stay regulated amid this. This is the only way we can hope to offer such external regulation.

The destination doesn’t matter. Once we don’t sink, it often takes care of itself. Reaching the equivalent transformative point where the offer of nurture is accepted, such as brushing hair, and where play becomes possible, means that we are well on the journey.    Donald Winnicott (1990, p.228) using the metaphor of disentangling a knot, describes this process well,
It is emotional growth that has been delayed and perhaps distorted, and under proper conditions the forces that would have led to growth now led to a disentanglement of the knot.

Carol Duffy

Hambrick, E. P., Brawner, T.W., Perry, B (2018) Examining Developmental Adversity and Connectedness in Child Welfare-Involved Youth, in, Children Australia: Understanding Outcomes for Care Experienced Children, 43 (Special Issue 2): 105-115, Cambridge University Press

Kezelman, C. and Stavropoulos, P. (2012) The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery, Australia: Adults Surviving Child Abuse (ASCA)

Perry, B.D., Pollard, R.A., Blaicley, T.L., Baker, W.L., and Vigilante, D. (1995) Childhood Trauma, the Neurobiology of Adaptation, and “Use-dependent” Development of the Brain: How “States” Become “Traits”, in Infant Mental Health Journal, Vol.16, No.4, Winter 1995

Porges, S. (2017) The Pocket Guide to The Polyvagal Theory, New York: Norton

Van der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Viking: New York

Winnicott, D. W. (1971) Playing and Reality, London: Routledge

Winnicott, D.W. (1990) The Maturational Process and the Facilitating Environment, London: Karnac Books

Contact Carol Duffy if you have any questions

See Carol Duffy LinkedIn Profile for more information

Sunday, October 13, 2019

‘Acting Out’ Behavior of Traumatized Children, through the Lens of Polyvagal Theory

Recently I have been learning, or trying to learn may be more accurate, about polyvagal theory. I am thinking about its application in work with traumatized children and young people. Although, what I have understood so far is relevant in many other areas of life and work. I have been reading Stephen Porges (2017) – The Pocket Guide to the Polyvagal Theory: The Transformative Power of Feeling Safe. As the 2nd part of the title implies, this is fundamental to working with trauma, and hence my interest. If the title of Porges’ book suggests easy reading, i would say it is not, but it is written clearly, and I am finding it very helpful.

Learning a new theory is always a challenge, but when a theory is connected to our own experience it is easier to conceptualize.  It also helps us when a new theory fits well on the top of other theories, which we already understand well. Development is usually incremental.  I believe in the practical implications and use of theory. As Kurt Lewin (1943) a pioneer in organizational psychology famously noted, there is nothing so practical as a good theory.  Tongues (2016, p.80) succinctly states the usefulness of a good theory, 
A theory is an explanation, a set of ideas about how something works, and the practical application of good theory can be invaluable.
I think polyvagal theory is very useful in helping us understand some complex issues. So, I am going to try and apply it to something i have been talking about recently – the meaning of ‘acting out’ behaviour of children who have suffered complex trauma. In particular, the phenomena of ‘running away’ behaviour, which i wrote about in a previous blog (Tomlinson, 2015a).

Porges explains that a vagal pathway (nerve) is part of the autonomic nervous system and poly means there are many of them. The vagal pathways function to protect safety. They alert the person to threat and mobilize a protective response. This happens at an unconscious level, which Porges refers to as neuroception.  In other words, it is the nervous system that is identifying threats to safety, as well as opportunities for enhancing safety and well-being. Dana (2018) explains, 
Neuroception results in the gut feelings, the heart-informed feelings, the implicit feelings that move us along the continuum between safety and survival response. Neuroception might be thought of as ‘somatic signals that influence decision making and behavioral responses without explicit awareness of the provoking cues’ (Klarer et al., 2014, p.7067).
When we are in danger neuroception takes charge and over-rides our thought processes. This was demonstrated to me vividly in a personal experience.  I was on a beach in Israel where a group of soldiers had set up a temporary camp.  Suddenly, I heard a loud bang behind me. Before I knew it, I was sprinting and ended up about 30 yards down the beach.  I was safely in the sea before I stopped to turn around.  Thankfully no-one was injured.  There had only been a minor explosion of a small cooking gas canister and nothing more sinister.  I remember wondering how I moved so quick and so far without even thinking.  Good job my neuroception was working well and gave the orders to flee! 

Problems arise when the vagal pathways have been impacted by trauma, especially of the complex kind. The neuroception becomes hypervigilant, misreads situations and may respond to safe situations as if they are dangerous. We know this well in our work with trauma. 

Theoretical understanding of the centrality of safety in healthy development and treatment is not new. Bowlby (1952, 1988) explained the concept of how a secure base is the starting point of healthy development during infancy. In the treatment of trauma, Pierre Janet in the 19th century, outlined that safety/ stabilization was the first phase of treatment followed by processing and integration (Kezelman and Stavropoulos, 2012).  

In work with traumatized children and others, safety is the starting point.  The child must actually be safe and then reach the point where he/she also feels safe.  Feeling safe is not the same as being safe. It might take a year or longer of being safe, before he/she begins to feel safe. And there will be plenty of ups and downs along the way. Before connections can be achieved, safety must be established. Only when a disconnected or unconnected child begins to feel safe will he/she be able to take the risks involved in connecting. Once the process of connecting begins the child is moving towards integration.  
The foundations of well-being can be considered as safety, connection and integration (Tomlinson, 2015a).  
A brief look at Porges’ breakdown of the autonomic nervous system, into three distinct functions helps elaborate our understanding of safety. The oldest part of the nervous system is the dorsal vagal circuit, which developed over 500 million years ago. It can be considered reptilian in its nature. This is part of the parasympathetic nervous system. The dorsal vagus takes hold when a person feels trapped and in life-threatening danger. The typical responses include, freezing, becoming immobile, fainting and appearing dead. The aim is to be still, to avoid attack. And if attacked the heart rate and breathing are slowed, blood is withdrawn from the surface of the body to the organs. This is a survival, energy conserving response making death less likely if attacked and injured.  

Another feature of the dorsal vagal circuit is dissociation. This is where the person who is physically trapped in a traumatic situation becomes psychically removed from their body.  Again, this is not a conscious process.  Sometimes afterwards a person talks about being outside of their body, observing what was happening but not feeling the pain.  It is also possible that they may have no conscious memory of the event. Dissociation is a protective function, but if repeated regularly it can begin to have serious consequences for healthy functioning.  As Van der Kolk and Newman (2007, p.7) state,
 …posttraumatic syndrome is the result of a failure of time to heal all wounds. The memory of the trauma is not integrated and accepted as a part of one's personal past; instead, it comes to exist independently of previous schemata (i.e., it is dissociated).
I was fortunate to begin my work at the Cotswold Community, a therapeutic community in England. It was for boys who had suffered complex trauma. The therapeutic approach was based on the work of Psychoanalyst and Pediatrician, Donald Winnicott. Our consultant Barbara Dockar-Drysdale (1958) had developed the concept of a ‘frozen’ child. This was one of the syndromes of deprivation (1970, 1970a), that children developed as defence mechanisms in response to repeated trauma, including neglect and abuse. A ‘frozen’ child usually had the most serious levels of abuse and neglect often from birth.  I think the frozen child had much in common with a child whose dorsal vagal circuit is hypervigilant. Dockar-Drysdale explained her preference for the term ‘frozen’ rather than ‘affectionless’, which was also used at the time, because, 
…‘affectionless’ sounds final, but a thaw can follow a frost.
A thaw of something frozen inevitably means movement. This progression can also be linked to the second part of our autonomic nervous system, which developed 400 million years ago. This is the sympathetic nervous system and is mobilized in response to danger. As in a thaw, mobilization means movement and is a progression from the freezing function of the dorsal vagal circuit. The sympathetic nervous system prepares our body for action. Faced with danger this is in the form of fight/flight.

Accurate neuroception detects a threat from which there is a possibility of escape, as in my experience on the beach. Where neuroception is over-active, as is often the case with traumatized children, danger may be perceived where there is none, or the level of it is exaggerated. So, the child over-reacts, and fights or takes flight when there is no actual need. This can happen very quickly from a state of apparent calm and is often bewildering to those involved.  However, we might all recognize our own ‘trigger’ points, which can lead to defensive over-reactions. (pic, Anxiety Canada, 2019)

Thinking of this in relation to running away, there may be different things going on. The child who runs away maybe in a fearful state and has sensed a threat, whether it exists or not. The aim is to escape. Another child in the same situation, may perceive the threat to be even more serious, and he or she may freeze rather than flee. The dorsal vagal circuit for this child may be dominant and the first form of defence.

For anyone working with this, such as a carer, the fleeing child may evoke more anxiety than the freezing child, though the fleeing child may be healthier and less traumatized. This reminds me of Winnicott’s (1956, 1967) concept of the antisocial tendency and delinquency as a sign of hope. The fighting/fleeing child is at least ‘alive’ and mobile. The nuisance caused by the child also contains hope, which provides an opportunity for us to respond and nourish.  Children who have suffered inescapable terrifying abuse, often feel that their bodies are useless and a source of shame. It seems a natural and healthy consequence in the process of recovery that the ability to escape might be put to the test. Feeling that this is now possible can be seen as a hopeful development.
Clearly, we don’t want traumatized children running away just to prove that they can. There is also always the possibility that the situation is not so benign and something real is causing fear. We always need to be vigilantly aware of any possibility of abuse or potential harm. Establishing and preserving safety is always the number one priority.  We should make sure that the environments we provide for children are nurturing and emotionally containing.

We can also help the young person gain a sense of physical mastery in many other ways. For example, playing sports, bike riding, running, skipping, music and dancing. Games such as tag and, hide and seek, which allow a feeling of being able to escape might also provide an excellent way of fostering a newfound sense of belief in a competent body. We can see that as Porges says, the mobilization of the sympathetic nervous system, can be playful and not just fight/flight.  Simon Bain (2012), a resident of the Cotswold Community in the 1970s, seems to suggest this when he talks of his memories of running away, 
Although, you could say, I wasn’t a success - the funniest and indeed my fondest memories are the ‘running outs’ we used to do, with the staff spending half the night chasing us. 
Porges (2017, p.129) explains, 
The difference between the fight/flight and play is that while mobilizing, we’re making eye contact and engaging each other. We’re diffusing the cues of threat with social cues, so we can utilize the sympathetic nervous system to support movement without moving into defensive fight/flight behaviors. When we involve the social engagement system, we can even use the oldest system, which is immobilization, and we can be in the arms of someone that we feel safe with.
The final and most recently evolved part of the autonomic nervous system is the ventral circuit. As with the dorsal vagus this is part of the parasympathetic nervous system.  It evolved 200 million years ago and is uniquely mammalian. The ventral circuit looks for safety and social connection. In this sense it could be considered as a preventative and anticipatory part of the nervous system. It gives us the capacity to co-regulate (Dana, 2018). The neuroception involved is picking up cues for connections that will add to our safety and hence improve our potential for survival. Unfortunately for many traumatized children this function of the nervous system is shut down and underdeveloped. 

Conditions of safety and repeated positive experiences are essential for it to develop and come into use. This will happen as the dorsal vagus and sympathetic circuits are less active. As freeze, fight/flight are reduced, moments of calm are increasingly possible. Connection is a hugely protective factor that promotes further development. Once connections are established potential threats are reduced. As Porges (2017, p.43) explains this important aspect of polyvagal theory, 

"Moreover, and perhaps most important, the theory explains how safety is not the removal of threat and that feeling safe is dependent on unique cues in the environment and our relationships that have an active inhibition on defense circuits and promote health and feelings of love and trust (e.g., Porges, 1998)."
Once protective connections are established, these can be used to anticipate and prevent the activation of the dorsal vagal and sympathetic circuits. Once this begins the individual is more in the connecting and less in the defensive state. This begins a positive spiral where the person is on the road to recovery. Acting out, such as running away are now less likely.

I have outlined how the three parts of the autonomic nervous system may be activated and their use in promoting our safety, survival and well-being. Understanding the different functions is vital to effective treatment. For example, the sympathetic circuit of fight/flight, whilst being more difficult to manage may mean the child is in a healthier state than if he/she was freezing and immobile.

Using running away as an example, not running may be at both ends of the spectrum of frozen and connected. Stillness can be due to calm safety or fear. The difference between the two can be sensed by our neuroception – how we unconsciously read and are attuned to what is happening. The difficult job of responding to running away behavior offers the potential bridge between the dorsal vagal and ventral circuits.  The fight/flight and playful mobilization of the sympathetic nervous system, however challenging may also contain the hope that Winnicott referred to over fifty years ago.

As Porges (2017, p.56) states, 
I want to emphasize that understanding the response, not the traumatic event, is critical to the successful treatment of trauma.
Bain, S. (2102) Comment posted on John Whitwell: A Personal Site of Professional 

Bowlby, J. (1951) Maternal Care and Mental Health, WHO Monograph 2, Geneva: World Health Organization

Bowlby, J. (1988) A secure base: Parent-child attachment and healthy human development, New York: Basic Books

Dana, D. (2018) The Polyvagal Theory in Therapy: Engaging the Rhythm of Regulation, New York and London: W.W. Norton and Company
Dockar-Drysdale, B. (1958) The Residential Treatment of ‘Frozen’ Children, in Therapy and Consultation in Child Care (1993), London: Free Association Books

Dockar-Drysdale, B. (1970) Syndrome, in Therapy and Consultation in Child Care (1993), London: Free Association Books

Dockar-Drysdale, B. (1970a) Need Assessment – 11, Making an Assessment, in Therapy and Consultation in Child Care (1993), London: Free Association Books

Kezelman, C. and Stavropoulos, P. (2012) The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery, Australia: Adults Surviving Child Abuse (ASCA),

Klarer, M., Arnold, M., Guther, l., Winter, C., Langhans, W. and Meyer, U. (2014) Gut Vagal afferents Differentiately Modulate Innate Anxiety and Learned Fear, in Journal of Neuroscience, 34(21) pp.7067-7076

Lewin, K. (1943). Psychology and the process of group living. Journal of Social Psychology, 17, 113–131. Reprinted in, The complete social scientist: A Kurt Lewin reader, (Gold, Martin, Ed) (1999) (pp. 333–345). Reprinted (in part) in Cartwright, 1951, Chapter 7

Porges, S.W. (1998) Love: An Emergent Property of the Mammalian Autonomic Nervous System, in Psychoneuroendocrinology, 23(8). 837--861

Porges, S.W. (2017) The Pocket Guide to the Polyvagal Theory: The Transformative Power of Feeling Safe, New York and London: W.W. Norton and Company

Tomlinson, P. (2015) Integration and Connection in Well-Being and Recovery from Trauma

Tomlinson, P. (2015a) Reasons a Traumatized Child Runs Away?

Tonges, M.C. (2016) Nothing so Practical as a Good theory, in Nurse Leader, February 2016, Vol. 14, Issue 1,

Vagus Nerve Diagram (2011) Seng Nduwe Ngamuk

Van der Kolk, B.A. and Newman, A.C. (2007) The Black Hole of Trauma, in van der Kolk, B. A., McFarlane, A. C. and Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press

Winnicott, D.W. (1956) The Antisocial Tendency, in D.W. Winnicott (1984) Deprivation and Delinquency, London and New York: Tavistock Publications

Winnicott, D.W. (1967) Delinquency as a Sign of Hope, A talk given to the Borstal Assistant Governors’ Conference, held at King Alfred’s College, Winchester, April 1967, retrieved from 

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Thursday, September 5, 2019

Patrick Tomlinson 33 Blogs and Articles

Click here to download a Free PDF download of my 33 Blogs and Articles on Professional and Personal Development, Leadership, Integration, Neuroscience, Trauma, Empathy and Therapeutic work with Traumatized Children, among other subjects. Please feel welcome to share.

Friday, May 24, 2019

Shared Adversity, Shared Understanding: Foster Caring with a Disability

I am delighted to introduce this inspiring guest blog by Jon Powton. I came across Jon recently when I read an article in the Guardian, a national UK newspaper. He was featured in it about being a foster carer with a disability. Jon talks movingly of becoming disabled; of the adversities, prejudices and discrimination experienced; of the barriers to becoming a foster carer; of being a foster carer – the challenges and rewards; of the care system and politics.

The reality of exclusion of people with disabilities from foster care (and many other aspects of life and work) has gone ‘under the radar’ for too long. This is a great loss to us all. Jon is doing an excellent job in raising awareness. I hope you enjoy this this thought-provoking article and please share. 

Patrick Tomlinson

Disability and Adversity
Adversity is a word you hear quite often as a foster carer. It seems to sit hand in glove with the profile of many of the children who come into the care system. The adversity, hardship and horror that some children and even their families may have faced, can leave lifelong scars that few other people can truly relate to.

From most people’s perspective adversity applies to us all in some way on occasions in life. We’ve all experienced low points in our own way. The death of a relative, or a serious injury that has made life difficult for a period - losing a job, the ending of a relationship or financial hardship. There are many reasons, but with time and support those scars do tend to heal, and often we can change our own circumstances to improve things. I suppose one of the main groups who can experience lifelong adversity in a similar way to ‘looked after’ children are people with disabilities or serious life limiting illnesses and conditions.

I wasn’t born with a disability, I grew up around it, and lived in a house with it all my childhood.  My grandfather was confined to a wheelchair and lived with my parents, my siblings and I until his death when I was eleven. He died from complications caused by Mus­cular Dystrophy. The very same condition that I was diagnosed with six years later. This was a bombshell! It may seem naive considering the circumstances of my childhood, but no one ever thought that me and my brother would have the same condition.  So little was known about when I was born back in seventies. Nobody truly understood how it worked or how it transmitted through DNA.

It led to a hard time for me. Seventeen isn’t a good age for anyone at the best of times. I felt anger and bitterness about this dream shattering news, the disappointment about my life goals being taken away and fear of my new future - all suddenly being piled on top of the insan­ity of being a teenager. It was not an easy time at all. In fact, it was the best part of a decade and a half before I was anywhere close to coming to terms with it, if we do ever actually come to terms with such a thing. Maybe it’s more of an acceptance thing in the end, an acceptance of not being able to change it and its inevitable impacts!

Perhaps the hardest part for me were the memories I had of the illness that I’d witnessed first-hand in my Grandfather. The slow creeping decay as the condition develops and chips away at a person’s function. The gradual fading away, the lack of dignity that this illness can cause in the end. I know that in some way this will inevitably be my fate. I knew it then, and I know it now, which makes the acceptance part very real and very significant!

I have seen both sides of disability, firstly not having it and being able bodied, then having it and not being fully able bodied. 
Caring for a life limiting condition is not the same as caring with a life limiting condition. 

I have perhaps the unique perspective of both points of view. Now I am a foster carer, I’m the person with the condition doing the caring.

Inevitably as expected I became disabled slowly over time in an ever-decreasing spiral of capa­city. I trained to be an engineer, and I worked in heavy industry for as long as my condition would allow. The fact that I was eventually ‘turfed out on my ear’ because I was disabled, I will omit from the tale, mostly because it sounds like sour grapes. I then spent several years trying to get back into work within my original skill set, and ultimately failing because I have a disability. I was often the best candidate in the interview until I mentioned my condition. Funny how things can change...

This was perhaps my first taste of disability adversity - the way employers run away from it and don’t see beyond the heightened insurance risk or the perceived lower productivity. I have be­come gradually aware over time to how these new kinds of adversities creep up on you. For a per­son with a disability, adversity isn’t something that stands alone. It comes with a whole host of other issues that pile additional weight onto it. Discrimination, bigotry, attitudinal prejudice, bully­ing and exclusion also play a major part on day-to-day life.

It can present itself in many ways. Some are obviously cruel and intentional, like being laughed at and called names because you walk differently or look different, not being given equal opportunit­ies and so on. Some are unintentional like events that don’t have proper disabled access, toilets or parking. There are lots of reasons, many I haven’t mentioned.

Society itself has a lot to answer for in the way people with disabilities are treated, especially con­sidering that 1 in 5 people have a disability of some kind. Most people only see disability that is either extreme or obvious. Most of us don’t look like Stephen Hawking, but for some reason are expected too, and that anything less somehow doesn’t seem worthy of the title. Be­cause of their own discomfort around serious disability, people form a negative opinion about it that they apply to the word in all circumstances. Most disability is in fact hidden, for example diabetes, or a hearing or visual impairment. 
I can’t tell you how many times I’ve been told to get out of a dis­abled parking space because I don’t ‘look’ disabled. I have Muscular Dystrophy, not man flu....

I’ve recently become involved in a project to examine why more people with disabilities are not actively recruited to be foster carers, and why people with disabilities often don’t engage with employers or events. This has allowed me to highlight some of the key issues around disability and the lack of proactive inclusion for disabled people in mainstream society. It is il­legal in the UK to discriminate against gender, race, sexual orientation, religious denomination, disability etc., etc. We are all aware of the politically correct version of how it should be. We are unfortunately also all very aware of how things far too often play out in reality.

It is perhaps better to phrase it as, 
Not being excluded isn’t the same as being included’ 

As no one actively telling you can’t do a thing, is not the same as someone actively engaging with you and telling you that you can. Albeit similar in terminology, in practice the differences are huge. As I said, I personally know what it is like to apply for dozens of jobs and be the lead candidate right up to the point I mention my disability. I know how it feels to be laughed at on the street. I know what it’s like to not be able to attend events because it’s on the third floor with no lift. This has giv­en me the ability and the right to speak out about it from first-hand experience. I know what it’s like to be a foster carer with a disability and be told I shouldn’t be one!

Society doesn’t engage with disability because historically, all the way back to antiquity a person’s value is judged on their productivity. Even now, how many companies have a ‘piece work’ produc­tion mentality, where the more you do, the more you earn. It’s called the pay packet society. This ethos is carried to this day into mainstream society. Perhaps in many it’s a subconscious thing, but in my experience often it’s not. It filters down through generations where disabled in real terms be­comes a label that seems to mean lesser than abled.  This paints all disabled people as incapable of anything and everything, in complete ignorance of their actual skill set!

This is the reason most employers don’t want us. This combined with the obvious insurance factors, the health and safety aspects or the provision of support they need to put in place to facilitate dis­abled people in the workplace. Great word facilitate, great in hyperbole, not so good in reality.

How many disabled people’s CV’s are Kept on File for further positions’... We all know what it means. It means Not good enough’, but it’s just impossible to prove, so why challenge it.... I see very little facilitating in the wider world at a pace that meets the needs of disabled people. Let’s face it, realistically as an employer why give yourself the hassle of employing Mike, when you can employ Bob who doesn’t have a disability?   Well, perhaps with a little more insight into disability, employers would see the hidden skill sets disabled people possess. Such as, the constant ability to adapt, the drive to overcome challenges, the determination to prove themselves equal, the compassion for others, the pride at being productive and of value, the loyalty they show to the companies who give them equal opportunities. The strength of character and all the things you’re all going to list that I forgot. We don’t live in the 1870’s. This is 21st Century Britain, A former su­perpower, former ruler of most of the known world, former industrial powerhouse, former a lot of things. Surely our great past should have given everyone enough intellect and skill to quickly find a way into the future where this country leads the way in getting the most out of everyone’s ability, even those who can’t climb stairs or lift heavy things. How much better off would we all be if we stopped writing 20% of the population off before finding out where their value is?

It would be remiss of me not to talk about fear, the fear people have of disability. I have met people who have asked me if they can catch it, today in the 21st century, CAN I CATCH IT....seriously, if that is still a thought that people have then not enough inclusion is going on. I have two children living with me who have been with me for eight years, from being very small children. They don’t even often see disability or notice it in people that often. They have become so included in disabled being normal that they just see people as people. They have no fear of a person with a learning disability, facial disfigurement or a person in a wheelchair. To them, like it should be to us all, disability is normal life, and disabled people are not to fear or mock, they are to help and involve. This is what inclusion brings - natural equality and compas­sion. 
No-one chooses to be disabled, no child’s first choice is to be fostered.

I do understand fear of disability. Even as a person with one I still have it; I quite honestly find very severe disability a little unnerving. This is purely because I feel vulnerable, and is a failing in my­self, that I try to overcome. For example, I was once pushed over and injured by someone with a very profound learning disability, not deliberately I must add, but due to my own lack of balance and my condition I couldn’t prevent it. This was enough perhaps understandably, to create unease in me around people with those issues, I struggle with their unpredictability.

For most, it’s their own lack of exposure to disability as children that plays into their lack of un­derstanding and unease around it. It is and always will be human nature to fear what we do not understand. Some people just don’t want to get over it, they just can’t deal with it, and look at people with a disability like I look at spiders. Though if we endeavored to bring disability to people more often and earlier, not just when the Paralympics is on, perhaps we can fuel accept­ance in new generations. I will however never accept spiders.

The question as to why disabled people don’t engage is tricky. Like everyone who judges dis­ability as a thing, we also critically judge ourselves, I know I do. We can and do create some of our own problems and build upon our own reluctance to have another go at things in the face of more ridicule or further rejection. We can also have an elevated sense of entitlement on occa­sions where we all think the world owes us special treatment. Some people with disabilities have this as a permanent personality trait. The vast majority do not, for me it comes and goes. It would be ridiculous to say that I do not have my own fears of myself, and of my limitations and of my future. I suppose I do on occasions allow them to impact me negatively. The key bit of that is ‘on occasions’ not permanently and I constantly try to rise above it, but I accept it is harder for some than it is for me. These fears make me reluctant to engage too, and I battle with myself to do so. I think the battle is the war I need to win in myself to change things. So, I push aside the fears and anxiety as best I can, and throw myself head first at life and the role I now have. Win or lose I am determined to try because the children I care for are more important than I am. They are what matters most to me, not my limitations. I do it for them and want to change the world for them. Like anyone who sees themselves as a parent, foster parent or otherwise we all want the best for our kids!

It is at this point I must sing, (If somewhat reluctantly as I’m not here to plug) the praises of the fostering agency I work with, the National Fostering Agency (NFA). After engaging with me about dis­ability and disability recruitment into fostering – NFA changed their training venue in my hometown be­cause it had no disabled access. This was entirely of their own doing when they realised the situation, and they actively engaged with me to find a more suitable location. This follows on from the amazing support they have given me from the very first conversation I had with them when I wanted to foster!

It’s proactive engagement like this that feeds into a better future for everyone. The children who need safe, happy homes; disabled people who feel valued and relevant; and the staff who gain insight and experience around disability and its issues, which helps them have a more inclusive and positive view of disability to carry forwards throughout their careers.

I was asked when writing this to show some ways in which I have met the challenges I have listed, and that has proven difficult to answer. To be honest I don’t have a strategy as such, I try to face things head on. I do have a sense of humour, but I feel the same hurt and anger as any other disabled person when I get mocked in the street or judged as incapable. Shouting and screaming isn’t the answer, I tried it, and it doesn’t work, but neither is hiding away a solution. I just get on with it.  I try to be the best and most engaging person I can be, and change people’s view of disability one person at a time. I hope that’s enough. It’ll take more than me to change the world, but I can change my bit of it. I still get annoyed on occasions and tell people they are being stupid and ignorant, but only after I try reason and common sense. Some people are just too moronic to recognise it. I have a low tolerance threshold for stupid, sorry. 
I do try to show people that a condition or a limitation isn’t a definition. I’m not defined by my Muscular Dystrophy, I’m affected by it. 

It may seem ridiculous to some, but my condition gave me some things back for all it took away. It gave me compassion, mental strength, and a dogged de­termination to be seen as the same. Not to mention an understanding of ‘adversity’ that I can use to relate to the children whom I care for. Like them I know what it’s like to suffer at the hands of others. Those experiences gave me the strength to overcome it and that’s what I need to give them.

Adversity is not a disabled dance troupe, nor is it owned by the disabled, though perhaps they do have a stake on the longevity of how they experience it. Adversity is suffering, it’s pain, it’s de­pression, fear, shame, it is turmoil and it hurts like hell. Exclusion isn’t the solution. Tolerance is a skill that must be learned by us all, me included. Exposure to the things we fear and lack understanding of is the only way to learn about them and overcome them. But I suppose there is little point in me preaching to the converted. So, I suggest if you are a disabled person reading this, go and engage, challenge misconceptions, challenge bigotry with intellect. Go and do the show and tell at school, openly talk about it, you are the expert on the true meaning of disability. Sow the seeds of future acceptance by challenging the current ignorance!

Becoming a Foster Carer
If you want to find true value and acceptance, then perhaps go and foster and use the skills you have that no one else recognises. I have seen first-hand what it feels like to see children accept and inherently promote disability as normal. It’s an amazing thing to see, and it’s an amazing skill to give them, to not be afraid and to overcome what life throws at them, not just with resolve and determination but with pride in themselves. 
I foster because of my abilities, not my disabilities. 

But I recognise that I have gained some unique skills and reference points about life because of the experiences disability has forced upon me. It is the emotional competencies of a foster care that are most important. Disability only comes into if it seriously affects the job demands. I have just tried to find the silver lining on my cloud.

I would expect many people who read this to think, ‘That’s not for me, I can’t do that, I don’t want to lose my benefits, I don’t want to look after crazy damaged kids.... etc., etc.’  This is the point where I need to set straight some of the misconceptions people have about kids in care. The children and young people in care don’t have the skills that you have. They don’t have the ability to process life in the way you do, why would they, nobody ever taught them how. They don’t have the benefits of the upbringing you had from your parents, or the strengths you found in the life you may have had to forge for yourself. They are victims, they are not the cause of their situation. It was caused by all of us, all the people in society who turn a blind eye to the failings in ourselves and the systems we put in place. 
Poverty and lack of social mobility, poor education, substance abuse, lack of options and inequality. These are the problems that create the situations that usually bring children into care.  

And yes, some people just are not fit to be parents through their own failures, but that itself always has a deeper routed cause often based in the above!

The children I have met in the course of my fostering career have been varied and different. Some have bigger things to resolve and deal with than others, but they are all affected by the failures of others. They are affected by the same stigmas and attitudinal prejudices that we as disabled people face. Many resonate with the same fears, angers and self-loathing that I had. Most import­antly though, they do have the ability to heal, they just need our help to do it. Some of the most amazing and most surprising people I have ever met are looked after children. They are not bad. Some have just experience bad things that they have normalised. Some have experienced things that would break us. They have not only lived it for years, they have somehow survived it.

I agree fostering is not for everyone, but that’s not to a person’s detriment. It takes courage to ad­mit you can’t handle it, but I believe it takes more courage to try. It takes more to give yourself to it, to make any difference you can to these children no matter how small, no matter how ungrate­ful they appear at the time. In the end it’s valuable, one day they will recognise that value and maybe that little bit of horror you changed will help break a cycle for the next generation. Their children won’t be victims like they were, because of the skills you gave them.

I realise the thought of losing benefits is always a big issue to disabled people, and everyone thinks they are going to end up on the streets selling the ‘The Big Issue’ newspaper. It’s just not the case. Fostering is hard, it can be thankless, and it is often emotionally draining. To many, disabled or not, it has little appeal. The UK government recognises this obvious fact and have tried in many ways to make doing it viable and rewarding. This is why fostering falls into a special category called ‘home based therapeutic care’. This means that disability benefits are not affected by being a foster carer, you can foster and still claim what you claim. There may also be significant tax breaks.   Wherever you are I would al­ways recommend you get independent professional advice. You may find out that your financial worries about fostering are unfounded.

Over the years people have said to me that fostering is easy money, or money for nothing, and have questioned how hard can it be? The answer is, 
it’s absolutely hard enough to be massively under-subscribed. Hard enough to break your heart on occasions. 
It is in no way like looking after your own birth children. Imagine the hardest parts of raising your own chil­dren, then times it by sexual abuse, starvation, neglect, attempted murder, physical abuse, foetal drug and alcohol addiction, psychological abuse, torture and sexual exploitation or trafficking.

Do you think children without problems come into care? That they are in care because they have not experienced one or many of the above, and it’s just a holiday. No child comes into care because their home life is good. 
The Challenge and Reward of Being a Foster Carer

To those who criticise foster carers, and there are many who do, or those who question a foster­ing agency’s business model’s morality, saying it is wrong to profit from fostering - I don’t know, I don’t run the business. Personally, I would suggest no more so than it is to profit from be­ing a Physiotherapist or a Dentist working in private practice. Is it wrong to run a profitable busi­ness in the human services? Or is the profit the reason the businesses are successful? Surely if the outcomes for children are good, then the cost is worth it. In England, there are many Local Authority Children Services in crisis, or struggling. You don’t tend to find it with tier one independent agencies.... just a thought. Isn’t the private sector driven to do better, to succeed? Surely the motivation for any business to work is its ability to provide the best service and be better than its competitors!

It is easy to say it’s easy, easy to belittle by those who don’t do it and don’t understand its realit­ies. I would suggest if it’s so easy then please go and give it a go for a year. I won’t even say I told you so, when you realise just how spectacularly you are wrong!

Be warned though, to any of you who think fostering is just some sort of path to easy money or some sort of job for old rope. You will very quickly find yourself wrong and it’s probably not for you. It’s not a job for anyone without huge commitment, dedication and perseverance. It is a professional and difficult role, for which you must be trained. The very best is expected and demanded of you and it’s 24/7/365. It takes great mental strength, drive and determination to succeed to do it well. Fostering is a Job that very quickly becomes a vocation for those who love it. Vocation or not we are professionals, who play a major role in the rehabilitation of children’s well-being. We are at the vanguard of caring for and slowly fixing those who society disavowed, abused and mistreated. Nobody has ever re­mained a foster carer for the money. Any that set out with that in mind will not last. But it is im­possible to do it without money - self-esteem doesn’t pay the mortgage, the rent or the gas bill. Moral high ground doesn’t put food on the table or allow me to clothe, feed, transport, take on holiday, pay for school dinners, trips, toys, Christmas, birthdays etc. No fostering allowance pays for the love and care and attention I give my children, that’s free and always has been. The fostering al­lowance merely facilitates the provision of a home for them to live in and the required necessities to allow a normal life for the children.

To the disabled person, if you do consider it, you should not expect special treatment because you have a disability. You will be (and rightly so) assessed like everyone else and surely that’s a good thing. You will succeed or fail based on your ability to meet the needs of a child, not your disability. If you fail then that’s because you cannot meet those needs. Be realistic and be prepared to be treated like everyone else. A lot of able-bodied people can’t meet the needs of a child either. Hand on heart it’s the most rewarding thing I have ever done. It actually matters. It’s worth it and it changes lives. To me it is a privilege to be able to look after other people’s chil­dren and change their futures for the better. So, if you believe you can do it, find out. Currently in the UK there is a need for 10,000 foster homes.  There are 13,000,000 people with disabilities. 0.07% of the disabled community who could solve the national tragedy of foster care shortage. Less than one tenth of one percent! There are also big foster care shortages in many other countries, such as the USA. The same principle applies. 

Fostering has given me a purpose beyond myself, it has given me back a sense of self-worth that the world tried to beat out of me. It has made me a better person and I am stronger because of it. I would recommend it to anyone who wants to challenge themselves and rise above the stereo­types and labels society wants to put on you. But most importantly, help give a future to these children and young people.


Frances Ryan (2019) Being a foster carer is the best thing that I've done with my life, in The Guardian

See Jon Powton LinkedIn Profile for links to relevant articles, etc.

Contact Jon Powton if you have any questions -