Thursday, December 10, 2015

Why we all need an Integration Agenda

http://mowatcentre.ca/the-integration-agenda/

This is part 4 of my blog on the Need for Integration (links to the first three can be found in the references). 

I was motivated to write this blog after a colleague, Liz Glencorse, referred to the ‘Integration Agenda’ in Scotland.  The Integration Agenda (2011) is a Scottish Government initiative to integrate Health and Social Care services.  Further initiatives to develop the agenda have followed and significantly to include housing (2013).  Similar agendas have been implemented in other countries.  The picture above is from a Canadian initiative.  It has struck me how much the concept of integration has grown in influence. 

My first experience of integration as a concept was over 30 years ago in my first ‘proper’ job.  It was about enabling traumatized ‘unintegrated’ children to become ‘integrated’.  This was based on the work of Donald Winnicott (1962), the English pediatrician and psychoanalyst.  His concept states that a child is born unintegrated and becomes an integrated person, usually during infancy.  Unintegration is normally a short term developmental stage.  Traumatic experiences such as abuse and neglect can impact on a child’s development in such a way that integration isn’t achieved.  Disintegration however, can happen at any time in a person’s life.  Temporary disintegration is sometimes considered healthy. For example, following a significant loss.  It is only a problem when recovery becomes stuck or exacerbated by further difficulties.

The American Psychiatrist and Neurobiologist Daniel Siegel (2006) claims,

“The central idea of interpersonal neurobiology is that integration is at the heart of well-being.”

Confirming the centrality of integration to therapeutic work, he also states (2014) that, “We as therapists are not really ‘shrinks’; we are ‘integrators’."  I would argue that well-being in this context can be considered at the individual, relational and collective levels.  I would also add that it is the integration of these levels that is really at the heart of well-being. 

Of course the detail of what integration means is variable, but in essence the concept is increasingly recognized to be relevant on the micro and macro levels. This makes perfect sense.  It is difficult to become or remain an integrated individual in an unintegrated environment.  In an earlier blog, I mentioned Andrew Mawson the social entrepreneur, who worked on integrating health and social issues in inner city London.  This led to improved community well-being, where people began to achieve both individually and collectively.  He continued this philosophy of ‘learning how to join things up’ in the Water City Project, 

“If you join the dots, that is a new city.  And if you connect science and technology in an integrated way into that, that’s a very exciting opportunity for jobs and skills for people of East London over the next 25 years………….

The psychologist, Isaac Prilleltensky (2006) has also made this point well.   

Psychological Wellness is a psycho-ecological concept that highlights the importance of promoting favorable conditions that nurture the personal, relational and collective well-being of individuals.

Overall wellness can only be achieved through the combined presence of well-being in these three areas – the central space on the diagram represented by the W.

Steven Johnson, the best-selling author of seven books on the intersection of science, technology and personal experience, also talks about the connections between the micro and macro.  In his 2010 TED Talk, ‘Where good ideas come from’, he says, 

“The network patterns of the outside world mimic a lot of the network patterns of the internal world.” 

 

He claims that great discoveries come more out of connections rather than isolated ‘eureka’ moments and ‘encourages us to connect ideas rather than protect them’. He claims that "Chance favors the connected mind”.  It could also be argued that it favors the connected community.

Inevitably I see the relevance of integration to my work in services for traumatized children and young people.  Because traumatized children are usually in a state of unintegration or disintegration, the task of integration is at the center of the work.  Recovery from trauma involves integrating traumatic experiences into one’s personal narrative. For unintegrated children, first of all this means there must be the development of a sense of self.  Only from this can experience become integrated.  The child needs to know who he is before he can know what has happened to him.  

There are clear stages in the recovery from trauma just as there are in ordinary development. Kezelman and Stavropoulos, (2012) refer to the importance of phased treatment, first outlined by Pierre Janet in the nineteenth century,

“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.”   

 They also argue that the experience of the service as a whole, and not just the clinical intervention is part of the treatment process.  “Neural integration is not assisted – indeed is actively impeded – by unintegrated human services which are not only compartmentalised, but which lack basic trauma awareness.”

However, as integration is at the heart of general well-being, I also hope that something can be understood of the wider relevance.  Why is it important? On the micro-level of a human brain – the brain functions well when the different components are integrated (see Siegel video).  For instance, effective decision-making takes pace when the emotional and cognitive parts of the brain are connected.

The strength of intellect is undermined if it isn’t integrated with emotion. We could use an orchestra as a metaphor – the brilliance of one part will be lost if all the parts are not successfully integrated.

The same can be seen in families, teams, organizations, communities and societies.  We know this well if we enjoy team sports. Without integration any kind of development and achievement is likely to be undermined. 

However, integration doesn’t mean merged.  The distinction and difference of the constituent parts is what makes a strong whole.  It is the way that difference is managed and connected that is important.  For example, we could be living in a community where the neighboring community is different but connected, or where there is a wall separating the two.  We know which is healthier, though there may also be healthy a degree of tension between the connected parts.  The challenge for us is how to become better integrated.  A good starting point is by putting integration at the top of our agenda. 

My Scottish colleague who referred to the Integration Agenda, also remarked what a huge challenge this is.  How hard it is to connect different parts and collaborate effectively.  Again, this is true from the micro to the macro level.  The challenge can be painful, individually, relationally and collectively.  My first response, to this question was one of deflation, thinking how impossible it is!  However, in reality it is the intent and struggle to move towards integration that is important.  There is no such thing as a perfectly integrated state.  Integration is ongoing, new experiences and circumstances constantly need to be integrated. 

To bring this back to the unintegrated or disintegrated child.  He is faced with a huge task and we know that it will be painful.  We also know the potential benefits and the cost of not going on the journey of recovery.  By working on the core issue of integration ourselves we provide a model alongside the child. 

It is the model of what is going on around the child that is most helpful to him.  This includes the individuals that are closest to him, the relationships around him as well as the wider environment.  If we are focused on integrating our own experiences, integrating better with our colleagues, between our departments, with the wider community and society – we are providing a model for health. 

The way in which the concept of integration is becoming integrated in so many ways, is very exciting.  I agree with the point made in Bessel van der Kolk’s book (2014, p.109), that “most research is me-search”.  We are most engaged when something has an important meaning.  Bessel van der Kolk himself is a great role model for integration.  In his work he integrates, ‘developmental, biological, psychodynamic and interpersonal aspects of the impact of trauma and its treatment’.  His book ‘Psychological Trauma has been described as the first integrative text on the subject’.  http://www.confer.uk.com/biogs/biog_kolk.html

If we can connect our own ongoing need for integration to the tasks we are involved with, there is more potential for growth than by anything else we could put on the agenda.  We only need to think about the many ways in which better integration might benefit our own life and work.  If we are working on integration, development and achievement are likely outcomes.

References 

Tomlinson, P. (2015) The Need for Integration – Part 1 Leadership and Management, https://goo.gl/jEfTws

Tomlinson, P. (2015) The Need for Integration – Part 2 Integration and Connection in Well-Being and Recovery from Trauma, https://goo.gl/tlnFkM

Tomlinson, P. (2015) The Need for Integration – Part 3 Integrating and Connecting - The Essence of Trauma Recovery Environments, https://goo.gl/SHXqju

Steven Johnson (2010) TED Talk, Where Good Ideas Come From | Steven Johnson | TED Talks, https://goo.gl/iYVldv

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),   http://goo.gl/t9o3lA

Andrew Mawson, Water City CIC, Connecting People, Business and Place - Water City Legacy,

Nelson, B.W., Parker, S.C. and Siegel, D.J.  (2014) Interpersonal Neurobiology, Mindsight, and Integration: The Mind, Relationships, and the Brain, in Brandt, K., Perry, B.D., Seligman, S. and Tronick, E. (Eds) Infant and Early Childhood Mental Health: Core Concepts and Clinical Practice, Washington DC, London: American Psychiatric Publishing

Prilleltensky, I. (2006) ‘Psychopolitical validity: Working with power to promote justice and wellbeing.’ Paper presented at the First International Conference of Community Psychology, San Juan, Puerto Rico, 10 June 2006.

Dan Siegel video - On Integrating the Two Hemispheres of Our Brains, https://goo.gl/sARWjq

Siegel, D.J. (2006) Series Editor’s Foreword, in, Ogden, P., Minton, K. and Pain, C. Trauma and the Body, New York: Norton

The Good Governance Institute (2001) Rethinking the integration agenda: a discussion report from the Good Governance Institute, https://goo.gl/xHW1AA

The Scottish Government (2011) The Integration of Health and Social Care, http://www.gov.scot/News/Releases/2011/12/12111418

Winnicott, D.W. (1962) “Ego Integration in Child Development”, in, The Maturational Process and the Facilitating Environment, Hogarth Press and the Institute of Psychoanalysis: London (1972)

Wednesday, November 4, 2015

Why Horses can be so Therapeutic in Work with Traumatized Children and Young People – Part Two, One Year on!

Introduction
A year ago Debbie Woolfe, founder of Stable Relationships wrote a guest blog on her work in providing Equine Assisted Learning to children and young people, https://goo.gl/RreOKx

I explained then my reasons for interest in this subject. During the last year my research has continued to confirm the view that therapeutic work with children and young people (also adults), which involves the use of nature has great potential.  During the same time, Debbie’s venture has shown great innovation, which has captured the interest of the media in the UK. In the last year her organization, Stable Relationships has been featured in two national newspapers, TV and radio.  She has taken her horses and team across England and into inner city schools, where many children had never previously been able to see and touch a real horse.  This is a great TV clip, seeing the children’s responses to meeting horses in their school https://goo.gl/YSCZKr

As I said, research supports the relevance of this work.  Bessel van der Kolk (2014, p.80) states,

“In the past two decades it has become widely recognized that when adults or children are too skittish or shut down to derive comfort from human beings, relationships with other mammals can help.  Dogs and horses and even dolphins offer less complicated companionship while providing the necessary sense of safety. Dogs and horses, in particular, are now extensively used to treat some groups of trauma patients.”* 

And,

“After multiple suicide attempts Maria was placed in one of our residential treatment centers.  Initially she was mute and withdrawn and became violent when people got too close to her.  After other approaches failed to work, she was placed in an equine therapy program where she groomed her horse daily and learned simple dressage.  Two years later I spoke with Maria at her high school graduation. She had been accepted by a four-year college.  When I asked her what had helped her most, she answered, “The horse I took care of.” She told me that she first started to feel safe with her horse: he was there every day, patiently waiting for her, seemingly glad upon her approach. She started to feel a visceral connection with another creature and began to talk to him like a friend.  Gradually she started talking with the other kids in the program and, eventually, with her counsellor.” (p. 150-151)

Debbie’s new blog describes her journey of the last year and shows how ‘Stable Relationships’ is such an apt name for her organization.  Relationships are central to the work, between her team and the horses, between each other, with the children and their carers, and between children and the horses.  The horses become the focal point within which learning and healing relationships can take place.  Debbie explains important aspects of the work that involves horses.  However, much of what she describes is also about the importance of relationships and role modelling.  This comes through in her blog and infectious enthusiasm.  I hope you will find her insights, as I do, to also be of wider relevance to therapeutic work with children as well as other spheres of ‘people work’.   

Patrick Tomlinson

The last time I wrote a blog for this site I had been running Stable Relationships for about 6 months. We are now a year and half into our journey and, to date, it has been an amazing and challenging experience. In this blog I would like to share some of the challenges we have faced, and lessons we have learnt. I would also like to thank Patrick for his encouragement and helpful support.

As I type, I am sat in our cabin. It is a beautiful log cabin with wooden floors and still a hint of the wood smell that was so prominent when it was first built. As I look out of the quaint paned glass windows I can see dew soaked, tufty grass fields, filled with majestic horses, grazing peacefully. It is a windy but sunny day and the shadows dance on the ground as they are cast and commanded by the leaves of the old oak tree overlooking the cabin. It is, by far, the most beautiful place I have ever worked; and as the leaves turn yellow, then orange, then red, making the trees into longer lasting mini balls of rainbow, all around me; I can’t help thinking how lucky I am to be a part of Stable Relationships.

It is just a part though. It is my business but it feels like it runs through me, rather than is run by me. I am part of a team. A large team, with many horses, organisations, young people, and direct colleagues. Anyone who knows me well, will say that I like to be in charge….and really don’t like to be told what to do. I have a tendency to ask for advice but then act in accordance with whatever I had already decided to do, before I even asked. Being part of this team has changed that about me. A colleague described our immediate team of four, as lone wolves. I would say that was true when we started. All four of us probably preferred to just get on and do things our own way. It isn’t true anymore…we have had to learn to work together.

A horse herd has various roles within it. However, these roles are not set in stone and sometimes they swap. Each horse has a value to the herd and if they tried to survive alone, they wouldn’t last very long. Our team has developed in the same way, although horses know this and behave in this way naturally; for us, it has been a steeper learning curve! Creating programmes that are engaging, educational, and focused has been a mix of equine knowledge and pedagogy.


Individually, I know about children, young people, and teaching, and my colleagues know about everything to do with horses. When we started we were more rigid in the roles we had, but as we have developed we have all learnt about the other aspect. I have learnt that playing ‘, Duck, Duck, Goose (or ‘Horse, Horse, Pony’), the popular children’s game where one child chases another round the outside of a circle, is not the best game, when horses are part of the circle, even if they are really, super calm horses. However, my colleagues have learnt that there are many circle games that horses and children can play together…and we all now work together to think of new games that are equally fun for horses and children. Working creatively as part of a team has been one of the biggest and most unexpected pleasures to date. It is how horses work, effortlessly, but for us it is an ongoing learning process.

It has sometimes been challenging. At times it has been a clash of priorities, values, and worlds.  I really dislike conflict, as do most people! That may be where some of my lone wolf-ness comes from. I’d rather get on and do something myself than have a conflict with another person. I’d rather avoid a disagreement than work through something, because I’m never sure what the other side of a disagreement will look or feel like. However, this avoidance has also had to change. The horses leave no room for pretending things are fine if they are not; in the same way that a traumatised child or young person will know if you are having an ‘off’ day. It was clear to all of our team that we needed to be honest about our feelings in the same way that the horses are. If we wanted to teach ‘Emotional Intelligence’, we needed to be emotionally intelligent. Not just when we are with young people, but also at the core of our business, and the core of ourselves. Of course, that is an ongoing process, but our awareness of it, and commitment to it means that we have had to learn to deal with challenges head on. I have learnt what is on the other side of conflict, within this herd anyway.

The EPONA approach (Kohanov, 2001) teaches that a horse will experience an emotion honestly, work out the message behind the emotion, change or accept something, and then let it go…or go back to grazing. For example, in a situation where there may be a conflict, if one of our team hasn’t liked how another has acted or responded to something, it is often easy to let the feelings build in the hope of avoiding the conflict. However, the feelings stay as energy that can be picked up by horses, young people, and ourselves. They make us harder to read, less clear, and less effective in our work. When we are able to act as a horse would; address the issue, change or accept something and then let it go, we are once again clear to work effectively. I have learnt that through experience.

On some level I guess I thought that if there was conflict within our team, it might last forever and possibly be the end of our team. I have learnt that feelings really don’t last forever, if they are managed. Ignoring them seems a sure way to make them intensify though.  It has come as a bit of a revelation that dealing with uncomfortable feelings like those felt in a situation of potential conflict, when they are still quite small, means that they pass much quicker. Happily, to date, our team is getting much better at this and we have all experienced that on the other side of conflict, we are all still here.

There was a situation a while ago that made me feel pretty angry. I don’t often feel strong emotions relating to the way that young people are managed when they are not with me and so I was surprised by how strongly I felt. The feelings led to a lot of reflection though, so I’m sure they were useful! A young person had to leave his session early but had not been told previously. This meant he spent the whole morning looking forward to his horse time, to be told at the point of riding, that he had to leave. The reason he had to leave was that one of his relatives had died a few months earlier and that day was the day his social worker had decided to tell him. Understandably he became very distressed when he was told he had to leave. I’m sure he would have become even more distressed when he was told the news about his relative.

It made me question why the situation had been handled as it had. Could he not have stayed an extra hour to have his horse time? Why had he not been told about leaving early previously? I wondered if it was maybe because no one felt able to help him manage his emotions. Maybe they wanted his understandably, heightened levels of frustration, confusion, sadness, and anger to be kept at bay until the very last minute, so as to keep things calm for as long as possible? As adults working with traumatised children and young people, we do try to keep things calm. ‘Calm is where we can learn and make friends’, I tell the young people I work with. However, through the conflicts I have had to face head on, I have discovered that calm is on the other side of managing emotions…not avoiding them.

If something scares a horse everyone around that horse will know about it. They make a fuss…they run fast or they fight. It isn’t hidden. They also get over it pretty quickly once they realise it is safe or something has changed. Watching that boy have to leave his horse session just made me question whether it was him who couldn’t manage his emotions very well, or whether it was others around him, who found it too painful to have a brave conversation. A conversation that would maybe have contributed to a big emotional response, but also might have been short lived, teaching that feelings don’t last forever. A conversation that was full of potential to see that calm can be on the other side of emotional chaos, and that maybe people are capable of going back to grazing just like horses.

Our journey has been one of challenging priorities. I believe we are all changed, and are all a little more understanding of each other’s worlds. Often this learning has been comical (to the other people anyway)! I have found it funny that on entering a barn filled with horses and people a colleague said ‘that must be your work experience person over there - the one with the green hair’. It was actually a member of care staff and my work experience young person was the one dressed very smartly in horse clothes with her hair tied back neatly. Perceptions of a troubled teenager! They have found it equally comical when I turn up to work wearing fashion cowboy boots in the middle of winter…’How is it even possible to work in this cold?’ or when I complain about my hat not fitting over my hair, and end up getting sunstroke instead of wearing it. Apparently, these are things you just know if you work with horses?! On one occasion, a colleague asked if an entire car park of teachers could stop teaching and move their cars so that our horse lorry could get into the playground. He was as surprised as I was about the sunstroke, that teachers can’t just stop teaching to move their cars.

As I said, we have all had some steep learning curves. In the same way that horses do though, we have learnt to accept the strange goings on of each other’s worlds. Occasionally now, I look like I know what I’m doing when I lead a horse or tie up a hay net. My colleagues definitely look like they know what they are doing as they sit in a classroom, on little people’s chairs, and act out a puppet show about the fight/flight/freeze response to a group of children.

We have been teaching emotional intelligence. We have been teaching how to work well in a team, how to develop good social skills, how to manage feelings, how to trust and be trusted, what happens in our brains when we have big feelings, and how to feel calm. As I reflect on the last year and a half, I am aware that the horses have always had these skills and have been leading us every step of the way. We are following them as they create their magic and continually show us how to be better people, a better team, and only then, better teachers who can hopefully help to make a better difference through our work.

Debbie Woolfe

References

Kohanov, L (2001) The Tao of Equus: A Woman’s Journey of Healing and Transformation Through the Way of the Horse, New World Library: California

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

* (See, e.g., B.M. Levinson, “Human/Companion Animal Therapy,” Journal of Contemporary Psychotherapy 14, no. 2 (1984): 131-44; D.A. Willis, “Animal Therapy,” Rehabilitation Nursing 22, no.2 (1997): and A.H. Fine, ed., Handbook on Animal Assisted Therapy: Theoretical Foundations and Guidelines for Practice (Academic Press, 2010).

Further Reading

Horsing around in Childhood Really can Change your Life - First Evidence-Based Study to Measure Positive Levels of Stress Hormones in Children in Touch With Horses


Stable Relationships Media Links

https://youtu.be/GpzWUwdxPhc  Link to BBC Radio Shropshire Interview, Oct 2015 – Debbie and children talking about feelings, flight/fight/freeze and calming
https://www.youtube.com/watch?v=c8pEDy8wy4U&feature=youtu.be  Link to Channel 5 News Report, June 2015 - some great comments by Debbie and children on horses on the subjects of relationships, feelings and being calm
http://www.thetimes.co.uk/tto/education/article4437669.ece  Link to The Times Article, May 2015)
https://www.youtube.com/watch?v=U0M5PO6x7IE – Stable Relationships - Our First Year! A picture Video 


Follow us on Twitter: @StableRels


Monday, September 14, 2015

Reasons a Traumatized Child Runs Away?


I have been thinking about the link between trauma and running away. In work with traumatized children and young people, running away can be one of the most challenging and troubling themes.  However, as a universal theme it is one of most important matters we need to find a way of thinking about and working with.  We can’t just ‘lock’ children up or ironically ‘throw them out’ after they’ve ran away. 

First of all, I should make it clear that I am not implying that the American actor Willie Aames was a traumatized child.  I use the quote only because I think it makes at least three useful points. One is that running away as with many behaviors can have different meanings beneath the surface.   Secondly, Aames implies that his behavior was a communication.  It also seems that no-one picked up on his communication in the way he was hoping for unconsciously.  Thirdly, he makes it clear that his conscious view only emerged many years later. So, as a child he didn't know why he was running away.  If he had of been asked he probably could not have given a meaningful answer.  Even though the quote says that he wanted someone to run after him, this doesn't explain why he had the impulse to run.  Why did the impulse develop when he was five? 

For most children there is a point in their development where they realize they can run away.  This may just be a sign that the child has a healthy curiosity about what else might be out there.  The child realizes she has the potential to go outside of her parent’s world.  It may be a way of experimenting with crossing boundaries.  To run away one has to go over a line.  This possibility, which is more an interest in exploration and discovery may enter the child’s imagination and dreams even if it isn’t literally acted out.  Is the urge to run away a move towards independence?  “Once I ran to you, now I’ll run from you”, as the lyrics to the song ‘Tainted Love’ say.  The child might feel excited and also slightly fearful about the possibilities. 

A traumatized child may have far more troubled connections with the impulse to run away.  It is clear that one of the terrifying things about trauma is that it is inescapable at the time.  The body is unable to escape, leaving the mind and body unprotected from the full horror of what is happening.  The only form of escape especially for children who face repeated traumas such as abuse may be to dissociate. In other words their mind becomes removed from the body.  As if it isn't happening to them.  Physiological and psychological mechanisms kick in to reduce pain and increase the chance of survival.

As a result, the child's body might feel useless to him.  He may feel let down by his body and ashamed of his 'failure' to escape (van der Kolk, 2014). We often see traumatized children who are lacking basic physical competence.  Many have difficulties in co-ordination and can appear clumsy.  Self-esteem deteriorates and the problem of having an incompetent body and mind grows. 

As a child begins to recover from trauma he will begin to gain confidence.  He will become physically and mentally more capable.  For the reasons I have mentioned, gaining a sense of physical mastery is extremely important for these children.  Running might be one of those areas of mastery along with other physical activities.  Their 'useless' bodies now begin to feel more capable.  One upshot of this is that they can now experiment with escaping.  I can only imagine if a small child has been unable to escape terrifying situations at the hands of an adult, as he grows bigger it must be liberating to be able to run away.  The message might be, I am no longer powerless and I can get away when necessary.  Just the experience that it is possible might be enough.  The child can't necessarily trust that there won't be a need at some point.

If a traumatized child feels empowered by being able to run away, in some ways it might be an important step forwards.  If this is the case we need to be careful not to be punitive and harsh in our response.  This would be a bit like punishing a victim for giving up the victim role.  I would add that it is generally a good thing not to be punitive and harsh towards a traumatized child.  This isn’t likely to induce a feeling of wanting to stay.  In fact, what we do on the child’s return can be crucially important.  How do we express our concern but also provide her with the space to discuss, explore and say anything that might be important?  Does the child feel welcomed back? How do we feel about having her back?  Sometimes people may feel relieved and angry at the same time? 

Even if there is a healthy aspect of development in a child running away, those being ran away from are not likely to welcome it.  So, what are the kind of questions to consider?  


One well known and key question is whether the person is running away from or to something.  Or as the American novelist Sherwood Anderson said it may be both?

Is it possible that there is actually something going on in the living situation that the child is running away from?  For example, is she being bullied?  On the other hand, is someone luring her away?  Are there actually seriously unsafe situations that she is either running away from or to?  Does the child just feel safer, more free and in control being away from people?  Is she running away from risking the possibility of a good relationship?  Is there something positive she is running to?  Such as a wish to be reunited with family.  Even though we might have concerns about the family the wish for connection is natural.  

As I have said, running away is often a very difficult experience for those who are being left behind.  It can feel that a child running away is rejecting the care being offered.  On top of this there can be a lot of worry and anxiety involved.  When I started work looking after 10 traumatized boys it wasn’t long before I experienced a child running away.   Given the children’s lack of concern for safety and their vulnerability the risks were significant.  We were located in a therapeutic community on a farm, about 6 miles from the nearest town.  Sometimes by the time a boy who had ran off got outside of the community he would come back, already tired by his efforts!  This was one advantage of the location. Running away didn't put the children in such immediate danger as it might in a city.  There have been many reported instances of children in out of home care, getting involved with gangs, drugs and sex, etc.  This inevitably causes huge anxiety for the adults looking after the children.  The anxiety can escalate so that all attention is on stopping the child from running away and little on thinking why she may be doing it. 

It is also worth paying attention to our feelings and thoughts while the child is ‘missing’.  What is the running away evoking in us?  For example, is the child projecting some of her fears in us? Is she giving us a taste of what it feels like to be abandoned and run away from?

A colleague, Tuhinul Islam Khalil (2013) mentioned that in Bangladesh, children living in a large residential home where he worked were often running away and ‘dropping out’.  Contact with the children’s mothers was not encouraged as many of them were sex workers.  Tuhinal recognized that the children needed their ‘mums’.  He changed the organization’s policy so that, “Mum can come and visit any time they want, they don’t even need appointment to come. So, it is like magic, within a month the dropout rate has nearly gone”.  This was an excellent example of thinking about the underlying reason and meeting the need.

Back to my days of trudging around the muddy fields looking for run-away children.  Sometimes I might find the child and he would return with me.  Often it felt like a game of cat and mouse.  This in itself could be exciting for the child and after a few hours he would usually return on his own accord for a warm bath and food.  Simon Bain, a resident of this therapeutic community in the 1970s, commented (2012), “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”.

This raises the question as to whether the need to ‘run away and be found’ can be built into daily life.  For instance, hide and seek type of games or more adventurous orientation activities for older children.  I imagine that hide and seek is a universally popular childhood game.  Capturing why this game can be so meaningful, Winnicott (1963, p.186) said, “It is a joy to be hidden and a disaster not to be found”.  The child has a simultaneous wish both to be hidden and to be found.  Symbolically this may represent the child’s inner self being hidden but also wishing to be found.  Some children might feel like no-one cares enough to look for and find them.  They might feel they aren’t even noticed and seen.  ‘Out of sight out of mind’, as is so often the reality for traumatized children. 

Sometimes when a child ran away, being the one to go look for him was actually a preferable activity to some of the alternatives, such as cleaning the house or attending a difficult meeting.  Of course, we couldn’t easily admit this, but it highlights one of the possible dynamics.  As adults, what might we have invested in the child running away?  Might the child be running away for the adult?  Is the child running away from something that he senses is going on between the adults?   Thinking about what we do and feel in response to the run-away child may give us a helpful clue.

In one of the training sessions I attended in those early days of my career we watched a video of a well-known psychologist talking about his work in a famous institution.  He said that sometimes a child could not be stopped from running away so rather than ‘run after him’ they tried to ‘run with him’.  I found this a revelationary way of re-framing the problem.  Maybe sometimes our job wasn’t to stop a child running away but to make the running away safe.  To be alongside the child.

Sometimes a child may run away on his own and other times with another child or group of children.  This can raise additional worries and questions.  Such as, is one or more of the children abusing another? What are they doing when they are away?  Are they getting into exciting delinquent activities?  If they feel excited having adults on the run do we make matters worse by joining in with the chase? If we don’t are we like the neglectful parent?  What happens to any children who do not join in with the running away? Is all of our attention on them distracted, so running away becomes a way of gaining attention? Is what we are providing in the home interesting, nurturing and stimulating so that there is a bigger pull towards staying rather than leaving? 

Knowing the child’s history may also give us important clues.  Is there a pattern of running away in the child’s life?  Did important people in the child’s life run away?  If the child did run away before what happened afterwards? Did she get punished or eventually moved to another placement? Is the running away a form of testing to see what we will do?

Running away can also be seen as a symbolic wish to escape fears and situations, which might be connected to the past rather than a reality in the present.  A traumatized child feels as if the trauma or the possibility of it is still present.  Is being on the move a way of avoiding pain?  If the child had someone alongside her to hold and work with her pain would the need to run away change?  If we work on facing the pain, might the need to run away get worse?  Thinking what the running may mean symbolically can be a helpful area to explore.  A psychologist, Rudy Gonzalez explained a useful example to me.  He had noticed in Australia that children in ‘out of home’ care would often be attracted towards a train track if there was one close by.  Young people and adults who have ‘behavior problems’ are often referred to as being ‘off the rails’ or ‘on the wrong track’.  Rudy refers to Sharon who could often be found by the train tracks,

“We could have judged Sharon’s behaviour as being only destructive, which may have resulted in a punitive response.  In contrast, seeing the behaviour as an attempt to act out a positive desire which was to get on the ‘right track’ led to a more empathetic response.  Through her behavior, Sharon had introduced the symbol of the train tracks.  Travel metaphors such as trains and train tracks are full of symbolic possibilities – excitement, envy for those on the train, danger, change, escape, being on the move, a new life.” (Barton et al., 2011)

I think that is a good place to finish, there is plenty to think about on this subject!

References

Bain, S. (2102) Comment posted on John Whitwell: A Personal Site of Professional Interest, www.johnwhitwell.co.uk

Barton, S., Gonzalez, R. and Tomlinson, P. (2011) Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for PracticeLondon and Philadelphia: Jessica Kingsley Publishers

Tuhinul Islam Khalil Interviewed in July 2013 by Ian Watson, Institute of Research for Social Science (IRISS), UK, Residential Childcare in Bangladesh.[Episode: 40] http://irissfm.iriss.org.uk/episode/049

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. (1963) Communicating and not Communicating Leading to a Study of Certain Opposites, in Winnicott, D.W. (1990) The Maturational Processes and the Facilitating Environment, London and New York: Karnac


Sunday, August 30, 2015

The Capacity to Think: Why it is so Important and so Difficult in Work with Traumatized Children


I have used the image of Descartes the 17th century French mathematician and philosopher because of his famous line, I think therefore I am.  I am using this quote simply to state that the capacity to think is the distinguishing feature of being human.  This capacity gives us great potential as individuals and a species.  Conversely not being able to think causes great limitations.

It didn’t take me long when I began work (1985) in a therapeutic community for ‘emotionally disturbed’ children, to discover the difficulties I would have in my own thinking.  Out of the ten boys in our home there was one who had earned the reputation of being able to drive everyone ‘round the bend’.  Whenever this 12 year old boy approached me with a manic look on his face, the best I could do was hold my hands behind my back to prevent myself from pushing him away.  Thankfully I was successful in that.  I can’t remember anything else I did or thought but maybe that was an important enough achievement.  This is why we had regular meetings with our supervisors and consultant child psychotherapist to help us think about the children. 

It seems obvious that not being able to think is a major and common difficulty.  However, the huge numbers of people who have suffered trauma, especially complex trauma during childhood are often misunderstood.  Their difficulty in thinking is unacknowledged and they are held responsible for their ‘thoughtless’ actions.  Trauma causes many problems in thinking.  For example, difficulty in linking cause and effect, inability to make appropriate decisions and plans, the misreading of people’s feelings and intentions.

“Trauma results in a fundamental reorganization of the way mind and body manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.” (van der Kolk, 2014, p.21)

Despite the importance of thinking in child development, cultures have evolved where thinking is often relegated.  Sometimes with good reason. For instance, if we need a working population that is going to sit by a conveyor belt all day long, obedience and conformity might be more useful qualities than thinking.  Schools and parents might be encouraged to foster this culture: learning by rote; repeat after me; do as I say; tests based on memory.  However, in today’s complex world it seems that helping children develop the capacity to think should be the main goal of education, at home and school.

Real learning needs the opportunity to work things out for oneself.  Clifford-Poston in her book ‘The Secrets of Successful Parenting’ asks,

What does a child need in order to learn?
·                A secure base from which to venture into the world.
·                Permission to be curious.


If curiosity and safety are central to learning, Einstein clearly did not think much of his education.  He said that ‘It is a miracle that curiosity survives formal education’.  He also added, ‘The value of a college education is not the learning of many facts but the training of the mind to think’.  As safety and curiosity are so important to learning, it is evident how disadvantaged a traumatized child can become.  Curiosity and imagination can feel dangerous to such a child.  A child who is constantly on guard can’t relax into being curious. Simply being curious may also have been a precursor to abusive experiences.  Imagination, which can be a retreat may also be too risky as it leads to re-experiencing traumatic events.

The very nature of trauma means that the experience is overwhelming.  Trauma is a profound emotional shock.  The brain and body go into survival mode.  During infancy, severe neglect can also be included as a trauma.  When trauma happens out of the blue, such as a car accident, the people involved are likely to recover in time. When a child experiences multiple traumas, the traumatized state is likely to become permanent.  The expectation isn’t recovery and a return to normal.  Trauma has become the ‘normal’ and the child is constantly on the alert for the next terrifying event. Usually, what helps someone to recover from trauma is one’s own internal resources and support from others.  Where a child not only experiences trauma but has little support the impact is multiplied.  Where those who are supposed to protect and nurture the child actually inflict the trauma, the impact is unthinkable.

What makes complex childhood trauma so devastating is that it also happens at a time before the ‘thinking brain’ has fully developed.  This part of the brain, located in the cortex is often referred to as the executive function. 

“Executive functions are processes that support many everyday activities, including planning, flexible thinking, focused attention and behavioural inhibition, and show continued development into early adulthood.” (Knapp and Morton, 2013, p.1) 

Of course the executive function in an integrated person is also connected to the feeling, emotional part of the brain.  Good decision making for example, relies on the thinking and feeling parts of the brain working together in an integrated way. 

A child who is traumatized early in life, often has an underdeveloped capacity to think.  The brain develops according to experience.  For a child to develop thought he needs to experience the care of a thoughtful caregiver. 

"It is almost a truism that children learn to think by being thought about; that an infant’s essential learning about him or herself takes place in the encounter of one mind with another from the very moment of birth.  (Waddell, 2004, p.22)

The kind of thinking Waddell is describing is both conscious and unconscious.  It relies upon emotional attunement.  The ‘good enough’ parent is responding repeatedly to the infant, often without being fully aware of the detail and mirroring that is taking place.  Without this the child’s development is severely hampered. Lyons-Ruth (2003) found that maternal disengagement and misattunement during the first two years of life was strikingly linked to dissociative symptoms of their children in early adulthood.  She concluded that infants who are not truly seen and known by their mothers are at high risk to grow into adolescents who are unable to know and see (van der Kolk, 2014, p.121).  In other words they will have difficulties in thinking.

However, in the absence of serious trauma a little thought and attunement may go a long way.  We must also remember the child’s innate tendency towards growth and resilience.  Wilfred Bion (1962) made the important point that the infant’s first thoughts would happen in response to the gap created by absence, i.e. by thinking about the mother who is not there.  This means that there is also a process of development that happens outside of direct interaction between a child and caregiver, but within the context of a secure base (Bowlby, 1969).  This has something in common with Winnicott’s (1958) concept of the ‘capacity to be alone’.  This ability to manage and even enjoy the sense of being alone, paradoxically as Winnicott points out, initially relies on the presence of another.  The idea is that in the presence of a safe and reliable other, it is possible to develop a sense of one’s own direction and thought.

A child who has suffered complex trauma is likely to both, not be able to think and to actively stop any thinking that might be possible.  The child’s thoughts can also become a source of terror as they link her back to the trauma.  This may happen persistently through, flashbacks, nightmares, and physical sensations, such as panic and anxiety.  To survive this exhausting onslaught the child’s brain/body system may shut out both thoughts and feelings. 

“…they focus their energy on not thinking about what has happened and not feeling the residue of terror and panic in their bodies.” (van der Kolk, 2014, p.133) 

This happens purely as a primitive survival response.  However, though feelings and thoughts may be blocked out of consciousness, the child’s body continues to register the huge stress that he is under (van der Kolk, 2014).  It isn’t hard to see how this scenario is going to lead to a pile-up of secondary adversities for the child.   Such as, 

·           Difficulty living in the present.
·           Inability to use opportunities for nurture and learning.
·           Problems in relating to anyone, including getting on with peers.
·           Poor health due to unhealthy routines, problems with eating and sleeping.

The difficulty goes on and on in a relentless cycle.  This is why helping such a child is so demanding.  The earlier the difficulty started, the more severe and the longer it has gone on for, the harder it is.  This is one of the reasons for the appalling fact that some 10 year olds or even younger children have lived in 30 or more failed placements. 

So, what are the key elements in enabling recovery to happen?



Safety is the starting point.  The child must actually be safe and reach the point where he feels safe.  This in itself might take a year or longer and with plenty of ups and downs along the way.  One reason while a settled and consistent placement is so important.  To achieve this those working with the child must be able to think, individually and together.  Thinking in this context means to be able to receive and notice everything that is going on with the aim of making some sense out of it.  It means being able to hold bewildering realities, strong emotions, contradictory possibilities and to think rather than react.  However, this is likely to be difficult for many reasons (Tomlinson, 2005), 
  • The child is likely to behave in a manner that is hugely demanding, challenging and confusing, which is physically and mentally exhausting.  Thinking is hard when we are tired and anxious.
  • Moving from a thoughtful to reactive state can happen very quickly.
  • The child will do things that are extremely difficult to understand.
  • The ‘normal’ response may not only not work it may make things worse. 
  • Understanding is required to see what lays beneath the behaviour.  The helpful response may be counterintuitive.
  • As soon as you think you’ve worked something out something else will contradict it.
  • When we do think about a child, he may do everything possible to stop us.
  • The child has stopped thinking because it leads to no good in his world.  Therefore our thoughts are perceived as a threat and something that may link him back to trauma.
  • A traumatized child may associate adults thinking about him with adults abusing him.  Ordinary caring thoughtfulness may be completely alien.
  • The child may attack and reject our thinking in a hostile way.  This may also be a form of testing to see if we will give up or retaliate.
It can be seen how thinking and understanding the child is essential on many levels.  It could be argued that the child will not be able to think about himself until the adults working with and looking after him can.  For the child’s disassociated and unintegrated experiences to become integrated, someone else must be able to bear and hold those ‘bits’ of experience together.  The reality that others can do this helps the child sense that her experiences may be possible to survive.  Surviving the child’s attempts to destroy the thoughtful care being provided offers the hope that the worst she has experienced can be survived.  And therefore that maybe she can also be survived. 

This challenging work will impact on those directly involved with the child and also anyone else who is involved, such as supervisors and managers.  It is crucial to maintain an environment where thinking can take place.  As soon as this goes there is likely to be another failure. It sounds clear, but the problem is that we are always on the edge of finding our own way out of the difficulty.  Those involved have to face very painful and sometimes shocking realities.  One way of getting out of this, is by adopting similar survival strategies to the child.  Cut off from our thoughts and feelings.  Distract ourselves from thinking.  Focus on other things and close down the opportunities for thoughtfulness.  If this happens temporarily to one person, others can step in and support.  It is a serious problem only if it becomes the norm within the culture.

The symptoms of such a culture include, 
  • A lack of openness and a focus on control.
  • A move towards a closed system, based on secrecy and denial, which are the typical dynamics of sexual abuse.
  • A dismissal of thoughtful insights, which might be labelled as indulgent, or ‘letting the child get away with it’.
  • Frequent cancellation of all meetings, which offer an opportunity to think about the child.
  • Quick reactive responses to situations.
  • A lot of doing and ‘busyness’.
  • A tendency to blame and a lack of empathy. 
As with the traumatized child this begins to look like a traumatized environment. It isn’t long before the secondary adversities of this also begin to pile up, causing far more extreme symptoms. 


The capacity to think is central to ordinary child development.  Complex childhood trauma greatly compromises this.  To help a child recover from trauma and to resume ordinary development, an intervention based on thoughtfulness is essential.  To provide this is extremely challenging both on an individual and collective level.  We may give up and also adopt a defensive response, which is likely to cause a failure.  To prevent this from happening we have to be constantly working together on the difficulty.  However much thinking is required cannot be prescribed.  It has to be enough to match the difficulty that is involved. 

In a strong culture based on these principles it is more likely that not only can we survive but also offer traumatized children and young people the hope of recovery. 

References

Bion, W. R. (1962) Learning from Experience.  London:  Karnac Books/Heinemann
Bowlby, J. (1969) Attachment, London: Hogarth Press

Clifford-Poston, A. (2001) The Secrets of Successful Parenting: Understand What Your Child’s Behaviour is Really Telling You, Oxford: How To Books

Knapp, K. and Morton, J.B. (2013) Brain Development and Executive Functioning, published online January 2013, http://www.child-encyclopedia.com/Pages/PDF/Knapp-MortonANGxp1.pdf

Lyons-Ruth, K. (2003) The Two-Person Construction of Defenses: Disorganized Attachment Strategies, Unintegrated mental States, and Hostile/Helpless Relational Processes, in, Journal of Infant, Child, and Adolescent Psychotherapy, 2 (2003): 105

Tomlinson, P.  (2004)  Therapeutic Approaches in Work with Traumatized Children and Young People:  Theory and Practice, London and Philadelphia:  Jessica Kingsley Publishers

Tomlinson, P. (2005)   The Capacity to Think:  Why it is Important and what Makes it Difficult in Work with Traumatized Children, Therapeutic Communities: The International Journal for Therapeutic and Supportive Organizations,  26(1):41-53

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

Waddell, M.  (2004) Attachment Anxiety, Young Minds Magazine 72 September /October.  London:  Young Minds

Winnicott, D.W. (1958) The Capacity to be Alone, in, International Journal of Psycho-Analysis, 39: 416-420