Thursday, June 18, 2015

Integrating and Connecting - The Essence of Trauma Recovery Environments


This blog is Part Three of ‘The Need for Integration’.

We as therapists are not really "shrinks"; we are "integrators". – Nelson, et al. (2014)

In the previous two parts I have discussed: the concept of integration in child development; the need to integrate management and therapy; how integration as a concept spans over 50 years from the psychoanalytic tradition of Donald Winnicott to the neuroscience perspective of Daniel Siegel among others; and how connection is central to integration and our well-being.

If neural integration is as Siegel says at the heart of well-being and trauma disrupts healthy development, then recovery is about completing the process of integration.  A person or any living system that is integrated is one where the different parts work together in a functional way.  For individuals there is mind-body and sensory integration, and an effective balance where emotion and reason complement each other.  The same analogy can be applied to social groups, such as families, teams, communities and societies.

For children who are traumatized during the first year or so of life, integration may never have been achieved.  For others who had more healthy early development the task may be about repairing disintegration brought about by trauma.  Children who have suffered complex trauma need a healing approach that includes all aspects of their daily life.  This is a total environment whole systems model.  The same principal may also be relevant to many seriously traumatized adults.  This is especially true when the trauma(s) took place in environments where disconnection, conflict and dysfunction were predominant. 

The aim of recovery is to create connections that can be personally integrated.  Connections can be thought of in relation to oneself, between internal and external worlds, in relationships with others, and the wider community.  The level of connection that traumatized children need means that those who are involved in the therapeutic work must be highly attuned.  Emotional attunement is receptive to connection and creates secure attachment.  The mirror neurons of a baby will begin to connect with an attuned caregiver from birth.  The primary carer-infant relationship is of central importance as is the network of connections surrounding it.  In the healing of trauma, just as in ordinary development ‘it takes a village to raise a child’.  Or as Perry and Szalavitz (2006, p.231) said,

“What maltreated and traumatized children most need is a healthy community to buffer the pain, distress and loss caused by their earlier trauma.  What works to heal them is anything that increases the number and quality of a child’s relationships.”

Networks of connections provide a potentially stronger level of support and emotional containment.  This powerful network is then internalized and integrated by the child as part of his internal model.  A good support network is the single strongest protection against becoming traumatized (van der Kolk, 2014, p.210).  The architecture of the brain comes to represent the architecture of the social environment. 

“Secure attachment promotes neuronal connections, helping to strengthen and integrate key brain structures.”  (Stien and Kendall, 2004, p.8).

I was fortunate 30 years ago at the beginning of my career to find myself working in a therapeutic community where integration was the central focus of the work.  Our task was specifically stated as to enable emotionally unintegrated children to achieve integration.  The model of the community’s approach was also strongly based on the belief that the way the organization functioned as a whole was key to the children’s development.  All relationships and roles in the community were considered part of the healing environment.  The role of the maintenance staff and domestic assistants were considered equally alongside the work of teachers, care workers and therapists.  This is one of the features of trauma-informed environments – everyone’s role is important and therefore needs to be integrated into the system as a whole.

Einstein’s view that ‘example isn’t another way to teach it is the only way to teach’, provides a good principal for how we approach the task.  If integration is the aim of trauma recovery then we have to practice integration in every aspect of our work.   To begin with, the adults who are working with such complex children and young people, need to have a reasonably robust level of personal integration and resilience.  The team working with the child needs to be integrated and coherent.  Different disciplines need to work together rather than compete.  The whole organization - leadership, management, care, education and therapy must work together.  The relationships with other stakeholders, such as referring agencies, families, local government and community also need to be integrated.  Achieving all of this is a daunting task, not least because traumatized people tend to create further disintegration and disconnection rather than integration and connection.   

A lot of this work to do with integration is about making and sustaining positive connections.  Connections with the children, with ourselves and our histories, with our colleagues, with external agencies and the local community.  To help think about these different levels of integration I will return to the work of Andrew Mawson who I referred to in my first blog on this subject.   He is a social entrepreneur involved in the regeneration of communities in the East End of London. 

As well as being a social entrepreneur it could be argued that in essence Mawson is an integrator and connector.  For example, in Bromley-by-Bow he integrated health and social issues.  The Bromley-by-Bow medical centre became a place where people didn’t just go to see a Doctor, but to join groups and meet.  Neighbors from different ethnic groups began to talk to each other, sometimes for the first time in decades.  Elderly patients, joined art classes and other social groups.  As people became connected the community as a whole began to develop and lift itself out of decade’s long decline, deprivation and depression. 

When the 2012 Olympics were awarded to Britain money was invested in developing a water city.  After the docks and associated industries had closed, the old river and canal system of London that used to be the lifeblood of the community had become unused and derelict.  Ironically the once vital water system now became a barrier that kept communities apart and isolated.

Eric Reynolds, Founding Director of Urban Space Development, talking of the water city project says,

“A key part of what we’ve still got to do is create a sense of connection.  Again, if you go up this wonderful river westward you will find bridge after bridge, after bridge, after bridge, after bridge………If you put a road in there is a tendency for stuff to happen.  Now London has expanded because of those life lines.”

Andrew Mawson continues,

“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 story is about recognizing these development nodes and understanding that if you fly into city airport and look down from an airplane all you will see is water.  And you will see the six and a half miles of waterways that connect the royal docks to all these development nodes.” 

A personal part of this for me is that while I was working in an organization providing a therapeutic service for traumatized children, I also spent an inspiring few days in Bromley-by-Bow.  This was a part of training in strategic leadership.  On reflection, I am struck by the parallel of the importance of connection and integration on both the micro and macro levels.  It is central to the micro level of individual recovery from trauma and to the macro level of community regeneration.  It is also interesting that the language of social entrepreneurship and neuroscience meet together. 

Both the individual and the community are plastic, i.e. capable of recovery and growth, however difficult and traumatic their histories.  Just as neural pathways develop in the brain and build a network of connections, the building of bridges in the water city symbolically represent a pathway to new growth.  In work with traumatized children both the micro and macro levels are important, but it is when there is a synergy between them that there is greatest potential for recovery.  For a child this synergy would be like having a safe and attuned relationship with a primary carer, within a healthy partnership between parents, within a caring extended family, within a safe and thriving community.     

A significant part of my work in recent years has been in developing therapeutic models in residential and foster care for traumatized children.  Strong models are ones where everyone whatever their role is involved in the process of integration and connection.  For example, a therapist might be doing what Siegel recommends – working to improve the integrative functioning of a child’s prefrontal neocortex.  While the task of the organization leader might be about building integrative connections inside and outside of the organization.   

One of the main satisfactions for me in my work is in helping organizations create models that integrate different perspectives in a way that is culturally sensitive.  In 2011 I co-authored a book with the Lighthouse Foundation who work with homeless young people in Melbourne, Australia.  A recent review (McNamara, 2015) said,

“In Australia, the most clearly articulated model of Therapeutic Residential Care is that offered by the Lighthouse Foundation (Ainsworth 2012; Barton, Gonzales and Tomlinson 2012) that owes much to the Cotswold Community in the UK.” 

Before I began working with Lighthouse they had integrated into their model, some of the Cotswold Community’s therapeutic approach where I started in 1985.  This is an excellent example of how different perspectives from different times and cultures can be successfully integrated.  Another review of the book (Steckley, 2013) said,

"From the introduction through the final appendices, I was struck by the constant and integrated presence of thinking, feeling and reflection as integral to meeting the needs of young people, whether at an individual or organisational level..... This book offers vision and motivation to those with requisite courage to work towards a more humane system of care for children and young people………….Elements of neurobiological and social ecological theories of development, the Sanctuary Model, organisational psychology, systems theory and even anthropology are also well integrated and usefully applied at relevant points throughout the book."

The very process of creating therapeutic models if they are to be of any use to traumatized children who need to become integrated and connected, also needs to be one of integration. 

My three blogs on integration have moved between the micro level of the individual brain to the macro level of leadership, organizations and society.  While this might seem a little awkward I think it is essential.  We can’t consider the individual as an isolate.  We are all part of a wider system.  Well-being is about the integration of the individual, relational and collective levels (Prilleltensky, 2006).

References
The quotes by Eric Reynolds and Andrew Mawson are on a video on this site,

Water City CIC, Connecting People, Business and Place, http://www.water-city.com/

Ainsworth, F. (2012) ‘Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-Informed Model for Practice.’ Book Review, in Children Australia, 37, 2, 80

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

McNamara, P.M. (2015) A New Era in the Development of Therapeutic Child Care in the State of Victoria, in, Whittaker, J.K., del Valle, J.F. and Holmes, L. (2015) Therapeutic Residential Care for Children: Developing Evidence-Based International Practice, London and Philadelphia: Jessica Kingsley Publishers

Nelson, B.W., Parker, S.C. and Siegel, J.D.  (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

Perry, B.D. and Szalavitz, M. (2006) The Boy who was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook New York: Basic Books

Steckley, L. (2013) The British Journal of Social Work, February 2013

Stien, P.T. and Kendall, J. (2004) Psychological Trauma and the Developing Brain: Neurologically Based Interventions for Troubled Children, New York, London, Oxford: The Haworth Maltreatment and Trauma Press

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