Attachment ant Trauma"It is critical for children to form healthy attachments to their parents if they are to proceed through the developmental tasks of life and have a working model for future successes and relationships."
What is the mission of CALO? CALO provides world class residential services for troubled adolescents. We facilitate lifelong attachment and healing between families and their children.How is the mission accomplished? CALO provides a safe and secure base for families to explore, experiment, and develop healthy relationship and life skills. CALO believes intimate relationships are the best part of life and are critical for children to have a successful life.
CALO Guiding Concepts - Children get what they need, not what they earn
- Nurturance is a right
- Fairness is getting what you need
- Change agent is relationships
- Permission to feel
- AII interactions are therapeutic opportunities
- Alliance not compliance
NON-CALO: Level System/Behavioral Modification
CALO: Nurturing, support, relationships[/list][/list]
NON-CALO: Confrontation
CALO: Joining--attunement[/list][/list]
NON-CALO: Attachment behavior avoided
CALO: Attachment behavior embraced[/list][/list]
NON-CALO: Structure
CALO: Rhythm[/list][/list]
NON-CALO: Time-outs
CALO: Time-in[/list][/list]
TERMS/DEFINITIONSStudents: The title we use for the adolescents in our program. Typical students will be between the ages of 13-16 upon admission and 14-18 at discharge.
Residential Coach: The front line, direct care staff. Residential coaches play a significant part of the change process in adolescents. Students spend most of their time in the structure of the program so all residential coaches, under the direction of the student's therapist and administrative team, need to know how to implement, model and coach students towards change.
Parent(s): Parents can visit CALO as often as clinically appropriate to visit their student. In facilitating attachment, having the parents involved in treatment and participating in the milieu is critical. Students don't earn time with parents and can request more contact with parents than weekly therapy if clinically appropriate. CALO requires all staff to introduce themselves to parents and to be of any assistance that the parents need. CALO especially wants parents to meet every worker over the phone. Students will tell parents "tales" and "stories" so the parents need to know each worker so there is some trust in clarification.
Bonding: Emotional events that evoke attachment behaviors; each bonding moment strengthens the connection/loyalty/bond to the attachment figure. Females talking about relationships, males golfing together, a son playing catch with his father, and a mother nursing her child are examples of bonding activities.
Attachment: An enduring and reciprocal process by which an
emotional relationship develops with a specific person. Healthy relationships bring safety, comfort, trust, soothing and pleasure. Loss or threat of loss to the person evokes intense fear and distress. Having a relationship with a parent does not insure that the child is "attached" to her. Attachment refers to the unique relationship between child and parent through which the child is able to proceed with the major qualities of his own psychological development.
Attunement: "The intersubjective sharing of affect" (Stern, 1985). There are (or should be for healthy attachment) thousands of attunement experiences in the first two years of the mother-child attachment. Attunement between staff and student is being on the same emotional level and understanding without having to verbalize these emotions.
Affect: The non-verbal outward expression of inward feelings. "Affect is not just facial expressions but the whole non-verbal meaning in the person."
Affect Regulation: One's ability to appropriately bring mood and affect into harmony.
Milieu: Or the "environment" of the therapeutic model. The Milieu is usually the most significant part of the change process. Students spend almost all of their time in the milieu. Residential coaches are not just to create a bond with students but help adolescents regulate emotions for the rest of their life. Coaches should help sooth students, regulate, control rhythms, process, and hold students accountable with love in the daily interactions in the milieu.
Rhythms: As opposed to "structure" alone, living life in consistent rhythms helps students manage their moods and affect long-term. Students are more vulnerable to change and trusting of staff when adults caring for them are controlling the rhythms of the milieu. "S/he who controls the rhythms controls the house." Coaches should talk to the students about almost everything that is going on in their personal lives and on campus -- visits, activities, sessions, etc. Every change in the students schedule and structure alters the rhythm of the program. The more consistent the rhythms, the more vulnerable and trusting the students are of the staff caring for them.
Core Beliefs: Early experiences with caregivers shape a child's core beliefs about self, others, and life in general. Experiences of the baby and young child are encoded in the brain. Emotional experiences of nurturance and protection are encoded in the brain's limbic area) the emotional center. Over time, repeated encoded experiences become internal working models core beliefs about self, self in relation to others, and the world in general. These core beliefs become the lens through which children (and later adults) view themselves and others, especially authority and attachment figures. Core beliefs serve to interpret the present and anticipate the future.
ATTACHMENT THEORISTSJohn Bowlby—Pioneer of attachment therapy. Developed attachment theory out of his work with abused children in England. Much of our understanding of attachment and trauma treatment stems from his initial work. Many other professionals have taken the reigns since then and have expanded upon his work.
CALO follows and implements the framework that Bowlby set forth as well as several attachment experts. Specifically, CALO follows the work of Daniel Hughes as he has extensive experience in residential treatment of attachment.
Daniel A. Hughes—- Clinical psychologist in Waterville, Maine.
- Specializes in child abuse and neglect, attachment, foster care, and adoption.
- Cites, employs, and uses some of the frameworks of Milton Erickson, Connell Watkins, Nancy Thomas, Deborah Hage, Allan Schore, Stanley Greenspan, Ann Jernberg and other therapists and clinicians.
- Utilizes a "psychodynamic perspective in interpreting for a child and his parent how past experiences of abuse and neglect are affecting his current affective, perceptual, and cognitive experiences and his related behaviors."
- Works with treatment centers such as the Attachment Center in Evergreen, Colorado and with Villa Santa Maria in Albuquerque.
- Recognizes that traditional interventions of play therapy, parent education, and cognitive behavioral techniques are not sufficient to effect significant progress with the poorly attached child.
ATTACHMENT THEORYBowlby has stated that the most basic need humans have is to reach out and connect with someone. We have this need from our development in the womb. Children want to know -- "do I matter to you," "do you notice me," "can I depend on you?" Bowlby -- "unfortunately a mother [parent] can be physically present but emotionally absent."
BASICS:
- Infants are predisposed to be attached to caregivers.
- Infants seek proximity to parents in times of distress (survival, biological function)
- The child will organize own behavior and thinking in order to maintain those attachment relationships, which are key to psychological and physical survival.
- The child will often maintain such relationships at great cost to his/her own functioning.
- The distortions in feeling and thinking that stem from early disturbances in attachment occur most often in response to the parents' inability to meet the child's needs for comfort, security and emotional reassurance.
- In children, attachment to primary caregivers influences the child's physical, neurological, cognitive, and psychological development. It becomes the basis for development of basic trust or mistrust, and shapes how the child will relate to the world, learn, and form relationships throughout life.
- "All children, at the core of their beings, need to be attached to someone who considers them to be very special and who is committed to providing for their on-going care."
- "Children who lose their birth parents, especially those who have experienced the trauma of abuse and neglect, desperately need such a relationship if they are to heal and grow."
- "If children in treatment are not experiencing an attachment to a parent, whether because of lack of ability or opportunity, the therapist is greatly limited in her efforts to assist the child in beginning to heal and in wanting to work to become 'special' to self and others."
- "Stopping the abuse is not enough. The results of the abuse often live on within the child and render him unable to take advantage of the new opportunities presented to him."
- "To have a chance for a good life, he must be able to form a secure attachment with his new parents and develop healthy attachment pattems that facilitate his affective, behavioral and cognitive development." (S. Greenspan, 1988, 1989)
- Stern (1985) states that the infant's "first order of business" is to form the core sense of self and others.
- "The nature of the attachment to the mother influences all later socioemotional transactions." A "working model" for future relationships develops because of this parent-child relationship. (Schore, 1994).
- When the abuse is at the hands of his caregiver, a child is most likely to experience maladaptive attachment.
- Trauma impedes development of trust and subsequent development of self and ability to relate and attach to others.
- Schore (1994) stresses that the affect regulation and attunement experiences between the mother-child are the core of the child creating his origin of self.
- Kaplan (1995) states the parent-child attunement breaks down "whenever there is a consistent and prolonged loss of empathy."
- The child who has infrequent attunement experiences perceives himself as being flawed and often feels empty, hopeless, and helpless.
- "Children who are subject to profound neglect have few of the experiences of physical comforting and affection that are central to attunement and which are necessary for secure attachment."
- A critical or sensitive period for attachment is early in the child's life. The older the child, the higher the chances the student will be resistant to attachment.
- "Our hypothesis is that access to childhood pain becomes a powerful deterrent against repetition in parenting." -- Frailberg
- "Attachment is an addictive process -- the more you do it the more you like it."
- The symptoms of emotional loss are almost parallel to drug withdrawal.
HEALTHY ATTACHMENTHealthy attachment occurs when the infant experiences a primary caregiver as consistently providing emotional essentials such as touch, movement, eye contact and smiles, in addition to the basic necessities such as food, shelter, and clothing. If this process is disrupted, the child may not develop the
secure base necessary to support future healthy development.
* "The child discovers that he can develop himself as a worthwhile and competent individual without sacrificing the basic attachment with his parents."
* "Within a healthy attachment, discipline is a fact of life. The child may grumble, but he accepts the fact that one parental role is to teach...has basic trust that this teaching (though at times annoying) is ultimately given in his best interests."
The core beliefs of children who have experienced secure attachments in the early years are as follows:
Secure Attachment Core Beliefs:Self: "I am good, wanted, worthwhile, competent, and lovable."
"My influence is felt as part of a family system."
"My needs will be constantly met by my parents because they love me."
Caregivers: "My parents are appropriately responsive to my needs, sensitive, dependable, caring, trustworthy."
"The world is safe and/or my parents will keep it safe."
Life: "My world feels safe; life is worth living."
"I know I will have repair when negative experiences occur."[/list]
CAUSES OF POOR ATTACHMENTFactors which may impair healthy attachment include but are not limited to: 1.) Multiple caregivers
2.) Invasive or painful medical procedures
3.) Inconsistent or inadequate care at home or in day care (care must include holding, talking, nurturing, as well as meeting basic physical needs)
4.) Sudden or traumatic separation from caregivers
5.) Frequent moves and/or placements
6.) Hospitalization at critical developmental periods
7.) Neglect (of physical or emotional needs)
8.) Sexual, emotional, or physical abuse
9.) Chronic depression of primary caretaker
10.) Illness or pain which cannot be alleviated by caretaker
11.) Prenatal alcohol or drug exposure
12.) Neurological problem in child which interferes with perception of or ability to receive nurturing (i.e. babies exposed to crack cocaine in uterus).
Children adopted at birth can still have significant attachment issues -- we don't know all of the reasons why yet but it is believed some of the reasons are:
1.) Pre-natal-Drugs? Activity? Did not know about pregnancy?
2.) Birth trauma
3.) Ingrained desire to be with birth mother-smells, voice of birth mother in womb, activity of birth mother, did birth mother listen to music and adoptive mother didn't?
4.) Do adoptive parents have their own attachment issues? Are they guarding against bonding because afraid of losing child or view child as not of their "own?"
SIGNS AND SYMPTOMSWhat Does Attachment Look Like?Diagnosis relies heavily on events that happened, not the behaviors that are manifest. ODD, CD, ADHD, RAD can look a lot a like so it is the history that is really important.
On the outside, children with attachment disturbance often
project an image of self-sufficiency and charm while masking inner feelings of insecurity and self hate. Infantile fear, hurt and anger are expressed in disturbing behaviors that serve to keep caregivers at a distance and perpetuate the child's belief that s/he is unlovable.
- "Perceive caregivers as violent, cruel, rejecting, and unpredictable. Safety is increased through avoidance, silence, denial of one's own...
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- No signs of longing or distress when one caregiver leaves and another arrives.
Behaviors Associated with Problematic AttachmentUnable to engage in satisfying reciprocal relationship:
1. Superficially engaging, charming (not genuine)
2. Lack of eye contact
3. Indiscriminately affectionate with strangers
4. Lack of ability to give and receive affection on parents' terms (not cuddly)
5. Inappropriately demanding and clingy
6. Persistent nonsense questions and incessant chatter
7. Poor peer relationships
8. Low self esteem
9. Extreme control problems - may attempt to control overtly, or in sneaky ways
10. Poor cause and effect thinking:
11. Difficulty learning from mistakes
12. Learning problems - disabilities, delays
13. Poor impulse control
14. Other poor conscience developmental issues
C. Emotional development disturbed: child shows traits of young child in "oral stage"
1. Abnormal speech patterns
2. Abnormal eating patterns
D. Infantile fear and rage.
1. Chronic "crazy" lying
2. Stealing
3. Destructive to self, others, property
4. Cruel to animals
5. Preoccupied with fire, blood, and gore
E. "Negative attachment cycle" in family
1. Child engages in negative behaviors which can't be ignored
2. Parent reacts with strong emotion, creating intense but unsatisfying connection
3. Both parent and child distance and connection is severed
*** Clients with attachment disorders may also be sexually inappropriate due to poor boundaries and insight. At times, sexual inappropriateness may even be violent in attempts to connect with someone else. ***
Compromised Attachment:Self: "I am bad, unwanted, worthless, helpless, and unlovable."
Caregivers: "Parents are unresponsive to my needs, insensitive, hurtful, and untrustworthy."
Life: "My world feels unsafe; life is painful and burdensome."[/list]
- Students with poor attachment are "Likely to experience deep shame, intense rage, pervasive anxiety, and extreme isolation and despair."
- "They are also likely to manifest a variety of destructive and selfdestructive symptoms whose functions are to attempt to make life bearable when it is lived outside the basic reality of interpersonal relatedness."
- "These children often make their new parents' love, support, guidance, and directions ineffective and permeated with stress, conflict, and disillusionment."
- They work very hard to control all situations, especially the feelings and behaviors of their caregivers.
- They relish power struggles and have a compulsion to win them.
- They feel empowered by repeatedly saying, "No."
- They cause emotional and, at times, physical pain to others.
- They strongly maintain a negative self-concept.
- They have a very limited ability to regulate their affect.
- They avoid reciprocal fun, engagement, and laugher.
- Avoid needing anyone or asking for help and favors.
- Avoid being praised and recognized as worthwhile.
- Avoid being loved and feeling special to someone.
- Enveloped by shame at the origin of the self.
PROGNOSIS OF UNTREATED ATTACHMENT AND TRAUMA"The unsolved mystery is why, under conditions of extremity, in early childhood, some children who later become parents keep pain alive...we hope to explore these problems in the further study." - Frailberg
Children who never form secure attachments to adoptive parents often later seek out their primary abusive caregiver, searching for a connection to a parent, generally with no chance of either healing or developing a new pattern. They then wander the world, experiencing and causing pain and despair.
Adults with untreated attachment have high rates of conduct disorder and anti-social disorder. Issues that further interfere with one's ability to be successful in life.
COACHINGWhat Is My Job As A Coach? To mentor, engage, supervise and be an example of integrity to young adults at CALO. Effective coaching jump in the "mud" with students and climb out together. Coaches who utilize metaphors, clear boundaries, and who develop healthy relationships with the students at CALO are the most effective and facilitating change.
What Is The Most Important? The most important role you have, before doing anything else is to
keep the students safe -- physically first, then emotionally, psychologically, sexually, etc. Everything else you do for good in the student's lives should come after being vigilant about student safety. Before you do anything, ask yourself, "Am I doing everything to keep this (these) student(s) safe? For example: "Are all of their seatbelts fastened before I pull out of this parking lot?" "Do I have all of the students I am in charge of in my line of sight right now?" "Am I being especially watchful of (student) who is having a difficult day?" "Are students figuring out my patterns of bed checks during the night?"
HOW TO BE A GREAT COACH- If the student does not respond to cues say, "we are behind you and we will give you a chance to do better later."
- Apply good cognition to wrong or negative behaviors-- "You hugged that stranger. You must love her very much." "You are chattering again, you are worried that you don't exist." "You are bossing me around again. You want to control me."
- At no time should children be punished for failure to comply with coaching. The coach simply says, "We will try again later."
- Don't attempt to coach a child who is out of control: The anger curve for many of the students is quick to peak, so it is imperative that all contact in which confrontation is a possibility is approached with coaching as opposed to questioning.
- The students need constant feedback on want is positive and negative. Make your feedback as objective as possible-- "You seem very hyper right now. Most people don't like being around someone who is out of control." Instead of, "You are driving me crazy. Will you please calm down?"
- Be on the rhythm of the student. Instead of asking why the student does things, point out to them why they do it: "You are hiding behind me because a stranger has just come into the room and you are a little scared." "You are sitting real close to me because you need to feel close to someone right now." "You told the truth because you feel bad about what you did." "You came and gave me a hug because you are hurting and need me to help you feel better."
- Scolding, questioning, punishing produces shame and evokes defense mechanisms as opposed to internalizations of moral lesson.
- Coach the student as if they know nothing about the game. Don't assume they have skills expected of their age group. Tell the player what to do and how to do it -- the more you leave open for interpretation, the more confused and frustrated the student may get. If a player does not follow the rules he/she is benched -- not because they are a bad player but because they are not being a good teammate.
- Healthy coaches do not expect to be loved and do not attempt to get his/her emotional needs meet from players.
- Emotional signals are the music of a person's behavior. Remember not about stopping the bad but raising the good -- don't get caught up playing whack-a-mole.
- Consequences and coaching point out the relationship between what children do, how they feel, and how their behavior affects others.
- Coaching helps students shift out of shame ["I am a flawed person"] and into guilt ["I did something wrong"] by activating a higher level response system -- the social engagement circuitry.
- Tricks of the trade: Don't ask the students lots of questions. Questioning is likely to be perceived by the student as accusatory and will push the child into defense mode. Instead, "Why did you break that toy" becomes a coaching moment from the staff: "this is where you say to me: Shellie, I broke my toy because I was mad." "Where were you?" becomes..."this is where you say to me: Jordan, I was hanging out in the bathroom because I didn't want to do my school work." "Didn't I tell you to do your chores?" becomes..."Kelly, I heard you tell me to do my chores but I chose not to do them."
- Coaches show students how to do something by being hands on and not just shouting from the sidelines.
CONSEQUENCES & DISCIPLINE- Staff and parents should avoid power struggles.
- Focus on choices the students can make to improve their lives instead of coercion or force from the authority figure.
- In correcting many types of behavior, it is best to provide the adolescent with at least two choices, one that encourages a healthy way of living and regulating self and another choice that leads to a logical consequence if the student continues to make bad choices. For example, if a student is escalating in the cafeteria, staff would offer the student two choices, "[Student], I can see you are having a difficult time right now. I am so sorry you are struggling. Because of where we are you have two choices, 1) you can regulate those emotions so we can talk about this later with your therapist and continue to remain here as a team in the cafeteria or 2)we can leave right now and go back to [place] to cool down. Which would you prefer?...How can I help you re-engage in an appropriate way?" If the student persists in negative or escalating behavior and/or does not respond to the options, staff must be okay with and respond consistently to the second option provided to the student. Otherwise trust and effectiveness is lost. Do not Iet the student manipulate after a staff has allowed the student sufficient time to make a decision by suddenly agreeing to option #1 when realizing staff are following through with option #2. With empathy state, "I see you now realize a better option. I am happy you are able to think clearly but unfortunately your behaviors and patterns do not feel safe to me so we need to follow through with option #2. I really hope next time you will remember this experience and make the right choice sooner." During all of the interactions the staff or parent is calm and is not condescending. The approach is to help the student make better choices that lead to a successful life.
- Consequences should be connected to the behavior and not arbitrary decisions by the authority figure. If the student is slow waking up on time he should wake up earlier and not have a consequence of less talking.
- Choices and consequences are not commands or punishments!
- Not all student mistakes should have consequences. Only those that are pattern in nature, interfere with the functioning of self or others, or pose a threat to the safety and welfare of self or others.
- Remember, with many students, closeness is the real issue -- because you practice supportive control -- I want you to meet expectations and not allow life to punish you. Cognitively help them regulate after and during struggles.
- Remember, students can tell where your heart is at even if your words and behavior are appropriate.
- Discipline, regulate with, stay in control -- always, always, always follow with nurturing love.
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