MODELS IN THERAPEUTIC WORK WITH TRAUMATIZED CHILDREN - PART 2 PATRICK TOMLINSON (2014)

Date added: 08/10/20

In my previous blog, I discussed how models develop in childhood as internal ‘templates’. By the time a child becomes an adult, he or she will have a way of relating to others based on their ‘internal working model’. Once a child is born the parents ideally have some clear ideas about what will be good for their baby, and the capacity to provide it.

We all know from observing and/or being a parent that there are different versions of how to look after children. Usually, our version is based on our childhoods, what we have learnt in our families. If they have internalized a positive experience of being parented, most parents want to parent as theirs did.  If they have not and they haven’t been able to acknowledge the difficulties, they may also parent similarly and repeat the negative experiences. This is how a cycle of deprivation and abuse continues. Or if they are more in touch with the reality of their childhood difficulties, they may wish to be different than their parents and bring up their children in a better way. However, even with all the knowledge now available, few first-time parents will have received much formal education on parenting.

Add into the equation that both parents will have had different childhood experiences and will have differences and similarities in their views on parenting. Some difference may be positive because it provides their children with a wider range of qualities. However, too much difference in dealing with basic issues could be too contradictory, unpredictable and unhelpful. Sometimes the parents might not be conscious of their differences until they have a baby, their child reaches a certain age, or particular situations arise. Each stage and event of childhood can have the powerful effect of resurfacing strong feelings in the parents, related to their childhoods, which they may not have been aware of or had repressed. On the positive side, how the parents manage their feelings, work together and resolve differences are vital parts of parenting. It provides children with a role model on how we can positively cope with difficulties and how differences can be useful rather than harmful.

The relevance of parenting is clear when we think of therapeutic models. Whether we are working in foster care, residential care, therapy or teaching, parent-child dynamics will be involved. The task will require that the foster carer, residential carer, therapist or teacher can reflect upon and untangle what is in the child’s best interests. One child who was living in a residential children’s home complained to me,

You can tell how each of the carers was brought up because they all have different rules and attitudes at mealtimes.

There is nothing like the way we eat together to highlight differences! In the absence of a clear and agreed model, the carers were doing their own thing based on their points of view. There could be 8-10 adults in a team, so the potential for confusion is huge. It can be hard for two parents to provide the necessary consistency for a child, so providing it among a large team is incredibly challenging.
When there is a team working with a child it is especially helpful to have a model. Traumatized children need predictability and consistency, to help them feel safe and to stabilize their emotions. Only once this achieved can they begin to make use of the experiences they need to recover and develop. Without a clear model, chaos is likely to rein. For many years various reports, investigation’s, etc. into ‘looking after children in care’, have found that a clear ethos or philosophy, along with strong leadership are the most consistent factors in positively run organizations that have good outcomes for children and young people. What used to be termed a philosophy of care, is now more frequently referred to as a model of care. Whether we are talking about care, therapy or teaching, having an appropriate model is essential.

A model needs to be based on the best information available for the specific task. For example, if we are teaching an autistic child, the research and theoretical base will be different from that for therapy with a traumatized child. There may be some overlaps but there will also be differences. I had a steep learning curve when I began work with traumatized children and another one when I moved and spent some time working with children who were diagnosed with Asperger’s Syndrome. The model that worked with one didn’t work with the other. It can be said that in working with any child, we need to be adaptive to each child’s personality. For instance, it is now well-known that everyone has different learning styles and therefore different learning needs. But the differences between children with different types of complex needs are especially challenging to adapt to. Turner et al. (2007, p.537) has said that in work with complex trauma a variety of approaches are necessary and, 

“Helping people who develop posttraumatic stress disorder (PTSD) in the after¬math of a traumatic experience is a complex process that cannot simply be described like a cookbook recipe.”

A model can provide guiding principles, standards, specific techniques, do’s and don’ts. But most importantly it should equip the people doing the work with the ability to think within a framework and work things out together.  A model provides parameters within which things can be tried and monitored. What works can carry on and what doesn’t may need re-thinking or persevering with. Having a benchmark provides a point from which new ideas can be critiqued. If there isn't a benchmark how do we notice how far something is drifting - a bit like walking in the fog, without even a vague marker to keep a sense of direction.

Having a good model on paper is not a guarantee of good outcomes. Other important factors will also determine success. For example, is the model embedded in the culture, is it understood and do people feel a sense of ownership. It is particularly important that a model is culturally sensitive and considers cultural values, language and belief systems.
In work with traumatized children, as I mentioned in the previous blog, every aspect of the environment and how the different parts work together is vital. Different terms like, integration, congruence, and joined-up have been used to explain the importance of this. A trauma-informed environment is necessary, and this includes everyone who is in any way involved – carers, therapists, teachers, managers, senior executives, administrators, etc. Creating this requires a cultural change because how people think about the children, the task and how they relate to each other is all relevant to the model.

Effective leadership and implementation of a model is a challenging task.  To fully establish a strong culture with a clear model can take at least 2-3 years, if not longer. By this, I don’t just mean that a model is created on paper, but that it becomes genuinely reflected in the way that individuals and the organization work. When a model is fully established, it can be recognized by the positive qualities that run through the organization, with everyone speaking the same language. It will be reflected in the consistent quality of relationships between adults and children and at all levels of the organization. Ultimately any model aims to achieve the best possible outcomes for children, so continually evaluating, learning and adapting must be part of the culture. As I have said, a model is never finished, it is always evolving.

Reference
Turner, S.W., McFarlane, A.C. and van der Kolk, B.A. (2007) The Therapeutic Environment and New Explorations in the Treatment of Posttraumatic Stress, in van der Kolk, B. A., McFarlane, A.C. and Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press

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