From the beginning of and throughout therapy, I describe its goal as “integration.” Though this may seem long mere semantics, I consider it a disservice to patients and their families to use words like healing, recovery or reversal. Such terms imply erasure of things that cannot be erased and suggest a conclusive process of limited length.
Living with developmental trauma is a lifelong journey. There can be many life giving moments in the journey, but integration is an on-going process. I find that trauma survivors respond better when they understand this idea from the beginning.
for developmental trauma survivors involves internalization of a sense of safety, predictability and connection to one self and others.
We aim to achieve this goal through a process of secure attunement aiming to:
(1) Help patients enhance emotional regulation;
(2) Help patients develop a more organized and secure attachment.
In my experience, the following aspects provide an effective therapeutic framework for creating secure attunement*:
2. Enhanced sense of safety using action in a safe space (see more below).
3. Improved emotional regulation using SI activities adapted for the age of the client when the trauma took place.
4. The first three aspects lay the ground for safe-regression (see below) to take place, and possible integration.
Safety as a quality of the therapeutic relationship is a core goal in therapy. However, with trauma clients in general, and complex and developmental trauma in particular, it is especially important. For an extended period early in therapy, the main focus of therapy must usually be engaging in activities that foster safety. A variety of techniques and tools facilitate this goal.
As an expressive therapist, I most often use “imaginal space,” also known in psychodrama as “surplus reality,” an abstract creative space of play, fantasy and spontaneity in which a client is able to explore and engage with different aspect of her experiences through art, play, movement, dance, drama, music and so forth.
Any type of activity that involves creativity and movement, that the therapist feels comfortable using, is likely to be effective. This could include things as simple as taking a walk, jumping together on a trampoline or in a room, dancing, singing together, etc.
The point is for the client to be engaged in something that involves multi-sensory inputs, is light and relaxing for the client and allows for interaction with the therapist, usually on topics of what feels safe and later in the process, what does not feel safe.
These activities in the therapy room foster creativity, playfulness and spontaneity while allowing for slowly introducing things that involve some element of risk and autonomy, yet not too much, not too early. Because it is a drawn out process of interacting around topics fraught with danger for the client but carefully modulated to protect the client’s sense of safety, I call it safe attunement.
Interaction with the client about any activity emerge from the client’s experience. For example: the therapist might start by asking the person to pick different colors of crayons/markers and draw with these on paper. If this request is too big of a task with which to begin, only draw lines.
Then, the therapist might ask the client to select from a pile of fabrics ones that represent these colors. Then, the therapist invites the client to lay the fabrics on the floor like it represents the lines on the paper. The therapist next invites the client to stand close to them for a few seconds, then, far from them, inviting her to walk with her next to these colors on the floor and notice how it feels. Over time, the therapist begins to grow on these experiences to increase embodied play and sensory integration.
If the patient finds it hard to engage, start with any activity that the client would like to join, even by talking while walking in the therapy room instead of sitting and talking.
Survivors of developmental trauma need more than an experience of attunement, they need repetition of it. You can witness this experience easily in playing with a two-year-old. Let a child run away, then chase her and snatch her into your arms. Your reward will be loud laughter and a command, “Again!”
Activities repeated over a number of sessions build a sense of safety, enabling the client to enter what I call safe regression. Perry suggested that patterned repetitive experience in a safe environment has an impact on the child brain (Perry. 2007 p. 134).
is therapist-assisted exploration of an attachment developmental phase that did not advance since the developmental trauma took place.
When a child is ready to enter this phase, often we begin noticing some ordinary regression in overall behavior, usually outside of the therapy room and reported by parents. When this happens, I increase the frequency of therapy to more than once per week.
Much of the focus up to this point has been about containment in therapy. Now comes a more demanding phase and a more intensive pace of therapy is necessary. In part, this shift is to ensure that the therapist can respond adequately to whatever regression marked entry into this phase.
The primary focus of the phase is a combination of sensory integration creative activities that are playful and spontaneous and selected to be appropriate to the age at which the trauma took place.
Repetition is a defining mark of the phase. Some clients do the same or similar activity in every session for weeks. Therapist-client communication for extended parts of sessions is often similar to that used with a pre-verbal child. This situation is the case for some adult clients as well.
: One of my clients spent several months in sessions that were play and SI based activities. Then he began to show signs of regression at home and in therapy, so I increased sessions to twice per week.
He had shown particular interest in singing. I invited him to sing along with me. The first time we sang together, he sang a few words, though I could barely hear his voice. In the next session, he sang loudly along with me. This singing continued for several weeks. One day, he asked to sing a song to me by himself. A few sessions later, he sat and sang by himself for the entire session, glancing up at me often to make sure I was listening. This reflects a predictable trajectory of content, moving from SI activities to performance for the therapist.
At about the same time that the boy began to do more performance in sessions, his parents began to notice improved behavior and emotional regulation at home.
An adult patient at this stage showed interest in drawing. For months, we had a predictable format in sessions. He would draw and I would sit with him in the most supportive (attuned) way I could without distracting him. Every few minutes, he would glance at me to make sure I was looking at him. I would smile, or nod; he would continue drawing with a contented look on his face.
Clients can work with clay, dance, reading aloud, poetry, etc., as a medium of expression. Some clients are ready for a change in the nature of the activity sooner than others, but overall the need for safe regression activities supported by an attuned therapist takes a while.
At some point things change, often quite suddenly, like a growth spurt. What felt like a comfortable, appropriate activity may suddenly seem out-of-place. This change is a sign that safe regression is continuing and it is time to select activities that are more advance developmentally.
emerges when the client begins to display improvement in self-regulation and is able to demonstrate openness in relationships outside of the therapy room to the secure attunement that was first present in the therapy room.
Integration does not mean a perfectly secure attunement. Patients will experience movement throughout their lifetime between a sense of attunement, misstatement,and reattunement.
*When I am working with children who suffer from the developmental trauma I always work with at least one of their caregivers on a weekly basis as well.
**When there is a need, I refer my clients to other professionals that work closely with me to address different aspects of the integration process such as nutrition, physical therapy, occupational therapy, massage therapy, acupuncture and so forth.
Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C. H., Perry, B. D., … & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood. European archives of psychiatry and clinical neuroscience, 256(3), 174-186.
Perry, B., & Szalavitz, M. (2007). “The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook Child Psychiatrist’s Notebook–What Traumatized Children Can Teach Us About Loss, Love and Healing.”
Schore, J. R., & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36(1), 9-20.
Wylie, M. S., & Turner, L. (2011). The attuned therapist. Psychotherapy Networker, 35(2), 19-27.