Abstract
Early exposure to multiple trauma has a cumulative and pervasive effect, often resulting in complex symptomatology that includes Post Traumatic Stress Disorder (PTSD), as well as a variable group of symptoms, including self-regulatory disturbances, dissociative experiences, negative view of self, and difficulties in the relational context referred to as complex-PTSD.1,2 Complex trauma exposure results in loss of core capacities for self-regulation and interpersonal relatedness. 3 The developmental timing of the trauma and the presence of secure attachment relationships prior to trauma play a determinant role in impact.4,5 The presentation calls for a nuanced understanding of the interdependent impact of trauma on neurobiology and healthy development to formulate and implement integrated psychotherapeutic interventions. This article describes the psychotherapeutic process of addressing complex trauma in a 14-year-old adoelscent and critical considerations for attachment-focused trauma work.
Case History and Initial Assessment
Ms. C, the seventh child to parents from a lower socio-economic status, later adopted at age 8, presented with severe affective and behavioral dysregulation, dissociation, aggression toward her adoptive mother, and self-harm behaviors. She could recall a few memories of her early childhood, living with her biological family, and losing her mother when she was four. At age 5, she, along with her sibling, was allegedly abducted by unknown perpetrators, where she was made to work as a housemaid and perform chores atypical for her age. She was subjected to physical, sexual, and emotional abuse, being stripped, beaten up with canes, and burnt across various parts of her body. After a year, she and her sister escaped and got on a train to a large city. However, she lost contact with her sister during the journey. As her biological family could not be traced, the child protection services placed her in a childcare institution, where she had formed confiding relationships with her inmates.
At age 8, she was adopted by a motivated and committed single mother who was a special educator. The adoptive mother identified specific developmental and emotional problems with the child, such as high activity levels, frequent “un-understandable” and “out of proportion” outbursts in response to apparently nonthreatening cues, and running away from home. She placed her in an alternative school because she was sensitive to the child’s developmental needs. Employed caregivers supported the mother in parenting, with whom the child adapted quickly. However, caregivers had frequent and abrupt changes due to challenges.
There were contrasting instances of seeking emotional support from her mother and the caregivers to dismissive behaviors and extreme physical aggression posing harm. Developmentally inappropriate play behaviors and bedwetting episodes were reported. These symptoms and behaviors indicate that some parts of the child had begun to experience this new environment as potentially safe and caring, while some parts perceived it as restrictive and impending abandonment.
The child was often bullied at school and in the neighborhood for her appearance and adoptive status, thus reinforcing her negative self-concept. Her behavioral challenges worsened during the lockdown, including disinhibited online engagement, multiple self-harm behaviors such as self-cutting, spraying aerosols on her body to produce skin burns, eating chilies, and eventually extending to threats to jump off heights, breaking property, and swallowing sharps. She also had dissociative experiences such as repeatedly seeing a man who might harm her, responding with intense arousal, and not being recollected completely by the child. The mother continued to make attempts to “understand the child behind the problems” but was concerned about the child’s and her safety. Worsening aggression necessitated inpatient management.
The initial week of inpatient care was characterized by episodes of aggression, dissociation, and challenging self-harm behaviors, which occurred upon demands not being met or during dissociative experiences of reliving past traumatic events. She would appear fearful, describe vivid details, hide in the cupboard or under the table, or lock herself up in the bathroom. (In the later sessions, she reported she would do this when she was abducted and abused in order to protect herself). She required sedation to manage severe self-harm attempts and aggression, Furthermore, underwent multiple investigations and surgical referrals for having swallowed sharps.
There were several indications for the diagnosis of c-PTSD. Figure 1 represents case conceptualization. The current presentation was triggered by experiences including abuse, loss of a friend, and abrupt change in caregivers that could have resulted in the child beginning to “make sense of her past trauma,” experiencing feelings of “abandonment,” “thwarted belongingness,” and the eventual destabilization. In the absence of a consistent attachment figure and lack of core capacities for self-regulation, self-harm evolved as a coping mechanism during periods of arousal and dissociation.
Case Conceptualization.
Principles and Approach to Psychotherapy
For children and adolescents, trauma work needs to be approached sensitively in the context of a protective environment and a well-developed therapeutic relationship. Traumatized children often have multiple working models of themselves and their caregivers and may have challenges with compartmentalizing normal negative experiences (e.g., rejection, demands unmet). An attachment-informed phase-oriented approach to trauma work 6 was adopted. Therapy was done inpatient over eight weeks (weekly 4–6 sessions).
Phase 1: Stabilization and Building Attachment Relationships
The initial goal of treatment was to focus on stabilization, enhancing the sense of safety, and addressing dissociation. Sessions focused on building rapport, safety education, and boundaries in interpersonal contexts. Clinical evaluation revealed temperamental difficulties and concerns in the cognitive and socio-emotional developmental domains.
Trauma-Abusive Relations and Experience
Unreasonable financial demands triggered aggression and behavioral dyscontrol whenever the mother negotiated for an alternative. This was postulated to arise from a give-and-take and conditional relationship for survival that she had in her past relationships. On regaining composure, she would report that during the aggressive episode, she felt as if she was defending herself against a man who was beating her; however, she ended up expressing anger and hitting the mother instead. Instances of locking herself in the cupboard or bathroom, holding a stone in her hand for self-defense, were reliving experiences alongside nightmares and intermittent recollections of traumatic events. She described that she would desperately try to kill herself during these instances as she feared being caught and exploited.
Re-enactment of trauma was noted in play sessions, wherein the child and her sister came on a big truck to a big city and a queen’s house. She would avoid a hot water bath because she feared being burnt (sensory memories). The child was often in a “hyperarousal” state, beyond the “window of tolerance.” 7 Graded introduction of relaxation strategies, grounding, and debriefing incidents after a period of affective stability were attempted. Crisis intervention plans and safety agreements were discussed.
Trauma-Attachment
The child faced difficulty in developing a consistent and secure relationship with the mother due to her past experiences, attachment insecurity, and mother’s parenting practices that were based on discipline and rules. In the case of traumatized children, mistrust or betrayal from significant adults who have almost always set rules to benefit themselves, rule-abiding becomes a challenge. 6 There was a strong sense of abandonment whenever she perceived the physical/mental absence of her mother.
Adoptive Mother as a “Parent”
Part of the child’s issues stemmed from a disrupted attachment with the adoptive mother. Understanding the mother as a “parent” and as a “person,” addressing fear of abandonment and thwarted belongingness was the preamble to attachment work. Sessions with the mother focused on assessing parenting through caregiving and attachment narratives. Early experiences hindered the development of secure attachment relationships in the mother’s life. The adoptive mother had lost her father at a young age, and her mother remarried. She grew up as a self-made individual, “found happiness in helping others,” and pursued her mother’s vision of “child adoption” to give back to society. As an individual trying to heal from her own difficult past and insecure attachment, she had challenges in emotionally connecting to the child during the initial years of adoption. However, she overwhelmingly satisfied the child’s instrumental needs. The mother and child lived in different rooms at home, and the appointed caretakers stayed with the child. Though the mother focused on providing instrumental support, she tried enhancing her parenting style with consistent efforts to create an emotional bond by spending quality time, negotiating rather than instructing, and giving the child space for physical comfort such as hugging and sharing their experiences. The mother and child developed an affectionate relationship and respected each other’s choices; however, unpredictable periods of dismissive and aggressive behaviors from the child were challenging for the mother to comprehend.
In the stabilization phase, symptoms were understood from a biopsychosocial perspective. A child-centered approach was initiated; a therapeutic alliance between the child and mother aided in managing crisis situations. Part of the exploration of phase one work involved helping the mother understand child’s actions and working to develop a more empathetic meaning for the child’s behaviors. A nonjudgmental and nonblaming approach toward the mother was key in facilitating empathy for herself as a parent. The mother was gradually involved in co-regulation, which played a role in building attachment, wherein the child would experience the mother as a safe, reliable, and secure base.
Phase 2: Working on Trauma Processing and Re-attachment
As the crisis events became less frequent, the child was more amenable to working on emotional regulation skills such as building emotional vocabulary, labeling, contextualizing emotional dysregulation, co-regulation by the mother using cue words, and creating physical safety spaces in the ward. The child could narrate her thoughts and feelings better during this phase, which was fragmented rather than consolidated. Though periods of dissociation continued, the child was gently helped to become aware of these changes. As part of developing a coherent narrative, the child preferred to write her life story. Given her academic difficulties, a combination of audio recordings and drawings was encouraged.
In her narratives, the child spoke of having four mothers: the biological mother (meri maa), the stepmother, the adoptive mother, and the woman with whom she had stayed during the abduction. She spoke fondly of her memories with her siblings, her biological and stepmother. Her descriptions of her adoptive mother reflected her as someone who looked after her instrumental needs but did not comfort her. She spoke of feeling comfort with her soft toy as it would listen and could never hurt her.
Mother’s own attachment experiences influenced her parental identity and parenting practices.
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The mother believed in being a “democratic parent” and treated the child as an “independent adult.” However, considering the child’s emotional and attachment needs, a co-regulating environment, flexible structure, norms, and consistent routines were important. The mother understood the need for strengthening attachment by providing “
Mother started to recognize attachment cues and respond in a sensitive and attuned manner, establishing a “secure cycle.” Owing to the child’s multiple inconsistent, disorganized, and traumatic attachment patterns in the past, it was challenging for the child to engage in reciprocal and attuned interactions with the mother. Joint play, craft work, shopping for herself (gaining autonomy through age-appropriate activities), and quality time, including activities of the child’s interest such as watching movies and dancing, provided space for “success experiences,” thus promoting a positive sense of self in the areas of perceived competencies. Parallelly, enabling the mother to have an empathic stance toward the child and reassuring her presence helped the child gain a sense of safety and trust in her relationship.
While the mother was committed and consistent, intense aggression posing potential threats to the mother’s safety and well-being was a concern. The child’s developing insight into her symptoms was a positive factor in addressing this concern. Addressing dissociation throughout the initial phase facilitated graded experiential reintegration. When the child’s reflective capacity improved, a safety/ crisis management plan was discussed with the child and mother. The child could list how she could regulate herself and how she wanted the mother to respond during times of aggression. Despite setbacks, the mother-child dyad was able to implement the safety plan with therapist support. Differential reinforcement strategies to facilitate adaptive behaviors and unreasonable demands were integrated as the attachment relationship improved, and the child did not perceive negation from the mother as abandonment but was able to contextualize it. The mother was upskilled in setting limits with the child and helping the child understand realistic boundaries and the consequences of her obstructive behavior while establishing a “secure cycle.”
Over the course of therapy, the child moved from thwarted belongingness to “feeling safe” with her mother. This process of change was evident in one of the conjoint activities, where the child made a drawing of her mother and herself. Depicting the child offering her heart to the mother, the mother initially contemplating and later accepting child’s heart.
Phase 3: Joining the Developmental Trajectory: Building Intra and Interpersonal Resources
The child’s strengths in nonacademic activities such as cooking, grooming, and arts and crafts served as an avenue for emotional regulation and building self-concept. Despite her limited written and expressive abilities, she was able to express herself through art. She would also nurture and tutor younger kids in the inpatient setting, which served as opportunities for ego-strengthening. The child prepared a toy house that represented “safety” and shared it with other children, reflecting the movement toward integration (Figure 2).
Toy House Made by the Child, Now Housed in the Play Therapy Room (picture included with child’s assent).
Significant improvement in behavioral issues, self-harm tendencies, and attuned communication was noted. Plans regarding the child’s vocational rehabilitation and post-discharge care were made, with the mother as a co-regulator. The need for a predictable routine and focus on the mother’s mental health was emphasized. A stepped approach to contingent responses to the child’s behavioral problems based on the intensity and the child’s reflective capacity in a given context was developed actively involving the child.
Outcome at 6 Months
At six months post-discharge, the child could manage her distress better with her mother’s assistance and engaged in extra-curricular pursuits along with open schooling that was more flexible and suited to her needs. Periods of aggression and dissociation were less of a problem, and the attachment relationship continues to nurture healthy socio-adaptive functioning.
Reflections and Discussion
This case highlights the experiences and processes in the management of children with complex trauma. Overall, a phase-oriented approach has been recommended for managing PTSD in adults, and the guidelines for trauma work in children stress upon maintaining stability in functioning and appropriate developmental trajectory. 9
Children with severe ACEs, and thereby hampered emotional and cognitive development, have challenges in articulating their traumatic experiences, interfering with trauma reprocessing and integration. Dissociative experiences pose a major challenge in therapy as they are not integrated into the sense of self, resulting in discontinuities in conscious awareness. 6 Therapy, in this case, involved movement back and forth within and between phases until the child reached good stabilization and building an attachment relationship with the mother, where the mother can support the child to explore, resolve, and integrate her traumatic experiences.
An important goal of trauma work is to enhance a sense of safety, trust, and belonging both in the therapeutic relationship and with the primary attachment figure. It is crucial to help caregivers see a possible role for themselves without feelings of failure and blame and with empathy for the child and themselves. Therapy aims to rebuild attachment and help the parent-child dyad see a different relationship with shared goals. This attachment relationship acts as a secure base for the child to achieve their optimum potential, which was missed in previous relationships. A strong therapeutic alliance, containment and consistency, bringing internal conflicts to conscious awareness, empathetic understanding of the child’s acts as “making sense,” establishing a secure attachment relationship, and cocreation of meaning were key processes that brought about corrective emotional experiences aiding in reframing the self and worldview. Caring for a traumatized attachment-disordered child poses challenges even for a committed adult. 6 Motivation and preparation of the primary attachment figure plays an important role in reestablishing attachment. Addressing parental attachment experiences and mental health concerns helps gain critical insights and prepares them for moments of attunement and connectedness. Termination of therapy must be planned sensitively, as oftentimes, the therapist becomes a key attachment figure, where termination could reflect a sense of abandonment. Lastly, it is important to pay attention to therapist support, as trauma work is overwhelming as much as rewarding it can be.