20 Jun Complex trauma in residential care
Residential care is not a place for the faint hearted. It is difficult, emotionally draining, triggering and at times unsafe. Often children who reside in residential care have had multiple failed placements, further institutional trauma from crisis endings and tend to be placed in the “too hard basket”. The systems around them can lack cohesion, a shared understanding of needs and can be chaotic, further compounding the complexity of the child’s needs. We have failed in our duty to keep these children safe and their needs are complex and chronic and at times beyond the scope of practice for many professionals. Many children we see come with a variety of diagnoses including ADHD, ASD, ODD, Social Anxiety, Attachment difficulties and Bipolar. While on face value many children would meet criteria for most of these disorders, due to skills deficits in social, emotional, cognitive and relational functioning across multiple settings; they often miss the bigger picture and the true nature of what the child has experienced.
Complex Trauma, first proposed by Judith Herman in her book “Trauma and Recovery”, is both a compassionate and theoretically sound way to understand the intensity of need and the horror of what was experienced. It provides both residential care staff and clinicians a realistic and empathic formulation of a child’s needs. For example; increasing empathy is an unlikely goal for a 12-year-old boy with complex trauma. A trauma informed goal might be focused on supporting him to experience any difficult feelings in his body instead of dissociating(flight) or becoming aggressive (fight). Constantly reviewing our expectations while still maintaining hope and a fundamental belief in the resiliency of the child, is the cornerstone of working in residential care. It is very easy to become down hearted and enmesh ourselves with the hopeless and helpless aspect of the child, who does not feel worthy of our time or connection and is frequently pushing us away. Change is hard-earned and seldom seen if we view change through normal child development. However, through a complex trauma lens, nuggets of change can be viewed and celebrated.
As a Psychologist working in residential care, assessment of outcomes can be challenging; particularly when external systems need to see that change is occurring frequently. Change is not linear in complex trauma, but very bumpy and at times regressive. We have all heard the phrase “when the child feels safe, they show us their true pain”. If we have achieved our first goal of safety, the child begins to wonder “is this person capable of seeing the good, the bad and the ugly in me without running away or hurting me?” When this curiosity starts, we see extremes of behaviour and the hurt, pain and torment can become a tidal wave that no one is prepared for. It may appear in extreme aggression, sexualized behaviour or suicidal ideation and it tends to push people away, because we become swallowed in its intensity and power. If we can tolerate this barrage of raw pain that is often frequent and unrelenting, then children can recover with some learning and we have made a shift.
This shift is often not revealed in behavioural change, which can leave us feeling incompetent or ineffectual as practitioners. However, what I have seen clearly is shifts in relationships, seemingly inconsequential examples of moments of true connection between child and carer. Residential staff might make statements like “he allowed me to sit with him when he cried”, “when I asked him if he was worried he said yes”, “she become angry but it was short-lived and she was able to talk it through”. These qualitative examples reveal significant attachment shifts in children, who often respond to feeling vulnerable by becoming enraged or absconding. The child is now attempting to use the attachment figures around them for emotional support, guidance and connection. A fragile hope that maybe this person can meet a need, that was never met. Hopefully, the child will then internalize these positive attachment experiences into internal representations and start to feel worthy, but this is a long and grueling path. Only then might we catch a glimpse of a shift in behaviour, some evidence that change has indeed occurred. Measuring relational shifts in the traumatized child is still in it’s infancy, but it seems a more apt measure of the therapeutic value of residential care. I do not suggest throwing our CBCL’s and SDQ’s away, but simply being realistic in regards to how change looks in complex trauma.