Trauma-centered therapy: Healing the wounds of abuse and neglect

Categories: JCCA Spotlight

April is Child Abuse Prevention Month. In our community, residential, and preventive work, JCCA works with families to make sure all kids are raised in a safe and loving home. However, it is the nature of our mission that we also have to work with children who have been victims of child abuse. JCCA’s dedicated staff are experts in bringing culturally-aware, trauma-focused treatment to young people who have had some very damaging childhood experiences.  This interview with Amy Morgenstern, JCCA’s Director of Psychology for Community Based Programs, illuminates important issues in caring for traumatized children.

JCCA: How long have you worked at JCCA?

Morgenstern: I’ve been with JCCA for eight years. And previously, I was a psychology extern here.

JCCA: Can you talk a bit about the kinds of trauma the kids in our care experience?

Morgenstern: These kids have experienced chronic and complicated trauma before coming into care, whether it’s caused by abuse and neglect of their caregivers or the violence in the communities around them. The trauma often doesn’t stem from a single primary incident—it’s ongoing and complex trauma. It’s important to remember that their parents or caregivers have themselves often experienced serious trauma in their lives and this creates problems in how they’re able to deal with the demands of parenting and their children’s trauma.

The many layers of trauma that these children have experienced have a tremendous impact on their functioning. One of the most significant problems they have is the ability to engage with and trust other people and forge relationships of any kind.

JCCA: How do you deal with that?

Morgenstern: Addressing this is absolutely the first and primary thing we must do before any good work in treatment can be accomplished. We have to gain the child’s trust—a large task that requires tremendous patience and time. We have to show them that we’re understanding and able to create a safe space for them. This sometimes involves the actual physical space we’re in. For example, some children, because of traumatic events in their past, are uncomfortable in a small office with a closed door, so we have to change the setting for their comfort.

JCCA: What are your treatment models and methods?

Morgenstern: JCCA is committed to the use of evidence-based treatment models that are well suited to the individual, like Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). We try to be creative in our techniques, keeping the relationship uppermost in our mind. We also try to show our empathy for the caregivers and teach them how to better parent and understand their children.

With younger children, we often use play therapy, which helps them create a narrative to make sense of what has happened to them. It enables them to learn how to tell their own story. We also realize that many of these kids have grown up in homes where no emotion words (like love, afraid, lonely, etc.)  were ever used, so they really have no vocabulary to describe and explain their feelings. We have to help them build this language in order to begin the conversation about their emotional state. We do this through games, playing with toys, and creating art.

With adolescents, it’s necessary to teach them how their early traumatic experiences affect their daily behaviors, and how these patterns create obstacles for them in life. So we try to address the ways in which they can make changes to meet their own goals. It’s absolutely amazing what they can do when they actually see and understand the root of their behaviors.

For children in foster care, we also have to deal with a certain amount of guilt and ambivalence if they are happy with their foster families. We try to assure them that it’s ok to have positive feelings for their parents and their foster parents. The main thing is to provide understanding and empathy, and to preserve them in stable, loving homes.

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JCCA: Can you share a story of your work with a particular child and family?

(NOTE: All names and details have been changed to maintain confidentiality.)

James is a 13-year-old boy who came into foster care after his grandmother abandoned him at a psychiatric hospital, where he spent several months before he was ready for discharge. He was referred for therapy to address impulsive behaviors and physical and verbal aggression; he was also referred for medication needs assessment and management to address what appeared at the time to be a budding thought disorder. When we met James, we didn’t know much about him other than that he had a significant family history of schizophrenia, had experienced physical abuse at the hands of family members, had a mother who would disappear for months or even years at a time, and had an incarcerated father whom he hadn’t seen since he was a toddler. Can you imagine how unfairly the odds were stacked against a youngster like James?

During the initial phase of therapy, he was virtually impossible to engage; he made minimal eye contact, was disinterested in conversation or interactive play, and seemed not to be able to remember my name or even who I was from one session to the next.

Unfortunately, due to his behaviors and his poor interpersonal skills, he moved among several foster homes during the first few months of his placement in foster care. Foster parents seemed to work very hard to connect with him, buying him gifts and taking him out, but their efforts felt futile, and each of them eventually gave up. During therapy sessions, I learned quickly that I could not do much more than follow his lead, and many sessions were spent watching him play and simply narrating his behavior. I felt a lot of pressure from well-meaning foster parents to “work on” his behaviors and lack of warmth, but his behaviors showed me that he was nowhere near ready. He had experienced so much attachment trauma that it was going to take time and patience before he trusted me enough to let me into his world. To force myself in would be re-traumatizing. In the meantime, I focused my energy on his foster parents, helping them understand the ways in which his early trauma impacted his behavior, in order to switch their perspective from “What’s wrong with him?” to “What happened to him?”.  For example, one foster parent planned a birthday party for him at a local kids’ restaurant that she knew he loved. She was dismayed that on the day of the event, he refused to shower or get ready. She felt frustrated and unappreciated. I reminded her that in James’s past, gifts from his mother had come at a cost, as she would often buy him presents, then become irate and abusive when he did not demonstrate what she considered to be adequate appreciation.

It felt like very little progress was being made in therapy or in any other part of James’s life until about three months into treatment. A family member came forward hoping to see James, but he expressed a strong desire not to see her, as some of his difficult memories were associated with her. I was asked to help make the reunification happen, and I explored various creative ways to bring them together (i.e., Skype, phone, letters, etc.). However, after a few sessions, it became clear to me that James was becoming triggered in discussing this family member. Seeing her would be a traumatic reenactment. Ultimately, I advocated for him to use therapy to address his feelings about this family member, and to hold off on seeing her until he felt ready; in other words, I allowed James to dictate his own limits, thereby giving him power over the situation. Moving forward, our relationship improved, and slowly James became more comfortable with me. One day he brought in a small crossword puzzle book that he’d earned at school for good behavior and I discovered that he loved doing crossword puzzles. As we worked on a puzzle together, he started talking—first about friends at school and other relatively insignificant issues, but then about important parts of his history and some of his internal struggles of which I (and the other members of his team) had been totally unaware. I stayed quiet, just listening. The more I listened, the more he talked.

At around the same time, it started to become clear that James’s current foster placement was not working. I thought of another foster parent with whom I’d worked in the past, who I knew had had success and even adopted two children with similar histories and behaviors to James’s. I worked with James to plan for the transition. Because I knew him pretty well by then, I was able to advocate for things that I knew were important to him (he loved Ramen and cooking shows on TV, for example). In therapy, we rehearsed the first meeting with his new foster parent. During the meeting, I talked to the foster mother about his likes and dislikes, and encouraged him to share as well. I could tell that it was meaningful to James that I could speak about him so confidently, that I had taken the time to get to know him, and had given him the space to be himself and to allow me in at a pace that was comfortable to him. I could also tell that the fact that I knew and trusted this foster parent meant that he could trust her, too.

This foster parent has been fantastic with James. The road was bumpy at first, but she has made it clear from the start that she would not give up on him, and she’s kept her word. If she ever feels overwhelmed, she can depend on our treatment team for support, venting or seeking advice from the people who know James best. She has also shown James that she plans to treat him like he is one of her own: we knew that the relationship would work when she brought a birthday cake and threw a small party at the agency only two weeks after he moved in. Whereas other foster parents had placed James in respite care when they took vacations, this foster mother took him with her, introducing him to her adult children, grandchildren, nieces, and nephews, and making him part of the family immediately. Currently, James and the foster parent are planning for their upcoming adoption.

In therapy, James is a new person. He is coherent, thoughtful, and warm. He is able to verbalize when he cares for someone, and tells me each week that he missed me and is happy to see me.  He is similarly close with other members of his treatment team, including his psychiatric nurse practitioner, social worker, and sociotherapist. Quite significantly, we are no longer concerned that he might have a thought disorder. The positive and consistent relationships in his life have actually helped him to think and communicate more coherently. We are currently planning for his permanent discharge with the agency and with therapy.