Working with Traumatized Parent-child Dyads: Challenging the Internal Working Model

Douglas Goldsmith, Ph.D.

Executive Director

The Children’s Center

Overview

• Understanding secure attachment• Understanding the impact of trauma• Assessment of the internal working model• Challenging/Repairing the internal working

model in treatment

Secure Attachment

• The caregiver is perceived as a reliable source of protection and comfort

Secure Attachment

• When I am close to my loved one I feel good, when I am far away I am anxious, sad or lonely

• Attachment is mediated by looking, hearing, and holding

• When I’m held I feel warm, safe, and comforted• Results in a relaxed state so that one can, again,

begin to explore

Holmes (1993)

Secure Attachment

• Promote exploration of the environment• Expand mastery of the environment• “I can explore with confidence because I

know my caregiver will be available if I become anxious.”

• The infant gains confidence in his or her own interactions with the world

Weinfield et al (1999)

Secure Attachment

• Attachment is a reciprocal relationship

• The parent offers caregiving behavior that matches the attachment behavior of the child

• The child, using social referencing, checks in with the mother “looking for cues that sanction exploration or withdrawal” Holmes (1993)

Anxious Attachment

• Lack experience with consistent availability and comfort

• Attachment behaviors are responded to with:• Indifference• Rebuffs• Inconsistency

Anxious Attachment

• Anxious about caregiver’s availability• Afraid that the caregiver will be unresponsive

or ineffective in providing comfort• Experience anger about caregivers

unresponsiveness

Anxious Attachment

• Shows overt aggression toward the inconsistent mother

• “Don’t you dare do that again!” but has to cling because he knows from experience that she will.

Holmes (1993)

Impact of maltreatment

• Peer relations are disturbed• More withdrawal and avoidance

• Physically abused children are more aggressive toward peers

• Display unusual or aggressive behavior in response to distress of peers

• More depressive symptoms

Impact of maltreatment

• School functioning is compromised• Representational models of self are more

negative• Experience distorted ongoing parent-child

interactions• More negative family relationships• Poorer developmental outcomes

Lyons-Ruth & Jacobvitz 1999

Impact on the parent-child relationship• “A frightened or frightening attachment

figure presents an inherent conflict for an infant. Fear of the parent activates the attachment system, and the infant feels compelled to seek proximity; however, proximity seeking increases the infants fear, and he or she then contradicts the approach.”

Lyons-Ruth & Jacobvitz, 1999

Relational PTSD

• Parents may be traumatized even if not present at the trauma:• Withdrawn/Unresponsive/Unavailable

• Emotionally and functionally unavailable• May have suffered trauma in the past

• Overprotective/Constricting• Preoccupied about the trauma re-occuring

• Reenacting/Endangering/Frightening• Repeatedly ask about the event

Scheeringa & Zeanah (2001)

Parental Response to Trauma• Parents experience:

• Helplessness• Frustration with inability to protect

their children

Osofsky ( 1995)

Impact of Parental Anxiety

• Unable to hear their children’s distress

• Withdraw to protect themselves emotionally

• Difficulty tolerating children’s anxiety and aggression

Osofsky & Fenichel, (1994, 1996, 2000)

Children’s Response to Trauma• Loss of sense of basic trust• Loss of security• Destabilized “Secure Base”

Compromised emotional development

Infants and Toddlers

• Following violence in their home or community:• Increased irritability• Immature behavior• Sleep disturbances• Emotional distress & crying• Fears of being alone• Physical complaints• Loss of skills – regression in toileting and

language• Increased separation distress

Appleyard & Osofsky (2003)

Young Children

• Re-experiencing of the traumatic event• Avoidance• Numbing of responsiveness• Increased arousal• Fear going to sleep to avoid nightmares• Restricted range of emotion in play• Serious, disorganized, somber

Appleyard & Osofsky (2003)

Parental Response to Trauma• How does the parent make sense of the

child’s new behaviors?• Is the child perceived as understandably

anxious? Or too clingy?• Is the parent able to be patient and

supportive? Or is the parent pushing the child too hard to resolve the trauma?

• How is the “Circle of Security” impacted?

Internal Working Model

• “Through a history of responsive care, infants will evolve expectations of their caregivers’ likely responses to signs of distress or other signals of the desire for contact”

• Bowlby believed that, “What infants expect is what happened before.”

Weinfield et al (1999)

Impact of the Internal Working Model

The model governs how children feel toward

each parent and about themselves, how they expect to be treated

and how they plan their own behavior toward

their parent

Internal Working Model

• Anxious infants learn to see the world as:• Unpredictable• Insensitive• The self does not deserve better treatment

• These beliefs are carried forward to new relationships and new experiences

Weinfield et al (1999)

Internal Working Model

• “When the expectation of being hurt, disappointed, and afraid is carried forward to new relationships, the anxious infant becomes an angry, aggressive child.”

Weinfield et al (1999)

Bowlby

• The IWM governs how he feels toward each parent and about himself, how he expects each of them to treat him, and how he plans his own behavior towards them. They govern too both the fears and the wishes expressed in his day dreams

Bowlby

• The IWM of a parent and self in interaction tend to persist

• The IWM comes to operate at an unconscious level

• As child grows older and parents treat him differently there is a gradual updating of the IWM

Bowlby

• But for the anxiously attached child• Updating is obstructed through defensive

exclusion of discrepant experience and information

• Patterns of interaction are habitual, generalized, and largely unconscious

• They persist uncorrected and unchanged even when dealing with persons who treat him differently from his parents

Maintaining Proximity

• When attachment behaviors such as searching, calling, and crying persistently fail to regain the figure, the child is forced to marshal defensive strategies that exclude this painful information from consciousness.

Solomon & George

Response to Trauma

• When a child feels unwanted and unlovable (mirrored by representations of the attachment figure as one who cannot care for or rejects the child), representational models reflect a complex interplay of multiple representations of self and other that are to some degree incompatible and difficult to integrate

Solomon & George

Understanding the Post-trauma IWM• How has the trauma impacted the child’s view

of the parent? Others? Sense of safety?• How has the trauma impacted the parent’s

view of the child?• Permanently damaged?• Needing extra care and nurturing?• Fears getting close?

Assessment of Parent’s Point of View• Interview questions:

• Could you give me a thumbnail sketch of your child?• Tell me about a time in the past two weeks when you

and your child really clicked.• Tell me about a time when you didn’t.• What gives you the most joy in your relationship?• What gives you the most pain?• Where do you turn for emotional support?

Steele (2003)

Assessment – Secure Base

• Over the past two weeks can you think of a time when your child was:• Hurt?• Frightened?• Separated from you?

• What did your child do?• How did you respond?

Assessment of the Child

• Utilize narratives to gain an understanding of the child’s view of adults

• Clinical interview

Treatment - Bowlby

• A therapist applying attachment theory sees his role as:• Providing the conditions in which the patient

can explore his representational models of himself and his attachment figures

• Helping the patient reappraise and restructure the models in the light of new understanding

Treatment - Bowlby

• Five therapeutic roles• Provide a secure base• Help the patient consider ways in which he

engages with significant relationships• Encourage exploration of the therapist-

patient relationship• Consider how perceptions are a product of

childhood relationships• Recognize that past images may no longer

be appropriate

Challenging the Parent’s IWM• Parental Insightfulness

• What do you think was going through your child’s mind?

• Gain a comprehensive understanding of the parental point of view

• Gently challenge the point of view

Challenging the Child’s IWM

• Utilize play therapy to understand the child’s world view

• Gently challenge the child’s perception by intervening within the child’s play

• Utilize empathy to challenge the child’s expanded world view that may include adults outside of the family circle e.g. “Adults are never helpful” “No one understands”

Challenging the Child’s IWM

• Use observation and interview to understand how the child’s perception of peers has been impacted

• Group therapy may be instrumental in helping the child view peers less negatively or defensively

Parent-Child IWM

• Parent-child therapy is utilized to:• Help the parent respond empathically• Interpret the child’s play• Confirm/correct child’s view of trauma• Practice nurturing skills• Learn to set limits• Help child with emotion regulation

Supportive Parent Intervention to address PTSD• Increase protection for highly anxious

children• Temporarily change sleeping arrangements• Actively demonstrate safety• Allow child to maintain closer proximity when

possible• Decrease toileting demands on very young

children• Increase use of transitional objects

Supportive Parent Intervention

• Increase structure for acting out behaviors• Remind children that rules haven’t changed• Continue with consequences• Increase communication and help child

understand their response to trauma

Secure Base Interventions

• Nurturing • Concept of good grandparenting

• Anticipating needs• Helping child regulate emotions• Parental emotional availability• Structure and consistency• Experience of being in one’s mind