The process of assessment, planning and therapeutic intervention at Genesis cte is rooted firmly in well-researched, evidence-based thinking, that has its origins in Attachment Theory and the best understanding of how children mature physically, emotionally and socially. These approaches are underpinned by developmental neuroscience and a clear understanding of what children need to maximise healthy brain development. Most of the children and young adults in our care have experiences of being parented and cared for in ways that have detrimentally affected the normative, healthy maturational process. Sometimes this has been further exacerbated by mental health and/or developmental problems that further undermine healthy resilience and the development of independent coping mechanisms. In all cases, our approach is based upon firm principles of parenting and caring that include:
- Being sensitive and emotionally responsive to children’s need for attention
- Providing effective and consistent comfort to children when they are stressed (co-regulation of affect)
- Being a good first companion, as children learn how to enjoy and stay connected to other people
- Knowing when to allow children to struggle and work through challenges for themselves, to help build resilience
- Protecting children from the dysregulating effects of our own negative emotions, by carers consistently applying their own abilities to self-regulate and manage stress (always being the adult in the room)1
1 [From: ‘Brain-Based Parenting – The Neuroscience of Healthy Attachment’ by Dan Hughes & John Baylin (2012)]
At the core of Attachment Theory is the belief that, in order for us to grow and mature into socially and psychologically successful people, at the earliest stages of our life we need to form a close, mutually satisfying, bonded relationship with at least one primary caregiver. It is this relationship which provides a physically and emotionally secure base from which infants can build the necessary the confidence to explore the world, take risks, and grow and develop as personalities. However, this process can be disrupted for one reason or another (including parental failings), leaving the child with weak and tenuous attachments. The specific nature of the relationship with their primary caregiver is, in large part, the determining factor in the attachment style of child. Attachment styles are defined as:
Primary caregiver is emotionally available, perceptive, responsive and attuned to their child’s needs and psychological state. Children are therefore able to use primary caregiver as a secure base from which to confidently face the world. The internal working model of the child is one that expects their needs to be met, their emotions to be regulated and that they can freely and safely explore their environment. As the child matures, their relationships tend to be stable, trusting, reciprocal and mutually satisfying.
Primary caregiver is emotionally unavailable, imperceptive, unresponsive and rejecting, especially when the child is emotionally needy, frustrated or angry. Consequently, these children tend to present as significantly clingier and more demanding than securely attached children. The internal working model is one where the child expects their emotional needs to be ignored, and therefore adopts a protective, ‘deactivating’ strategy in respect to attachment. Rather than be ignored or rejected, they disassociate from contact and repress their emotions more generally. As the child matures, their relationships tend to be marked by mistrust, defensiveness, emotional distance, coldness and pseudo-independence.
Primary caregiver is emotionally inconsistent, unreliable and unpredictable, sometimes responding positively to their child’s emotional needs, and sometimes being distracted and un-attuned. Consequently, children tend to be more anxious, more distressed at separation, more difficult to soothe, and much clingier than securely attached children. The internal working model is one where the child is constantly unsure of what to expect in terms of emotional response. As the child matures their relationships tend to be marked by neediness, anxiety, impulsiveness and insecurity.
Primary caregiver is unable to protect the child from trauma and/or abuse (and/or is the source of trauma and abuse); nor are they able to properly acknowledge it, reassure them or soothe their child. In these circumstances, often the primary caregiver has mental health, substance abuse or other significant psychosocial problems of their own. As such, their caregiving responses tend to be highly erratic, punitive and even hostile. Although these children are still driven to seek out care, nurture and safety when it is provided, they tend to experience it as traumatic, as it rekindles memories of abuse. The internal working model is one where the child expects those who try to care for her will also hurt and abuse her. The sense of being cared for is both the source of potential safety and extreme fear. As the child matures, their relationships tend to be marked by extreme mistrust, hostility, entitlement and demanding behaviour, lack of empathy and emotional dysregulation. Many children cared for by Genesis cte exhibit behaviour and emotional responses most often associated with disorganised attachment styles.
Intersubjective communication is a reciprocal experience between people, where each is open to both influencing and being influenced by the other. Almost all children with attachment difficulties (especially those with a disorganised attachment style) struggle with the essential ‘give and take’ of relationships. Rather, high-levels of anxiety and a fragile sense of security tend to drive highly controlling behaviours, which make the experience of attempted caregiving as less frightening. Similar patterns of behaviour can be seen with their peers. However, these behaviours make it more difficult for the child to recover from trauma.
To successfully care for children and young adults who display emotional, psychological and behavioural traits most often associated with significant attachments issues (especially those with a disorganised attachment style), Genesis cte are committed to an approach based on the principles of Dyadic Developmental Psychotherapy. This approach was developed by Dan Hughes, and is based on a theoretical understanding of attachment and intersubjective relationships; and the impact of developmental trauma. DDP is a model which is as much about therapeutically framing day-to-day interactions of caregivers, as it is about individual psychotherapy. Growth and emotional healing emerge from real-life relationships marked by healthy patterns of relating and communicating. The aim is to help the child or young adult to feel less fear and shame, and to see the need to exert complete control relationships recede.
Playfulness, Acceptance, Curiosity, Empathy (PACE)
PACE (Playfulness, Acceptance, Curiosity, Empathy) is a core principle of DDP which intended to shape the way caregivers think, communicate and behave towards the traumatised child, in order to maximise their feelings of safety. It is based upon how successful parents connect to their infant children, in a way that ensures a secure attachment. By adopting this approach, the troubled and traumatised child can begin the painful process of let others get close to her emotionally. She can begin to trust.
In order to create an atmosphere of lightness and enhance an initial sense of connection with the child, therapists and caregivers need consistently maintain a light tone of avoid, indicating clearly that relationships are non-threatening and even joyful. It is essential the traumatised child does not feel judged or criticised. Playfulness does not mean being funny or telling jokes all the time. Sometimes children are sad, and this needs to be acknowledged in the way the caregiver communicates. Playfulness is about helping children be more open and positive about their life, one step at a time. Sometimes traumatised children can find it difficult to share in excitement, fun and enjoyment, experiencing at the time (or shortly after) as anxiety, which they find difficult to regulate. Playfulness is helps children cope with intensely positive, as well as negative feelings. It makes them less defensive, even when it is necessary guide or gently admonish the child for minor negative behaviours.
At the core of the child’s experience of safety is unconditional acceptance. This does not mean all behaviour, including behaviour harmful to the child or others is simply accepted. All children need to boundaries, expectations and limits. However, whilst behaviour does need to be corrected, the underlying thoughts, feelings and urges that reflect the child’s motives need to be accept without judgement. That is, the child’s inner world is not right or wrong, but simply is. There is a distinct difference between criticising the child’s behaviour and criticising their sense of self. This crucial distinction is at the centre of every interaction between caregivers at Genesis cte, and the children and young adults they care for.
The foundation of acceptance is curiosity, especially in relation to the motivations for behaviours and the thoughts and feelings that underlie them. Curiosity is an approach in which the caregiver makes it clear that it matters to them why the child behaves in a certain way, in order to help them come to clearer understanding. Many children and young adults with significant attachment problems simply do not understand the reasons for their behaviour. Curiosity is essential to help the child identify that their unacceptable behaviour does not mean that they are flawed or bad as individuals. Rather, they need to understand that their behaviour is often the only way they currently have of expressing the highly stressful, confusing and frightening thoughts and feelings they have. It the caregiver is open, interested and curious, the child or young person may be able to communicate some of these bad thoughts feelings without recourse to negative or self-destructive behaviour.
Empathy is the process whereby the caregiver’s compassion can be felt by the child or young adult themselves. It is when the caregiver actively showing that the their inner-life, however sad, disturbed, confusing and frightening, really matters to them. It is about the caregiver actively communicating that however distressing the experience for the insecurely attached child, they do not have to go through it alone; that with the strength, care, love and commitment of the caregiver, together they will get through the difficulties. It is about caregiver communicating that they will not abandon the child, emotionally or practically, whatever the difficulties.
Communication Using PACE
PACE is a proven method of helping caregivers focus on the whole-child and their inner experiences, not merely their outward behaviour. It helps children with highly insecure attachment styles gradually begin to become more secure and trusting with adults generally, and caregivers in particular. Further, as the caregiver differentiates between them as personalities and their behaviour, so the child begins to discover that they can do better; they can make sense of and manage their emotions, thoughts and behaviour. It also allows the caregiver to find successful ways of repairing relationships, when they are inevitably disrupted. Putting limits on behaviour is essential for all children. However, insecurely attached children often experience boundaries as a total rejection of them personally, devastating their fragile sense of self. PACE provides a way of rebuilding these relationships at these break points successfully and safely. Using PACE as the foundation of communication, also allows the caregiver to reduce the conflict, defensiveness and withdrawal that often seems ever-present in the lives of children with significant attachment difficulties. It also the caregiver to stay focused on the child’s strengths and positive features than lie beneath the challenging behaviour.
Shield of Shame
Highly insecurely attached children, especially when confronted with their wrongdoing, find themselves overwhelmed by a sense of all-encompassing shame. Shame differs from guilt inasmuch as the former induces a global sense of being a flawed, bad person, whereas the latter tends to relate only to the unacceptable behaviour itself. Whereas a securely-attached child who feels guilty about something they have done, can relatively easily acknowledge their behaviour and move to ways of reparation and repair, the shamed child needs to find an alternative strategy in order to protect their very fragile sense of self. The alternative is to collapse under the weight of self-disgust and self-loathing Consequently, shamed child often come up with a series of highly-defensive responses, particularly if faced with blame and anger at something they have done. They will in turn, deny, minimise blame others and finally explode with rage. The objective for the caregiver must therefore be to avoid shaming children, but find ways of helping them separate the sense of who they are from what they’ve done. PACE is a crucial tool in this respect.
Many, if not most of the children Genesis cte care for, have socialisation and psychological difficulties that originate in their earliest relationships with primary caregivers. However, not every child or young adult has problems that are limited to attachment difficulties, or indeed have specific attachment difficulties at all. Among the numerous other challenges face by our children and young adults include those of mental health (especially mood and anxiety disorders), self-destructive behaviours (including self-harm and suicide risk), abuse experiences and/or personality and identity issues (particularly those showing patterns of behaviour, thinking and feeling usually associated with emergent borderline personality disorder). Our approach to this range of problems remains firmly based in the core ideas of DDP and PACE. These principles provide staff with ways of thinking and interacting with children and young adults that best foster the building of trust and safety. However, within the small range of specialisations offered by our service, some additional theories and techniques enhance our primary philosophy.
Emergent Borderline Personality Issues
Borderline Personality Disorder describes a tendency to experience a range of sometimes highly unstable feelings, an inability to self-soothe and a common pattern of erratic, sometimes self-destructive behaviours. These behaviours (that include relationship instability, emotional dysregulation, dissociative emotions, vulnerability to exploitation, self-harm and risk-taking) are used as coping or distraction mechanisms, to deal with what can be extremely distressing symptoms for the individual. It seems highly likely that this condition is, in part at least genetic in origin. A predisposition contained in small abnormalities in the amygdala and hippocampus are exacerbated by negative life experiences, leaving the individual suffering a plethora of interconnected psychological and social difficulties. This condition seems to disproportionally effects girls, usually beginning in mid-adolescence. The recovery process can be slow, and sometimes incomplete, even over a lifetime. However, a carefully constructed combination of appropriate therapeutic interventions, a safe, nurturing, boundaried environment, and exposure to positive relationships and life experiences can help the individual develop new and healthier copying skills, and new ways of getting genuine pleasure from their lives.
Principles of DBT
DBT (Dialectical Behaviour Therapy) is a skills and insight-based approach developed in the 1980s by Marsha M. Linehan, specifically to address the complexities of Borderline Personality Disorder. It is intended to help the individual identify strengths and healthy copying skills they already have, and addresses negative thoughts, beliefs and assumptions that make life much harder. Essential among these skills are:
- Mindfulness (how to accept and be present in the moment)
- Distress Tolerance (how to cope with unpleasant feelings, rather than run away from them)
- Emotion Regulation (how to better control rapidly fluctuating and intense moods and feelings
- Interpersonal Effectiveness (how to better interact with others in ways that are assertive, maintains self-respect and strengthens relationships)
We understand self-harming behaviour as causing intentional damage to the body, as a maladaptive way of coping with and/or communicating with extreme and intense emotional distress. These behaviours can range from superficial cutting to life-threatening self-poisoning. These behaviours can be confusing and frightening for the person themselves, their family and friends, and professionals working with them. With many, many years of experience within our teams, we have developed and refined ways of working with self-harm in a way aims to give the sufferer themselves the best of chance of moving away from these behaviours, and towards more adaptive and healthy coping strategies. Because self-harm can easily become entangled in a core sense of self, it can take patience, thoughtful interventions and imaginative ways of managing risk to achieve lasting success. This includes the development of Alliance Agreements to minimise the risk of life-threatening self-injury, along with a ‘safer- tolerance’ approach. That is, to adopt and non-confrontational to superficial self-harm as a way of enhancing therapeutic opportunities and relationships, a fostering lasting change.
Child Sexual Exploitation
Some of our children and young adults have been victims of sexual abuse and exploitation, including those who have been ‘groomed’ by individuals or groups (where they’ve been manipulated by adults into sexual activity in return for money, drugs and alcohol gifts or perceived affection). For a significant proportion, among the primary reasons they were unable to effectively protect themselves is a series of underlying vulnerabilities, that including attachment issues, socialisation and relationship difficulties, emotional instability and mental health issues. Our approach, again informed by the principles of attachment theory and DDP, is to both address holistically the more general issues faced by the child or young adult, as well as providing direct therapeutic support for specific, unresolved trauma issues.
Post-traumatic Stress Disorder
Symptoms of Post-Traumatic Stress Disorder (PTSD) can occur when any person is exposed to traumatic events such a sexual assault and/or potentially life-threatening situations, either as one-off events or repeated over a prolonged period of time. Further, the witnessing of violence directed at others (particularly close love ones like a mother or a sibling) is also a common cause of trauma like symptoms. These include having disturbing, intrusive thoughts and vivid dreams and flashbacks directly related to the traumatic event/s and emotional instability in direct response to trauma related cues. In addition, they often at greater susceptibility to depression and anxiety disorders, along with an increased risk of self-harm and depression. Younger children tend to display less overt symptoms, but tend to express distress through play and key relationships. Recent studies confirm that PTSD causes significant neurological and biochemical changes in the way the brain functions, directly effecting the way emotions and emotional memories are processed. Many of our children and young adults have been exposed to significant traumatic events, some over long periods of time. Therapeutically addressing PTSD like symptoms also requires the same sort of approach as describe above in terms of attachment problems, personality problems and other mental health problems, both in terms of individual therapy and the provision of therapeutic social care based on DDP and PACE.
Autistic Spectrum Disorders
Some of the children we care for, not only have significant early attachment problems, but also face the challenge of having developmental difficulties, such as those associated with being on the autistic spectrum. Growing up they have often found social interaction and communication significantly more difficult than many of their neurotypical peers; also, often displaying restricted interests and ritualised behaviours. For these children, in addition to the DDP and PACE approaches, subtle changes are required in how the child is communicated with, with caregivers taking extra care to ensure they are understood, and they also have a clear and accurate understanding of the child and their wishes and views. Specific cognisance needs to be taken in regard to the sometimes highly restricted preferences of the child, along with their need for certainty and predictability in their lives. Our objective, as with all children, is above all to help them improve their confidence, skills and abilities in developing and sustaining positive social relationships with peers and adults.
Sexually Harmful Behaviours
When defining harmful sexual behaviours current guidelines refer to a continuum of concern, from ‘healthy’, to ‘problematic’ to ‘harmful’. Identifying where a behaviour ‘sits’ within this continuum can be challenging, although it is vital in tailoring an effective response. There is a growing body of evidence which suggests children who harm others have likely experienced significant trauma in their lives, whether this is exposure to neglect, physical abuse, sexual abuse and/or emotional abuse. It is unsurprising therefore that those that develop a distorted understanding of relationships and sexuality (which manifests in their behaviour) are most likely to have come from this group. As such, the highly complex needs of these children extend well beyond an approach that can be defined merely by risk management of their sexually harmful behaviour. Central to our ability to meet these needs are the principles of care and therapeutic intervention which guide all our other work (attachment theory, DDP and PACE), which in our view are by far and away provide the most the most effective tools for this particularly challenging and high-risk group. A much as anything, these children require a non-judgmental, non-confrontational, empathetic and nurturing environment, in which genuine growth and change can be fostered. In addition, early assessment and specialist intervention, which seeks to identify and manage risk, and build resilience and understanding of healthy relationships, has also been shown to produce the best outcomes for children who have presented with sexually harmful behaviour.