When six-year-old Mandi* came to us, she had suffered significant trauma in her early years from a drug-addicted mother, a father in prison, and several disrupted foster placements. She reacted to any limit setting with uncontrollable tantrums, terrorizing and discouraging her latest well-meaning but uninformed foster family, whose only recourse as instructed was to send her to a time-out room alone. Mandi repeatedly trashed the room in her rages. With no answer for her outbursts, the family could no longer bear them. As a last resort, she was sent to Wellspring, a multi-service mental health agency in Bethlehem, Connecticut, for residential treatment.
Post-Traumatic Stress Disorder has two faces: The first results from specific events, like rape and the impact of other forms of violence and terror; the second is cumulative, resulting from repeated abuse, abandonment and neglect during the first three years of life. Mandi suffered from cumulative trauma, which also contributed to her problems with attachment.
The neurobiology of these two forms of trauma is similar in many respects. With cumulative trauma, memory of early traumatic mother-child interactions remains pre-verbal or non-verbal, encoded in the brain body. These traumatic residues take the form of reactive trauma templates, which trigger seemingly unrelated and disproportionate responses to circumstances and events. Because these physiological, neurological and emotional processes are sensory based and reactive to stress, they tend to operate outside of cognitive, verbal processing. Because these memories have no words, and words cannot reach them, treatment and parenting must incorporate other modes of processing than cognitive verbal approaches or behavior modification alone. This has major implications for the treatment of traumatized, attachment resistant children like Mandi, but also for traumatized adolescents and adults.
If treatment is to have any hope of success, it must be relational. In his seminal work on the neurobiology of affect development, Allen Schore showed how the developing brain is shaped by early relational experience for better and for worse. The question is whether and how it can be re-shaped by corrective relational experience in later life. Martin Teicher at Harvard claims that the brain is already hard-wired by the age of three, so whatever has happened cannot be undone. Others such as Siegel, Cozolino and Farber claim that brain pathways can be altered through the continued plasticity of the orbito-frontal cortex. What this requires, however, are qualitatively different relationships that provide safety, closeness, caring and support. But both positions are true, for if change comes only through the quality and consistency of relational care, that care regrettably may not be available to most of these children.
Mandi was just as reactive initially at Wellspring. However, with our understanding of the traumatic underpinnings of her reactivity and our experience with children, staff learned quickly that by scooping Mandi up into their arms and holding her close, she calmed down quickly, allowing herself to be comforted and cared for. This gradually established a bond with the child based on care and trust. At our request, this intervention had been authorized in advance by state service providers (legal guardians) and by Mandi’s foster parents, because we were confident it would work. The question is why did it work?
Bessel van der Kolk, a recognized authority on trauma, made this salient point about effective treatment. “Because young children and threatened adults cannot inhibit emotional states that have their origin in physical sensations,” approaches to treatment and parenting need to be modified to incorporate “bottom up” rather than “top down” modes of processing. Because traumatic memory is implicit, or sensory based, rather than verbal, “bottom up” modes of intervention and processing for PTSD are body-based and sensory focused. They are specifically designed to address the critical role of stress in generating trauma-based emotional reactivity and behavior. Treatment not only works through the medium of corrective relationship for the long term, it must also manage stress in the short term, so that positive relational experiences from therapy and parenting can have a healing effect. These two dimensions of intervention and care must be woven together.
The cornerstone of “bottom up” processing, particularly with traumatized, attachment resistant children, is safe, healing touch. Touch is a powerful medium for both healing and for harm, because it directly contacts the body, the senses and the emotions. As a medium for receptivity and mutual exchange between the physical and psychic fields shared between people, touch is profoundly relational. The ability of touch to provide comfort and establish heart-to-heart connection makes it an ideal mode for “bottom up” processing.
What Mandi responded to so positively was the simple act of being held, soothed and comforted, rather than being sent off alone to her room. Scooping, as we called it, brought relief from the traumatic impact of how she experienced limit setting as a basic rejection. It relieved stress and made processing possible once she was soothed, comforted and reassured – once she was brought back into relationship. Treatment could then proceed with Mandi both in terms of the touch intervention used and the trust that gradually developed from it with the staff. Touch as a way to alleviate stress and inhibit reactivity provided the foundation for further treatment. Instructing her foster parents in the use of safe, healing touch, knowing how important it was to Mandi, became the basis for her successful return home.
Because the misuse of touch in physical and sexual abuse has harmful effects, risk prevention has tended to dominate the clinical stage at the cost of clinical effectiveness. “No touch” policies have been instituted by many agencies to guard against potential abuse, but more pointedly to guard against the threat of litigation. This is done without considering that more harm may be done to a child by perpetuating early touch deprivation and how a sexually or physically abused child will learn the difference between healthy and harmful touch. What Wellspring has done is take a pro-active approach to the use of touch in treatment that combines an in-depth understanding of its integral role in development with ethical and practical guidelines for safe and sound practice.
The use of touch in treatment is applied not only to traumatized, attachment resistant children like Mandi, but to traumatized adolescents and young adults as well. The use of safe, healing touch at Wellspring is permission based, treatment related and trauma informed. It stems from ongoing assessments of each client and family, which includes not only an assessment of sexual abuse, but the assessment of hyper and hyposensitivity to touch that can differentiate sensory integration and sensory modulation problems from problems with attachment. Equipped with this information, staff is trained with ongoing supervision in the different levels of safe, healing touch, ranging from supportive touch to permission based and clinically authorized nurturant holdings designed to fill in developmental gaps. Stress reduction for clients suffering from PTSD is a by-product of this approach.
Within our adolescent residential program, for example, and based upon mutual agreement, parents who were withholding of touch based on their own parenting, are encouraged to hold their children once they are able to recognize its importance for their child’s health. This invariably has had a positive effect in helping families to develop healthy, affectionate and supportive relationships, which in turn has facilitated successful returns home.
When these relational and “bottom up” modes of processing are woven into the fabric of an intensive multi-modal treatment program, which is anchored in turn by individual, group and family therapy, they add the necessary means and power to address and heal traumatic residues from the past.
* Names have been changed to protect privacy.