CREATIVE PSYCHOTHERAPY WITH DEVELOPMENTAL AND COMPLEX TRAUMA

It is my pleasure to introduce this guest blog by Carol Duffy. Based in Mayo, Ireland, Carol is a child and adolescent psychotherapist specialising in play. She is also a clinical supervisor and trainer. She has over 15 years’ experience working with attachment disruptions, trauma, and sensory regulation. Carol is also married and mum of three vibrant and wonderful children. As this blog shows, she fully understands the importance of safety, regulation, attunement and repair after ruptures in relationships. She also shows the value of play as a healing process. Carol describes beautifully how play and safety are so connected in therapeutic work. I hope you enjoy this thoughtful and insightful blog and please do share. Patrick Tomlinson

Part 1 The deceptive simplicity of psychotherapy using play and creative approaches is quite paradoxical to explain. In many instances, it must be seen, felt and experienced to be fully understood. There is a wealth of science available to us now to consolidate what we as creative psychotherapists experience and contemplate so frequently and fluently in our work. Play and creativity are often cited as having transformative, therapeutic, healing and reparative potential, amongst many other qualities. However, when does playfulness become therapy? When does creativity, joy and spontaneous laughter become healing and reparative? 

There is an abundance of research that indicates what we need to pay attention to. There are evidence-based strategies that tell us what to do. But none of these matter unless we pay close attention to the ’how’ of what we do and realise that our greatest ’tool’ is the use of ourselves. While we can describe a symphony of wonderful play ideas that are designed to activate wellbeing and interrupt trauma-induced behaviours - if we are not playful, then it’s not play. It becomes more of the same...another intervention full of good intentions, that is not useful to the client. The intervention becomes part of the story of origin and cannot possibly interrupt it.

In the ninetieth session with my teenage client, I was simply brushing her hair while she imagined her future. Her future had hope, realism, and possibility attached to it. She imagined me in her future as our relationship had become something that mattered. She casually referred to it without flinching and without hints of fantasy. After 70 sessions a level of trust had developed, and she asked me to brush her hair. After ten more sessions, she engaged with me in thinking about her future. In the beginning of her therapy, notions of the future didn’t exist, or at least when they did, they sounded fantastical and impossible. The past sounded rosy, which of course it wasn’t.

Everything felt fragmented, disjointed and at times it was very difficult for me to stay awake. I think this was due to her deeply embedded dissociative coping style. Our clients don’t tell us how they coped and survived unspeakable terror; they show or project it into us.

In many cases having creative approaches available and a permissive environment is all they need. Their coping becomes visible in how they approach the play and/or you. But dissociation is more difficult to describe. The more entrenched it has become the more automatic it can be for the client. I noticed a heavy energy in the room, a sleepiness and a pressure so great that staying present in the moment seemed almost impossible. I imagined that for this client, staying present in her pain was simply unbearable and so she shut down. She had to shut down so much that now the coping had become automatic. This feeling of shutting down can also be felt by the therapist when they are truly attuned to their client. This has been a common experience of mine with those clients that have suffered profound and/or early relational trauma. 

Early in the therapy, my energy and therapeutic presence were entirely focused on trying to just stay with her. Expanding her ability to even tolerate my presence, was underpinned by a visceral drive in me to pull away and a belief that I was useless. But none the less I stayed present, interested and tried to engage and communicate safety through my eyes, my voice, my body, and my self. I used my prosody, eye contact, body language and facial expressions to communicate interest. A desire to be with her and that she was deserving of unconditional positive regard.

Above all, I tried to communicate safety. Through my reflective presence, I tried to give her an experience of herself that felt whole.

This is what we do when babies are born. We reflect back to them their being. We look at them with interest and joy, and we balance it, so to not over stimulate. We watch for excitement, interest and fear and we respond in kind. We tend to do this automatically and often without conscious awareness. It comes naturally to many of us. But for those of us who never received this, the need to have the experience replaced somehow, is fundamental. This work requires a conscious and deliberate focus. Play also offers an invitation to engage that can disarm or bypass habituated defence/coping mechanisms like dissociation. I tried to be an external regulator and container for her experiences. This took work, hearty supervision, energy and a type of focus that is quite difficult to explain or fathom.

This is the work when we try to engage with young people who have suffered developmental trauma and attachment disruptions. The success of the therapeutic models we use rests heavily on how we deliver them. Or rather how we embody them. We use our selves, much like I described above. We give our undivided attention. We try to communicate a felt understanding and reflect back interest, validation, understanding and at times an invitation to go a little further in our journey together. It is new ground for us both. As the therapist, you must exude and communicate that this is a safe terrain. Just like any parent of more than one child will tell you, it’s a different journey with each child.

I saw my first movie in a movie theatre back in 1987. It was “Three men and a baby”. I remember my young eyes seeing Tom Selleck cradle the little baby he was suddenly responsible for after he found her on his doorstep. The tragedy bearable within the comedy. He was reading to her from an architecture magazine. His friend criticised him for his choice of reading material and I distinctly remember him saying “it’s not what I am reading, it’s the way I am reading it that matters”. My child’s brain imprinted on that message, but it is only now that science has fully explained the resonance. Porges (2017, p.187) captures this very well,

Also, we need to remember that we live in a culture where people say, “It is really what I say and not how I say it that’s important.” But our nervous system is telling something different to us: It says, “It is not really what you say – it is how you say it”.

Our nervous system responds more to the tone and physical expressions than the words.

The work of Bessel van der Kolk (2014) and his aptly titled book, ‘The Body Keeps the Score’, illuminates the way our bodies hold the memories of our trauma, as felt physical sensations rather than conscious memories. The work of Allan Schore, Bruce Perry, Daniel Siegal, and many others on the significance of regulation and a significant “other” acting as an external regulator highlights the potential power of the attuned therapeutic relationship.

When someone engages with us playfully and communicates warmth, interest, and safety, their tone of voice and facial expression can communicate a type of felt safety. When this is paired with the fun and joy of play it creates a potent combination of both safety and connection. This enables regulation by the “other” and in turn, begins coregulation and the beautiful tapestry of social engagement. The pleasure it brings causes our bodies to crave it again. As it patterns it can then become an alternative and healthy habituated response as opposed to an automatic defensive response.

From my perspective, this also closely matches what Jaak Panksepp taught us about the importance of play as one of our emotional circuits in the brain. The joy play brings counteracts the effects of stress and fear. And of course, others such as Donald Winnicott have for a long time emphasized the importance of play in childhood development and therapeutic work. Winnicott (1971, p.44) stated the centrality of play in therapy,

Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible, the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play.

Play amplifies our capacity to engage positively with others. This is a crucial therapeutic power of play (see Schaefer & Drewes, 2016). Play can generate positive emotions and promote bonding. Play is a creative, imaginative process. It happens in the space between two or more people. It is a shared experience, which also acknowledges separation and the boundaries between those involved. Play is a way in which feelings and experience can be expressed symbolically. Symbols and creative expression can communicate what cannot be put into words.

To describe the work of a psychotherapist these days who specialises in trauma or attachment, one will unavoidably be ensconced in the work of such amazing pioneers. However, the complexity and intricacies of the collective works of these people will only bring us so far. For again, it is not the ’what’ we play or how brilliantly we can describe it for that matter, that will ultimately reach our harder to reach clients…it is the ’how’ we play. Play and playfulness are felt experiences, that must feel ‘real’ to be meaningful. The simple description of finally reaching a place where I could brush the hair and nurture the adolescent child who now sat before me, did not and could not reflect the painfully slow at times pace that it took for such safety, regulation and trust to develop. Upon this, all other areas of her healing took place. This is where play and creativity became healing and reparative.

I once was asked, how do we explain what is happening, when it appears we are not really doing anything? My answer is that what may appear simplistic and ’nothing’, reflects a vitally important interpersonal process.

To support such wounded people to tolerate your very presence and to experience safety and co-regulation is the essence of complexity, and yet is deceptively simple in many ways. It is at the root of trauma recovery and attachment repair.

Good relationships can heal and repair and are the foundation of good mental, physical and indeed social health. For ordinary child development and recovery from trauma, an attachment relationship is necessary. And what facilitates attachment is attunement. An attuned ‘other’ is necessary for regulation to take place. Once external regulation has happened over and over again, the capacity for co-regulation and subsequent self-regulation grows. This is now cited across the literature and indeed, as above, in popular fiction. Relationships are portrayed as the answer to so many of life’s difficulties. Relationships can buffer, mitigate against stress already endured and protect against potential traumas. I often describe healthy relationships as being nature’s own antibiotic and vaccination all rolled up into one.

The reason for the volume of documentation and publicity is because it’s true. Relationships are that powerful and they can heal and transform the potential of people’s lives in ways that can be unfathomable. Recently Hambrick et al. (2018) highlight that the wealth of our current relational health is the most powerful predictor of our future outcomes. This even surpasses the impact of any adversities we may have experienced. This warrants much optimism. We must harness the positive and powerful regulating effects of healthy relationships, which will undoubtedly lend themselves toward the capacity to thrive following adversity.

Part 2 What happens when relationships are the very thing that we fear? What happens when the greatest danger experienced by someone is also the vessel of the healing potential?

Nature’s cure, sadly, is often also nature’s cause.

For so many people, who have experienced the harsh environments of childhood trauma where the very people they turned to for protection were the source of their terror and pain, the idea of a relationship being the answer to their problems may seem absurd and dangerous. It may feel as terrifying as it would be to stand in front of an oncoming truck. Can you imagine that feeling? The pulsing of your heart, the beating in your ears, irregular breathing, the cold panic, the desire to run, kick, and scream, or the out of control impulses that may take over? The fear may take such a hold of you that you collapse and lose consciousness. Now apply that terrified state to the seemingly attractive and benign qualities that one may perceive about the relationships we offer to those impacted by complex trauma. This sadly is the lived experience that many traumatized people have for much of their life. The tragedy is that they crave and fear the connection they so greatly need. The Shakespearean irony here often results in a classic Shakespearean tragedy. We may even hear narratives such as, ’they were offered every support going’ or ’they didn’t want the help’ or ’they couldn’t be helped’.

It is this intersection we now must turn our unrelenting attention to. The intersection of where we attempt to support another through a relationship, and they are very scared of it. This is where and when, that the ’how’ of what we do really becomes important. We know that when the body has been hijacked by overwhelming events, it becomes primed for defence, not for connection.

When trauma happens repeatedly it patterns as Perry et al. (1995) showed us, and our, “States become Traits”.

The connections in our brain that fire up in response to fear and threat, get used repeatedly and strong neural connections develop there. These essentially form the go-to patterns of behaviour in our brains. Areas of the brain which are not getting used, for example, areas that are better able to think, reason, feel joy and gentle pleasures, become a little more barren and less populated. The more populated areas become our driving seat and our ‘government’ will reside there. They direct our behaviours.

If the areas primed for defence or threat become most populated, they are also the least able to think, the least able to rationalise or contextualise. Unintegrated traumas from the past will feel present. Benign experiences that are happening presently, such as, a person offering a secure, helpful, and possibly even transformative relationship, will unavoidably remind that person of their previous other relationships. The overused and by now overactive defence mechanisms will kick in. They now have the most seats in power. They will overrule and shut down the parts of our brain that could actually help them contextualise and set this relationship apart. Without that capacity, this new relationship will melt into the same pot as all the others. Without ability to contextualise it, the threat is very real and present. The person will do what nature intended in response to a threat – run, defend, attack or collapse – all of which are designed to enable one thing and one thing only…survival.

These responses are very important and protective in the context of a real threat but become unhelpful when they are habitually re-acted. We need to be respectful to these protective reactions and help the client feel safe in the therapy context. 

Porges (2017, p.87) goes as far to say, “Feeling safe is the treatment”.

Safety is certainly the first stage and lays the foundation upon which all therapeutic work takes place.  Kezelman and Stavropoulos, (2012) referring to the pioneering work of Pierre Janet, the French Psychologist and Psychotherapist, in the field of dissociation and traumatic memory, in the nineteenth century, state, “Phased treatment is the `gold standard’ for therapeutic addressing of complex trauma, where Phase I is safety/stabilisation, Phase II processing and Phase III integration.”

And so, we must use ourselves to externally regulate and to communicate safety above all else. We cannot do this by trying to engage the parts of the brain that have been overruled. The parts that relate to rational thoughts and reason. We harness the curative and transformative powers of play to regulate nervous systems and engage the right, emotional brain with non-verbal emotional transactions that exude calm, consistency and safe presence. Presence that doesn’t seek to change or alter the frightened self in front of us. But presence that seeks only to engage and to engage safely. Presence that recognises that if we can manage a shared smile or moment of joy together then we are on the path. Presence that remains available even in the mix of confusion and doubt. Many times, we will feel that confusion and doubt as strongly as our clients. Presence must externally regulate long before there is co-regulation and even longer before there is self-regulation. Presence that communicates, “I’ve got you. I am here. I will not leave you in this alone. I want to be with you no matter what. You will be okay because in this moment, right here and right now, I will paddle for us both and keep us both afloat.” We use our supervision, self-care and support networks in the same way, so that we can stay regulated amid this. This is the only way we can hope to offer such external regulation.

The destination doesn’t matter. Once we don’t sink, it often takes care of itself. Reaching the equivalent transformative point where the offer of nurture is accepted, such as brushing hair, and where play becomes possible, means that we are well on the journey.   Donald Winnicott (1990, p.228) using the metaphor of disentangling a knot, describes this process well,

It is emotional growth that has been delayed and perhaps distorted, and under proper conditions the forces that would have led to growth now led to a disentanglement of the knot.

Carol Duffy

References Hambrick, E. P., Brawner, T.W., Perry, B (2018) Examining Developmental Adversity and Connectedness in Child Welfare-Involved Youth, in, Children Australia: Understanding Outcomes for Care Experienced Children, 43 (Special Issue 2): 105-115, Cambridge University Press

Kezelman, C. and Stavropoulos, P. (2012) The Last Frontier: Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery, Australia: Adults Surviving Child Abuse (ASCA)

Perry, B.D., Pollard, R.A., Blaicley, T.L., Baker, W.L., and Vigilante, D. (1995) Childhood Trauma, the Neurobiology of Adaptation, and “Use-dependent” Development of the Brain: How “States” Become “Traits”, in Infant Mental Health Journal, Vol.16, No.4, Winter 1995 PDF download https://adoptionsupport.org/wp-content/uploads/2012/09/Module-5-Handout-5.3.pdf

Porges, S. (2017) The Pocket Guide to The Polyvagal Theory, New York: Norton 

Schaefer, C.E., and Drewes, A. (2014). The Therapeutic Powers of Play: 20 core agents of change (2nd ed). Hoboken, NJ: Wiley.

Van der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Viking: New York

Winnicott, D. W. (1971) Playing and Reality  London: Routledge

Winnicott, D.W. (1990) The Maturational Process and the Facilitating Environment, London: Karnac Books

Contact Carol Duffy if you have any questions [email protected]

See Carol Duffy LinkedIn Profile for more information https://www.dhirubhai.net/in/carol-duffy-3101b26a/