Case study

profileSalman Wahid
SWK313Module4Week8_Trauma_Powerpoint2019.pptx

Module 4: Attachment Theory & Trauma Informed Practice

SWK313 Engaging with Individuals and Families in Partnership

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Important – self care

Your wellbeing and safety is important as we work through this Module. Exploring topics associated with trauma can evoke strong emotions and trigger memories or distress. This can be a challenging area for practice in human services, regardless of our personal histories and experiences.

Seek support:

Lifeline (13 11 14)

Parentline (1300 30 1300)

CDU Equity Services – Counselling (http://www.cdu.edu.au/equity-services

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A definition of trauma

“Trauma can arise from single or repeated adverse events that threaten to overwhelm a person’s ability to cope. When it is repeated and extreme, occurs over a long time, or is perpetrated in childhood by care-givers it is called complex trauma”

Kezelman, C (2014) Trauma informed practice. Adult Surviving Child Abuse. Retrieved from https://mhaustralia.org/general/trauma-informed-practice

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Trauma-informed practice

A framework for practice in a range of settings

Relevant for working with children, adolescents, adults, families and communities

Uses theories of trauma to guide assessment, intervention and care, service provision and policy development

Strengths-based, facilitating recovery, avoiding re-traumatisation

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Complex trauma

Multiple events over an extended period of time

Interpersonal aspect (e.g. involves caregiver relationship)

Isolation & disconnection from others & supports

Impacts include:

Relationships

Emotional regulation

Behaviour

Memory

Cognitive processing

Brain development

Sense of self and safety

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Types of child maltreatment

Definitions vary however 5 categories are commonly identified:

Physical abuse

Emotional abuse

Neglect

Sexual abuse

Exposure to family violence (D&FV)

From: CFCA Resource Sheet (2015) What is child abuse and neglect https://aifs.gov.au/cfca/publications/what-child-abuse-and-neglect

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Theories of human development

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Categories of Attachment

Type
(B) Secure Child feels safe and secure with carer and explores environment Carer readily responds to child’s needs
(A) Anxious-Avoidant Child shows little preference for carer (ignores, unresponsive) Carer insensitive to child’s discomfort, little physical contact
(C) Anxious-Resistant (Ambivalent) Little interest in exploring, extremely distressed, not easily comforted by carer Care is inconsistent in responding to child’s needs, uninvolved, withdraws
(D) Disorganised-Disoriented Child confused, shows contradictory behaviour in presence of carer Child should find comfort but is stressed. “Maltreatment”?

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Recap - Ainsworth’s categories of attachment

Complexities – cultural context of our experiences, relationships, parenting, childhood

Secure relationships – central to developing a positive sense of self, emotional regulation – look to caregiver for comfort, cues

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Brain development

http://www.news-medical.net/health/Human-Brain-Structure.aspx

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Trauma Response Patterns

Everyone is likely to experience a traumatic event in their life but people’s experience will be different and their ability to cope and recover varies widely.

How might people react to stress, pressure, danger?

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Individual response to trauma influenced by

Personality

Support available

Previous experience of trauma

Age

Protective responses broadly include:

Immobilised (hypoarousal) – freeze

Mobilised (Hyperarousal) – fight/flight

Also include social engagement – safe, connected with others – calm and soothe child/self

Dissociation

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Fight, flight, freeze… survival

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Neurobiological research

The CT scan shows physiological impact of neglect in early childhood including abnormal development of cortical, limbic and midbrain structures.

From Perry, B (2008) Child maltreatment: A neurodevelopmental perspective on the role of trauma and neglect in psychopathology (pp.93-129) in Beauchaine, T. & Hinshaw, S (eds) Child and Adolescent Psychopathology. John Wiley & Sons NJ

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Signs of emotional regulation

Eye contact

Speak with intonation

Attend to tasks

Change facial expressions

Actively listening

Remains calm

Responsive

Action oriented

Hypervigilant

Emotionally flooded

Reactive even to mild/moderate stress

Flat affect

Submissive or withdrawn

Constant state of fear – escalate quickly

Regulated

Dysregulated

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Complex trauma and survival

From infancy people learn to settle themselves or self-regulate

Children have limited capacity to defend themselves or escape, particularly when the threat to safety is from a caregiver or within the home

The younger a child when trauma occurs, the more difficult it may be to learn to regulate their nervous system

Adult response is crucial – children may be further traumatised or feel shame and confusion about their responses

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Complex trauma & survival

People can be ‘trapped” in fight, flight or freeze mode when they are unable to escape trauma or excessive chronic stress

Long term physiological, cognitive, psychological emotional, behavioural impacts

Traumatic memories can be triggered by a range of stimuli at a later stage – intrusive, distressing, emotional pain

Lead to avoidant behaviours – e.g. alcohol & substance abuse

PTSD shows trauma can impact on adult brain too however in early childhood the brain is still developing – future implications

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Memory

Trauma always impacts on memory and the extent depends on the duration and intensity of the trauma

Memories of trauma are stored along with strong feelings that accompanied those experiences (implicit memory)

Memories can trigger overwhelming emotions in the present day

Person is unable to make sense of their reactions

Triggers are diverse, and can be subtle – reactions can seem to “come out of nowhere”

Observations of behaviour – patterns that can discerned? Connect experiences, emotions, thoughts?

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Emotions

Emotions can provide a means for understanding and measuring how we are interacting and managing the outside world and our internal state

Trauma can led to difficulty with trust, empathy, impulse control, anger, shame, managing stress & emotional regulation

Difficulties with sleep can impact on emotions and capacity to cope

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Connection

Children understand their world and feel safe through their emotional connections with carers

Children develop and internalise patterns of relationships from repeated experiences with their own caregivers – this shapes relationships with others in the future (e.g. teachers, peers, partners)

The experience of trauma affects the bond of the relationship (attachment) between the child and caregiver

Relationships are based on threats, ambivalence, confusion, unpredictability

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Sense of self and others

Representations inform the way we reflect on experience, connect with people, develop understanding of our experiences – cognitive, emotional, physical responses

Our sense of self and our core beliefs are based on how our brain processes information, memories and emotions as a pattern of reality (e.g. I am loveable, worthy, the world is safe)

Abuse distorts a child’s representation and understanding of themselves and the world around them – child is disempowered

Low self-esteem

High sense of shame

High level of guilt

Disturbed body image

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Interventions

Increase predictability & safety of environment – manage change, provide times/places that are supportive, safe & calm

Develop calming strategies (self and others)

Knowledge of self & awareness of triggers – make sense of reactions, recognise & name emotions and gain self efficacy

Gain mastery of environments – skill development/stress management

Creative therapies to guide processing of traumatic experiences focused on healing, repair…

Build social engagement & protective, respectful relationships

Reshape their self-beliefs and representations

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Macro level

Prevention

Awareness raising

Address stigma, judgement and myths

Address factors that lead to institutional and systems abuse – trauma that is perpetuated, exacerbated by policies, programs, services and practices within government & non-government agencies (Australian Law Reform Report 84: http://www.alrc.gov.au/publications/17-childrens-involvement-care-and-protection-system/government-guarantee-children-care)

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Risk Assessment

Systematic gathering of data and information to evaluate risk and safety indicators to guide decision making & action

Analysis – systematic use of information to determine the likelihood and consequences of harm

Frameworks, tools, policy, legislation, & professional judgement

Used in a range of contexts

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Risk assessment – practice issues

Significant concept for practice & policy since 1990s

Contested and can be ambiguous or difficult to define – frameworks available & relevant?

Is the risk real or perceived? (evidence, information, point in time, whose perception?)

“At risk”, “vulnerable” – what do these labels mean for people? What about strengths or protective factors? Social justice and AOP?

“Social control” dimension of human service work (or protection?)

Risk management and a risk averse society? – political dimension of risk assessment

Professional accountability & scrutiny

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Module 4 Online Learning Activity

Case Study continued: Learning more about Jemima and Isaac

You have now seen Erica on 3 occasions. She tells you her cultural background is Aboriginal. She begins to open up about the problems in her relationship with Jim, and her worries about the impact of this on her children.

Erica explains that Jemima is from a previous relationship and that her previous partner was very violent towards her so she left him when Jemima was around 3 years of age and they have not had contact with him at all in the past six years. Erica is worried because she can see signs that Jim is becoming increasingly angry and frustrated with her.

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Module 4 Online Learning Activity

Erica describes Jemima as a sensitive child. Erica tells you that Jim is very harsh on Jemima, yelling at her often, sending her to her room and seems to favour Isaac. Erica has spoken to Jim about this but Jim responds by telling her she is ‘crazy’ and that Jemima needs to ‘grow up’. Erica tells you that Jemima has recently become very withdrawn.

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Module 4 Online Learning Activity

Respond to the following questions: 

How could you use attachment theory and trauma informed practice to understand this case?

Would there be any need for risk assessment in this situation? Why or why not?

What specialist skills and knowledge would you need to work directly with Jemima?

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Discussion

What risk vs protective factors are relevant to the case study? (think of the whole family, past & present)

Reflect on why you identified these factors as either risk or protective? What has informed your decision?

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