A Simple Summary of a Rich Presentation:
“Attachment Disorganization, Complex Trauma, and Dissociation:
Treatment Principles Based on Theories of Attachment and Intersubjectivity”
A presentation for NESTTD
by Daniel A. Hughes, Ph.D.
December 9, 2006
By Tracey A. McHugh, LICSW
We were quite fortunate to have Dr. Daniel A. Hughes as our final presenter of 2006. Deborah Rozelle, Ph.D. introduced him and her description of his work as a “profound offering to us as practitioners,” was indeed accurate. Dr. Hughes was thoughtful, insightful, humorous, inspiring, and moving as he gave a record number of NESTTD attendees the gift of learning about and from his therapy with children, adolescents, and their foster and adoptive families.
His work focuses on issues of trauma,, attachment, and intersubjectivity. When he realized that Attachment Theory in and of itself was not enough to assist these children in trusting that secure attachments were possible, he started to be more exploratory and playful with his young clients. Central to his thinking and his work is the concept of intersubjectivity – without intersubjective relationships, children don’t grow. Fortunately for me, at least, he was kind enough to summarize intersubjectivity as “together we (therapist and client) are going to experience events, my experience will influence yours and yours will influence mine.”
According to Dr. Hughes, there are three components of intersubjectivity: 1. Attunement (intersubjective sharing of affect helps a person to feel understood and helped – it generates, maintains, and directs conversation.) It is important to match the vitality of the child’s affect, not the child’s feeling. If the child is expressing anger, Dan will be more animated but not angry. Resistance occurs when there is no match of affect. “This is the non-verbal core of what we do,” stated Hughes. He wisely pointed out that therapy is not the talking cure, but the communication cure. However, communicating with words empowers children, improves their skills, and increases intersubjective abilities.
2. Joined Attention (therapist and child must be attending to the same thing.) Joined awareness can regulate the child’s attention more efficiently. Be open to and honest about learning with the child. Say, “When you told me that I was wrong, that helped me to understand. Thanks for that.”
3. Joined Intentions or Complimentary
Intentions – The intention is to help the child to get a sense of who he is
(loves soccer, is funny, good at drawing, farting). Be authentically curious
when you ask the child, “I wonder why you decided to communicate that way? Are
you wondering if I’ll bale out if you fart 7 times in a session? What’s it like
that I’m not baling out?” Utilize the child’s individuality and creativity to
communicate with him. It is important to show the child that you have
pleasurable experiences with him and that you enjoy, respect, and value him.
Through this intersubjective process, children are given the opportunity to have a subjective experience that contradicts their negative internalized sense of self. When parents tell children they’re bad, ugly, or stupid, they believe this to be true – it becomes their reality. Therapy gives them the ability to see themselves differently. It requires therapists to allow their child clients to have a positive impact on them. This subjective experience, over time, becomes the narrative. Children need adults to experience emotion with them. Co-regulating affective resonance helps children feel safer more quickly and increases their ability to regulate themselves.
Many of the children Dan works with can’t tolerate love, joy, happiness, etc. If the child’s experience is that he is a bad kid and you say, “You’re not a bad kid,” he thinks you’re lying. (This is often related to shame because shame so easily stifles movement.) Playfulness helps children move into more positive affective experiences, which begin the process of developing intersubjectivity.
When parents think children are bad, parents are not invited into the therapy room. Dan stresses the importance of maintaining empathy for and curiosity about these parents, and assuming they are doing the best they can. Dan asks himself if he experiences equal empathy for parent and child. If not, one of them won’t be safe.
How does all of this facilitate the move toward secure attachment? Affective Reflective Dialogue is the heart of Hughes’ treatment. If one’s story doesn’t reflect one’s affective experience, it is just words. What is the best way to learn about the world and one’s self? Through attachment - other people experiencing you, then your using their experience to organize your own. Dan advocates starting with more affective communicating, and then moving into reflective noticing, connecting in a quieter way toward the end of the session. He gives hyperactive children something to occupy their hands, which can help them to be more present for the session.
One of the greatest obstacles in working with severely traumatized children is shame. Dr. Hughes included some thoughts about shame and the importance of recognizing it and trying to work with and through it.
· It is underestimated as a reason why complex trauma is so hard to resolve
· It makes you want to hide
· It makes you dissociate
· There is a giant difference between shame and guilt (shame activates avoidance, self-contempt – one sees the self as bad/unlovable – it constricts exploration)
· Children resist looking at issues because of shame (adults, too)
· Allan Schore’s work
· Shame interferes with intersubjective learning
Dr. Hughes left us with some ways to attempt to sum up his work.
PACE = Playfulness, Acceptance, Caring, Empathic
10 S’s
THINGS TO INCREASE
1. SAFETY – continuity, communication, be aware of small things
2. SUCCESS – these kids don’t learn from their mistakes; avoid failure, and protect kid from self
3. and 4. STRUCTURE and SUPERVISION – need positive attitude by parent, limit choices, child not alone
5. SOOTHING – need to learn how to accept soothing – gently – don’t follow kids’ advice – push them into areas they don’t want to go
6. SMILING – keep positive attitude – keep positive energy
THINGS TO REDUCE
7. SHAME
8. STIMULATION (over stimulation)
9. SHOUTING
10. SHOULDs (don’t get tied to chronological age, etc)
I will continue to draw upon and be influenced by the wisdom that Dr. Hughes presented to us for the remainder of my career and throughout my life. When the program was over, the line to talk with Dan was quite long so I suspect I’m not alone in this.