After my two posts on developmental trauma (here and here), many trauma survivors and therapists sent questions on how to apply the secure attunement framework with adults who are survivors of developmental trauma. So here’s a framework—I call it Secure Attunement Expressive Trauma Integration—that I use in working with adults who experienced developmental trauma as young children.
What is developmental trauma?
Developmental trauma occurs early in life and disrupts normal sequences of brain development. As a result, other aspects of development, emotional, physical, cognitive, spiritual and social, are also impacted (see more).
Since the objectives of therapy shape everything that follows, let’s begin by defining the objectives of therapy in the context of developmental trauma:
Attunement is giving complete, non-judgmental, responsive attention to another person through eye contact, verbal and other nonverbal forms of attention (vocalization, speech, and body language) and response.
When attunement is obstructed it impedes the natural sequence of brain development and thus all other aspects of child development. If an infant does not receive enough stimulus, sustained attention, love, caring, and warmth on a predictable basis, or if an experience of disruption of care occurs that is overwhelming or prolonged, developmental trauma can result.
A major goal in trauma therapy is for clients to experience an attuned relationship with the therapist. Some clients, particularly those who experienced a major disruption in relation to a key caregiver in infancy or childhood, have never experienced attunement. Others may have been provided consistent attunement by caregivers, but were impeded in other critical ways by trauma.
Either way, clients require an attuned relationship with a therapist in order to feel safe enough to develop co-regulation and self-regulation and to expand their capacity to endure pain and experience joy. In “normal” childhood development these outcomes unfold naturally when consistent attunement is available. The goal now is to provide sufficient attunement to an adolescent or adult as a “bridge” for sequential development to unfold.
When attunement is experienced regularly in therapy, clients come to know, many for the first time in their life, that they are not alone in the world of emotions. Not only do clients feel less alone, but they also experience a reduced sense of misattunement with others in their life.
Let’s be clear: The process of trauma integration is long, and can be both life-giving and painful. The therapist first becomes a “co-regulator” with the client, help the client to normalize emotions and practice self-regulation. This lays a foundation for the client to carry on their experience of regulation outside of the therapy room, both with oneself and others.
A key goal in trauma therapy is a reduction in post-trauma stress symptoms and increased capacity to co-regulate (i.e., be able to manage difficult emotions with the support of a therapist) and eventually to self-regulate (ie: be able to manage difficult emotions independently.
Self-regulation is at the core of trauma therapy and refers to the ability to maintain control over our reactions (sensorial, emotional, cognitive).
In achieving self-regulation, Body Awareness is an essential tool, enabling us to mindfully monitor our body reactions and sensations. With the information it provides, we can understand what triggers anxiety (typically, visual, auditory, kinesthetic, or olfactory inputs from the senses, as well as movements, postures, physical locations, etc.). Body awareness also helps to determine which sensory experiences are useful in achieving a sense of expansion and thus are renewing and strengthening.
A variety of techniques and strategies can be used to achieve body awareness and promote self-regulation. Through activities like Grounding (bringing awareness simultaneously to what we experience in the body and to connecting to ground/earth) and Embodiment (bringing awareness to the body while also noticing sensations) we can enhance body awareness and promote self-regulation.
Self-sustainability refers to increased capacity to sustain stability and to experience joy with self and others. A self-sustainability plan—I call it an ISP or Individualized Sustainability Plan—is a comprehensive framework created for a specific individual to support emotional, cognitive, physical, spiritual and social aspects of wellness.
Such a plan draws from practices demonstrated to be effective in mitigating post-trauma symptoms and enhancing self-regulation. These typically include mindfulness and self-compassion practices, sports and movement, cognitive reframing and behavioral modifications, expressive arts such as visual arts, music, movement and dance, drama, and writing; brain-training and neurofeedback, and aspects of nutritional psychology related to the brain-gut connection, inflammation, and immune system.
Together, these objectives define Developmental Trauma Integration. The goal is internalization of a sense of safety, predictability, and connection to oneself and others. As survivors progress with integration, they experience less time in a sense of misattunement and greater fluidity in returning to a sense of attunement, and increasing capacity to self-sustain.
Secure Attunement Framework
The above highlights three objectives for therapy. Here’s the framework I use for implementing those objectives in work with adult survivors of developmental trauma:
- Experiential psychoeducation. Educate the survivor and family members, in ways appropriate to their developmental capacity, about how what happened to them in childhood affects them. Psychoeducation enables survivors to recognize that they are not broken, rather they are experiencing a predictable set of symptoms that follow trauma, a normal response to an abnormal situation. These symptoms can be difficult to live with but they evolved to assist human survival and are easier to manage when understood in this light.
- Action in a safe space. The use of action in a safe space (experiential modalities) is a highly effective strategy for working with developmental trauma. Since the injury took place in an age when imagination and playfulness were supposed to be dominant, laying a foundation essential to complex brain development. The therapist uses activities that involve playfulness, imagination, and spontaneity to trigger bottom-up access to the age when the developmental trauma took place.
A key challenge, of course, is that many survivors of developmental trauma have spent most of their lives using survival mechanisms that constantly aim to maintain a (false) sense of control. These habitual responses impede connecting with others or using spontaneity playfulness. In working with survivors who are in such a state, making art together, going for walks, listen or play music together, or adjacent to each other is often effective as a strategy for attunement. Sometimes even that is too much, so we slowly build a relationship until the survivor is ready to engage in experiential modalities.
- Improved self-regulation. In addition to ongoing psychoeducation, we begin to incorporate self-regulation activities using grounding and embodiment activities (focusing on sensory and bi-lateral integration).
- Safe regression. The therapist, just like parents, cannot be perfectly attuned to the client at all times. This provides opportunities for misattunement to take place in which the therapist can model how to re-attune in times of stress/triggering/withdrawal (stage three in the ETI trauma response roadmap).
Most of my clients with developmental trauma display reactive behaviors in relationships and difficulties in self-regulation at home and other settings (school, work, etc.). These often get “worse” as therapy progresses as clients benefit from expanded ability to take a risk in general and feel safer to display reactive behaviors in the therapy room.
The therapist models different responses to the reactiveness, first by calming down the reactive stress response (experiential self-regulation). In addition, the therapist can model re-attuning to and reconnecting to the client, and provide psychoeducation as to why he/she was reacting in such a way.
When clients come to understand that they react instinctively in certain situations, they often gain an important new insight: “This is not me, this is a result of something that happened to me." This is followed by an equally important realization: now I am doing something about it.
- Develop and practice an Individualized Sustainability Plan (ISP) for continued stability.
Trauma is complex and affects all aspects of wellness: emotional, physical, cognitive, spiritual and social. Therefore, such complex injury requires a complex response.
As a trauma survivor and trauma therapist, I came to realize that a comprehensive, integrative approach to trauma treatment provides the best chance we can offer survivors of complex trauma to reduce symptoms, enhance self-regulation, expand capacity to endure pain, and experience joy while increasing self-sustainability.