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This book is dedicated to Roy and Beryl Lanktree, Adelle Briere, and William N. Friedrich.
SAGE was founded in 1965 by Sara Miller McCune to support the dissemination of usable knowledge by publishing innovative and high-quality research and teaching content. Today, we publish over 900 journals, including those of more than 400 learned societies, more than 800 new books per year, and a growing range of library products including archives, data, case studies, reports, and video. SAGE remains majority-owned by our founder, and after Sara’s lifetime will become owned by a charitable trust that secures our continued independence.
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TREATING COMPLEX TRAUMA in Children and Their Families
An Integrative Approach
Cheryl B. Lanktree
John N. Briere
University of Southern California
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Library of Congress Cataloging-in-Publication Data
Title: Treating complex trauma in children and their families : an integrative approach / Cheryl B. Lanktree, John N. Briere.
Description: Thousand Oaks, CA : SAGE Publications, Inc., [2017] | Includes bibliographical references and index.
Identifiers: LCCN 2015029291 | ISBN 9781452282640 (pbk. : alk. paper)
Subjects: LCSH: Post-traumatic stress disorder in children—Treatment. | Family psychotherapy.
Classification: LCC RJ506.P55 L36 2017 | DDC 618.92/8521—dc23 LC record available at http://lccn .loc.gov/2015029291
This book is printed on acid-free paper.
Acknowledgments
We wish to acknowledge Karianne Chen, Colleen Friend, Anne Galbraith, Ros Gellatly, Malcom Gordon, Meghan Ingstad, Bruce and Jean Lanktree, Vikki Larsen, Eve La Salle Caram, Carl Maida, Lynda and Harald Manson, Usha Raj, Randye Semple, and Susanne and Stirling Sublett; former therapists and clients at MCAVIC, MCAVIC-USC, and Stuart House, Santa Monica-UCLA Medical Center; and colleagues and staff at USC; all of whom, in one way or another, contributed to the material and/ or supported one or both of us in the writing of this book. Thanks also to those clinicians who reviewed various versions of the manuscript:
Lucy Berliner, Harborview Medical Center
Megan Berthold, University of Connecticut
Joan M. Doris, University at Buffalo, State University of New York
Jennifer Elkins, University of Georgia
Julian Ford, University of Connecticut
Colleen Friend, California State University, Los Angeles
Eliana Gil, Gil Institute
Russell T. Jones, Virginia Tech
Richard Kagan, private practice
Stefanie M. Keen, University of South Carolina Upstate
Emily P. Taylor, University of Edinburgh
Becky L. Thomas, The University of Akron
Neil van Dokkum, Waterford Institute of Technology
Naomi Lynch White, The University of Akron
Much appreciation to editors and staff at SAGE Publications who made this a better book: Acquisitions Editor Kassie Graves; Editorial Assistant Carrie Montoya; Production Editor Jane Haenel; and Copy Editor Tammy Giesmann. Finally, ultimate thanks to our clients—children, caretakers, and school or agency personnel—and the many workshop attendees over the years who have employed ITCT in their work and provided us with helpful feedback.
About the Authors
Cheryl B. Lanktree, PhD, is Project Director of the USC Adolescent Trauma Training Center, National Child Traumatic Stress Network (NCTSN), a Research Assistant Professor of Psychiatry at the University of Southern California, and a licensed clinical psychologist in private practice. The developer of Integrative Therapy of Complex Trauma (ITCT), she has published various articles, chapters, and treatment manuals on the assessment and treatment of child trauma, and a book on treating complex trauma in adolescents with John Briere, Treating Complex Trauma in Adolescents and Young Adults. Her website is cblanktree.com.
John N. Briere, PhD, is Associate Professor of Psychiatry and Psychology at the University of Southern California and Director of the USC Adolescent Trauma Training Center, NCTSN. A past president of the International Society for Traumatic Stress Studies, he is recipient of the Award for Outstanding Contributions to the Science of Trauma Psychology from the American Psychological Association and the William N. Friedrich Outstanding Contribution to Child Psychology award from the Mayo Clinic Medical School. He is author of a number of books, articles, and psychological tests. His website is johnbriere.com.
1 Introduction
Integrative Treatment of Complex Trauma for Children (ITCT-C) is an evidence-based, component-driven model that integrates a variety of theoretical and clinical approaches to the treatment of complex trauma in children. Development and evaluation of this therapy was supported by the Substance Abuse Mental Health Services Administration, through its funding of the Miller Children’s Abuse and Violence Intervention Center (MCAVIC) from 2001–2005 and the MCAVIC-University of Southern California (MCAVIC-USC) Child and Adolescent Trauma Program from 2005–2009.
Although ITCT-C was originally designed for the treatment of multiply traumatized children aged 8 to 12 years, this book also includes interventions that can be adapted for children ages 5 to 7 years. There is also an adolescent version of ITCT, Integrative Treatment of Complex Trauma for Adolescents (ITCT-A), for youth aged 12–21, which is described in its associated treatment guide (Briere & Lanktree, 2013) and a separate volume (Briere & Lanktree, 2012).
ITCT-C has been empirically evaluated (Lanktree et al., 2012) and has been expanded considerably since the original treatment guide was released in 2008. This book incorporates extensive feedback from clinicians and workshop participants over the past five years, to whom the authors owe a debt of gratitude.
Because this is a comprehensive treatment model, its effectiveness is enhanced by the therapist’s knowledge, skill, and openness to the client, and his or her actual enjoyment of the therapy process. Although specific interventions and activities are described, this is not a how-to manual, nor is it
based on a “one-size-fits-all” approach. ITCT-C is designed to inspire therapists to approach the treatment of complex trauma in children from various perspectives. It offers a range of treatment components that are applied based on the results of ongoing assessment (using the Assessment-Treatment Flowchart for Children), and allowing for adaptations based on the client’s age, developmental level, level and type of symptomatology, and cultural/ ethnic background.
Unlike some other approaches for traumatized children, wherein treatment is limited to 12 to 16 weeks or less, ITCT-C is extendable to whatever period of time is most helpful in reducing the child’s trauma-related difficulties. In many cases, the effects of complex trauma are unlikely to remit in the span of several months—especially when the client suffers from a number of different symptoms and problems, there is a risk of further victimization, other environmental stressors are common, and attachment issues are prominent. In such cases, ITCT-C may easily require treatment periods which extend to 6 months or longer. Nevertheless, ITCT-C has been adapted to settings where shorterterm treatment interventions are required, for example, where there are funding constraints or where short-term treatment is the only option (e.g., drop-in clinics, homeless shelters, residential treatment facilities).
ITCT-C is relationally based, incorporating tenets of complex trauma theory (e.g., Ford & Courtois, 2013), attachment theory (e.g., Bowlby, 1988), cognitive behavioral approaches (e.g., Cohen, Mannarino, & Deblinger, 2006), and the Self Trauma Model (e.g., Briere & Scott, 2014). Because it is oriented toward the treatment of complex trauma, it can be used to address the effects of a wide range of adverse experiences, including child abuse and neglect, traumatic bereavement, assaults by peers, community violence, witnessing parental domestic violence, parental substance abuse, and trauma associated with severe illness or injury. It also includes a focus on the various impacts of insecure caretaker-child attachment relationships as they add to, compound, or intensify the psychological effects of traumatic experiences.
There are a variety of treatment components within this model, for example, affect regulation training, titrated exposure to traumatic memories, cognitive and emotional processing, and attachment/relational interventions, all of which are differentially utilized according to each child’s specific problems or issues. As compared to interventions for adolescents (e.g., ITCT-A), ITCT-C has a stronger emphasis on symbolic and expressive play approaches, the option of shorter individual therapy sessions for the child, greater emphasis on collateral and family sessions to facilitate appropriate caretaker support and parenting skills, and more of a focus on insecure attachment as it plays out in child-caretaker relationships.
In addition to individual therapy, ITCT-C can involve collateral, family, and group therapy. Weekly collateral sessions with primary caretakers are
integral to the model. Because of the critical role of caretakers in the younger child’s life, ITCT-C may also facilitate trauma recovery for the primary caretaker(s) in their own individual therapy, group sessions, or collateral treatment. In such cases, treatment may include the caretaker’s processing of traumatic experiences—both their own as well as the impacts of the child’s victimization—so that they can become more attuned to the child’s needs and develop a more secure caretaker-child bond. This approach also includes optional parent education classes, which are provided for caretakers struggling with parenting issues, as well as group sessions for caretakers involving trauma-related psychoeducation, trauma processing with peer support, and exploration of relationships and family systems.
As described in Chapter 17 and elsewhere, ITCT-C has been adapted for children in urban school environments, including “alternative” or “storefront” settings for high-risk students. The primary modality in such contexts is group therapy, with individual crisis counseling and shorter-term therapy sessions provided when needed. Teachers, school counselors, and social workers also receive consultations, training, and support. Parents are engaged whenever possible, but school-based interventions may be limited by less access to parents due to the schools’ hours of operations, as well as caretakers’ work demands, transportation problems, and, on occasion, discomfort with going to school sites.
ITCT-C particularly targets economically disadvantaged and culturally diverse children, many of whom are coping with additional stressors associated with poverty, unsafe communities, and social marginalization. Frequently, ITCT-C clients are dealing with immigration issues, acculturation challenges, separation from primary caretakers—some of whom may remain in their country of origin, and attachment/relationship problems associated with being reunited with family members after a period of separation. At the same time, however, ITCT-C is also used in settings with clients who may not be as economically or socially disadvantaged, and who may not be facing the same degree of external stressors.
Importantly, the client’s history of insecure attachment relationships and negative relational schema is addressed in his or her individual ITCT-C sessions. The therapeutic relationship invariably triggers trauma-related thoughts, feelings, and memories in the child, which, in the context of safety and security, can be processed and counterconditioned.
Empirical Support for ITCT
A treatment outcome study (Lanktree et al., 2012) conducted over a period of several years evaluated the effectiveness of ITCT (both ITCT-C and
ITCT-A) in reducing trauma-related symptomatology in a culturally diverse, largely inner-city sample of 151 children and adolescents. Most children were seen in a clinic environment, although some attended the school-based adaptation. In most cases, caretakers attended collateral therapy as described in Chapter 15.
A significant majority of these children had experienced multiple types of trauma, typically some combination of childhood sexual or physical abuse, psychological maltreatment, emotional neglect, family violence, loss of a loved one, community violence, and parental substance abuse, often compounded by caretaker-child attachment issues. In addition, some were referred by local hospitals and clinics following a traumatic medical condition (e.g., HIV/AIDS), injury (e.g., gunshot wound), or invasive medical procedure (e.g., amputation).
Although this study did not include a control group, clients’ scores on the Anxiety, Depression, Anger, Posttraumatic Stress, Dissociation, and Sexual Concerns scales of the Trauma Symptom Checklist for Children (TSCC; Briere, 1996) decreased an average of 41% (p < .001) over an average of 6 to 7 months. There were no differences in treatment effectiveness in relation to gender, number of traumas, ethnicity, or whether the client received ITCT-C or ITCT-A. However, longer-term treatment was associated with greater symptom reduction, as per other research in this area (e.g., Lanktree & Briere, 1995).
Structure of This Book
This treatment guide defines and describes complex trauma and its effects, followed by a discussion of the ITCT-C approach to psychological assessment, including the Assessment-Treatment Flowchart for Children (ATF-C). The reader is then introduced to the ITCT-C Problems-to-Components Grid (PCG-C), which assists the clinician in applying the results of the ATF-C to create a specific treatment plan for the child. Remaining chapters then present the treatment components that, as identified by the PCG-C, can be used to implement a customized approach to the child’s specific needs. These components are: Relationship Building and Support, Safety Interventions, Psychoeducation, Advocacy and Systems Interventions, Distress Reduction and Affect Regulation Training, Facilitating Positive Identity, Cognitive and Emotional Processing, Relational/Attachment Processing, Interventions with Caretakers, Family Therapy, and School-Based Adaptations. Finally, a chapter on ITCT-C supervision and therapist self-care is presented, followed by appendices containing ITCT-C tools and worksheets.
2
Effects of Complex Trauma in Children
One of the insights that has emerged as clinicians and researchers study and treat complex trauma effects is, in fact, the complexity of many maltreatment-related responses and the conditions under which they are likely to occur. This chapter reviews the meaning of complex trauma, its primary effects, and variables that complicate or intensify the clinical picture for children.
Complex Posttraumatic Events
Complex trauma can be defined as a combination of early and later-onset, sometimes invasive adverse events, usually of an ongoing, interpersonal nature. In most cases, it includes repetitive childhood sexual, physical, and/ or psychological abuse, often in the context of other family violence, concomitant emotional neglect, and harmful or marginalizing social environments. Some children also may have experienced medical trauma (e.g., chronic serious illness or serious physical injury) and/or traumatic loss.
Differences between “simple” or single incident traumas and more complex scenarios are presented below:
“Simple” Trauma Complex Trauma
Often:
• Non-interpersonal
• Single or limited trauma exposure
• Shorter duration
• Onset at a later age
• Support of caretaker/family
• Secure attachment with primary caretaker(s)
Effects of Complex Trauma
Often:
• Interpersonal
• Multiple exposures of different types of trauma
• Longer duration
• Onset at an earlier age
• Less or no support of primary caretaker/family
• Insecure attachment
As noted by Cook et al. (2005), “children exposed to complex trauma often experience lifelong problems that place them at risk for additional trauma exposure and cumulative impairment . . . in childhood, adolescence and adulthood.” The impacts of complex trauma typically extend beyond posttraumatic stress and often include attachment, self-capacity, dissociative, somatic, cognitive, and/or behavioral domains (Briere & Spinazzola, 2009; Cook et al., 2005; Hodges et al., 2013). In such cases, although children may be diagnosed with PTSD, major depression, and/or some form of anxiety disorder, these diagnoses generally capture only a limited aspect of the traumatized child’s symptoms, impairments, and behaviors.
A review of the literature suggests that exposure to complex trauma in childhood is associated with the following:
• Anxiety and depression, including panic attacks, free-floating anxiety, and phobias, as well as sad mood and major depression
• Cognitive distortions, such as low self-esteem, extreme helplessness, hopelessness, and potential overestimation of the amount of danger in the environment
• Insecure attachment, sometimes involving disorganized attachment, reactive attachment disorder, or a disinhibited social engagement disorder, as
well as, more generally, problems associated with close relationships, including excessive clinging or neediness, separation anxiety, or, alternatively, avoidance of attachments to parents or significant others
• Posttraumatic stress, including reexperiencing symptoms (e.g., nightmares and posttraumatic play), avoidance behaviors (e.g., avoiding people or situations reminiscent of the trauma), hyperarousal/ reactivity (e.g., hyperactivity, attention and concentration problems, aggression), numbing, and negative cognitions and mood
• Dissociation, including depersonalization, derealization, and disengagement
• Identity disturbance, including attachment-related problems in selfand boundary awareness
• Affect dysregulation, involving a relative inability to tolerate or control emotions and painful internal states, often leading to “externalized” behaviors
• Interpersonal problems, ranging from difficulties in forming positive, stable friendships to excessive distrust of others
• Self-injury, generally involving, in children, intentional behavior such as head banging, biting, cutting, or hitting self
• Sexual disturbance, such as preoccupation with sexual thoughts or feelings, or sexualized behavior, such as inappropriate sex play or involving others in unwanted sexual activity
• Enuresis and encopresis, involving problems with bladder or bowel control
• School-related difficulties, primarily learning disabilities and poor academic performance
• Social withdrawal, such as avoiding social interactions or friendships, or self-isolation
• Conduct disturbance, including truancy, aggression, stealing, or excessive rule-breaking
• Suicidality, which, although less common in younger children, may involve thoughts of killing oneself or actual suicidal behavior
The reader is referred to the following reviews for more information on trauma-symptom relationships in children: Briere & Spinazzola (2009); Cook et al. (2005); Ford & Courtois (2013); Meyers (2010); Nader (2007); the National Child Traumatic Stress Network (n.d.); Putnam (2003); and van der Kolk (2005).
Phenomena That May Intensify, Compound, or Complicate Trauma Effects
The list presented above may appear to suggest that the abuse-outcome relationship, although wide-ranging, is relatively straightforward. However, it is almost always true that other events, processes, and conditions intensify or complicate the effects of childhood trauma or maltreatment. Among these moderators of trauma impacts are the following:
Poverty and social marginalization. Social and economic deprivation, as well as racial, ethnic, or gender-based discrimination not only produce their own negative effects on children, they increase the likelihood of trauma exposure and often intensify and complicate the effects of such victimization (Collins et al., 2010). Children who are socially or economically marginalized may not be able to play or move about their neighborhoods freely without threat of violence. The increased stress of being constantly vigilant to danger, including from gang-related activity, combined with parental struggles to support their families financially, and the child’s reduced access to health and mental health services, can contribute further to the impacts of trauma or maltreatment.
Intensity, invasiveness, and complexity of maltreatment. Bodily violation, especially in sexual abuse, can especially result in symptomatology (Berliner, 2011; Collins et al., 2010). At the same time, it is rarely true that such acts occur in isolation. In the case of sexual abuse, for example, invasiveness is frequently accompanied by repeated and chronic sexual acts against the child, which may also include concomitant emotional abuse and neglect, especially when occurring in an intrafamilial context (Beitchman et al., 1992). More broadly, at least one study of cumulative childhood trauma indicates that the more kinds of traumas and other adverse experiences a child undergoes, the more complex and pervasive his or her symptom outcome (Hodges et al., 2013).
The abuse may have continued for a considerable period of time and the child may have tried to tell others without being heard or protected from further maltreatment. In some cases, the child may have been directly threatened with harm to his or her self or other family members if he or she disclosed the abuse.
Children in such circumstances can be reluctant to disclose maltreatment because of a belief that they somehow contributed to the abuse, and/or because they take responsibility for the anticipated repercussions of revealing the abuse secret, including disruption of the family, removal of economic support if the abuser is incarcerated or otherwise separated from the family, and anger
