Using creative communication in a trauma informed response to care planning and review.
Authors: Katie Wrench and Sharon Martin
This briefing provides an introduction to the language and theory of trauma-informed practice combined with practical knowledge and skills development for IROs direct work – to support thinking and working with parents, children and young people.
With a positive drive across the country to bring a contemporary approach to the traditional reviewing process for children and young people in care it is timely to consider how best we hold the child at the centre of the care planning and reviewing process. This also inevitably means thinking about how we best help the adults who care for and about the child to communicate their views, their worries, their hopes and fears. It means a flexible approach which celebrates the child’s life and achievements, and the strengths of their relationships but which can also, where necessary, address more difficult areas of concern with sensitivity and care. This duty of care applies to all parts of the team around the child.
For us, there are two key considerations for IROs in truly seeking the child’s input to the care planning process safely and respectfully. First is a need for an understanding of the impact of developmental trauma, of normative child development and what helps build safety into our interactions with children and adults. Second is a need to broaden our understanding of communication.
Understanding the impact of developmental trauma
We can build more effective relationships when we use ourselves as a resource – ‘to create the optimum conditions in which children and their families feel both confident and safe enough to express their views and share their lives with us.’ (Wrench 2018, p.11) Having a solid understanding of the impact of trauma on people’s functioning and of the ways in which we can support people to anchor to a sense of safety, this is always a good starting point.
Where individuals have experienced repeated stressors, complex relational trauma or have lived in environments characterised by danger, chaos and unpredictability, it is not uncommon for their belief systems to become very rigid. Children and their families might have a set of assumptions relating to relationships that could include:
- I cannot trust anyone, especially adults or people in authority.
- I am not safe.
- No one can help me.
- I am powerless.
- The world is a dangerous place.
- I am not a good person. I don’t deserve care.
Where people have lived for prolonged periods of time surrounded by danger, their brains and bodies can become over-sensitive to perceived threats in their environment; even though objectively they might recognise that the danger is not real. When explaining this to children I use the analogy of a smoke alarm that is set off when you’re just frying bacon; it’s a false alarm, there is no real ‘emergency’. Similarly, ‘the human danger response does not require actual, physical danger in order to be activated; it merely requires the perception of danger. Once your brain has labelled something as dangerous, regardless of ‘objective reality,’ your body will respond.’ (Blaustein & Kinniburgh, 2010, p. 27) Where children and families have experienced long-term or ongoing stressors, the range of incoming signals or triggers that are labelled by their brains as threatening or dangerous can be vast.
Where children have experienced relational or developmental trauma – or where their parents or caregivers have had these experiences themselves as children – it is not uncommon to see core difficulties in the capacity to self- regulate, together with a real struggle to maintain a comfortable state of arousal within what is known as the ‘window of tolerance’, a term originally coined by Dan Siegel (1999). This is the zone of arousal in which we best function; we are emotionally regulated, we can self-soothe, we can think and speak.
Survivors of complex trauma can experience triggers in the here and now that remind the body and the brain of the past, thereby activating the nervous system into believing that it is under attack again, moving out of the window of tolerance into hyper- or hypo-aroused states. Until practitioners help vulnerable children and their caregivers to function within the window of tolerance, they will not be able to readily receive, process and integrate information and respond to the demands of everyday life without great difficulty. Their ability to contribute meaningfully to the reviewing process will also inevitably be compromised.
The behaviours we see in children and their caregivers or family members when they perceive danger can vary. We know that although we may be unaware of it, some situations in the here and now can remind us of previous traumas; never fully discharged, the original fear or panic linked with the memory of the event may compel us to act as if it were happening all over again. This can be thought of as an over-active alarm system struggling to distinguish between false alarms and actual danger. Common triggers for traumatised children and adults include:
- Changes of plan or unpredictability
- Feeling a loss of control
- Feeling rejected or vulnerable
- Limit setting or confrontation
- Feeling lonely
- Sensory overload
Fear can dramatically alter thinking, feeling, and behaviour so IROs need to be aware of what these arousal states might look like during meetings. Tables 1.1 and 1.2 give suggestions of common fight, flight, freeze responses and although this is by no means an exhaustive list, it will support you to recognise possible signs that a child or adult is not feeling safe.)
Table 1.1 Trauma responses in adults
|Crying||Feeling stuck in some part of the body||Restless legs/numb legs|
|Hands in fists, desire to punch/rip||Feeling cold/frozen, numb, pale skin||Anxiety/shallow breathing|
|Tight jaw, grinding teeth, snarl||Stiffness or heaviness||Big or darting eyes|
|Desire to kick, stamp, smash with feet||Holding breath or restricted breathing||Leg/foot movement|
|Suicidal feelings/self-harm||Heart pounding or sense of dread||Restlessness, tension, feeling trapped|
|Rage/anger||Orientation to threat||Excessive exercise|
|Knotted stomach||Decreased heart rate (though can sometimes increase)||Running from one activity to the next|
Source: (adapted from www.trauma-recovery.ca/impact-effects-of-trauma/fight-flight-freeze-responses/)
In children, you may observe different responses. Look for moments when the intensity of the child’s response doesn’t match the context. Does the child’s response or behaviour confuse you or seem hard to explain? If so, ask yourself could this be the child’s trauma response?
Table 1.2 Trauma responses in children
|Hyperactivity/bouncing off walls/silliness||Running away||Daydreaming or looking dazed|
|Testing boundaries||Avoidance – sit alone in class||Over- compliance or denial of needs|
|Trouble concentrating||Self-isolation – stay in bedroom, not doing activities||Shutting down emotionally/constricted emotional expression|
Source: adapted from Blaustein and Kinniburgh, (2010, p. 27)
IROs direct work – practical strategies to help the child’s sense of safety
To begin to create a sense of safety for the child and family as an IRO, your priority must be to convey that you are safe, consistent, emotionally available and dependable if any trust is to develop.
Strategies to help promote a sense of safety:
- Be clear at the beginning about the focus of the meeting or consultation, so there are no surprises. Of course, sometimes you may need to go off course or change the plan midsession, but your structure should still be maintained with a clear beginning, middle and end. Ensuring the beginning and ending of your session or visit remain consistent throughout the involvement will help promote a feeling of safety and predictability.
- Depending on the age of the child or whether you’re meeting a child or an adult, consider beginning with some quick warm up activities or a check in and perhaps ending with the child’s preferred ritual such as a story or a song.
Strategies for responding to a child’s trauma state:
- If you become aware that a child is in a trauma state (hyper- or hypo- aroused), you will need to offer some modulation activity to sooth the child’s sensory system. In fact, such activities can be useful at the start and end of any meeting. A child with high energy will need different options to a child who is withdrawn. The ‘fizzy’ child may need to expend energy, so movement can be helpful. You could suggest a bounce on the trampoline outside in the garden or try counting how many star jumps he can do in a minute. Go for a fast, marching walk outdoors or play a game of push-me-over, pull-me-up with a younger child. A more withdrawn child will certainly benefit from activities that connect you, like throwing a ball to each other or blowing a feather across a cushion and back. All these sorts of activities activate the brain stem and can support improved regulation. Base your activity on where the child’s energy level is at.If you notice children beginning to dysregulate or see evidence of high arousal, it can help to have a little bag or box filled with options for sensory soothing. You can include something for the child to suck like a lolly or juice/water bottle or to chew like a toffee. It could be a sensory toy like a tangle or fidget cube to occupy little hands and ease anxiety. Gently blowing bubbles or simple, child friendly breathing exercises are also soothing activities to do together. (adapted from Wrench 2018, pp.28-39) You could think about having some resources available for use in the review meeting proper in a ‘calm box.’
Developing our own creative resources to allow for interactions that do not solely focus on the spoken word can also help nurture a less threatening experience of social work for children and families. But you need to believe in this approach – children will see right through you if you don’t. You need to believe in any creative activities and games you introduce to families. When you decide to offer an opportunity for play or art making or enjoying a game together, you start a conversation. As soon as a person shares his or her artwork or invites you to play, you are being invited to join that conversation and to learn something more about their world. ‘Think of creativity as introducing a new language, perhaps where words cannot be found, or feelings or experiences are too difficult to articulate; this is particularly critical when exploring traumatic events, which are often encoded in sensory fragments; a smell, a sound, an image, a taste, a bodily sensation.’ (Wrench 2018, p.47) In its simplest form, art making is a form of nonverbal communication. By introducing creative approaches, however, you allow both for self-expression and meaning making. You can support children and their families to ‘visually express and record their experiences, perceptions, feelings and imagination.’ (Wrench 2018, p.48) It can be a way of ‘telling’ more safely. It can help convey unspeakable things. As a sensory experience, it allows people to communicate in multi layered ways; visual, tactile, kinaesthetic. The product (the art object) allows people to be heard and seen. There is also evidence of that art making can support regulation, helping calm the mind and the body which is crucial for supporting to function within their window of tolerance.
A word of caution though here too. Unless you have formally trained as a creative therapist do not step outside of your skill and knowledge. Offering a creative response is offering an alternative means of communicating. Don’t feel you then need to start interpreting the symbolism in play or art making or to make blunt connections between what you see and the child’s lived experience. ‘Comment neutrally on what you see and on how the child is using the materials, which helps you stay connected. It is important the child feels neither led, judged or criticised’ so stick to open questions. (Wrench 2018, p.49) Try asking ‘Could you tell me about your drawing?’ rather than ‘that looks like your family.’ It’s important to avoid constraining possible meanings by imposing your own perspective. Curiosity is the best approach, together with giving your full attention and being interested in what is happening in the room – lots of wondering out loud. Or if someone is clearly struggling to explain something to you verbally ask, ‘Can you show me what that looks like?’ It can often be easier to draw a feeling or an experience rather than answering questions directly. An image (and this could be a shape, symbol or a colour) can hold great power in externalising or giving form to difficult or messy emotions.
Building your creative toolkit
It doesn’t take much to build a little creative toolkit to have with you in your boot or a big Mary Poppins style bag. Here are some ideas to get you started. We would always say that when we work only with what feels comfortable or familiar to us, this can be incredibly limiting. When it comes to children and families there is no ‘one size fits all’ solution to creative communication. The more options you have available the more likely it is that you will hit on the very thing that works for a child or adult, but make time for preparation and don’t assume the child’s parent or carer is going to be impressed if you pitch up with paints and sprinkle dust – check first!
- Have an oilcloth to cover the table/floor and allay any fears about making too much mess.
- Have baby wipes for wiping sticky hands or cleaning accidental spillages.
- Choose your materials to fit the context. Paint and glitter are hard to control in a family’s living room or school library. Too much choice can also be overwhelming.
- The quality of your materials matters. It conveys on a basic level that the child (or his Dad for example) deserves to work with decent products; that you value them. Bringing pencils that need sharpening, felt tips that have dried out or an empty glue stick is not respectful.
- My art box contains Crayola Twistable crayons (that never need sharpening) and washable felts. I do have more expressive materials like charcoal and pastels, but these do need to be used with more care. I also have craft materials like feathers, googly eyes, pom poms and tissue paper shapes. You’ll need a selection of paper, scissors (adult and child sized) and glue.
- If you have room in your boot, have a selection of magazines- it’s easy to pick these up for free in supermarkets, stores and travel agencies. You can use these for lots of different collage activities like a self-portrait or life graph.
- Small toys – I have several cloth bags (all stored inside a bigger bag) containing themed toys within. I have cars and emergency vehicles, animal families, dinosaurs, monsters/superheroes, human figures etc. These can be used in so many ways – for exercises like Family Sculpts, for metaphorical stories or to observe free play or play between a child and caregiver. They’re also handy for occupational play if you need to talk to a parent and there aren’t many toys in the family home for the child.
- Stories -and they don’t always have to have a ‘message’ to the child. They can be a lovely way of making a connection, beginning or ending a session.
(adapted from Wrench 2018, pp52-53)
Blaustein, M. & Kinniburgh, K. (2010) Treating Traumatic Stress in Children and Adolescents. How to Foster Resilience through Attachment, Self-regulation and Competency. New York: The Guilford Press
Siegel, D. (1999) The Developing Mind New York: Guildford
Wrench, K. (2018) Creative Ideas for Assessing Vulnerable Children and Families. London: Jessica Kingsley Publishers
Practical resources and tools can be downloaded via NIROMP: IRO Toolbox