THE ATTACHMENT SELF-REGULATION AND...

Workshop April2017

Formationsurletraumaetlemodèle d’intervention ARC 1

THE ATTACHMENT, SELF-REGULATIONAND COMPETENCY

(ARC) MODEL

DelphineCollin-Vézina,PhDDirector, Centre for Research on Children and FamiliesNicolas Steinmetz and Gilles Julien Chair in Social Pediatrics in CommunityTier II Canada Research Chair in Child WelfareAssociate Professor, School of Social Work & Associate Member, Department of PediatricsMcGill University

Workshop April2017

Youth in Out-of-Home Care

• DatafromtheNationalSurveyonChildandAdolescentWell-Beingshowedthat43%ofteenagersinout-of-homecarereportedatleastonementalhealthproblem:depression,anxiety,substanceabuse,suicidality,ADHD(1)

• Among9,942childrenandyouthinresidentialcaresettings(meanage10.4)(2)– 92%ofyouthreportedatleast2traumaticevents.– 80%wereratedashavingbehaviourproblems,70%had

attachmentissues,65%hadacademicdifficulties,and42%hadsubstanceuseproblems.

– Asthenumberoftraumasincreased,functionalimpairmentincreased.

(1) Heneghan etal.,2013(2) Briggsetal.,2012

Workshop April2017

Youth in Residential Care: A Quebec Study

Collin-Vézina etal,2011

N=5322.6

26.430.2

Gender

RacialGroup

Aboriginalor1stNationsBlack

WhiteorEuropeanOther

ChildhoodTraumaQuestionnaire

TypeofAbuse

Noneorminimal

Lowtomoderate

Moderatetosevere

Severetoextreme

Physicalabuse 38% 19% 9% 34%

Emotionalabuse 32% 26% 9% 32%

Sexualabuse 62%(none) 6% 9% 23%

Physicalneglect 45% 15% 15% 25%

Emotionalneglect 41.5% 24.5% 17% 17%

Workshop April2017

Compoundedmaltreatment:• 83% ofthesamplereportedatleastoneformofmaltreatment.

• 76%oftheyouthreportedMULTIPLE(2orMORE)forms ofmaltreatment.

• 64%oftheyouthreported3formsofmaltreatment.• 40%oftheyouthreported4formsofmaltreatment.• 19% ofthesampleexperiencedALL5TYPESofchildmaltreatment.

However,thereasonsthese53youthweretakenintochildprotectioncare(3sub-sections)werepoorlyreflectiveofthetraumasexperienced:

• 83,0%behaviourproblems• 26,4%neglect• 5,7%sexualabuse,• 5,7%abandonment• <5%emotionalabuse• <5%physicalabuse

Milne&Collin-Vézina,2014

Workshop April2017

Adolescent male whois…

Aggressive to peopleDeceitfulNot receptive to feedbackEasily frustratedBelittling Quick to anger

A young personwho is suffering

Workshop April2017

NTCSN: Principles of Trauma-Informed Care

NCTSNChildWelfareCommittee,2012

PartnerwithOtherAgenciesandSystems

MaximizePhysicalandEmotionalSafety

IdentifyChildandFamily’strauma-

RelatedNeeds

EnhanceChildWell-Beingand

Resilience

EnhanceFamilyWell-BeingandResilience

EnhanceStaffWell-Beingand

Resilience

PartnerwithChildandFamily

BroaderChild-ServingSystem

ChildWelfareSystem

Family

Workshop April2017

ARC: A Systemic Approach to Trauma

Blaustein &Kinniburgh,2010

Ofthehandfuloftrauma-informedinterventions,toourknowledge,onlyonepresentsamulti-systemicdesignthatallowsforimplementationamongdirect-carestaff.

Targetsthe3coreresiliencydomains:

A AttachmentR RegulationC Competency

• Evidence- andpractice-informedtreatment• Groundedintraumatheory,attachment,andchild

development.• Asawhole,thesetheorieshighlighttheimportanceof:

– Workingwiththeyouth-in-context,– Recognizingthattheyouth’scurrentadaptiveresponsesare

linkedtohistoricalexperiences,– Promotinginterventionwithintheimmediateenvironment–

whetherprimarycaregiversortreatmentsystems– tosupporttheyouth’sgrowthanddevelopment.

• RecognizedasapromisingpracticebytheNCTSNandSAMHSA

Workshop April2017

THE ATTACHMENT, SELF-REGULATIONAND COMPETENCY

(ARC) MODEL

Trauma-impacted CHILD

Flexibleapplicationaccording theinterventioncontext:Individual,family,andgrouptherapy;children,parents,milieux

Workshop April2017

The ARC Model

Competency

Self-Regulation

Attachment

ARC: A Systemic Approach

Attachment

Routines&Rituals

CaregiverAffect

Management

Attunement

ConsistentResponse

Self-Regulation

Identification

Modulation

Expression

Competency

ExecutiveFunctioning

Identity

TraumaIntegration

Workshop April2017

Conceptual Model: The Impact of ARC

Offeringacommonvisionof

trauma(knowledge).

Offeringasetofconcretetoolstousewithtrauma-impactedyouth(Know-how).

Enhancecaregiverand

professionalself-efficacy.

Diminishnegativeinteractionswith

youth.

Decreaseproblembehavioursandmentalhealth

difficultiesforyouth.Increaseyouth’ssense

ofsafetyinrelationships,emotionregulationcapacitiesandcompetencies.

Offeringspaceandopportunitiesforreflectiveprofessionalpractice

(« savoir-être »).

Research – Current Implementation in Quebec

Workshop April2017

ARC – Foster Care

• Sensitizationprogramforfosterparents– Objective:promoteplacementstability

• DevelopedincollaborationwithCISSSLanaudière;nowimplementedalsoatCIUSSSCentre-sud del’Île deMontréal.

• 7 cohortsoffosterparentsattwoinstitutionssinceFall2013

• Format:– 12weekly2.5hourmeetingsonthe10ARCblocs– 2individualmeetingswithapsycho-educatorassignedtothe

ARCgroupwithoptionalin-homesupport– Regionalandprovincialpracticecommunities

ARC – Foster Care

TotalDifficultiesScoreEmotionalDifficultiesBehaviourProblemsHyperactivityRelationalProblems

PrePost

* * **

n =36foster parents

Strengths andDifficulties Questionnaire(SDQ)Pre- andPost- at12week interval

Workshop April2017

ARC – Foster Care

n =36foster parents

Strengths andDifficulties Questionnaire(SDQ)Pre- andPost- at12week interval

TotalDifficulties (pre)

Average

Slightlyhigh

VeryHigh

TotalDifficulties (post)

ARC – Group Homes and Residential Care

• Trainingforeducatorsandclinicalsupportstaff– Objective:reduceuseofrestraintsanddeveloptrauma-

informedprofessionalpractices(beliefs,attitudes,behaviours)• 8unitstrainedsinceDecember2014

– CIUSSSCentre-sud del’Île deMontréal,CISSSOutaouais,CISSSLanaudière,CIUSSSCapitale-Nationale,CIUSSSOuest-de-l’Île deMontréal,CISSSMauricie-Centre-du-Québec

• Format:– 1.5dayoftrainingforeducatorsandclinicalsupportstaff– 1additionalfulldayoftrainingforclinicalsupportstaff– Minimumsixmonthlyclinicalconsultation/integrationmeetings– SuggestedARCactivities

Workshop April2017

ARC – Juvenile Justice

• Trainingforeducatorsandclinicalsupportstaff– Objective:reduceuseofrestraintsanddeveloptrauma-

informedprofessionalpractices(beliefs,attitudes,behaviours)

• CurrentlyinprogramdevelopmentphaseinpartnershipwithCIUSSSCentre-sud del’Île deMontréal.

• Format:– 1.5dayoftrainingforeducatorsandclinicalsupportstaff– 1additionalfulldayoftrainingforclinicalsupportstaff– Monthlyclinicalconsultation/integrationmeetings(permanent)– SuggestedARCactivities

Workshop April2017

Building Block 1:Routines and Rituals

Attachment

Routines&Rituals

CaregiverAffect

Management

Attunement

ConsistentResponse

Self-Regulation

Identification

Modulation

Expression

Competency

Identity

TraumaIntegration

Knowledge: General Considerations

• Traumaisoftenassociatedwithunpredictability,chaos,andlossofcontrol.

• Youthmaybereactivetochangeandtransitions,andmayhavedevelopedrigidityintheirattemptstocontrolthemselves,others,andtheenvironment.

• Consistentroutinesandpredictabilityarehelpfultodecreaseinsecurityandvulnerability.

• Energycanshiftfrom‘survival’tohealthydevelopment.

Workshop April2017

Know-To: Intervention Tips

• Individualintervention– Beingpredictable(calendar,schedule)

• FamilyIntervention– Adaptingexpectations– Targetingkeymoments(morning,homework,

bedtime)• SystemicIntervention

– Avoiddisruptionsinroutines– Anticipatedifficultmoments– Createrituals– Improvecommunicationwithinteamsandbetween

systems

‘Savoir-être’: Challenges

• Adaptingexpectationstotheyouth’scurrentcapacities(e.g.,homework,hygiene,etc.).

• Acceptingthatroutinesthatworkwellforotheryouth,orforthesameyouthinthepast,mayneedtobechanged.

• Findingbalancebetweenfamilyorgrouproutinesandpersonalizedroutinesforeachyouth.

• Lighteningheavyroutines,makingroomforflexibilityin“military”styleroutines,oralternately,helpingdisorganizedadultstoestablishandsustainroutines.

• Creating“roundtables”withallpartners,takingamoremoderateapproach.

Workshop April2017

Examples from the ARC Manual

Building Block 2:Caregiver Affect Management

Attachment

Routines&Rituals

CaregiverAffect

Management

Attunement

ConsistentResponse

Self-Regulation

Identification

Modulation

Expression

Competency

Identity

TraumaIntegration

Workshop April2017

• Youthvigilance:traumatizedyouthcaninterpretcaregiveremotionsindichotomies(safetyvs.danger,approvalvs.disapproval,andacceptancevs.rejection)• Trauma-impactedyouthhaveextremelysensitiveantennae

todetectthreats,butoftenmakeinaccurateinterpretations• Caregiversmustconstantlymodulatetheirownemotions

inordertohelpyouthlearntomodulatetheirs• Workingwithyouthwhohaveexcessivebehaviours has

anemotionalandcognitiveimpactoncaregivers(reducedsenseofself-efficacy,angerandblametowardsthechild,shuttingdown,overreacting,overlypermissive).

• FamilyIntervention– Well-beingactivities(e.g.,identifying5strategiesto

helpyoufeelbetter)– Supportandhelp– Therapy

• SystemicIntervention:workerself-careandcultivatingasupportiveworkculture– Individualorgroupsupervisioncanbeusedto

normalizestrongreactionsandoffersupport– Ongoingtraininganddiscussions– Workloadandwork-lifebalance– Reflectionspacesaboutvicarioustrauma,

compassionfatigue,burnout…

Workshop April2017

• Recognizingandvalidatingthatourownchallenges,asworkers,arenumerous(overwork,reform…).

• Establishingatrustingrelationshipwiththefamilyortheteamisessentialbeforethisblockcanbeaddressed(recognizethevalueoftheirwork,normalize,validate,findsolutions,etc.);highlightstrengthswhilecreatingmoreandmorespacetodiscussmistakesandmissedopportunities.

• Inanorganizationalcontext,theteamleader/manager’sroleisvitaltocreateaclimateoftrustandopenness;themanager’sfullparticipationisessential.

• Acceptingthatdevelopingareflexiveanddeliberatepracticeisalongprocess.

• Linkreflectionsanddiscussiontoconcreteaction

Workshop April2017

Block 6: Modulation

Self-Regulation

Attachment

Routines&Rituals

CaregiverAffect

Management

Attunement

ConsistentResponse

Self-Regulation

Identification

Modulation

Expression

Competency

Identity

TraumaIntegration

Workshop April2017

• Trauma-impactedyouthhavealimitedawarenessoftheirpsychologicalstates,eitherbecausethecompetencieswereneveracquired,orbecausethetraumadeconstructedpreviouslyacquiredcompetencies.

• Low-toleranceforemotions;emotionsthemselvescometofeelthreatening

• Difficultywith:– Differentiatingone’sownemotionalstates– Decodingotherpeople’semotionsandcues– Communicatingemotionsinanappropriateway– Usingeffectivemodulationstrategiestomanageintense

and/orpainfulemotionalstates

• IndividualIntervention– Learningandpracticingmodulationstrategies

(breathing,imagery,progressiverelaxation,stressballs)

– Listeningtomusic,drawing,writing,etc.• GroupIntervention

– Socialcircus,dance,theatre,choir,etc.– Yoga,meditation– Trampolineandotherrhythmicactivities– Sportsandotherphysicalactivities

• Systemic Intervention– Ensuringthatyouthhaveeasyaccesstomodulation

toolsandstrategiesatalltimes

Workshop April2017

• Whenin“dangermode”ordealingwithtriggers,childrenarelessabletouselanguagetocommunicatetheirexperience.Modulationisanecessaryfirststepbeforeattemptingtohelpthemidentifyorcommunicatewhatishappening

• Usingresourcesinadeliberateandintentionalway,basedontherapeuticobjectives,ratherthaninamechanisticway

• Ensuringthattheactivitiesandstrategieschosencorrespondtotheyouth’sdevelopmentallevel(asopposedtochronologicalage)

• Usingactivitiesasopportunitiestogettoknowandunderstandthechildratherthanasanobjectiveitself(e.g.,ifachildrefusestoansweraquestionorelaborate).

Workshop April2017

Building Block 9:Identity

Competency

Attachment

Routines&Rituals

CaregiverAffect

Management

Attunement

ConsistentResponse

Self-Regulation

Identification

Modulation

Expression

Competency

Identity

TraumaIntegration

Workshop April2017

• Traumatizedchildreninternalizenegativeexperiencesandseethemselvesasunlovable,unworthy,helpless,ordamaged.

• Traumatizedchildrenmayrelyondissociativecopingmethods(fragmentationanddisconnectionfromtheirexperiences,multiplesensesofself).– Difficultyintegratingacoherentsenseofselfacrossexperiencesandaffectivestates.

• Traumatizedchildrenoftencurtailexplorationtofeelsafe,relyinginsteadonrigidcontrolandrepetition.

UniqueSelf

Develop anawarenessofone’sindividualcharacteristics.Listenforandreflectstatementsthatsupportthis.

“Aboutme”books,personalcollages, creativeexpression,hobbies,otheractivities.

PositiveSelf

Abilitytotune into,name,andownpositiveattributesofself.Considerrelativesuccess,smallvictories,redefinesuccess.

Makealistofpositiveattributes,wallofsuccess,superheroselfactivities,otherartisticactivities.

CoherentSelf

Abilitytointegratemultiple aspectsofselfacrossexperiencesandaffectivestates. Notice andnormalizefragmentationwhileworkingtocreatecoherence.

Concrete timelineactivities,“Myhistory”book,aspectsoftheself(artistic)

FutureSelf Abilitytoenvisionpossibilities,selfinthefuture,waystobecomethatself.Set goals,makelinksbetweencurrentactivities andfuture goals.

Activitiesthatprojectthechild5,10,20yearintothefuture,annextothe“myhistorybook”

Workshop April2017

• Suchreflectionsonidentity,pastandfutureselves,etc.,cannotbedoneinameaningfulwayunlessthechildhasasenseofsecurity(Attachmentblocks)andareasonabletoregulateaffect(Regulationblocs).

• Canbedoneataveryconcretelevelifneeded(e.g.,foodsIlike,etc.)

• Creativeandartisticactivitiesshouldbepartoftheprogramingastheyofferanalternativetolanguage-basedreflections

Intervention: examples of activities

IdentityMasks CoatofArms

TotemPole

Workshop April2017

ALL QUESTIONS CAN BEADDRESSED TO

DELPHINE COLLIN-VÉZINA:delphine.collin-vézina@mcgill.ca

Thank you for your attention & participation!

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