Tag Archives: Magic Moments

Healing the Attachment System

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My observations in India – just as my much longer experience in El Salvador – have led me to question the idea that the way to heal attachment disorders is either by the establishment of a potentially secure attachment relationship through adoption or foster parenting, or through intensive and lengthy psychotherapy. That is not to say that I saw uniformly effective healing in either place, but just that I observed alternative healing methods that seemed to me to have promise. 

In each children’s home, for example, there are multiple caregivers, at least one central parental figure, and (when all is going well) a secure environment. The secure environment is not only associated with the person of the caregiver but is also related to adequate food and shelter and freedom from threat. At Love and Hope, Rachel is the central parental figure, and the children also have important relationships with the tias and tios (female and male caregivers), the cook (as witnessed in the “papusa maker” video), and a social worker and psychologist on staff; the high caregiver-child ratio is one of the strengths of the home. At Deenabandhu, there are two central parental figures – Prajna and Prof. Jayadev – and the important continuity of one (the same) skilled and caring teacher throughout the early years of school. In addition to these strengths in each home there are the important relationships between and among the children – age mates and older-younger pairs. Perhaps the power of the peer relationships is enhanced by aspects of the culture; in El Salvador it is not uncommon to see a young boy carrying a baby on his hip. At any rate, the richness of the interpersonal environment offers many opportunities for finding security in a trusting relationship, contingent social interactions, and the subjective experience of caring and personal recognition. 

 

 It is important to recognize the apparently contradictory results of the Romanian orphanage studies that point to the dangers of early institutionalization and the need for a primary caregiving relationship such as through adoption or foster care (Zeanah et al, 2011, Fox et al, 2010). When viewing the films of the children in these orphanages, the caregivers appear to be surprisingly pleasant and sometimes engaging in friendly, even helpful, interactions with the children. The main problem, I guess, is the lack of contingency of caregiver responses, especially in infancy. That is, the children are fed without reference to their cues or initiatives, aggression in the free play situation is not responded to helpfully, and the caregivers do not play with the children. I guess I would suggest that the big difference I observed between what I saw in the films of the Romanian orphanages and what I saw at Love and Hope and Deenabandhu is greater personal involvement of the caregivers and the children so that relationships were encouraged, the children were known for who they were as little individuals, and there was a lot of interaction between caregivers and children – in play and in academic learning. This is related to the idea of “magic moments“, or “lost momentos magicos” of earlier posts. 

I am reminded of Bruce Perry’s observations that traumatized children initially do better when allowed to seek out particular caregivers to fill specific personal needs – such as one caregiver to roughhouse with, another to provide food, another for comfort at times of emotional distress, another to help with homework. I am also reminded of Peter Fonagy’s therapeutic model of mentalization. That model avoids directly engaging the attachment system without simultaneously working on building reflective capacity that can guard against what one might call the “regressive pull” to intense destructive relationship patterns that were established in early childhood. Fonagy’s model was originally designed to treat adults with Borderline Personality Disorder, many of whom have experienced early trauma. However, it seems to me to be equally relevant to children – at least those with the cognitive capacity for mentalization – who cannot trust adult caregivers and cannot comfort or care for themselves. None of this means that developing a trusting and loving caregiving relationship with a single person is not healing. It is just to say that – at least now in my thinking – I am leaning towards the idea that there are multiple ways of healing the attachment system of children who have experienced trauma and severe neglect.

 

I hope my readers can make comments on this posting.

 

Bos K, Zeanah C, Fox N, Drury S, McLaughlin K, & Nelson C, Psychiatric outcomes in young children with a history of institutionalization, Harvard Review of Psychiatry, January/February, 2011, pp. 15-24; Fox S, Levitt P, & Nelson C, How the timing and quality of early experiences influences the development of brain architecture, Child Development, January/February, 2010, Vol. 81, Number 1, pp. 28-40).

 

Photograph by Ginger Gregory

 

 

 

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Conflict and Repair

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This series of photographs illustrates a beautiful example of the repair of a conflict between two children, with many magic moments. E, in the blue shorts, is a 6-yo boy who hit K, the boy in the blue jeans, with a ball. The hit was most likely accidental, but K, who is 4-years old, began to cry and went to get the caregiver, L. In this photo, L is listening to E’s account of the story. A 7-yo girl, B, is the audience. In the the first photo, J has just finished voicing his complaint, and L is looking at D questioningly, waiting for an explanation. 

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In the second photo, E is defending himself, proclaiming his innocence of the charges. K is watching silently. B stands silently as witness. L explains that K was crying, and that E needs to apologize to K and help him feel better, even if it were an accident. B continues to stand, watching, her little hands on her hips. E is refusing to apologize to K. L is firm but gentle, her voice quiet and slow-paced. This is a magic moment, because L does not express anger or impatience, yet she persists.

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In the third photo, L bends down to talk to E. E looks as if he is going to run away, and L takes hold of his arm. E is kicking his foot, rebelliously. At last, E says he is sorry, but he growls it out with a scowl. L tells him that he must say it again in a nicer way. E repeats his angry apology, and L quietly insists again that he say it nicely. This is another magic moment, because instead of getting angry, she persists in a quiet, non-reactive way. E finally says he is sorry – not exactly “nicely” – but without a growl. Here is another magic moment, in that L accepts a gesture that is less than perfect. She must have had the sense that at this point she could help bring the situation to a good resolution. 

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In the fourth photo, L tells E that he should give K a hug to make him feel better. This is too much for E, so in another magic moment, she opens her own arms and encloses the two little boys in a group embrace. 

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In the fifth photo, the embrace continues, but L is preparing to let them go. The boys are giggling.

The magic moments in this set of photos focus on L’s patience, calm, and slow pace. These factors in addition to her quietly loving attitude allow her to side-step provocation into a struggle and generate the creative solution of the group hug. As she watches the scenario, B takes in the gestalt of the repair of conflict scaffolded by an adult, including the magic moments. All three children are more likely to repeat at least one of the elements of this repair in future conflicts.  

 

 

The Workshop: Magic Moments

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Day II: The Workshop

A good group gathered for the workshop, including representatives of four orphanages. I began the workshop with a description of brain development. I used Dan Siegel’s ingenious model of the brain in which the thumb represents the brain stem and midbrain, and the fingers curled around this core represent the cortex. The thumb, the evolutionarily primitive brain maintains essential functions such as heart and respiratory rate, sleep, appetite, and reaction to threat of danger (objective or subjective), but also reward, regulation, and mood (Bruce Perry). The fingers are the “thinking brain”. The thumb develops first in life, and the fingers don’t “come online” until around 1-year old.  You can see where I am going with this, because M entered the home at age 1, and therefore he moved into an enriched environment after most of this development took place. The circumstances of his earlier life were known to be depriving and neglectful. I also reminded the participants that development was unpredictable and that boys were generally more vulnerable than girls. It has been observed that in the home the girls tend to do better than the boys, both from the point of behavior and also achievement. 

Then I reminded the participants of the notion of “magic moments”, those moments in the interaction between caregiver and child when the pair confronts a choice between (1) taking the risk of trying something new (and more energy-demanding in the short run) or (2) slipping down the slippery slope into a problem pattern such as a struggle, and instead of following the old problem pattern they find their way to a better path. I showed them two clips of children at the home that demonstrated magic moments, pointing out that these magic moments prepared the way, or increased the probability, for future magic moments; in other words, the more of these you practice, the easier it is to slip into a good path in the future. Both clips illustrated child and adult working side by side. In one, a boy was grating carrots with an adult, and in another a girl was being helped to cut cucumbers with a big knife. In both, the side-by-side aspect of the activity was emphasized. My message (despite the fact that some cynics in the group thought that some of the behavior was influenced by the presence of a camera) was that when children practice tasks at the side of an approving adult, the task becomes more doable by the child independently in the future. 

Then I began the Presentation of “M”:

 M entered the home at age 1-year old. I invited the participants, now that they knew about brain development in the first year of life, to consider what neurodevelopmental vulnerabilities M might have brought with him into the home. In fact, early on, Rachel identified him as having delayed speech. He was described as sweet, warmly attached to familiar adults, but unusually timid and fearful, crying a lot. Still, many foundational skills seemed in place – in one observation Sarah Measures did when he was 2-years old, he was able to engage in reciprocal play and had gestural language, his motor sequencing seemed OK, his language comprehension was good, his reading of social cues seemed fine, and he showed no signs of extreme sensory sensitivities. He was observed hanging around the other boys, on the edge of the rough and tumble play. Still, he eventually joined in and remained engaged for 30 minutes. 

I showed a video clip of M at 1-year old. He was a sweet-looking boy in a high chair, with a pleasant expression, playing with a toy on the tray of the high chair. When he dropped it, he patiently waited for the caregiver to replace it, which she did. He did not, however, give her a direct gaze, nor did he initiate a gesture to recover the toy himself. Yet, he was clearly interested in the child sitting next to him and to what was going on with her. 

In kindergarten, M’s teacher complained that he fell asleep in school. Sarah and I observed him, and he did have his head on the desk most of the time. His teachers seemed to not know what to do with this behavior. At this time, Rachel also had concerns about his not eating and having stomachaches, though the doctor could find nothing wrong. He continued to have crying spells and to spend more time sitting alone than the other children, sitting on the steps eating mangos. At other times, though, he would join in the fun.  I reminded the group of the physiological regulation problems that can be associated with problems in neurodevelopment in the first year of life. 

M Today: Video of M’s Noncompliance: Rupture and Repair

Step 1. I described the interactions I captured on film the day before. The first step was M’s refusal to change out of his school uniform, an expectation at the home. Tia (“Auntie”, caregiver) Ani and Jessica (the psychologist) tried to help him comply. Instead, he lay on the floor. Gentle persuasion got nowhere. In the clip, M’s foot is seen on the floor of the bedroom, where he is lying and talking in a whimpering, defiant voice. Ani’s voice is soft, and she leaves pauses that seem to say, “You can take over if you want.” She does not escalate the emotion. Later Ani explained that she was asking M what was wrong, and at first he said, “Everything is wrong!” He later explained that he spilled his yoghurt at school, and then further explained that the boys made fun of him for doing that. This information emerged bit by bit, allowed by Ani’s empathic approach. Still, M could not respond to the demand to change his uniform. In the clip he tentatively kicks the door in rebellion, but he is not “too far gone” yet. 

Step 2. The next clip is of Tio Luis, who comes to help Ani. His style is to use affectionate physical support, holding M around the waist (M is standing now) and bending his body gently in the same arc as M’s. Still, M shows he is not ready to respond; he grabs hold of the gate to resist Luis’ pull. He may still escalate. I suggest taking a break (who knows if this was the “right” thing to do?) and Luis backs off gracefully. M retreated to the bedroom and lay on his bed, covering himself with a blanket. I went into the bedroom with him and sat quietly on another bed. 

Step 3. There was music in the adjoining room, where Kirsten was playing the guitar with three littler boys. M got up and moved into that room, sitting on a chair on the outskirts of the action, watching. I moved to a position behind him; he turned once to look at me and then looked back. Kirsten made no fuss about his joining, nor did she make an explicit invitation for him to come closer. I was glad, because I thought M needed low-key responses. 

Step 4. M got out of his chair and lay on the floor next to the other children, with his cheek on the floor and his bum in the air, in a caterpillar position. There was a potential conflict with an assertive little boy when they both reached for the same object, but it did not escalate. 

Step 5. Kirsten gave the guitar to M to take a turn. M sat up and took the guitar and began to strum. She gave gentle instruction to M about how to do it and reminded the littler boy to get his hands off the guitar while M took his turn. Slowly, M stood up and strummed the guitar. After a while, he stood taller and assumed a little of a rock star posture. I thought, “This is how self esteem is redeemed.” 

Steps 6 and 7.  Later in the afternoon, I saw that M had changed the shirt of his uniform, leaving on the pants. Later still, before the birthday celebration, I saw that he had changed his pants as well. His twin brothers were celebrating their birthday, and he sat close to one of them, watching everything.

Because the evaluations from last time included the desire to hear more voices, I had decided to at this point divide into small groups for discussion. Here are some of the results of the discussion from these groups. 

Discussion from the Small Groups-:

-Tia Ani did not raise her voice to M in the bedroom because we have raised our voices before, and it doesn’t work. When the child is stuck in a rut, raising your voice doesn’t work. 

– It was a good idea for Luis to step in when he did, because collaboration between two caregivers is often helpful and can avoid a struggle. 

– There was a discussion about “teaching a child to manipulate” and what is the message to the other children if the understood consequence for “bad” behavior is delayed or not applied. I suggested that there must be communication among the caregivers (CG) so that there is no “splitting” (the child playing one CG off the other) and so that if one person gets confused and is tending to bend the rules, the second person can set him straight. These actions work against manipulation. 

– We also talked about how it is good to be flexible sometimes. Yet, “being flexible” can also be seen as a reflection on the CG’s job performance. In that case, it is good for the CG to explain her reasoning to her supervisor. 

– We discussed the timing of giving consequences. If the child is in a highly reactive state, reminding him of the consequence for his “bad” behavior is likely to escalate his aggressive behavior. Certainly he will not be able to “learn” from a lecture in that state, when his cortex (thinking brain) is “offline”. It is a challenge to assess the “state” of the child and then to make a decision about the timing of the consequence. All CG’s struggle with this challenge. We all thought that M should get a consequence later, when he could handle it. In this case, after M had calmed down and Ani had responded to him empathically in a gentle, slow paced way, he received his consequence easily. 

– All groups also thought that it was important to talk to M about what happened later. One participant suggested that if the child is unable or chooses not to talk, he may draw or write about what happened. I added that children may communicate “what happened” either in reality or in his unconscious fantasy in the form of symbolic play. 

– What were the “magic moments” in this scenario? (1) The first may be Ani’s choice to empathically question M about his day instead of immediately setting the limit about changing his uniform. (2) The second may be Luis’ joining Ani so that she would not be alone and vulnerable to being drawn into an old struggle pattern. (3) The third may be Luis’ “letting go” and allowing M to withdraw in order to “get himself together”. (4) The fourth may be Kirsten’s low key and implicit welcome of M into the group without stressing him. (5) The fifth may have been Kirsten’s allowing M to “take the stage” and in that way reclaiming his self-esteem. (6) Finally, the staff’s allowing M to pace himself in his eventual compliance with the rule, even though he had to accept the consequence of refusing to comply when he was asked. 

If you can imagine the child’s mind, you do not expect more than he can accomplish. You can empathize with his experience and help him feel less alone. You can in that way maximize the probability of his success. 

In the next posting I will briefly address the issue of working with families and then talk about the adolescents.

 

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Finding Magic Moments

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I continue to be inspired by the team of the Children’s Home, as they work to support the families of the children in the community. Complying with the directives of the local agencies, they have done evaluations of the children and of the families to which they are to be reunited, and they have given recommendations on the basis of these recommendations to the agencies. Even in the case of a mother who seemed incapable of taking basic responsibility for her child, the only case in which they could not recommend that child and mother be reunited, the Home did not devalue the mother nor judge her harshly. In questionable circumstances, the Home tries to find creative solutions with the families so that the people at the Home can maintain a relationship with the children even after the children move in with their relatives. 

I am planning another trip in April, this time perhaps without my team, since no one is free to accompany me. I am eager to go because I am hoping that in addition to giving a workshop, I will be able to visit an orphanage for children with HIV-AIDS, and perhaps begin to support the caregivers there.

My commitment to supporting the caregivers has only grown through this experience with the Children’s Home. In my work with parents here in Cambridge, I focus even more on helping parents understand their own children, “imagine their minds”, so that they can “find” them, comfort them in their distress, and help them grow and learn. And I am developing the idea of “magic moments” so that I can use it more effectively to help parents help their families grow stronger. 

Here are some examples of “magic moments” in my practice:

1. The parents of an 8-year old boy were told by his teacher that he was involved in some trouble at school with two of his friends. When his father came to pick him up at school, the boy told his father that he had not been actively involved in the problem behavior, and he described the situation to him. He then asked his father if he believed him. His father thought about it and answered, “Tom, I believe you. You are a truthful and good reporter. I might not have believed you last year, but things have changed. Now I see you as a truthful and good reporter.”  I told the father that I thought this was a magic moment. It would have been easy to doubt the boy, or even to hesitate, but the certainty in the father’s tone as he described what he said to his son was compelling. He recognized the new Tom. He gave Tom the chance to see himself in his father’s eyes as “a truthful and good reporter”. I think his son will always see himself a little differently from now on.  

2. In another family, there are two sisters who are frequently at odds. Recently, their parents told me about a magic moment in their family that happened between the sisters. The younger sister, who characteristically is demanding of attention and can be intrusive, was having trouble with a game and asked her older sister if she would help her. The older sister, who by contrast, needs her space and abhors being intruded on, did not complain and immediately moved to work on the problem with her little sister. It is hard to know what allowed this to happen. What is less hard to imagine is that it will happen again, and the more often something like this happens, the more likely it is to repeat itself. That is because magic moments accumulate and make the path to the new alternative easier and easier to take. It is like building infrastructure to a new city. 

3. A woman of my acquaintance has a new grandson, but there is trouble, because the child may have congenital disabilities of some kind. The grandmother is distraught, not only because of her fears about her beloved grandchild, but also because she is enraged at her daughter in law, whom she suspects to have abused substances during her pregnancy. As she tells me the story, I give her some important advice. She should feel justified to have her feelings, but not to show them to her daughter in law. Instead, I cautioned her to put aside her feelings when she is with the mother and baby and support the relationship no matter what. The baby will likely have to undergo frightening and painful medical procedures, and he will need his mother’s comfort. Supporting the mother-child relationship will make it more possible that the baby will be able to feel comforted by his mother, and that will allow him to build a sense of security and trust that others can help him when he is in need. 

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