Tag Archives: reunification

“A Healing Place”: Part I


I am in El Salvador and am reporting on a recent workshop I gave at the children’s home, Love and Hope, with my colleague and team member, Susana Fragano. Before my departure for El Salvador, I asked Rachel, in one of our regular skypes, what she and the tias and tios (caregivers) would like to have as the focus of the workshop. She said that what they really needed help with was how to manage severe behavior problems. She told me about some of the tantrums, insolence and noncompliance, and sexual behavior, of the children in the home. This behavior has gotten worse in the last year or so since LEPINA, the Salvadoran law that requires institutionalized children to be reunited with their biological families, has been implemented, causing most of the children in the home to be returned to their families in the community. These reunited children, when they return to the home at the request of their families – either for weekend visits or for longer stays – because the families declare themselves unable to care for them – demonstrate more problematic behavior than before the reunification. Whether the worsening in behavior is due to neglect and abuse the children report they have experienced during the time they were living with their families, whether it is a consequence of the disruption of a secure caregiving environment and the traumatic loss of the caring relationships they had enjoyed at the home, or whether it is simply due to their growing older, is not known.

In the next several blog postings I am going to report on my experiences at the home during this visit and the workshop we gave to the caregivers. For a reason that will become clear as I continue, I will call these postings, “A Healing Place”. I have awakened early to write, and as I open the curtains in the window of my favorite hotel in San Salvador, I look out on dark mountains in the near distance, palm trees and other tropical vegetation in the nearer distance, and the “Mister Donut” sign that protrudes above the rooftops and guides us home after a day’s work.

Pathway to Trouble

I introduced the workshop with a review of the sources of the problems that these troubled children now have. I reminded them of the important factors I have spoken to them about many times before: (1) Prenatal stress; (2) Early abuse and neglect; (3) A genetic contribution; (4) and the ongoing trouble caused by the effect of chronic stress on the developing brain. The more you repeat a problem behavior, the better your brain learns to repeat it. I would like to state at the beginning of this series of posts that many of the points I am making about traumatized children are equally valid in relation to children with serious developmental disturbances, such children on the autistic spectrum. That is because for these children ordinary life experiences with other people, even caring attention, can feel traumatizing.

Interrupting that Pathway to Trouble

This is what the stated goal of the children’s homes has always been. Put another way, it is “breaking the cycle” of the consequences of severe neglect and abuse. But this is very hard to do. It is also hard for caregivers to remember, to keep in mind, that the children they take care of have a story about pain and neglect in their brains. They carry it always, and it can emerge unpredictably in response to current experience. This story will not go away with good care. But it can become increasingly less potent, as a new story is created to take its place. The new story is about acceptance, trust, love, and hope. The new story is about healing.

A Healing Place

I then told them about an 8-year old girl I had observed the day before. Let’s call her “Angela”, not her real name. She entered the home at 3-years old as the victim of severe neglect and abuse, including sexual abuse. After 4 years in the home, she was “reunited” with her family. (It is important to remember that this ill-conceived law, LEPINA, was implemented abruptly, without adequate assessment of the families’ competence as caregivers, and without support for these families in the community.) When in Angela’s case the neglect and abuse began again, her family returned her to Love and Hope, with occasional weekend visits to her family. The day before yesterday, after a recent visit Angela made to her family, we observed her playing. She explained that she was making a “botiquin”. Neither Susana nor I understood the reference, so Susana asked her what a botiquin was. She explained that a botiquin was something that contained whatever you needed to make yourself better when you were hurt. With Rachel’s help, she carefully organized the contents she planned to put into the box when it was completed – band aids, tape, pretend thermometer, etc. Another girl in the home offered to help her with the project and was taping clean white paper onto the cardboard box with all the care of wrapping a present. As I watched this hurt child happily engaged in pretend play with the support of her primary caregiver and her friend, I thought to myself that she was representing in play the safety and comfort of Love and Hope. She was creating for herself a healing place.

Read this blog in Spanish.

Joy Osofsky, IPMH Weekend March 1-2


It is always a pleasure to have Dr. Joy Osofky present her work in the IPMH program. Her work identifying ways to assess and treat traumatized children has made her a pioneer in the field of child and infant mental health. This time, I found her video demonstrations of preparing families for reunification after separation due to domestic violence riveting.

The first video was of a child who was present when her father violently attacked her mother. The mother and father were both only 20-years old. The mother, who is intellectually challenged and illiterate, had had five pregnancies; the child in the video was the product of the fifth. There is an older brother who is the son of another father, and there were three miscarriages. The father was in trouble with the law since adolescence. When the baby was 2-months old, the father became upset with the mother, beat her, choked her, put her head into the wall, and threw her down the stairs. The father threw the baby out of the way. He went to jail as a consequence of this abuse.

During the time the father was in jail, Joy’s team worked with the mother and baby. The father finally realized his need for help, and he began individual psychotherapy. Then the child was introduced into his psychotherapy, and infant parent psychotherapy was begun. Finally, there were family sessions.

The video showed mother, little girl (now about 11-months), and mother’s sister. The child’s development was pretty much normal. She was content and exploring the toys, warmly engaged with her aunt. She was trying out language. She was not doing a lot of social referencing, though.

The issue of diagnosing PTSD in a child of this age was discussed. This child did meet the criteria in that she had sleep problems, other regulation problems, hypervigilance, and avoidance. We wondered if this were enough. We also wondered if the mother’s presence might reactivate her, since the mother failed to protect her from the father’s violence. It is true that we have good evidence of the memory of events and objects, starting at 4-months. Ed’s study is confirming that fact. If the memory is of domestic violence, and the events of domestic violence are repetitive, one would expect the baby to remember. However, this memory is not brain-localized memory. When terrible events occur in early life when the stress regulatory system is developing, the “memory” is a regulatory problem. The issue of memory is much more complicated when the memories are of events in the caregiving system. For example, in the tape that Joy showed earlier in the day, the mother of an 11-month old beat her, and the baby’s trauma was related not just to the events, but also to the intermediate time when the mother was not being physically abusive, but her care of the baby was inadequate.

Next we saw a video of the child with her father. We saw the first encounter with the father after his incarceration. In the film, she is on his knee and is screaming. We wondered if she were screaming because she remembered the violent attack, or if she were screaming because he was a stranger to her. Ed is doing a study on 4-month olds and the still face. Neurophysiology suggests that there are areas of the brain that are more sensitive to people than to objects. One of the group commented that the therapist might have intervened to calm the distress of the child, for the sake of the parent-child relationship. When the father leaned over to get a new toy, the baby stopped crying temporarily. Then he took her down from his lap, and she turned towards him and reached out her arms.

In another session, the mother entered and she greeted the baby with a big grin. The therapist tried to hand the baby to the mother, but the baby turned away from the mother back to the therapist. We talked about what the therapist might do at this point. We thought the therapist could speak for the baby, “She is not quite ready yet.” Or you could have the baby play with the therapist and check on the mother until she felt the mother was safe. In this session, the father then came into the room. The baby looked interested but pulled close to the therapist. At the time of this session, the baby was living in a good foster home, but the team was working towards reunification. The therapist asks, “Where is Mommy’s nose?” “Where is Daddy’s nose?” The baby points. Then the therapist puts the baby on the couch next to the mother but not in the mother’s lap. The baby looks after the therapist when she goes to another part of the room. The therapist says, “Dad’s doing a really nice job of letting her get readjusted. Takes her a little bit of time, all these transitions. If you let her go at her own pace … “ Then, while the mother is showing the baby her cell phone and its ring, the therapist goes out of the room to get her toys. Berry Brazelton, present at the discussion, said that he wished the therapist had not defused the situation, so that the parents could be helped to understand what was going on with the baby. For example, the baby is able to get interested in a non-human object, which is less stressful for her than a person. The therapist could help the parents understand that. Berry pointed to the fact that there is no substitute for observing behavior. He added that “the ability to observe and describe to the parents” what the baby’s feelings and intentions are, is a powerful tool. When the therapist went out of the room the second time, the father pretended to eat the baby’s hand, and she laughed. The baby looked much more comfortable. Finally, she wanted to get down on the floor to explore the toys.

In a session soon afterwards, the she leans towards her father and gives him a toy, then gives her mother a toy. The therapist narrates, “Show Daddy. Here, Dad!” The family was eventually reunited. A question from the group asked about prenatal identification of abused or neglected women and their partners so that it might be possible to intervene earlier. Joy mentioned David Old’s “Healthy Families” program. At the time of the birth evaluation, women are offered services.

Joy then talked about “Child-Parent Psychotherapy”, a psychodynamic psychotherapy that has been practiced and studied by Lieberman and Ciccetti, who have demonstrated good evidence of its effectiveness (Osofsky & Lieberman, 2011). CPP aims first of all to help parents to understand how to make appropriate developmental expectations of young children. It also helps parents to help their children name and cope with strong feelings. The group discussed issues related to CPP. For example, how does a therapist deal with the parents’ custom of physical discipline. CPP is not a guidance method, so the therapist would not be expected to tell the parents to not do something. Sometimes physical discipline may be a case of repressed or isolated affect in the parents. In other words, the parent may be angry at the child and unaware of that anger; then she may think she is making a rational decision to spank the child without knowing that she desires to hit him. Physical discipline may also be a learned problem solving behavior on the part f the parents. It may be a cultural issue. It may be related to mental illness (of the parent). The therapist takes all these possibilities into account when considering how to intervene in this situation.

One of the goals of therapy for traumatized children in Joy’s program is to develop a “trauma narrative” that puts the trauma into an acceptable perspective for the child. In her program they use video tapes to help the parents understand their child. For example, they use them to explain to the parents about the child’s sensitivity to sensory stimuli such as noise or lights. Joy is always looking for a “port of entry” into the caregiving relationship. She keeps her eye on the way affect is experienced and expressed in the family and how the family deals with it. What is the range of affect? How does the family achieve and maintain regular and sufficient but not extreme levels of affective arousal? How does the family help the baby establish trust in bodily sensations, so that the child can tell when he is hot or cold, hungry or full, or has to go to the bathroom? She uses the differentiation between “repeating” and “remembering”.

Another goal of the therapy is for the child to develop an increased capacity to respond realistically to threat instead of persisting in reacting with traumatic responses. In one of her examples, the 4-yo child was present when the mother went after the father with a knife. In the therapy session, the child brought a dream about a knife and daddy. The mother froze, but the therapist knew the story of what had happened. The therapist reached out to the mother and asked what she thought of the child’s dream. The mother said she remembered something she had told her about the knife and the dad, but that she did not want to talk about it. The mother had a hard time but finally was able talk to her child about how she had picked up the knife and threatened the father. The mother told the child that she did see this happen and the mother could see how this might have frightened the her. She said, “I was very angry at your Daddy.” The child said, “Maybe you would be very angry at me.” The mother responded, “No, no, I would never do that to you.”

Joy stressed the point that the central principle of intervention in CPP is that no matter which port of entry, modality, or domain you choose, you never intervene without considering the impact of your intervention on both members of the dyad. Outside of this central principal, the method is very flexible. Often you must work with one parent and child and then the other parent and child until you can work with both parents and the child. Joy reminded us that it is the parent who has the rightful place as the child’s guide through life and through this trauma. Your job is to facilitate the parent’s confident assumption of that role.

This reminder stirred in my mind thoughts of the orphanage in El Salvador. Whereas I appreciate the fact that the Salvadoran government implemented the law of LEPINA without offering the families any of the supports that the families in Joy’s program are being offered, I am not entirely convinced about “the parent’s rightful place”. Instead, I have come to believe that some parents are not capable – or will not be capable within the requisite amount of time – to protect and nurture their children, and that the children should not be left in their care. In some cases, attempts should be made to help the parents to change, but in others I believe that such attempts would be futile. That does not mean that the children would never see their parents (though in some cases even visits may retraumatize the child) nor have a relationship with them, but it means that the biological parents would never again have the role of nurturer and protector. Perhaps in these cases, if the parents were available to participate in such an intervention, the most therapeutic approach would be meetings in which both parents and children would be helped to deal with the anger and disappointment in one another and to grieve the loss of their family as able to provide a secure home.

Osofsky J & Lieberman A (eds.) (2011). Clinical Work with Traumatized Young Children. New York:The Guildord Press.