Select Therapeutic Frameworks Utilized at the Charlton School

Trauma Informed Therapy

Trauma-informed therapy acknowledges and takes into account patients’ past trauma(s) and the impact(s) on their physical and mental health, behavior, and capacity to effectively partake in therapy. For adults, adolescents, and children older than 6 years, the fifth edition of the Diagnostic and Statistical Manual (APA, 2013a) defines trauma as:

1. 1.Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
2. Directly experiencing the traumatic event(s).
3. Witnessing, in person, the event(s) as it occurred to others.
4. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
5. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

Trauma-informed therapists are cognizant that patients’ current manifestations (e.g., thought patterns, behavior, mental and physical health) may be a result of past trauma. The manifestations due to trauma may be varied depending on the individual and the specific trauma, and may be delayed in expression. The DSM-5 (APA, 2013a) defines Post-traumatic Stress Disorder based on the following criteria:

A. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific re-enactment may occur in play.‍
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

B. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

C. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

D. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation), typicallyexpressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

E. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

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Another framework for understanding the effects of trauma, including in early childhood, is Adverse Childhood Experiences (ACE) based on the foundational study by the Center for Disease Control and Kaiser Permanente (Felitti et al, 1998). ACEs can include physical and emotional neglect; physical, emotional and sexual abuse; family dysfunction such as family mental illness and divorce, poverty, death of a family member; incarceration of a family member or close friend; substance abuse; or witnessing the abuse of a family or community member. ACEs can negatively influence physical and mental health and can disrupt social, emotional, and cognitive development, with greater number of ACEs being associated with greater probability of negative outcomes (Zeanah, Burstein & Cartier 2018). While the ACE model may be applied to understanding the potential impacts of early life trauma at an individual level, it can also be used to understand communities and subpopulations. Thus, the updated ACE pyramid includes intergenerational trauma (eg. Holocaust survivors, Indigenous peoples) and Social Conditions (eg. Poverty, Systemic Barriers).
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Trauma-informed therapy attempts to understand each patient in the context of their entire life, which includes current and all past life childhood experiences, and takes into account the impact of past trauma on current mental health and functioning. Trauma-informed practice utilizes therapeutic methods to promote emotional safety and openness and uses a collaborative framework to help patients understand the basis for their distress, empowering them with a new lens and options for personal healing.

Attunement

Attunement is an integral concept in attachment parenting and therapeutic relationships. Attunement “is a kinesthetic and emotional sensing of others knowing their rhythm, affect and experience by metaphorically being in their skin, and going beyond empathy to create a two-person experience of unbroken feeling connectedness by providing a reciprocal affect and/or resonating response” (Erksine,1998). Attunement in the context of parenting refers to a parent’s ability to read their child’s verbal and nonverbal cues in order to appropriately respond, thereby, enabling strong attachment bonds between parent and child such that the child develops a sense of security. Attunement in a therapeutic context encompasses many skills and qualities, such as active listening, mirroring, empathy, mindfulness and reflection, that enable an open, trusting patient-therapist relationship. The ability to attune to a patient often requires deeper engagement and understanding of the patient than what appears at the surface and skillful handling of transference and countertransference. Knowledge of developmental theories, such as Erikson’s Life-Span Development and therapeutic frameworks, such as Trauma-Informed models of therapy, as well as the patient’s experiences may be helpful, especially initially, to assess the current emotional status.

A therapist who is attuned to their patient will endeavor to continually monitor a patient’s responses, affect, and other non-verbal cues and will work within boundaries to ensure that the patient feels comfortable and safe. These therapeutic tasks promote an environment of trust such that the patient may communicate freely and take risks at their own pace. By understanding how each patient’s emotions influence their behavior, therapists can respond in such a way that the patient feels seen and heard.

Patients who have experienced mis-attunement during their childhoods have a tendency to expect emotional abandonment and therefore may struggle to develop healthy attachments. One role as a therapist is to model positive emotional connection and emotional security. While therapy may not help repair past relationships, the goal is to help patients develop healthy relationships, and be capable of working through conflict in future relationships.

Integrative therapy

Given Charlton’s commitment to an individualized and holistic approach using the biopsychosocial model, therapeutic work will vary to best suit the challenges and needs of each student. Staff at Charlton use what can best be described as an integrative therapy, meaning that different theoretical frameworks and techniques, as needed, are incorporated into the treatment plan, evolving, as therapy progresses. There are dozens of therapeutic models and within them, dozens of therapeutic techniques. Staff at Charlton with differing knowledge bases and experience are able to consult and learn from one another, expanding their professional skill set. By providing multiple perspectives based on varying knowledge bases and experience, our clinicians are able to gain a better understanding of the student, consider possible interventions, and formulate individualized treatment plans.

Aside from being able to tailor therapy to the needs of each student, integrative therapy also enables the use of the most current evidence-based practices as new research is published.

Examples of Therapies that may be Combined in Integrative Therapy:

• Aside from being able to tailor therapy to the needs of each student, integrative therapy also
• enables the use of the most current evidence-based practices as new research is published.
• Examples of Therapies that may be Combined in Integrative Therapy:
• Cognitive Behavioral Therapy (CBT)
• Dialectical Behavioral Therapy (DBT)
• Mindfulness
• Psychodynamic Therapy
• Equine Therapy
• Expressive Arts
• Music Therapy
• Family Systems Therapy
• Trauma Informed Therapy