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Trauma of young adolescent - clinical application of SPICC

Introduction

Trauma in childhood has great psychosocial, medical and interpersonal consequences

for a child and later on an adult. Mental or physical violence in children is common worldwide
bringing developmental and systemic trauma, resulting in psychobiological effects of chronic
overwhelming stress on the developing child which can be investigated on neurobiological
level too showing trauma's short-term and long-term medical and mental health consequences.
The impact of trauma on infants and young children occurs within a critical developmental
period and it is influenced by the quality of the relationship with caregivers. The primary
attachment style is formed as a result of it, based on the level of safety and security in that
relationship, determining child’s ability for self-regulate, form positive and functional
relationships, and quality of cognitive skills relevant to learning. The child’s self-identity
formation is impacted too. Relationship with caregiver tainted with uncertainty,
unpredictability and fear, affects child’s relationship with the world and with themselves as
they are being seen through the prism of this primary relationship and internalised. The
attachment system is a foundation to base clinical intervention to promote recover with young
children affected by complex trauma caused by childhood abuse and neglect. The consequences
of it reach on immediate and long-term results on attachment, biology, affect regulation,
disassociation, behavioural control, cognition and self-concept. The SPICC Model -
Sequentially Planned Integrative Counselling for Children is a treatment model developed to
heal childhood trauma with a use of various psychotherapeutic approaches such as
Psychodynamic, Humanistic, Gestalt, Cognitive Behavioural Therapy, Psychoanalytical,
Narrative, Choice Theory, Creative Therapy and Transactional Analysis. Trauma is
experienced on multiple levels, facilitating healing process on the mental, physical,
neurological and environmental level.

Attachment Theory and Play Therapy

Phase one on SPICC is a stage of joining with the child and represent the client centred
approach and it takes place after the initial assessment with parents of primary care givers. In
here therapist creates therapeutic relationship with child through non directive methods like
play therapy created by Virginia Axline. The purpose is to make them feel safe and heard, listen
to their story and validate their opinions creating trust and confidence in therapeutic

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relationship and the process. Trauma is the harmful interruption of safety, agency, dignity and
belonging, which consist of fundamental needs of all human beings.

Children develop cognitive, interpersonal, emotional and physical competencies

throughout their development building sense of efficacy and achievement useful while facing
life challenges (Masten & Coatsworth, 1998, 205–220). Traumatic exposure can interrupt that
process, making children focus rather on their physiological and emotional survival creating
deficits in their self-mastery and quality of interacting with an environment. Child-centered
play therapy is encouraging competency development especially when embedding the work
within an attachment relationship. Play is the child’s primary modality to communicate internal
experiences, master developmental tasks, and self-regulate (Perry, Hogan, & Marlin, 2000) and
traumatised children are impacted by their inability to play, especially in case of a complex
trauma, causing intense physiological arousal. Play helps children is addressing feelings
identification in a neutral way, discovering and exploring unique aspects of themselves, and
have an opportunity to practice problem solving that serves as a foundation for the development
of executive functioning.

Attachment theory provides a developmental perspective on early relational trauma

between children and caregivers. Attachment studies indicate that attachment disorganisation
stems of fear, either of caregiver or caregiver perceived as distressed. Many of caregivers
transmit their own unresolved traumatic histories onto their children in either verbal or
nonverbal ways, causing their disorganised attachment pattern
(Main & Solomon, 1990). Often, it is parent’s own PTSD symptoms like avoidance or
hyperarousal add significantly to that process. Also early sexual abuse is causing overwhelming
and intolerable emotions of fear, sadness, shame and anger, that child avoids or disassociates
from through withdrawal and acting out. That all builds a great wall between a child and the
world, that can be slowly named and softened through the play therapy and joining with the
child to understand and appreciate them creating basis for the new sense of self-worth.

Self-regulation

Phase two in SPICC model is steeped in the Gestalt Therapy approach. Here the child
is invited to build up awareness while continuing telling their story by getting in touch with

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emerging emotions “(…) the main aim of Gestalt therapy as enhancing a person’s awareness
of what they are experiencing in the present moment.” (Nortje, 2016, p. 15). The main focus is
to identify true reactions and emotional patterns that emerge from the narrative and honour
them in here and now despite built resistance and deflections. That is the foundation ground
for self-regulation development in a child, the ability to regulate affect including the ability to
modulate physiological arousal. Small children rely on their caregiver to provide soothing
when distressed or overwhelmed through a number of sensory experiences such as touch,
movement, and sound (like swaddling, rocking, and singing). Over time, children internalize
these experiences and start forming their own, more sophisticated strategies for self-soothing
and managing physiological arousal (Kopp, 1982). In early years, children express themselves
through a range of adaptive and maladaptive behaviours to communicate their needs, including
crying, tantrums, facial expressions, running away, and other demonstrations of urgency or
demand (Bowlby, 1982). A child who did not receive a safe, supportive caregiving
environment will develop alternative ways to cope with distress like withdrawal, isolation,
compliancy, or dissociation. Other symptoms may include hyperactivity, aggression, self-
harm, sleeping problems, and difficulty managing bodily functions. The use of movement and
sensory-focused activities helps children to connect to their bodies in a nonthreatening,
developmentally appropriate manner. Guiding a child through play activities that involves
movement and other sensory experiences, while providing reflection and containment, enables
children to develop awareness of their internal physiological states and ultimately the ability to
tolerate and modulate internal states. Moreover, acknowledgement of emerging emotions in
here and now helps also to identify patterns of supressed anger, fear and resentment, that
unexpressed may cause life-long guilt and low self-esteem. “What are the consequences of low
self-esteem? Low self-esteem has been implicated in overweight and obesity, anxiety,
depression, suicide and delinquency (…) low and decreasing self-esteem in adolescence was
linked to adult depression two decades later (…)” (Santrock, 2019, p. 304).

Development and self-identity

Processing traumatic experiences should happen in a way that is consistent with child’s
cognitive and emotional development. Four young children experience of traumatic events are

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contained in physiological experience of terror associated with lack of safety and security
(Schuder & Lyons-Ruth, 2004). In that case clinical interventions must include reparative work
within the attachment system (Lieberman & van Horn, 2008). SPICC model includes, in
addition to individual work with the child, engagement with the caregiver in education and
dyadic work throughout the course of treatment. This multi-layered approach builds capacities
within the caregiver and within the caregiver–child relationship.

Theories of child development serve a guideline to understanding capacities,

limitations and needs of children in their distinct moment of development. For example 12
years old child is at the last stage of cognitive development formal operational according to
Piaget and fifth developmental stage according to Erikson identity versus identity confusion. In
that age, a child is able to cognitively separate the problem from himself, however only starting
to explore their self-identity “Able to think abstract and more logical, develop images of ideal
circumstances. In solving problems can become more systematic, developing hypothesis about
why something is happening and testing new hypothesis on how to solve the issue.” (Santrock,
2019, p. 304) becoming introspective and reflective in their socioemotional development.

Self-development and self-identity formation happens in relationship to the caregiver,

that is why this process is derailed, when a child experiences an environment that is violent and
chaotic or a caregiver who is unable to respond and attune to them. A child internalises negative
feedback of their environment, developing negative or fragmented self-identity or even under
develops it in cases of neglect. Therefore, the initial intervention is to work with the
environment, particularly the caregiver, to develop consistent, positive mirroring and reflection
for the child. Kinniburgh and Blaustein (2005) identified four interrelated facets of the self for
trauma intervention: the unique self, positive self, cohesive self, and future self. Children do
not have developed abstract thinking so experiential learning is advised, like games supported
by reflections, that help a child to develop a positive self-identity based on identified talents
and characteristics. Awareness of sociocultural characteristics begins as early as 4 to 5 years
old, and identification with a specific group and the mutual impact on identity continues to
evolve throughout the lifespan (Aboud & Doyle).

Phase three of SPICC model is facilitated by Narrative Therapy and helps developing
in a child different perspectives to reimagine sense of self and boost self-esteem. “According
to theory, the client's narrative, constructed within the context of a safe and trusting therapeutic
relationship, serves as a metaphor for the increasingly integrated emotional self.” (Cook‐
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Cottone, 2004, p.177). It happens through exploring alternative stories for the client to
deconstruct their own following the principle “The person is not the problem, the problem is
the problem” (Jones-Smith, 2014, p. 528).

Behavioural Theory and Neurobiology

Trauma is experienced in the body, overwhelming child’s ability to cope with thoughts,
sensations and emotions connected to experience. Symptoms of PTSD are associated with
differences in biological stress symptoms, brain structure and function causing deficits in
developmental progression of behaviour, cognition and emotional regulation in traumatised
children. It is measured and continuously researched by developmental psychopathology,
developmental neuroscience, and stress and trauma studies. The DSM-IV-TR diagnosis of
PTSD is made when criterion.

“Type A trauma, is experienced and when three clusters of categorical symptoms are present for more than one
month after the traumatic event(s). These three clusters are Criterion B: intrusive reexperiencing of the trauma(s),
Criterion C: persistent avoidance of stimuli associated with the trauma(s), and Criterion D: persistent symptoms
of increased physiological arousal” (American Psychiatric Association, 2013m p.947).

It is associated with dysregulation of at least one major biological stress system as well as
several different brain circuits, which makes the psychotherapeutic and the
psychopharmacological treatment of individuals with early trauma complex and challenging.
Cluster B, for that instance, characterises with reexperiencing intrusive symptoms as a
classically conditioned response that is “(…) mediated by the serotonin system and is similar
in some ways to the recurrent intrusive thoughts experienced in obsessive compulsive disorder,
where serotonin and norepinephrine transmitter deficits play an important role” (Dell'Osso, B.,
Nestadt, G., Allen, A. and Hollander, E., 2006, p.605), which means, that conditioned stimulus
(external or internal) activates intrusive memories.

Trauma can also be activated in the process of growing up in the dysfunctional environment
both micro and mezzo.

“Neurobiologist Steven Porges speaks to the hard-wiring of our sociality in the ways that our brains function to
respond to each other. Certain transactions between individuals may down-regulate the action of the sympathetic

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nervous system which is triggered by stress. (…) The young person's limbic system and physiological stress
reactions may be temporarily reduced by accommodating his or her parents' expectations, although in the longer
term, anxiety (…) may emerge through symptoms. (…) Rather, the nuclear family's undifferentiation has become
'bound' in the symptoms and impaired functioning of one or more vulnerable family members. In other words,
the symptomatic person has absorbed the chronic anxiety that belongs to other members of the system, and this
anxiety has manifested in symptoms.” ( MacKay, L., 2012, p.234-235).

The child’s biological stress response system is made up of different, interacting systems, that
work together to direct the body's attention in the way, that protects them against environmental
life threats and to shift metabolic resources away from homeostasis and toward a fight or flight,
and/or freeze reaction (Chrousos & Gold, 1992).

“The stressors associated with the traumatic event are processed by the body's sensory systems through the brain's
thalamus, which then activates the amygdala, a central component of the brain's fear detection and anxiety circuits.
Cortisol levels become elevated through transmission of fear signals to neurons in the prefrontal cortex,
hypothalamus, and hippocampus, and activity increases in the locus coeruleus and sympathetic nervous system.
Subsequent changes in, catecholamine levels contribute to changes in heart rate, metabolic rate, blood pressure,
and alertness” (Chrousos & Gold, 1992, p.1248).

This process also leads to the activation of other biological stress systems, especially related to
the limbic-hypothalamic-pituitary-adrenal (LHPA) axis, and the locus coeruleus-
norepinephrine/sympathetic nervous system (SNS) or catecholamine system. That impacts the
serotonin system, oxytocin and the oxytocin system and the immune system disrupting the
body's ability to regulate its response to stress. Development taking place while experiencing
trauma, along with dysregulation of biological stress systems can adversely impact child’s
brain development.

Pathways to healing occur in environment, that promotes safety, dignity, agency and
belonging. One of the main principles to restoring sense of safety is creating predictable daily
routines, that establish structure, hep children to organise experience and develop sense of self-
empowerment.

In phase four od SPICC therapist is challenging the child’s destructive beliefs, thoughts and
attitudes encouraging development of new ways of thinking using Cognitive Behavioural
Therapy, which “assist a child with getting in touch with their thoughts and behaviours, and
deal with self-destructive beliefs. The CBT model (which follows a cognitive approach)
suggests that one’s thoughts influence one’s beliefs, which consequently influence one’s

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emotions and behaviours.” ( Nortje, 2016, p.19). That happens through addressing their
maladaptive behaviours and replacing them with more effective and beneficial actions while
taking responsibility for the outcome and measuring responses. These “(…) approaches are
intended to improve emotional and cognitive regulation, help parents and children make
meaning of trauma experiences, help children master trauma reminders and avoidance, and
enhance children’s personal safety.” (McGuire, Steele, and Singh, 2021, p. 20-21). Therapist
is working with young client and their caregivers to support them in developing these new
routines having structure in daily living, predicable schedules and sequential tasks to feel safer,
decreasing the need to control their environment with problematic behaviours.

Competent self

Phase five of SPICC model is devoted to experimentation with new behaviours using
Behaviour Therapy techniques, that enable young person to rehearse and evaluate, what they
have learned so far. Firstly, in the counselling setting and later on in real life situations as well.
It is crucial at that stage for a young person to receive positive feedback about their new skills
and behaviours risked, as the affirmation enables them to settle new choices and behaviours
creating new habits. “In this phase, the child is encouraged to rehearse new behaviours within
the counselling setting and experiment with it to acquire new adaptive skills. According to
Geldard et al. (2013), it can be assumed that the child will generalise new skills to their wider
social environment and ultimately acquire more adaptive functioning.” ( Nortje, 2016, p.20).
Behavioural Therapy was developed by Skinner and Watson inspired by Pavlov’s experiments
and concepts of classical conditioning linking stimulus with reward to evoke learned response.
Skinner further developed the concept to an operant conditioning to connect learning with
experienced consequences as rewards and punishments.

Children who experience complex trauma invest most energy into survival rather than in the
development of age-appropriate competencies. “Children may lag behind peers in a variety of
developmental domains or fail to develop a sense of confidence and efficacy in task
performance”(Shonk & Cicchetti, 2001, p.7). In order to support competency development in
traumatised child, clinicians promote the building of executive functions to increase the child’s
ability to effectively engage in problem solving, anticipation and planning. Children are

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supported in forming an causal understanding between actions taken and outcomes. They are
motivated to develop a habit of considering, implementing, and evaluating choices. As a result
they are forming new self-development paths, healthier identity and sense of self based on
positive and empowering experiences from the past and present creating new narrative of their
life.

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