Book review: Building the bonds of Atachment by Daniel Hughes

Hi everyone,

I just read a very informative and heartfelt book on raising children with reactive attachment disorder or PTSD. It’s written by a well known child psychologist, Daniel Hughes. He has worked for many years with deeply traumatized children and their foster or adoptive families. He believes in a strong partnership between the therapist and parents, and specific therapeutic and parenting techniques that will create over much time and with many obstacles a secure attachment in a child who never had one.

To make his points, he tells the story of Katie. It follows Katie and those around her from birth to age eight. Katie’s mother Sally was very young when she had her. She never had approval from her own mother and temporarily having a baby brought that for her. However because she herself wasn’t raised in a loving home, she didn’t have the slightest idea on how to nurture a newborn. She would sometimes pick up Katie and hold her and sometimes leave her to cry. There was no routine for meals, or play, or even changing her diaper. More often than not Katie was just left to cry and cry. When Sally’s abusive husband Mike was around, things were worse. He often would grab Katie roughly or shake her or have Sally “get that kid to shut up.” So her mother’s coming to her, rather than bring comfort brought emotional distress as Katie could sense her mothers fear and frustration.

Katie stayed with her parents until she was 18 months. By that time she had her arm broken when Sally flung her on the bed, and Mike’s brother saw Mike shaking Katie. By that time now being able to walk, and having more of a sense of what was going on around her she would often “make her parents mad” by spilling things etc.

It seemed that any attention was better than none and the only way to really get her parents attention was to upset them. But then would come the terror of their physical and emotional abuse and neglect.

When the brother saw how mike had treated Katie he did call social services and Katie was taken into care. Her first foster home was with a woman named ruth and her children. Ruth saw Katie as “strong willed” and needing lots of supervision, very hyperactive but that was all in the beginning. Then it seemed her behaviors would get worse if Ruth wasn’t constantly around or she was left alone for too long.

Throughout Katie’s four foster homes she had the same therapist. This was a play therapist who worked well with children who did not have a trauma background. She would use play therapy techniques and would not have any of the foster mothers in the room with she and Katie. There didn’t seem to be the same behaviors displayed at therapy as were at home which made it imposible for the therapist to really work on the behavior.

Katie was moved from Ruth’s to Karen’s to Susan’s foster home. Each foster parent basically had the same approach that of using behavior modification. Praising any positive behaviors with rewards and ignoring the negative. This again will work with many children who understand cause and effect and are motivated by praise. But Katie didn’t even have the capacity to form a relationship with someone that wasn’t based on manipulation and feeling such self-hatred that deep down she knew no one really wanted her.

So these behavior programs backfired. Katie would work to earn the rewards only when she really wanted something. And then go back to acting however she wanted. She would steal, lie, go into rages, pee on things, and generally make things hell for the family. In a couple of families her behavior caused tention between the parents and siblings began to really resent Katie.

In Karen’s foster home Karen got so frustrated trying to do right by Katie, and Katie seeming to do things “just to get her back,” that she turned to spanking hitting and scratching Katie on occasion. Obveously she was moved from that home.

Susan was the last foster mother Katie had before going into attachment specific treatment. She was truly caring, and truly committed to doing anything possible for Katie. They tried all the behavior methods. She tried to be with Katie as much as possible do fun things etc. But Katie again kept showing such manipulation and unpredictable emotions that Susan never knew what was really going on. In spite of so much upheaval Susan was determined to keep Katie. And did for much longer than any of the other foster parents. But the last straw was when she was helping Susan cook for a family party and put her own fecies in hamburger. (wisdom around having a child handle raw meat aside!)

This was Susan’s breaking point. But she didn’t take it lightly. She felt like she had really let Katie down. Katie’s caseworker was very discouraged himself as he’d followed Katie’s progress or lack there of. He talked with his supervisor and she realized Katie’s case was much too complex for mainstream foster care. She recommended a therapeutic foster home. The caseworker, Susan and the play therapist were skeptical and a bit defensive. They knew something was wrong but why wasn’t their type of care good enough? The supervisor explained how parents in therapeutic homes are trained in specific ways of parenting specific to children with attachment disorder and trauma histories. It is extremely specialized as is therapy.

The caseworker knew there was no other alternative and was curious about this approach. This is how Alison and Jackie came into Katie’s life. Alison was an extremely caring and competent therapist in the field of trauma. Upon meeting Katie she did not fall for Katie’s manipulations or back down when she went into a rage. She set the expectations (that Susan and the caseworker would be in the room, when Katie could play with toys and when she couldn’t etc) and Katie followed though with much anger. This is where Alison diagnosed Katie with post traumatic stress disorder and attachment disorder.

Alison recommended Jackie and her family as a good therapeutic parent for Katie. As with Alison, Jackie was extremely skilled at giving Katie boundaries but also empathy right from the start. Not five minutes after walking through Jackie’s door, Katie had a tantrum about getting crackers for snack instead of cookies. Jackie emediately was firm with her about this, and held her in a safe restraining position when she became so angry that she was trying to hurt Jackie. The social worker thought this was a bit much over nothing but Jackie assured him that this needed to be done. A little shocked he decided to leave them to it.

The next day at therapy Alison established how therapy would work. Jackie would be in every therapy session sitting next to and touching/holding Katie. Alison would first always be playful and silly with Katie to get her to relax and connect in a non threatening way. This included games like this little piggy, counting Katie’s freckles, and drawing a circle on Katie’s face with her fingers. And generally seeking eye contact, playful tone of voice ETC. She also facilitated these playful interactions between Katie and Jackie which were the basis of a nonthreatening way of being in relationship.

Firmly but still in a caring way Alison would then steer the conversation to more difficult topics. Like what it was like to be in Jackie’s home, her strong emotions etc. During this time Alison would coach Katie to say certain things like how mad she was at Jackie, or how she felt bad and like no one wanted her. Or whatever feelings associated with what was happening. Sometimes Katie would start by expressing some emotion and Alison would pick up on the intensity and match it. When Katie resisted in speaking her feelings Alison would speak them for her which would often elicit an emotional response. Katie was able to let her anger out in the office with Jackie safely holding her.

When they discussed Katie’s behaviors Jackie and Alison would always express genuine empathy for what was behind the behaviors. Like “you were really mad that I didn’t let you go swimming and it was really hard for you to do this or that chore.” Instead of punishing her for her response or tieing it into some reward that had nothing to do with what had happened.

It wasn’t long before Jackie realized that allowing Katie to participate in activities unsupervised and with unscheduled time as most seven year olds would do was not working for her. So with Alison’s guidance Jackie provided a firm but very nurturing therapeutic home environment. Anytime she was not at school she was extremely close to Jackie. She would sit right by her when they doing chores or just sitting. Katie often hated this and had frequent rages where Jackie would hold her, make eye contact and say over and over again that she cared about Katie and knew how hard these feelings and rules were for her. Also Jackie and Alison realized that it was hard for Katie to handle too many fun activities. Anything like playing outside going somewhere like to the zoo ETC would stir up too many feelings for Katie. She would deep down feel like she didn’t deserve the fun, that something bad was gonna happen after something good and in general it would cause her to get emotionally off track.

So Jackie would keep such activities to just what Katie could handle. For example for her seventh birthday rather than having a “big party” they just had a normal day where Katie got to choose what kind of cake they had, and got a small present. One thing that was a solid part of all this was “Mom time.” This was time right before bed where Jackie would do relaxing things together with Katie no matter what else happened that day. They would sing songs together, sometimes eat candy, cuddle, play with dolls ETC. At times Jackie would give Katie a bottle to try and give her the experience she did not have as an infant with that key mother/ child interaction. She would only do this when Katie asked for it, and when she knew it wasn’t a manipulation.

It seemed that for mom time Katie would put aside the fighting for just that time and often be able to take in what was being given.

This was an intense struggle for Jackie and her family. Katie demanded constant attention during this time. I think what kept Jackie from being burned out was the support of her husband and teenage children, as well as her relationship with Alison. Alison would always see Jackie before the therapy session to see how she was doing emotionally and talk about what they’d cover in therapy that day. If Jackie didn’t have that unconditional support from Alison I doubt she would be able to do this work.

After a disasterous thanksgiving dinner, where Katie manipulated the whole of Jackie’s family and then spilled hot gravy in her sister’s lap, that was the hardest moment for Jackie. She could not hold back her anger, and she told her husband to look after Katie for that night. She knew she needed a break and could not come back into an empathetic place that day.

She was self- reflective enough to realize that her trigger was about her relationship with her mother, and wanting her mother to aproove of how much she was doing with Katie and how well she was doing. She always felt like her mother liked her sister more and never expressed affection to her that she could take in. Alison gave Jackie time to process these feelings and Jackie was able to even have her mother in for a session where they were able to clear the air. This made a difference to how Jackie worked with Katie.

The process was often one step forward five steps back. But very slowly the steps forward stuck. Katie was slowly accepting love, saying how “hard it was to work on love,” and feeling bad when she did something to upset Jackie. It became no longer about manipulation but about a genuine interest in Jackie’s reactions. She was able to eventually connect the consequences with her behaviors. She went through a time of physically hitting herself/ head banging in order to try and numb her feelings and not hurt Jackie. Alison and Jackie encouraged her to express all her feelings and that feelings wouldn’t hurt them. She had to let them out because keeping them in hurt Katie.

Katie made a huge amount of headway in realizing that she was not bad, that her parents were wrong for what they had done. This took a very long time as it was at the root of Katie’s behaviors and no self-worth. This was done by Jackie affirming the power of their relationship a million times a day, providing consequences not punishments and playful empathy and curiosity. This was reinforced in therapy by very careful interventions from Alison where Katie could speak her feelings to her birth parents through looking at pictures, or role play. In this way she was able to resolve the deep rooted shame caused by abuse and neglect and separate Jackie as a loving mom.

Around this time talk turned to adoption. Most children in therapeutic homes are there for six months to a year and then move on, this was true of Jackie’s last foster placement. Alison and the caseworker argued that though Katie’s attachment to Jackie was new, the full attachment just recently occurring, that it would survive the separation. That Katie would turn to Jackie for comfort and Jackie would still have an active role in her life. A strong intuitive feeling in Jackie drove her to second guess this plan. She truly felt that Katie had become part of her heart and the heart of the family. She couldn’t imagine what Katie’s life would be like if Jackie wasn’t in it, no matter how gentle the parting.

It was Jackie’s husband who brought up the idea of adoption. He knew his wife was thinking along these lines but hadn’t wanted to say anything. They together came to this decision. Alison and the caseworker made it clear that Jackie needed to be clear she wasn’t adopting Katie out of fear for Katie’s life in a new home or guilt that she couldn’t be a forever mom to her. But the family was clear this wasn’t the case.

Things were rocky for Katie at just being told of adoption. All the caseworker could say when Katie demanded to stay with Jackie’s family was that they would find the best family for her and he hoped it would be Jackie’s. Katie did throw a tantrum and hit Jackie. But then felt totally ashamed and like she must be a “bad kid.” The repair in this instance happened very quickly and Katie wasn’t set back by it. Jackie sharing tears with Katie and saying she was scared too of what could happen made Katie feel like they were in this together.

Jackie did not want there to be a long build up for Katie around this. And she thought they broke the record for the fastest foster to adoption process. The total joy that the family experienced when they got the news was completely heartfelt.

This child made it against all odds. She overcame abuse since birth, and four failed foster placements. She fought first against Jackie as the enemy, and then the fight became against Sally and Mike and realizing that they were wrong and that she was good. That she deserved a good mom. This would not have happened if not for a trained trauma and attachment therapist. And a commited therapeutic family. From reading several blogs on this subject I know that such stories sadly are few and far between. The reality is that just finding a therapist who even remotely understands attachment and trauma, doesn’t get manipulated by the child or blame the parents is a huge obstacle. Another big one is that parents when choosing to foster or adopt go through a honeymoon period where the child acts perfect for weeks and months. Then suddenly major behaviors emerge and the family is stranded. Getting services especially after a finalized adoption is almost impossible. The whole service system can’t wrap their minds around this condition, so blame parents, just don’t bother to help and basically turn their backs. And with all healthcare, the ones that don’t have the money for private therapy treatment centers ETC get almost nothing.

The majority of parents that I read about end up stripped of everything good in their lives. They’ve poured their hearts into proper treatment, proper parenting, support groups and anything else. By the time children with attachment disorder are teens their brains are going through such changes that the internal experiences of how they understand relationships are harder to shift. They become extremely abusive to the family and it hits harder because at this time they’re not children that can more easily be redirected. It just seems to get worse as they get older. And the family though still loving the child, feel incredibly bitter at the system that had no clue as to how to keep these behaviors from getting worse and often family members get PTSD as a result.

This book I feel shows the ideal circumstances for a child with these issues. In many cases there are a lot more failed foster placement and even dissolved adoptions. Many therapists that do more harm than good and erratic treatment. I wish that every story could turn out like Katies. Where obviously there will always be more work to do because of her start in life. But by the end she won the birthright of any human being: to have a deep sense that they’re special, loved and good people no matter what. It was a hard won battle for Katie, Jackie and her family and Alison. I hope this book gives readers an in depth understanding of trauma and attachment disorder in children and what works and what doesn’t for real healing to take place.

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