1. The Therapeutic Web when Working with Children and Young People Virginia Williams Principal Psychologist virginia@warehouseone7.com www.warehouseone7.com

2. Goals Explore what we understand about webs and systems, how they are similar, different and otherwise related Highlight the critical importance of balancing fluidity and structure in creating cohesive, integrated life-experiences Apply and elaborate on parallels from these discussions in the development of the brain as a web-like system Understand how the Neurosequential Model of Therapeutics (NMT) creates a platform for brain-healing work for individuals who have experienced developmental trauma Identify and discuss the principles inherent to NMT, webs and integrated systems on 3 levels; 1) a case study, 2) applied to our broader system of support, 3) via a self-focused strengths analysis

3. Goals Explore what we understand about webs and systems, how they are similar, different and otherwise related Highlight the critical importance of balancing fluidity and structure in creating cohesive, integrated life-experiences Apply and elaborate on parallels from these discussions in the development of the brain as a web-like system Understand how the Neurosequential Model of Therapeutics (NMT) creates a platform for brain-healing work for individuals who have experienced developmental trauma Identify and discuss the principles inherent to NMT, webs and integrated systems on 3 levels; 1) a case study, 2) applied to our broader system of support, 3) via a self-focused strengths analysis

4. Key Resources www.childtrauma.org https://childtrauma.org/wp-content/.../08/Perry-Bruce- neurosequentialmodel_06.pdf https://childtrauma.org/wp-content/.../08/Perry-Bruce- neurosequentialmodel_06.pdf www.drdansiegel.com/

5. web w ɛ b/ noun noun: web; plural noun: webs a network of fine threads constructed by a spider from fluid secreted by its spinnerets, used to catch its prey. a complex system of interconnected elements Examples of webs, and any human-created webs??? What is the purpose of these different webs? What is key to their success?

6. system ˈ s ɪ stəm/ noun noun: system; plural noun: systems; noun: the system a set of things working together as parts of a mechanism or an interconnecting network; a complex whole. a group of related hardware units or programs or both, especially when dedicated to a single application. a set of principles or procedures according to which something is done; an organized scheme or method Examples of systems, and any human-created systems??? What is the purpose of these different systems? What is key to their success?

7. What is a system? https://www.youtube.com/watch?v=UWWgchSaYQU Nit and Wit: “A system is an entity that maintains its existence through the mutual interactions of its parts”

8. Rigidity versus fluidity: can they co-exist?

13. integration ɪ nt ɪˈɡ re ɪʃ (ə)n/ noun noun: integration; plural noun: integrations the action or process of integrating; bringing together the process of interconnection that enables distinct parts or components to work effectively as a whole Dan Siegel: “ Acknowledging the differentiated functions; strengthening the linkages”

14. What is behind this experience of integration? Within the images: 1.Repetitive patterns that are predictable 2.Stimuli are appropriately challenging 3.Emotionally attuned The 4 R’s: Repetitive, Relevant, Relationally Rewarding

15. This one?

17. Experiencing a non-integrated stimulus? What is different?

18. The Brain: A system integrated by a web NIMH.nih.gov “Mental disorders: addressed as disorders of brain circuits” (2010)

19. The Neurosequential Model of Therapeutics ( NMT, Perry et al., 1995, 2000) The brain develops in a sequential, bottom-up way in a “use dependent” manner Stimuli enter through the brainstem and midbrain, and associations in the patterns of neural activity being experienced are matched against previously stored patterns of activation Patterns that are novel or detected as similar to a previous threat spark a wave of alarms in the primitive (bottom) areas of the brain Functionally, this capacity for alarm-activation that occurs before complete processing and interpretation (i.e. before all levels of the brain have been involved) is behind classic motor actions such as moving one’s finger away from heat, jumping in response to a loud, unexpected noise.

21. What happens when the developmental sequence is interrupted? Maltreatment (i.e. absence of appropriate experiences, exposure to harmful and / or biologically unforeseen experiences) interrupt and alter the sequence of brain development Excessive activation at the brainstem and midbrain, associations between a host of state-based cues that occurred at the time of alarm-activation and the experience of threat Persistent, repeated activation of the lower parts of the brain results in use-dependent alterations in these areas – they become sensitised, over-reactive and dysfunctional.

23. Can a brain be healed once the neurodevelopmental sequence is disrupted? “Therapy” is based on the premise that experiences can heal, restore and repair the brain NMT: experiences will be therapeutic if: 1. They impact at the same level of brain function at which sequential development was disrupted (the primitive brain) 2.Result in new associations between state-based cues and alternate “non-alarm” responses is possible 3.Occur with sufficient frequency and repetition to become a “pattern” 4.Occur within the context of healthy human interactions

24. Clinical implications of the NMT Integration was experienced when: 1.Stimuli were appropriately challenging: RELEVANT (in other words) - “your interventions need to meet me where I’m at, and create a sequential web to where I need to be” 2.There were Patterns, Repetition and Predictability: REPETITIVE (in other words) – “the modulation of my brainstem and midbrain depends on P, R and P! My brain is good at detecting similarities, but it will take lots of time and practice to store new associations” 3.It was possible to be emotionally attuned to the stimuli: RELATIONALLY REWARDING (in other words) – “be aware of my arousal states as I can’t be just yet, I am too busy trying to keep safe. I am not good at guessing your emotions and will need your help with that too. Please let me have lots of experiences and activities within the bounds of a healthy relationship”.

25. Andrew, 12 year old male Andrew lives with his mother, brother and step-father in a home they have been renting for the past 18months. Andrew has contact with his father about once per month during an overnight stay about 45 minutes from his usual residence. Throughout his life so fa, Andrew has experienced a fair amount of unplanned change including multiple relocations due to relationship changes, eviction and other factors outside his control. His parents of each struggled with substance misuse and possible (undiagnosed / treated) mental health issues. Both of his biological parents experienced chaotic childhoods and are without a cohesive family support. Andrew witnessed significant domestic violence during which he would mostly try to escape to his room, or into the company of his brother. He has had to develop a number of self- sufficiency skills (e.g. getting food for dinner and school, dressing and getting himself to activities) which he has used when his mother has been unable. He visits an elderly female neighbour and has recently began doing errands (e.g. taking bins out, general tidying) in his street after door- knocking his neighbours’ homes. Andrew displays a number of challenging behaviours particularly at school, including fighting and seemingly “unprovoked” aggression towards peers, defiance / avoidance of learning tasks and failure to follow through on instructions. He has been diagnosed with ADHD and ODD, and has been prescribed medication via a developmental paediatrician for the management of these issues. Andrew’s family was introduced to you by an Intensive Family Support worker who has been engaged with the family for about 6 months (further 4 months scheduled) to consider a therapeutic intervention:

26. Applying the principles of NMT to Andrew’s case: Reflect: What is the “treatment as usual” within medically-based therapies for Andrew? What would you do to promote healing? Applied Task: Group 1: Identify RELEVANCE within the response Group 2: Identify REPETITION within the response Group 3: Identify RELATIONALLY REWARDING within the response

27. Andrew, 12 year old male After some discussion about the idea of “learning new ways to cope with feelings” by the family support worker with Andrew’s Mum, and a subsequent phone consultation with therapeutic intervention team personnel, Andrew and his mother accompanied the support worker for a facilitated “drop-in” to the service. A positive response was reported by Andrew and his mother, with highlights being patting the resident frog, teaching his mother, family support worker and the member of the therapeutic team how to make origami frogs at the large art- bench, and taking a photo of this. A designated assessment and planning meeting was scheduled with both the family support worker and Andrew’s mum. The capacity for Andrew’s mum to engage as the most-likely difference- maker, current strengths within the family in terms of routines, safe-havens and positive connections were undertaken. An analysis of Andrew’s current strategies for regulation revealed a host of flight responses (withdrawal, avoidance, losing himself into playstation / ipad) with hyperarousal (tapping benches, non-engaging chatter, moving around when in situ) and then flight (physical defensiveness) as the escalation sequence when Andrew is emotionally overwhelmed. Mum committed to ongoing home-based implementation of an attachment-based parenting program that included opportunity to link Andrew’s behaviour to his past experiences and attempts to regulate in the present moment. Liaison between family support worker and therapist surrounded this work. Andrew began attending for sessions with his male “coach” who helped him learn about his ways of being OK in the world and how to make new ways when old ones weren’t working so well. Each fortnight, Andrew would check in on the frog, choose a drink and snack from the kitchen, and say hi to the people familiar to him in the space. Activities such as handball and “roll- ball” and later Uno became staples in Andrew’s sessions with his coach, as did drawing his ideas / thoughts down on the painted concrete floor when it was time to map things out. Integrating the clock as a way of managing the time in session for “active time” and “quiet time” helped and Andrew was able to follow instructions well. He began to self-identify things he was doing well in his time and batted-back praise about his achievements. Liaison between school and the family support worker continued with some improvements for Andrew at school at the time family support ceased.

28. Parallel analysis: is ours a system like the brain? Are we? Structured (rigid) and fluid (changeable) Integrated: acknowledging of our differentiated functions, committed to strengthening the linkages Only in existence to serve the overall function of the system Changing in a use-dependent manner Open to healing, mostly by sequentially-matched new experiences that reflect ideal development How do we do in terms of the 4R’s: RELEVANT to whom and how? REPETITIVE and what ways and with what effect? RELATIONALLY REWARDING to whom and how?

29. Therapeutic web strengths self-reflection: How am I meeting people where they are at? What are my tools and approaches to assess where people are at? What could I do differently? Do I have predictable, repetitive patterns and rhythms embedded in my approach? How do I know whether they add usefully to safety and trust? What is one thing I can do to harness more fully the power of P, R, P? Am I aware of how my approach is impacting the people I serve emotionally? What is my gauge for knowing we are on the same wavelength? Do I have tools for communicating and testing attunement in my interactions with others? What am I able to add?

30. https://www.youtube.com/watch?v=14tm7xMApvA