Case History: Sarah
Sarah is 10, in foster care and trying to manage complex trauma.
Sarah had been taken into care at a young age, after experiencing neglect, physical abuse and witnessing extreme violence. Although two previous foster placements broke down because of her controlling and aggressive behaviour, Sarah was now in a very good foster placement. Her younger brother, who she provided care for while living at home, had been adopted.
Sarah was suffering from nightmares about witches and monsters, as well as exhibiting occasional verbal and physical aggressive behaviour. Fears about death and difficulties with her peers were also worrying her.
As part of Sarah’s initial assessment, Dr Andrea Shortland met with the professional network surrounding Sarah. Speaking to her teacher, social worker and foster carer helped to establish a full history of Sarah’s early trauma, attachment relationships, losses and development. This involved all parties completing questionnaires to get a baseline and clear picture of current concerns. The Child Attachment Interview was used to help identify Sarah’s attachment style and coping strategies.
STAGE ONE- SECURITY AND STABILITY:
We identified that Sarah was spending a lot of her time on high alert for threat. Her aggression was a protective response easily triggered by something which seemed threatening to Sarah, even though she was now in a safe environment.
To reduce Sarah’s sense of threat, her environment needed to be managed to increase her sense of safety. Andrea worked with the professional system to implement a consistent approach to working with Sarah at school and home. This involved 3 sessions on a monthly basis to teaching staff and social worker.
Andrea also provided weekly individual sessions with Sarah’s foster carer (these were weekly for three months followed by every 3rd week throughout the intervention). Andrea supported Sarah’s foster carer in introducing a more structured and predictable environment. This helped to show Sarah she was now safe and the people around her were strong, committed and able to manage her behaviour. Sarah needed to trust that no-one was going to give up on her.
As Sarah had been worried about her brother, we recommended contact be made to reassure her he was safe. Face-to-face contact with her mother was reduced as this often caused Sarah a lot of anxiety. Instead her mother was supported to write letters to reassure Sarah of her of well-being.
15 sessions with Sarah and her foster carer helped Sarah begin to recognise and manage her emotions. She needed support in allowing her foster carer to nurture and comfort her, as well as to generally build her trust and feeling of safety with adults. To do this we used a mix of Theraplay and Dyadic Developmental Psychotherapy (DDP) informed work and Eye Movement Desensitisation and Reprocessing (EMDR).
STAGE TWO- TRAUMA PROCESSING:
To support Sarah in processing the trauma she has experienced, we ran 10 weekly sessions with Sarah and her foster carer together. Alongside this, the foster carer continued to have individual sessions every 3 weeks to focus on therapeutic caregiving. Bi-monthly sessions were also provided to Sarah’s teacher and social worker to review progress and strategies.
As part of this stage we developed a narrative of Sarah’s life to include her trauma and loss history.
EMDR helped Sarah to re-process her memories and her nightmares.
STAGE THREE- MOVING FORWARDS:
10 fortnightly sessions with Sarah and her foster carer together helped Sarah begin to move beyond her traumatic experiences.
By using EMDR and Cognitive Behavioural Therapy (CBT) we focussed on building social skills and impulse control to help Sarah build relationships with her peers and develop her ability to manage being in the classroom.
Overall, our work with Sarah lasted one year. Sarah’s nightmare’s stopped and when she did have an upsetting dream she felt able to speak to her foster carer and seek comfort. Sarah’s aggression stopped although sometimes she felt overwhelmed at school- to support this we helped Sarah develop additional calming strategies. She started to interact better with other children and was invited to birthday parties. Although she still lost her temper at times leading her to storm off when playing, this was a lot less frequent and there was no physical aggression associated with it. Overall, Sarah’s scores for anxiety, depression and PTSD reduced significantly.
The people around Sarah (her foster carer, social worker and teachers) reported feeling more confident and supported in their approach to working with her.