What type of care giving might a child have received in order to respond with such rage and distrust? While the article was written concerning foster care, what implication does it hav

Rachel,2 not yet 2 years old, stood looking at herself in the full-length mirror, a frown slowly overtaking her face. Deep in her throat began a low, grumbling growl. As the growl grew louder, she began hitting the side of her head and mov- ing slowly toward the mirror, her eyes glued to her own image. The growling became yelling, and she began slapping at herself in the mirror. I sat, stunned, unable to move or formulate a response. Her rage was palpable and deeply dis- turbing. Finally, I got up from my chair and went to her. I got down on my knees, gently held her shoulders, looked into her eyes, and said, “Rachel, this is not your fault! You are loveable and you are loved.”

A DISORGANIZED TODDLER IN FOSTER CARE:

Healing and Change From an Attachment Theory Perspective1

JANET MANN The Children’s Ark

MOLLY D. KRETCHMAR Gonzaga University

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This article focuses on the remarkable story of a deeply disorganized child, Rachel, and her experience in foster care with Janet and Paul Mann, founders of the Chil- dren’s Ark. Rachel and her mother were referred to the Ark, an innovative intervention center for at-risk fami- lies, when Rachel was 10 months old. After 11 months at the Ark, Rachel was placed into foster care with the Manns. On the basis of Janet Mann’s professional immersion in attachment theory, object relations theory, and especially the Circle of Security protocol (Cooper, Hoffman, Powell, & Marvin, 2005), Janet extracted 6 “principles” that guided her caregiving behavior with Rachel. These principles included: (a) Communicating the message, “I am here and you are worth it”; (b) viewing negative behavior as needed; (c) reading cues and reinterpreting miscues; (d) “being with,” espe- cially during periods of intense emotion; (e) working consciously toward relationship repair when disruption occurs; and (f) developing awareness of one’s own state of mind. This article explains and illustrates these princi- ples through Janet’s experiences with Rachel and pro- vides candid insight into what hurt children need for healing and positive change.

abstract

This article presents a remarkable story of a deeply trau- matized child who, by great fortune, was placed into foster care with Janet and Paul Mann, founders of the Children’s Ark, Spokane, Washington (described below). Her story

1Portions of this paper have been presented at various training work- shops, including at Project Same Page, which was supported by the Paul Allen Foundation. We wish to thank Rachel and her family for allowing us to use examples from her experience with Janet to illustrate the princi- ples in this article. In addition to her family, Janet extends her gratitude to her clinical colleagues, Sandra Powell and Kent Hoffman, who walked this journey with her, enriching the experience. The Circle of Security Project along with Janet’s work, interactions, and experiences with Glen Cooper, Kent Hoffman, and Bert Powell drove and framed the principles outlined in this article.

Correspondence concerning this article should be addressed to Molly D. Kretchmar, Department of Psychology, Gonzaga University, 502 E. Boone, Spokane, WA 99258-0054. E-mail: [email protected]

2In order to protect the privacy and to respect the confidentiality of the child represented in this article, her name has been changed. Further, the child’s adoptive parents provided full consent to the use of her story and read a complete draft of the manuscript prior to its submission in order to confirm that they were comfortable with its contents.

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to them, about whether they are worthy of care, and so forth. Children with secure attachment histories have a sense of trust toward others and feel the self-worth reflected by the nurturing care they have received. In contrast, chil- dren with insecure histories are likely to view others as less available and less trustworthy and to have internalized a compromised sense of self (Weinfield, Sroufe, Egeland, & Carlson, 1999). Of greatest concern are children with disor- ganized attachment strategies. These children typically have caregivers who are either frightening or frightened, placing them in an irresolvable approach–avoidance bind; “the infant is presented with a paradox wherein the haven of safety is at once the source of the alarm” (Main & Hesse, 1990, p. 180). Stemming from this paradox, researchers expect that these children will carry forward highly dis- torted models of the self and of relationships; models char- acterized by deep mistrust, fear, rage, and possibly violence. Some theorists further speculate that disorganization is a precursor to serious psychopathologies (Crittenden, 1995; see also Lyons-Ruth & Jacobvitz, 1999).

Children in the foster care system have likely suffered multiple attachment-related traumas, not the least of which is parenting that is traumatic and frightening. It is likely, then, that many of these children have insecure and/or dis- organized attachment relationships (Schofield & Beek, 2005). However, even when children have insecure and/or disorganized attachment relationships with their parents, being separated from these primary caregivers adds another layer of trauma (Charles & Matheson, 1990). For a young child, the very nature of separation is scary; even if what they had was abusive, it was at least familiar and perhaps even predictable. Children also have a remarkable capacity

demonstrates how a predictable environment and secure, loving care providers can foster change even when a child is profoundly disorganized, deeply mistrusting, and full of rage toward herself and others. Along with their commit- ment to her, Rachel’s care providers’ solid understanding of attachment theory and their ability to translate theory into practice were central to the progress Rachel made. In this article, we use Rachel’s story to illustrate principles of care- giving grounded in attachment theory that we hope will provide insight to other care providers. This story is ulti- mately one of great hope, not only for this child but for the thousands of hurt children in foster care.

Attachment Theory and Foster Care “Attachment theory,” first developed by John Bowlby

(Bowlby, 1969/1982, 1973, 1980), asserts that children have a primary and essential need to be “in relationship” with their caregivers. To ensure our survival, our evolutionary history prepared us to seek closeness or proximity to our caregivers, especially under conditions of threat or vulnera- bility (e.g., presence of a stranger, illness). When caregivers are available and welcoming, seeking proximity is easy and children’s feelings of safety and security are bolstered. When caregivers are unavailable (physically, emotionally, or both), inconsistent in their responsiveness, or frightening in some way (e.g., abusive), seeking closeness becomes more difficult and children’s feelings of security and safety are disrupted.

Bowlby (1969/1982) proposed that young children internalize “working models,” or representations about themselves and others that are based on their early attach- ment experiences. These models form the basis for chil- dren’s expectations about how others are likely to respond

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to be connected to their caregivers, even their abusive or depressed or addicted caregivers; this attachment is primal and visceral—built into our species to help ensure our sur- vival (Bowlby, 1969/1982). Removing a child, then, even for the child’s welfare, is likely to be deeply threatening and disorganizing in and of itself. In addition, because the pre- sent foster care system cannot ensure permanent place- ments for children, many children experience multiple placements, involving multiple separation and loss experi- ences, which only compound children’s deeply disturbed sense of self and other (Charles & Matheson, 1990).

The Children’s Ark: An Attachment- Oriented Solution

The Children’s Ark was founded in 1994 by Paul and Janet Mann, who then had over 6 years of foster care experi- ence and had provided care for over 40 children. The Chil- dren’s Ark began as a foster care residential program in which mothers who had lost custody of their children were able to live, full time, with their children in a safe, struc- tured, therapeutic environment. The hope was to minimize the separation experience between the parent and child (Kretchmar, Worsham, & Swenson, 2005; Worsham & Kretchmar, 1999). Presently, the Ark functions as an evalu- ation and intervention center that allows for daily and extended visitation between children placed in foster care and their parents. At the Ark, parents join their children each week day, retain the primary caregiving responsibilities under the Ark staff’s supervision, and are required to work toward improving their capacities for parenting and self- sufficiency. In addition to being with their children, parents participate in educational programs and in the Circle of Security, a group-based intervention in which parents learn about their attachment relationships with their children and how to enhance these relationships (Cooper et al., 2005; Marvin, Cooper, Hoffman, & Powell, 2002). Rachel and her mother joined the Ark when Rachel was 10 months old.

Rachel: A Teacher of Powerful Lessons Rachel was born into a chaotic family environment in

which the abuse of her older siblings by her father had already attracted the attention of child protective services. With her father gone, Rachel remained under her mother’s care in an in-home dependency issued by the State of Washington. When she was 10 months old, she and her mother were referred to the Children’s Ark for services after Rachel was diagnosed with multiple delays and failure to thrive. Rachel and her mother participated in the Ark for 11 months during which time the Ark staff became increasingly concerned about Rachel’s safety in the home and the impact of Rachel’s home environment on her development. Rachel’s mother agreed to voluntarily place Rachel in foster care with Janet and Paul Mann.

Janet Mann became Rachel’s primary attachment fig- ure. In her journey with Janet, Rachel was a powerful

teacher about what all children, but especially hurt chil- dren, need to develop to their ultimate potential and about what even temporary care providers can do to begin to heal the pain of the child’s past. Janet, an experienced foster parent well versed in attachment theory, had the wisdom to listen to Rachel and to see through Rachel’s compli- cated behavior to her vulnerability and tremendous need. It is in Janet’s words that we tell Rachel’s story:

After watching Rachel in the mirror, I was aware of pondering somberly how wounded she was. It was certainly clear to me that it was a dismal picture she carried in her head about how the world worked, whether or not she was valuable, how she would be responded to, and whether she could impact her world. Much of her rage seemed to be aimed at herself; somehow she carried the responsibility for the misery in her life. What, as a temporary caregiver, could I possibly do to help her?

I knew Rachel’s story, and I knew her family; so it was not hard to imagine how her picture had evolved. Rachel lived with her mother and 2 older sisters. Her father, who had sexually molested the older girls, had been court ordered out of the house. Her mother suffered from depression and was fearful and ineffectual with the older girls. As a result, Rachel’s needs, even her most basic needs, often went unmet or were delegated to the sisters. Life was chaotic, inconsistent, unpredictable, often frightening, and punctu- ated with violence.

When Rachel came to me she was an aggressive, anx- ious, and rage-filled little girl. Much of her aggression was aimed at herself. On occasion she also demonstrated aggres- sion toward others. She often made aggressive sounding

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noises, like growling, and sometimes engaged in a nervous, haunting laugh, especially in response to an escalation in her caregiver’s anger. Her activity level shifted easily into the frantic/frenetic range and often was accompanied by clumsi- ness and defiance. She showed a blatant disregard for her own safety; engaging with frequency in danger seeking, or at least “adult-grabbing” behavior. She manifested a general anxiety, moving sometimes unpredictably into an exagger- ated fear and startle response. She was extremely hypervigi- lant, as well as hypersensitive to the mood and availability of her caregiver. She demonstrated a very low tolerance for frustration, accompanied by no expectation that help was available. Occasionally, even a relatively minor frustration could lead to a rage response. Her behavior was controlling in many ways, especially around eating. She manifested a general inability to regulate her emotions. She was dismiss- ing of her own affect and resisted others’ attempts to comfort or soothe her. She was, in fact, resistant to relationship or any kind of intimacy at all and instead was extremely and compulsively self-reliant.

Between her history and her behavior, I could construct a pretty clear picture of what she would expect in relation- ship with others, particularly with me as her new primary caregiver. She would not expect me to meet even her most basic needs. She would expect me and her life to be unpre- dictable and chaotic. She would anticipate that I would be emotionally, and often physically, unavailable to her. She would assume that I could be either frightening or fright- ened; and that I would allow, and perhaps even engage in, violence and aggression. She would not expect me to have any tolerance for affect or intimacy; she would expect to be alone in intense emotion. She would expect me to put my own needs above hers and to abandon her in many ways.

Conversely, I knew also how I wanted her to see me. If she was to recover and function effectively in the world she needed to expect me to meet her needs, both physical and emotional. She needed to be able to count on reliability of routine and relationship. She needed me to be sensitive and available, and to be able to tolerate and validate her feelings. She needed to feel confident that I would support her explo-

ration and provide her with comfort and protection, and she needed to trust that repair was possible. These were lofty goals indeed; goals that I eventually learned to approach in very specific and conscious ways.

Rachel exhibited all of the signs of a highly disorga- nized child. The rage she directed at herself and occasion- ally at others would, without sensitive intervention, almost certainly predict very troubling outcomes that are all too common among children in the foster care system (Rosen- field et al., 1997). Research and clinical accounts tell us that foster children with disturbing behavior may elicit insensitive, punitive care; may be moved repeatedly as a result of their disruptive behavior; and are sometimes abused, again, in foster care homes (Kenrick, 2000; Rosen- field et al., 1997). It is not hard to imagine an otherwise well-intended caregiver shutting down or lashing out in response to Rachel’s rage, which would only reinforce Rachel’s disturbed models of self and other.

Janet understood Rachel’s rage and other troubling behavior to indicate her profound insecurity and intense vulnerability, and, as noted above, Janet also identified what she wanted Rachel’s experience to become. Janet’s professional immersion in attachment theory, object rela- tions theory, and especially the Circle of Security protocol (Cooper et al., 2005; Marvin et al., 2002) intersected with her daily experience with Rachel and deeply influenced her caregiving behavior. In conversation with several of her clinical colleagues, Janet extracted six “principles” that she felt best explained her caregiving strategies. These princi- ples are powerful lessons about what all children, but espe- cially hurt children, need. In describing these principles, we use Janet’s words as she tells more of Rachel’s story.

Principles

Principle 1: I AM HERE. YOU ARE WORTH IT. The first principle was to frame everything I did and every- thing I said with the message: I AM HERE. YOU ARE WORTH IT. There are two things that secure children know: that their caregiver is available should they need them, and that they are worth it (J. Cassidy, personal com- munication, July 5, 2002). These were two of the things that Rachel did not know. Starting with the day she stood before the mirror attacking her reflection, I tried to wrap her entire life in the message: “You are loveable and you are loved.” First, I was religious about reliability of routine and relationship, hoping to give her both a sense of security through structure and a sense of belonging. Bath time, for instance, was always at the same time and done in the same way. I always followed the same order of things. We always sang the same songs and played the same games. And, most importantly, perhaps, we always followed the bath with the same ritual: finding my husband wherever he was so that he and Rachel could have the conversation they had every night in exactly the same way: “Did you take a bath?”

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“Bath.” “Are you all clean?” “Clean.” “Did you wash your hair?” “Hair.” “What do you get now?” “BINKY!”

I filled Rachel’s day with as many routine and ritual experiences as possible. I identified activities that she par- ticularly enjoyed (e.g., singing songs), and I set aside at least one period of time a day to engage in them, no matter how difficult the day may have been. Rachel’s life had included far too few of these “connecting moments,” and I wanted her to experience delight as a regular part of each day.

I believe that predictability became a lifeline for Rachel. If ever I doubted the importance of it to her emotional well- being, then she was sure to remind me. My faithful practice was to carefully explain to Rachel everything that was going to happen, especially if it was at all out of the ordinary rou- tine. One week about half way through Rachel’s stay with me, I went away for a weekend. She was, of course, dis- tressed and disorganized by my absence, and on Monday morning she was struggling mightily to get it back together. I took her down to The Children’s Ark with me, and as I sat down she went off to play. Suddenly I remembered something I needed to do and so signaled a staff member to watch her and went upstairs. Apparently in my absence she came back to where I had been sitting and noticed that I was gone. When I returned I sat in the same chair and as she came around the corner and saw me sitting there again, she burst into heart-wrenching sobs. I was stunned. As her experience became clear to me, however, it made sense. I picked her up and tried to soothe her while telling her that I was sorry I had not told her what I was going to do, that it must have scared her that I just disappeared when it was generally my practice to tell her what was going to happen next. I told her that I understood also that it must have been particularly frightening for her right on the heels of my weekend away and that she must have felt abandoned again. I had come to know that Rachel really needed her reality validated; to be seen, heard, and understood by me were the beginnings of security for her. Like all children, Rachel needed at least one adult who “got it” about her.

Principle 2: BEHAVIOR AS NEED. The second principle was to try always to view her “problem” behavior as the expression of a genuine need (Cooper et al., 2005). It is so easy to feel personally defied by the behaviors of children like Rachel; to see them as somehow inherently bad or flawed or even malicious; or, at the very least, to see them as “acting out” to get attention. Instead, I came to see that Rachel was simply engaged in an ongoing attempt to get her needs met. Some children, Rachel among them, have learned that they are generally not heard and that their needs will go unmet unless they can escalate their “adult-grabbing” behavior high enough that they cannot be ignored. Seeing her behavior as the expression of a gen- uine need instead of “acting out,” allowed me as her care- giver to focus on ferreting out and meeting the need, rather than focusing on stopping the behavior.

One afternoon I was working late at the Children’s Ark. Our clinical director, Sandra Powell, was watching Rachel in another area of the house. She reported that Rachel was playing happily one moment, and the next she was racing around and around pulling magazines off tables and knocking over lamps. Rather than responding nega- tively to the onset of the behavior, Sandra recognized it as the expression of a genuine need (no matter how grace- lessly expressed) and responded instead to that. She picked Rachel up, held her in her lap, and said to her, “I bet you are missing Janet and wanting to go home. You do not have to run around the room pulling magazines off the table and knocking over lamps to tell us that, because I am here. You can sit in my lap instead and tell me how much you miss Janet, and I will comfort you until she is here.” Rachel settled into Sandra, knowing in some way that even if her particular need to have me was not going to be met at this very moment, just having someone understand her was enough for now.

Principle 3: CUES AND MISCUES. As discussed in the Circle of Security protocol (Cooper et al., 2005), not only will children like Rachel speak louder through their behavior if their bids to have their needs met are not heard, but they will also learn to speak their caregiver’s specific, unique “language” in order to stay in proximity with their source of survival. Children who are generally seen, heard, and understood learn to “cue” their needs directly and anticipate that they will be met. When, as with Rachel, there are needs that a child’s caregiver is uncomfortable meeting or fairly consistently fails to meet, that child will adjust her behavior accordingly to stay in at least the approximation of relationship, and may “miscue” needs. Essentially, the Rachels of the world learn to “pretend” like they do not need something because they have learned that it will be difficult or impossible for the caregiver to meet that need. My job with Rachel (and the third principle) was to be willing to override and say aloud miscues, to con- vince her that I was there and would meet her needs.

Rachel’s miscuing was so firmly entrenched that it seemed like she was not even aware that she had needs or at

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least any expectation that they could be met. In the begin- ning it felt like I was teaching her how to feel and how to cue. For example, several times she fell down hard enough to draw blood. It never occurred to her to cry out, look for a responsive other, or seek comfort. Under those circum- stances I would go to her and pick her up and say, “Oh, boy, that really looked like it hurt. Let’s go wash it off and find a Band-Aid. Let me hold you,” and so on.

Whenever I thought Rachel was miscuing me, I tried to figure out what she really needed, what was really going on, and then reflect aloud what I perceived her to be feeling or needing. It was always, of course, a guess; but I had little to lose if I was wrong, and if I was right, I had a lot to gain. When I guessed right, I immedi- ately had Rachel’s attention. Sometimes that was enough to calm her down and regulate her. Other times I went on to move her to and through intense, genuine, and appropriate emotion: an important step in healing. And the bonus always was that Rachel had one more experience of someone “getting it” about her.

Toward the end of Rachel’s stay with me, her new (adoptive) family made several visits to my home. During their third visit, we were all sitting in the family room talk- ing and watching Rachel play. Her quality of play began slowly to deteriorate until I thought she might disintegrate completely. I picked her up and put her in my lap, facing me, and asked her what was going on. She first tried to tell me that she was fine and then that it was about a problem with a toy; but I took a fairly safe guess and said to her, “I don’t think that you are fine at all, or that it is about the toy. I think that it is about those people sitting right over there, and what their being here means.” Unfortunately, Rachel already had had one failed placement, so I was bet- ting that a family visiting had meaning for her. She froze and looked deeply into my eyes. Then she looked over at them and back at me and burst into tears. She then could move both into expressing her feelings freely and talking about them, while allowing me to comfort her. I had the opportunity to begin in earnest the conversation about her move, to share with her my feelings about missing her, and to model for her new family how to help her grieve. All of this because of not letting a miscue go unchallenged.

Children like Rachel sometimes seem to regress tem- porarily, either in behavior or in skill level. Rather than a regression, I see this almost as a child “taking back” mis- cues; a way for them to say, “I didn’t get this need met, and I want it.” Rachel taught me many things, among them was to understand regression as a sign of an unmet need. One day I was in the playroom with Rachel, watching televi- sion. Without initially attracting my attention, she brought a baby bottle over to where I was sitting and posi-

tioned herself on my lap as if she were a tiny baby. Once she was fully in my lap, she looked into my eyes and handed the bottle up to me and said, “You do it.” Some- what puzzled as to what she was up to, I did figure out that she wanted me to feed her the bottle…and so I did. After a moment she took the bottle out of her mouth and said, “Blankie too.” Then I understood. I got a blanket, wrapped her up and cuddled her, rocked her, and fed her the bottle

while affirming for her, “You didn’t get enough of this when you were a little tiny baby, did you?”

Principle 4: “BEING WITH.” I realized quite early on that the only way to get Rachel somewhere else emotionally was to be with her wherever she was. Not only was it important for her to know she had feelings and to feel them, but it was

also important for her to feel met or held wherever she was. Wherever she was, I wanted her to feel validated, under- stood, and even joined. Because this was not the dance she had learned as an infant and because she had learned to shut down her feelings very early on, I found myself actually actively encouraging these walks through intense emotion. Thus, the fourth principle became to be willing to “be with” her in intense emotion rather than trying to make it stop.

I had learned early in my relationship with Rachel that when she was struggling internally with something that was difficult for her to manage, signals or cues became apparent if I was paying attention. Her play became less focused and her activity level more frantic and frenetic. She became more clumsy, almost as if losing control of her external being as her internal being struggled. Often her posture with me became much more openly defiant. I always tried to catch these signals so that I could go about helping her sort out what was going on. One particular evening I remember all of these signals happening one after the other, culminating in her standing on top of the coffee table, just a few feet from me, with her hands on her hips, looking right at me. After taking her down several times only to have her climb right back up, I finally put her on my lap facing me, held her firmly, against some resistance, and said to her: “I am going to help you figure out what is going on. Looks like you need some help. Looks like you are asking for help.” Then I took my best bet as to what was going on. In this case it was a pretty good guess that she was emotionally disorganized by a sudden and unpredictable increase in visits with her mother. So, I went on to say

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