In the spring of 2019, Scottish Attachment in Action met with a group of residential child care workers in Aberdeen. They enthusiastically shared how training in PACE (playfulness, acceptance, curiosity and empathy) and DDP (Dyadic Developmental Practice, Psychotherapy and Parenting) had transformed their relationships with young people. Staff members also talked about how they supported one another in order to stay connected with young people who sometimes presented very distressed behaviours.

Why do I need the training? DDP helps a social worker repair a relationship with a young person

“I did DDP level one training. It was four days and it was really good. I liked the way it was delivered by Fiona (SAIA Development Coordinator) and Edwina (Certified DDP Trainer). They offered real examples of how DDP can be implemented, and there were opportunities to think about our own practice.”

“As a social worker, sometimes dealing with a young person in distress, I can fall into saviour mode. I want to do things for people rather than just sitting with them and holding that emotion with them.”

“The training also allowed me to think about repairing relationships. For example, I was given the task of finding out about one young person’s experience of being in care. I was hopeful that I would get my task completed efficiently. As soon as he came down the stairs, I started speaking to him about his experiences in care. I forgot he doesn’t like being stigmatised or being looked after. It was first thing in the morning and all he wanted was to be left in peace. I was met with some resistance. I came away from that and thought about what the experience had been like for him. Later, I offered him a lift somewhere he needed to get to. I said I was sorry and I should have known that in the morning he was not keen on chatting to people. I acknowledged that his experience of being in care was unique. The discussion in the car continued, and he was much more open and engaged.”

“Prior to the DDP training, I had read one of Dan Hughes’ books. Before the training, I was kind of doing it (his method) but never had the terms to name what I was doing. The training gave me a frame of reference, and I feel a lot more confident now. It has allowed me to support other staff members with their practice by helping them to explore the meaning behind those emotions rather than just giving factual responses or going into saviour mode.”
 

DDP helps team members identify when they are struggling with blocked care 1

“As a staff team, we check in with each other to make sure we are as well as we can be. We were talking about how the children’s distressing behaviours can have an impact on us. If we are not taking care of ourselves and each other, this can impact on the way that we interact.”

“Prior to having an understanding of DDP, there wasn’t a clear understanding of blocked care. It is a very hard job we do and we love it, but it is very difficult at the same time. When you find yourself in the position that you’re not enjoying that relationship anymore, it can be very disheartening. 

DDP has allowed us to gain an understanding of what is happening especially within your brain, the hormones, and the impact that has on your ability to care. We want to re-ignite the passion again for the young people that we care for. That is not easy because we don’t have those positive experiences of looking after the children when they were little. They have come to us after they have suffered traumatic early childhood experiences and their behaviours display that. We try to understand where they have come from, what this is actually telling us, and how we can work the best to support them and ourselves.”

Reawakening compassion begins with understanding trauma

“We have one young person who displays a really high level of emotional need and that’s incredibly draining on the whole staff team. We check in with each other and make sure we have regular discussions. In order to reawaken compassion, we have taken the timeline to team meetings. We go through it and look where a young person has come from and the trauma that they have experienced. We remind ourselves that the young person isn’t doing something because they won’t do it but because they can’t do it. We think about the unmet need within a young person’s developmental trajectory.”

A young person responds to curiosity and empathy

“What we realised is that this young person needs a high level of physical touch. We give her lots of cuddles, bedtime routines, bedtime stories, and washing her hair. There is a lot of time invested in nurturing.” “Also, she responds to us being curious about what has happened. Instead of responding immediately to behaviours, I use wondering aloud 2. If she can’t respond verbally, the young person can give a hand gesture, thumbs up or down.”

“There is also a special place where she goes when she wants to speak to me. We haven’t seen as many of the distressed behaviours that we were seeing initially. There was a lot of physical aggression especially directed towards me and another colleague but that doesn’t exist anymore.”

“I think what we have done is create a safe space for her and there is safety within our relationship as well. When she is very dysregulated, I let her know, ‘If you need this time then I can help you regulate.’ We will sit and hug. I used to struggle with sitting with the really distressed emotion; I would have jumped in and tried to fix it. Now I know I need to sit with it, we need to work through this, and we need to understand this. I think that really helps with her.”

Sharing what works with a school builds a deeper understanding of behaviours

“The school were really struggling with her behaviour and so we used the timeline. We had a meeting with the school, and we spoke about how we worked in a relational way. We took the timeline and spoke about the trauma and the neglect she’d experienced. It gave the people in the room a greater understanding.
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You could physically see the body language of the teachers and guidance staff changed in response to what they were hearing. You could almost feel the empathy in the room. Now we have this really good relationship with the school, and they are understanding these distressed behaviours.”

PACE training changes mind-sets

“The three-day PACE training was a really good refresher and a reminder of what I should be doing on a day-to-day basis. You naturally have your own values that you bring to the role, but sometimes you should leave them at the front door. We need to think about things with a PACE attitude, rather than defaulting into our normal view on things.”

“I do outreach work with a young person who is coming up for 19 years old, but chronologically probably operates at a younger level. One of the principal things that I remind myself is the can’t not won’t principle. It is easy to say ,‘He’s nearly 19; he should be able to do x, y and z.’ I have to remind myself that although he’s 19, he can’t do a lot of things very well, like budgeting, managing appointments, and that kind of thing. It is the same with some of our other young people; it’s not that they won’t do things, it’s just that they can’t.”

Seeing how PACE works in practice motivates staff

“I get to see results. One young person, she doesn’t do physical touch a lot, but she asked me for a hug one day. I think she asked me because I work in a fairly open way with her and I have built up a really good relationship. I remember saying to a colleague, ‘That’s one of my best moments ever.’ People take for granted in day-to-day life that it is okay to ask for a hug, but when she asked me for a hug I thought, ‘Wow, that’s a moment!’”

A no blame culture helps adults stay open and engaged

“My supervisor and I reflect a lot on things that have happened; we are curious about things. We will look at how I have handled things, and we talk about how I am feeling. We had a situation last weekend where one of our young people, who had been doing a lot of alcohol and this affected his behaviour. He had gone out saying he was going to hurt himself, and I had to hold him to stop him from hurting himself. It was quite a traumatic event, but my supervisor talked through how I was feeling and how I was going to go forward with this young person. There’s never any blame and that helps me stay more open and engaged with a young person.”

DDP helps staff stay in the moment with young people

“Another thing I remember from the DDP training is the importance of always going with an open mind and not being judgemental. I really try to stay in the moment and think about how to match affect 3.

When young person is feeling heightened, you can match their affect to help them co-regulate.

The old calm down never really worked for them. If you can match their mood to kind of bring them down, I think that is really useful.”

A PACE approach helps staff respond with more sensitivity

“We put the PACE attitude into practice every day. We talk about a trauma-informed model, and PACE is a way to articulate that. I use curiosity with a young person to explore what is going on for them when they are distressed. When I have obviously got something wrong, I can say I am sorry for putting a young person in that position. I see young people being very responsive to that sort of dialogue. You are no longer telling them how they should feel, you’re actually having them tell you how they feel.”

“Young people can better regulate because we are not seen as a threat. You are no longer threatening them with your ideas or your words. You are no longer in the position where a young person is distressed towards you, and they can see that you have not got distressed by their distress. It is an attuned way of responding.”

Young people talk about the issues that are really important to them

“I wanted to improve the lives of young people and do something different in our children’s homes. DDP is was a way to address trauma. It is about healing trauma instead of us just adopting a behaviourist approach, which does not work.”
“It is creating a culture where we really listen to young people. Recently a young person told us, ‘There’s no food in this house!’” She was upset.
“Before the DDP training, we would have responded by pointing out that there was food in the house. This time we thought about what she was really saying and why this young person was so angry. We worked through a process with the young person.”
“About 40 minutes later she was saying, ‘All the staff are rubbish.’”
“All the staff are rubbish! My goodness that must be really difficult for you!” I said to her. “By exploring her perspective and feelings, the young person was able to open up about what was really troubling her. She was blaming herself for something that had happened in her past. Before we would have just dismissed her with, ‘There is food in the cupboard.’”
“It is really important that as a staff team we are able to keep ourselves contained and regulated because that enables us to hold on to and contain that anxiety for the young person. The end result was amazing. It had nothing to do with the food; it turned out it was about her feeling guilt over something that had happened in the past.”

“Young people are getting the message that you get them, you want to understand them, and they are responding with more open communication and more trust.”

“We have used that approach quite a few times with young people. Sometimes, they don’t want to actually speak. One young person used post-its and wrote, ‘Nope’ and held it up. Then we tried something else and he wrote, ‘Maybe.’”

Do the young people know that you are using this new approach?

“I don’t think they know, apart from one young person. She said these words, ‘Are you trying to therapeutic me?’”

“It has been so gradual the kids are just lapping up the connections and the curiosity. Some young people might say they had noticed something was different. They are choosing to stay with us longer. We have less significant incidents, and our staff are not off with stress.”

Residential managers notice the impact of the training

“Members of the team have come back from the training very motivated and excited saying ‘light bulbs were going off in my head all four days.’”

“We have embedded our ethos of care so that it is aligned with the principles of DDP and PACE and updated our policies and procedures so that they are clearly underpinned by relational/attachment-based practice.”

“We now write our daily written records in a way that is respectful and non-judgemental of our young people.”

 “The way in which we work with families has changed in a way that helps us understand the family script and how this impacts on the young person. This also allows for direct family work that is trauma informed.”

“Staff are able to de-escalate situations and do not resort to putative measures. However, we are also clear about what is not acceptable, and any risk-taking behaviours result in higher levels of supervision/safer care planning.”
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“DDP has given us an evidential baseline that explains our approach to other agencies within a variety of professional’s forums, including Police, Education, and Health Services. Sharing our approach with others encourages a holistic trauma informed understanding of the young person and their needs.”

​Further resources

1. Hughes, D.& Baylin, J. Brain-Based Parenting: The Neuroscience of Caregiving for Healthy Attachment. 2012: New York: Norton & Co.

2. Woodier D. Wondering aloud. Weblog. Available from: 
www.saia.org.uk/blog/wondering-aloud-building-support-for-young-people-who-are-in-crisis

3. Woodier D. Matching affect and why a dog is a man’s best friend. Weblog. Available from www.saia.org.uk/blog/matching-affect-and-why-dogs-are-a-mans-best-friend
 
Please note that the PACE and DDP trainings were commissioned by Aberdeen City Council and were delivered within a partnership agreement Aberdeen City Council, Scottish Attachment in Action, and Edwina Grant (independent psychologist and certified DDP trainer).

In the first year of an infant’s life, the parent’s or carer’s capacity to think about what is going on in the mind of the child allows curiosity and empathy about the child’s affect*. The carer provides the child with a kind of mirror image reflected in their parent’s or carer’s face and expression. The child manifests a mood or an emotion to a caregiver, who mirrors it in a display of understood affect. The infant who is crying and distressed sees sadness and distress in his caregiver’s face.

However, what adults usually do without even being aware of it, is mark or differentiate their display. For example, they may alternate a brief period of making a sad looking face with a soft smile, gentle voice, and rocking. This enables the child to recognise that the affect displayed by the caregiver is a representation of the child’s. This secondary representation allows a child to learn to calibrate and regulate his or her response rather than acting it out. 1,2
 
Many children who have been maltreated or who suffered disrupted attachments have not had enough experience with someone who can attune and connect with their affect. Yet, being able to experience a consistent, sensitive response from a parent or carer plays a vital role in helping children learn to regulate their emotions. How do we help children learn to regulate their emotions when they haven’t had these experiences early in life? How do we help them learn what it is like to have an adult who is trying to understand them and give meaning to their inner life and behaviour?
 
In order to reach out to these children, teachers, parents, and carers have sometimes been encouraged to try matching the affect of the child or young person. This isn’t always straightforward, and I have seen mixed results. One teacher said to me, “I try to match his affect when he is upset, but his voice goes up too high.”
 
Another asked, “How do I match his affect when his expression looks frozen or when he curls up in a ball?”
 
I have also seen teachers amazed at the results when they figure out how to do this. “When I said to him, ‘I understand you must be really upset,’ he got even more angry. But when I said in a more animated voice, ‘I get it! No wonder you are upset if you think you were going to get the wrong answer,’ he calmed right down.”
 
Success seems to depend on the child or young person being able to experience what it is like when an adult tries to understand him or her in a curious and empathetic way. It relies on an adult being able to notice the subtleties of a child’s expression and relate it to some underlying intention or meaning. This reflective capacity, often referred to as mentalizing, allows us to imagine the fears, desires, goals, hopes, and beliefs that underlies our own and others’ behaviours.
 
Someone who is mentalizing is curious, accepts that their assumptions about a child’s behaviour may be wrong but wants to try anyway, is aware of the impact of emotion, and is able to see a humorous side of things. However, mentalizing is also a fragile process. It develops naturally, for example, from the interactions between members of a family, but it can be easily switched off when a child or adult feels threatened or shamed. Similarly, when an adult becomes too rigid in interpreting a child’s intentions, when an adult lacks empathy for a child, or even when an adult has lost joy in relating to a child, it may be very difficult to recover that mentalizing stance.
 
What can we learn from the developmental processes, like mirroring, that can help us learn to match affect? The goal is not to present the child with a facsimile of their expression, but with a copy that is distinctive or marked. By matching the intensity and timing of a child’s affect -- for example, by matching the patterns of stress and intonation in the voice -- the adult demonstrates that understanding of the content of that emotion or mood. At the same time, the adult marks their display; for example, rather than shouting back at an angry child, the adult uses animated gestures. Sadness or disappointment can be matched by the tilt of the head or by an exaggerated sigh. Congruence but with a degree of differentiation allows the child to recognize the displayed affect as their own and not the adult’s.
 
One experienced practitioner explained some of these features in these examples: “So, if a child says to me, angrily, 'I am so stupid!' my verbal response to match affect would be to say in an animated tone: That's so hard for you when you think you are stupid!” I would also match the intensity and pattern in the child’s expression with my body language and facial expression. Likewise, if a child was sad and said: ‘I am so stupid,’ I would say the same words, but my non-verbals would be less animated in intensity in order to match the energy of the child's statement.”
 
The following steps may allow the child to get a sense of “you get me” and “you have understood me.” Although our goal is accurate mentalizing (giving the child the picture in my mind of what it is like to be them), we do not have to do this perfectly.  It is important that the child experiences the process we use to correct our understanding.

1. Build your attunement. Develop your awareness and sensitivity toward a young person. Can we detect subtle change -- for example, a different kind of smile -- and begin to tentatively give it some meaning?
2. Practice listening and being in the moment. Stop telling what is wrong and stop trying to offer solutions.
3. Practice matching the child’s affect. Try to match the energy of the child’s emotion, but in a way that also shows understanding.
4. Share your first faltering understanding.
5. Be ready to understand your own misunderstandings.
6. Watch how a young person responds when you use wondering aloud. Use this to improve your understanding of why things are difficult.
7. Look for that moment when a young person shows that they recognise themselves in something you have said or shown.
8. Be prepared to acknowledge and work with the person when they resist your efforts, without making them feel that they are to blame. “It is hard to work this stuff out. I am sorry I haven’t got it quite right. Can you give me another chance?”
9. Be aware of what impact a young person’s behaviour is having on you. If you feeling threatened or shamed and it is making it harder for you remain open and engaged with a young person, find others who can help mentalize you!

 
I was in a meeting at a school and one of the teachers, in a light bulb moment, asked this question: “So you mean our job is to help him learn to relate to others rather than give him an education?”
 
If I could go back and answer that question now, I would say something like, “Actually our job is to learn to relate to him first before we can expect him to relate to us.” Yes, relationships are vital to learning. They go hand in hand. It is just that we are used to teaching kids who have learned before they get to school that the knowledge adults have about the world is valuable. For other children, we need to be intentional about helping them learn to trust by giving them opportunities to experience what it is like to have an adult who mentalizes them. That experience of being understood is a key that unlocks learning. 3,4
 
This is a true story. Harry (not his real name), ten years old, sits at his desk with his head down. His teacher recognises something is wrong. She knows that the question Harry has been asked may have upset him: “Write about a character in a story who feels rejected.” She gently asks Harry, “Come outside with me.”
 
The teacher has prepared herself for a moment like this. She says to Harry, “I can see that it is not easy for you to tell me what is wrong. I would like to do something a bit different. I am going to talk for you.”
 
The teacher continues as if talking for Harry: “‘If I don’t answer my teacher when she asks me what is wrong, I’ll get in trouble. But I don’t know what’s wrong, and I don’t know how to tell you.’” As the teacher speaks her voice become more animated and she moves her hands in front of her like the two sides of a closed gate. She is trying to communicate the sense of frustration, of not knowing, that she imagines Harry is struggling with.
 
Harry looks up and makes eye contact. Silent tears begin to spill down over his cheeks.
 
The teacher pauses and then begins to talk about a time when she kept getting something wrong and didn’t know how to fix it. She begins to lighten the tone of her voice and Harry smiles.
 
Later the teacher reflects on what happened. Was she able to match Harry’s affect? She can’t be sure, but she feels like there was a moment of recognition when Harry made eye contact with her. She thinks that Harry’s tears may have come from a sense of relief that someone could talk about him without making him feel ashamed. What is Harry learning? He is at the beginning; this is the first of many moments when his teacher can talk for him. Gradually, he will understand more about himself, he will see that the emotions that overwhelm him can be understood by his teacher and don’t overwhelm her. He can learn that it feels okay when another person helps you regulate your emotional response. The barriers and fears that cause him to back away from learning will seem less because he is learning to trust.
 
Relating to young people using skills like matching affect allows us to communicate a deeper kind of understanding that can signal to a child that what I have to share with you is relevant and helpful. “If you can get what is in my mind, then I might be interested in what else is in your mind. Now I am interested in what else you have to say about what might work for people in my world”. 4
 
Just in case you think that the reference to dogs in the title was simply to get you to read this, some experts say that mentalizing is perhaps the most human of traits, and that the animals closest to being able to mentalize humans are dogs. Dog lovers probably already knew this, but It shows what a powerful advantage dogs gain by being able to notice the subtleties in expression of their human owners. How can dogs do this? Try hanging out with humans for several millennia: mentalizing is a great way to build companionship and have someone throw a stick for you.
 
 *Affect is often used as an umbrella term to include inner states that are relatively stable, such as an attitude toward a person and something shorter lived like a mood or an emotional response to a specific situation. It can also refer to something that child is not fully aware of and yet manifests in their expression or body language.  If that doesn’t confuse you enough, try reading James Gross’ explanation in, “The future is so bright I gotta to wear shades” Emotion Review 2010: 2(3); 212-216

References:
 
1. Fonagy, P. What is mentalization? Available from: https://www.youtube.com/watch?v=OHw2QumRPrQ
2. Fonagy P. Gergely G. Jurist E. Target M. Affect regulation, mentalization, and the development of the self. 2002.
3. Fonagy P. Alison E. The role of mentalizing and epistemic trust in the therapeutic relationships. Psychotherapy. 2014: 51 (3): 372-380.
4. Bevington D. Epistemic trust for AMBIT. Available from: https://www.youtube.com/watch?v=ZBeEOkwLToM
 
First published in www.saia.org.uk/blog 2019 © 2019 David Woodier, Inclusion Support Teacher. 
​Permission granted to reproduce for personal and educational use only. Copyright notice must remain intact.
Illustrations by Tom Donaldson  www.etsy.com/shop/tomdonaldsonart

I am teaching a young person with attachment difficulties.  
What do I do?
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These suggestions are not intended to be a substitute for a more thorough process of assessing a young person’s needs and level of additional support.
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• Check-in time - Think about getting everyone else settled and working so that you can
  give extra attention to the child who walks into your classroom and isn’t ready to learn.

 

• Attune to the child - Your sensitivity to even small changes in behaviour will help the young person learn that you are competent and caring. For example, try to notice how he looks when he feels he has failed or when he is anxious.

 

• Don’t overwhelm the young person with your interest or concern - Use some aspect of the curriculum or task to show interest in a young person.

 

• Be mindful – Be mindful of their difficulty with activities that require executive functioning, e.g. following multiple instructions, analyzing large amounts of information.

 

• Team work - Some children have teaching assistants. Think of that support person as being part of a team. You still need to get to know the young person and guide and monitor their learning.

 

• Emotional bodyguard - Subject matter can make a young person feel vulnerable.
  Themes such as family and loss can stir up strong feelings. It may be difficult to completely avoid these triggers, this makes it even more important that you learn to attune to the child so you can adapt material and intervene early.

 

• Homework - Don’t sacrifice high aspirations for a young person but remember that their situation at home might make homework difficult to complete.

 

• Shame less - Boundaries are important but try not to publicly sanction a child; a child who is already struggling with a sense of worthlessness may react negatively.

 

• Discipline with empathy - Listen to the young person - don’t try to fix the problem at the expense of really listening.

 

• Praise to build trust - Using exaggerated praise may damage your credibility. Learn to recognize when the young person is proud of something. Praise the process more than personal traits.

 

• Pair them up with another young person - Some young people can accept help from a peer more easily than from the teacher. The right young person can also help them stay emotionally regulated.

 

• Keep calm - Deal with low level disruptive behaviours in the classroom without showing you are stressed. Some young people are very sensitive to how stressed you look.
  They feel less anxious when they can see that you are in calm and in charge.

 

• Draw a line - If there has been a difficult incident remind the young person that they have a new start and that what happened won’t be held against them.