Trauma through a DIR Lens

Affect Autism: We chose play, joy every day

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This Week’s Topic

The topic of this episode is trauma through a DIR/Floortime lens. Maude Le Roux recently did a course on this topic through the International Council on Development and Learning and here she covers how to work with trauma clients through the Functional Emotional Developmental Capacities (FEDCs). This complements the previous trauma-related podcasts I’ve done with Galina Itskovich and Erin Forward and Taylor Anderson and focuses on the DIR/Floortime aspect of the work.

This Week’s Guest

Our returning guest, DIR Expert and Training Leader and Occupational Therapist Maude Le Roux has a DIR/Floortime clinic, A Total Approach, just outside Philadelphia, and a satellite location just outside Allentown, PA. She is an international trainer in many other modalities as well.

Trauma through a DIR Lens

by Affect Autism

https://affectautism.com/wp-content/uploads/2024/08/2024-08-16.mp3

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Trauma and Autism

Everybody’s talking about trauma and there are so many podcasts, blogs and articles about it. I haven’t felt worthy of covering this topic for a long time in a head-on way, but Maude is joining me this episode to take a DIR lens to the topic. My son’s medical trauma and the trauma I still face when I think about what happened to him, being in the hospital for four months following severe brain inflammation at the age of two, is one type of trauma. Autistic self-advocates talk about the trauma they face from attempts at being normalized by adults throughout their childhood.

Maude begins from the platform of an autistic individual having trauma. She points out that there are a lot of pieces to consider. Trauma is housed in the brain, even if we don’t recall it everyday. Trauma in an autistic’s life can be very different from other types of trauma, she says. They might be going through trauma, but because somebody says to them, “This is our secret“, they keep the secret. It will come out behaviourally, perhaps through stimming, and it’s just labelled as autistic behaviour. We may be missing the cues when autistic individuals are going through trauma, which is very tough.

In trauma you have the same structures that may be enhanced, like in the amygdala, that are enhanced in autism as well. Then, the biggest intervention in trauma is talk therapy. How can you do talk therapy with someone who doesn’t understand how to describe the emotions they are feeling? There are so many things to think about, Maude continues. The experience of trauma is very real. The numbers of trauma and anxiety are staggering, Maude says. Exponentially, autistic individuals are four times more likely than the neurotypical population to experience trauma when looking at the ACES data (Adverse Childhood Experiences).

At FEDC 1

Since the beginning of being asked to work with teams around trauma, Maude has used DIR/Floortime because it just fits her and the way she likes to work with anyone. It’s respectful and makes sure you are harnessing the individual differences. When considering the first Functional Emotional Developmental Capacity (FEDC 1), Self-Regulation and Interest in the World, we want to think about what self-regulation means and what having a regulated system means, Maude asserts. It’s a safety system.

The Functional Emotional Developmental Capacities (FEDCs) in DIR/Floortime

FEDC 1: Self-Regulation and Interest in the World

FEDC 2: Engaging and Relating

FEDC 3: Intentionality and Two-Way Communication

FEDC 4: Complex Communication and Shared Problem Solving

FEDC 5: Using Symbols and Creating Emotional Ideas

FEDC 6: Logical Thinking and Building Bridges between Ideas

FEDC 7: Multiple Perspectives

FEDC 8: Gray Area Thinking

FEDC 9: Reflective Thinking and an Internal Standard of Self

When you’re looking at trauma and FEDC 1, regulation is about getting into that safe zone so you can comply to the rigor of everyday life and meet performance expectations, Maude explains. When you’re looking at regulation in trauma-informed care, you’re looking at how to create safety and providing that container within which the individual can find a ‘place of landing’, having an anchor to co-regulate and pivot around to create this order of safety.

When you’re working with trauma in autism, Maude continues, you have to know that the regulatory system will keep resurfacing even more when you’re doing the trauma work. If you’re talking not autism, every single FEDC capacity that you’re climbing is going to be a place where dysregulation can happen at a much more rapid rate. The trigger of the super vigilance of the sympathetic arousal is so high in individuals who are trauma survivors, Maude explains.

So when you’re looking at FEDC 1, you may see in a non-autistic population, that they’re highly verbal and in the emotional phases at FEDC 5, but needing the safety of FEDC 1 throughout the entire process. You’re not looking at them as ‘levels’ of a step ladder. Regulation is always a consideration. The concepts of Floortime (co-regulation, wait-watch-wonder, pacing at their pace, joining them where they are at)–all of these wonderful, golden techniques–are so instrumental for trauma survivors.

The Safety Principle

The first thing that came to my mind as Maude and I were talking was an autistic child whose parents put their child in an intervention that tries to normalize them and every time the child sees that person, they’re going to get dysregulated. It may take them hours to calm down and feel safe again after being with that person who is making them do things that are unnatural to who they are.

Maude says that’s why it is so critical with the lens we are operating from. Yes, there’s the trauma lens, but what are our own biases and frames of reference, Maude wonders. It doesn’t matter what population we are serving. Safety becomes the therapy she insists. We have to beware of violating that safety principle.

If you look at the work of Dr. Stephen Porges on social engagement and the ladder that’s climbed from the ventral vagal, dorsal vagal to sympathetic arousal and the beautiful work of Deb Dana, Maude continues, we know about that co-regulation response from that neuroceptive “am I safe here or not” feeling. When you add in these components, Maude says, you can realize that you might be working at FEDC 5 to 9, but you still need to be working on safety with trauma clients.

If the safety is violated by a particular technique, Maude continues, that will add on to what has already happened to them, she asserts. In trauma-informed care, besides creating that safe ‘container’, thinking of the use of self in co-regulation, looking at not only the individual differences as the profile is now, you also have to remember that the trauma is never over when it’s over. The trauma trigger can be just as alive and real even if it’s years later, Maude states. The past becomes the present. You are re-triggering and re-traumatizing the individual.

Talk therapists are shifting in their dialogue from wanting survivors to talk through their trauma, and focusing more on working on the body and how it’s holding and keeping the score, as Bessel Van Der Kolk says. As therapists, it’s a serious consideration: Am I adding to the trauma, or am I allowing the person to be who they need to be in this moment? So, in therapy, Maude says, it’s essential what kind of a framework you choose.

Lingering trauma

A few thoughts came to me. We can think about a child or pet who was abused by a man and they are then scared of all males. The trauma stays alive and comes back when they see men. When my son had brain inflammation, I was an emotional wreck and my husband said to me, “Do you like being depressed? Why are you watching all of these stories of people who went through what we did?” while I was wondering why I never saw him cry about what happened to our son.

Then my mother-in-law had a conversation with me saying that everyone processes these experiences differently. When she is sad, she likes to watch a sad movie to cry to so it comes out. At some point days later, I came home to my husband telling me he watched a sad movie about a man who cared for an autistic son then found out he was dying and he said that he balled his eyes out. I realized that this was his way of letting out the grief of what happened to our son.

Trauma doesn’t have to be physical or sexual abuse or something super horrific. There are so many types of trauma. When we moved out of downtown Toronto to be closer to our son’s school, I was out for a run and saw young boys playing baseball and was struck with sadness from out of the blue, realizing that my son would never play little league baseball like my brother and I did growing up.

Trauma can hit us when we don’t expect it. Many parents of autistic kids have these experiences, and this gets into the concept of Ambiguous Loss that I discussed with Dr. Robert Naseef.

The Traffic Circle of Frustration

Another thought I had about what Maude said was that Dr. Gordon Neufeld talks about emotional playgrounds. One thing he finds astounding is that people avoiding emotional healing, which is the way around everything: to soften the heart and feel these emotions, which means feeling that sadness about things you can’t control. That emotional release is what helps your brain adapt and move forward with resilience, he states.

His whole definition of resilience is to have the tears (physically crying, which contain cortisol the stress hormone), or sadness about realizing that there’s nothing more you can do versus being stuck in that traffic circle of frustration and anger where you circle around and around trying to change stuff that you have no control over. In his work he talks about that shift from being in that traffic circle to adaptation.

Think about how frustrating and traumatic it must be to be in a body that doesn’t do what you want it to do when you have severe co-occurrences with autism. We are hearing now from autistic adults who have learned to spell or communicate in other ways that they understood everything happening in their childhood but couldn’t communicate that.

Feeling ‘Felt’

As a therapist in the room, Maude says, we are resonators of feeling felt, heard, and seen because when you’re a trauma survivor you feel like you don’t have a rightful place and feel unworthy. Any trauma is not chosen. It happens to you and you have to wonder why it happened, Maude says, and everybody struggles with that. This changes the way you build your self-identity.

All of us wish to get around these struggles versus going through them. This is not the talk for today, though, Maude insists. The issue is that every experience that we have depends on our own temperament and resilience that we have, and as Neufeld says, we are too focused on the end product in which we lose the process of how we get there.

The truth of all the empathy research is that we need to have empathy for ourself as a trauma survivor, Maude explains, and then empathy that we can then shape to feel for someone else, too, so the community at large can have compassion for each other. This is a very different animal. That comes only from that processed orientation to emotion.

The DIR Way

Maude often says to families when someone important passes away that you should bring the child to the funeral. You need to find a way for the child to express the fear and anxiety, rather than avoiding it to ‘protect’ the child. A lot of the work in trauma, too, lies in FEDC 5 when we’re trying to get some symbolic understanding of what the trauma means to my life, how do I embody what has happened to me, how do I figure out where I stop and where someone else starts, and that I have an identity and it’s not broken.

Something happened, and it’s hard, but I’m not broken. I’m here. When we, as therapists, Maude continues, in DIR/Floortime show the client that I’m here for you and you matter, that my time with you is a worthy time spent, and that I find myself valuing our time together–when we give that message–the client gets it, Maude says. That’s the Floortime way. We’re going to be together. We have this time where we can value each other. At the end of the day, we know that being with each other matters, Maude stresses.

At FEDC 2

This is where the Floortime perspective and the use of self comes in so much, Maude insists. When we look at FEDC 2 (Engaging and Relating), it’s a crucial place for a trauma survivor because what they want to do is disengage or dissociate. They want to go through the motions, but don’t really want to be in the moment because ‘in the moment’ may bring them too close to feeling what they don’t want to be feeling–the triggering, the flashbacks, or that the therapist is going to expect more of me than I’m prepared to give.

Maude specifies that we’re not talking about the same engagement challenges from an autistic individual that is avoiding because of individual differences or not understanding the moment in a fragmented moment of time. It’s a different flavour when you’re working with trauma, Maude says, and the combination of trauma and autism can be really hard. When you’re working with a trauma survivor on engagement, you’re working on messaging. Whether the client shares the details or not, we’re stressing that you matter enough for me to engage with, Maude explains.

Maude says that we can say to parents, “This was hard.” There’s nothing we can do to change it. It is what it is, but we can say that we want to spend time with you and make it happen for you and take this journey with you, together. When you do this, in the DIR way, the family feels at home. It opens up and enlarges the picture. It’s not just a bubble around them that’s feeling so hard. As a therapist, you can expand the bubble to include one more in the family’s village to take this journey forward. It is powerful.

The Safety is the Therapy

If I think about my son’s experience, as I mentioned in the podcast about medically complex children, whenever my son sees someone with a band aid on, he gets triggered. He had numerous IV changes and blood tests in the hospital when he was 2 years old. He is so concerned when he sees a band aid or ‘boo boo’ on others. In a Floortime way, we can explore that.

Maude says that there’s so many things about fear and in psychotherapy they can do exposure therapy. But what we often see, Maude explains, is that when you create the safe space, children know themselves what they need to work on. In trauma, she’s seen it over and over. When a band aid is an issue, it will come up. She doesn’t even have to initiate it.

When the safety is there, they will face their fears, but without the safety, there’s no holding them because they can’t face it alone. This is why she says that safety is the therapy, and the playful approach is the approach that provides the safety. Maude gave an example of a child who played with having predators in a jungle, with all of them facing towards the middle of the scene. The child played, talking herself through it, making the animals come closer then go back.

Then, the child took a little toy toilet and put it in the middle of the play. The child wants to do a sleepover so badly, but wets the bed. The toilet went in the middle of the scene and she didn’t touch it as she played with the predator animals around her, representing the threat of the bed-wetting issue. The therapist didn’t say anything about the toilet. The child needed to face the threat and be the animals and also be the victim.

Two weeks later, the child stopped bed wetting. They didn’t even talk about it. It’s the beauty of the Floortime method, Maude says. The child knows where they need to go. Some of it is hard stuff, Maude says, but when you create this safe container, the healing starts from within. And it’s their process. I mentioned that in Maude’s trauma course, the example was a child who had experienced intense trauma and Maude showed how they went through the FEDCs in their play with the child.

The Brain Doesn’t Forget

It makes me think that that’s why my son is so interested in people getting hurt in shows he watches and playing with figures having broken limbs, putting a cast on them, and going to the hospital after all of his fears around having been in the hospital when he was two that are probably subconscious at this point. Even going to the dentist can be traumatic when strangers come at you wearing a mask and gloves, carrying tools, for a child who’s had medical trauma.

Maude brought up another complex case she worked on where a girl seemed completely fine except that she could not handle buttons of any kind. They had to do a lot of hard digging. They found that the child was in and out of the hospital as an infant and the nurses would lay her against their chest where there were buttons on their shirts. That feeling of buttons brought back the trauma and was part of the trauma trigger. It was such a learning curve to figure out what it was because there was no tactile defensiveness. The brain doesn’t forget, Maude says.

At FEDC 3

The way memories are laid down is through the sensations of the moment and the emotions associated to those sensations, Maude explains. Anyone working with sensory or emotional trauma clients could trigger them, Maude says. That’s why DIR is such a safe method, with regulation, engagement, then working on the two-way discourse providing a medium of safety.

The activity doesn’t matter. There’s a rhythm of back-and-forth. Eventually up pops the thought from the client, Maude shares. In trauma, you have to be careful with that because in Floortime you’d usually say, “Hmm… I’m confused” whereas in trauma, you don’t, Maude asserts. Maude explains that if the client is already at FEDC 5 and 6, her and her team are just adding the foundation at FEDC 3 and 4 to give the client a better time at FEDC 5 and 6.

In trauma, they’d just keep the back-and-forth going at FEDC 3 because you know the memories are coming up in fragments. When you dream at night, it’s not really sequential, Maude says. It’s fragmented. It’s also what happens when these fragments of memories come through in therapy, she explains. You just accept it. If you said, “Wait, I’m confused” they’d shut down. So you just go with it in trauma, which is different than working at FEDC 3 with autism, Maude explains.

At FEDC 4

Maude continues that at FEDC 4, having the structure is as important as with anyone. Depending on when the trauma occurred, the client may struggle with the stages of structure–building enough of the amygdala, the praxis, and motor planning in getting there. The client’s nervous system got stuck at the time that the trauma occurred.

Then the development that had to come after that which is still part of myelinating the brain, Maude says, doesn’t happen at the stage or age that you want it to be, so you have to re-structure FEDC 4 and spend a lot of good time there to help them find a place where the emotion can land, Maude explains. They create many, many stories.

Another thing that’s different from autism, Maude continues, is that when a client is building their structures of stories in FEDC 4 in Floortime, we tend to put playful obstruction in there to get the sequences out in that problem-solving, but in trauma you don’t. You will do the whole thing about role play and make sure they’re taking in your role, as well as their role, and you don’t challenge as you might in FEDC 4 in autism.

Instead, you work on constructive problem-solving from their notion and their perceived reality, Maude stresses, because their perception of the reality is going to be very skewed, based on what they’ve experienced, and a lot of that reality distinction doesn’t happen until FEDC 6. But in FEDC 4, you’re putting down the structure on which that reality base can land later to improve their perception that this present moment is the present moment and the past is the past, Maude offers.

At FEDC 5 and 6

You are creating experiences in FEDC 5 and 6 where the client is having many more positive experiences around the same emotions that, over time, can replace the bad memories associated with the same triggers, sensations, and emotions, Maude continues. The more you’re building those positive experiences with the same emotions and sensations, the further away you can move away from being triggered, even though you can’t forget. It’s about decreasing the impact of the trigger, Maude shares.

I shared that if anyone hasn’t yet listened to the previous three podcasts, and especially the last podcast where Maude talked about building the structure at FEDC 4 for FEDC 5, please go back and look at it so you can better grasp what Maude is talking about.

Parent Regret

What I heard Maude say answered the question I had in my mind. Parents often regret giving their child an intervention that may have caused their child trauma thinking that their child will never forget and be triggered by them. Maude just said that we can work through those experiences in play and work through the FEDCs to recreate a new, safe environment that can slowly overshadow the old experiences.

Maude says that you only know what to do at the time you know how to do it. What you did at the time is what you thought was best, so be kind to yourself. Our brain is plastic until the day we leave this earth, Maude states. You can change any brain, despite the child’s age. Can we say perfection? Nobody’s perfect. But we can make it functional and we can decrease the triggers over time when we apply safety and security, she says.

This is where we need to know who is in the village around you. Are they speaking the same language? One thing that DIR/Floortime gives us is that the social worker can do it, the speech therapist can do it, the educator can do it, the occupational therapist can do it. They all talk the same language, which is so much less confusing for the child.

When we all do that, one is not doing exposure therapy while another is doing injection therapy and vagus nerve stimulation, another is doing DBT, and another CBT. Is the team all using the same sense of safety? Maude has had sessions where she simply sat on the couch watching YouTube videos with a client. She’s seeking a sense of connection because the child isn’t willing to give. She’s trying to enter the child’s world to be able to bring them into her world to show the child it can be safe.

Parents, let the bus of the past go by, Maude suggests. She knows it’s not easy. You did the best you could at the time. Every decision you made, you made because you thought it was good for your child, and that must be ok. Maude hopes that families choose DIR.

Magnitude of the Trauma

Trauma is such a loaded word. When you talk about the ACES (Adverse Childhood Experiences) such as poverty, war, divorce, abuse, etc., these can all be labelled as trauma and everyone experiences trauma differently. But, there is a feeling out there that some traumas are worse than others, so I asked Maude what the idea of little ‘t’ is where there’s a bunch of little traumas that add up over time (versus being raped or watching your parents getting murdered or some horrendous trauma).

Maude says that it’s only the perception of the child at the time. What might look to us as a little ‘t’ trauma, may have been big in the child’s perception and that memory stays big until they get through it which is until we can get through it in a way that can transpose of the magnitude of the event. The perception of the trauma survivor at the age and stage that it happened is what is the magnitude of the trauma, not how we as adults look at it, Maude says.

The parent or adult can think that the child is being overly sensitive. It may be a little ‘t’ for us, but in the child’s perception, if it was a huge piece for them, then we better take it seriously, Maude cautions. If the perception is the bigger piece of it, we need to really consider that even the small ‘t’ can linger for a very long time, and it does in Maude’s experience. It therefore behooves her to really look at it without regard to how big or small the event was in our, the adult, perception.

Stimming and Trauma

I asked Maude about what she meant when she said earlier that some autistics who have been through trauma might stim more. She said that you need to pay very close attention to stimming if there has been trauma. Most Floortime therapists don’t call on stimming. We know the client’s individual differences and that their vestibular system needs support, and perhaps they’re trying to access vestibular input through their visual system, for instance. There is a reason for it. Always give space for the stimming.

Maude says that she is trying to figure out why the individual needs to stim right now. What happened just before this? Maybe this was a release after a hard activity. She will allow them to release the tension then redirect to a movement activity to allow them to release it through the movement. Maude starts to see that the client gets relief from the movement activity, such as going on a swing, for instance. Where there is stimming from trauma or a sensory need, it’s the same, Maude says, but she might give it a bit more time, depending on the individual’s profile.

DIR is a Valid Approach for Trauma

DIR is a valid method for trauma in many ways, Maude says. The DIR/Floortime approach is a respectful, warm, embracing way of helping somebody feel that they’re worthy and that “I want to be with you and I want you to be with me and I want you to feel felt and feel me. I want you to see my kind eyes and voice so you can reach within and bring yourself in the moment.” Maude hasn’t found another method that works as well.

Plus DIR is developmental. Plus it’s respectful to the unique individual differences. Plus it enhances the family and brings the parent to a place where they can connect with the child. Floortime just gives you this fullness that can reach out at so many different levels and bring peace, Maude shares. If we do this, tomorrow will always be there. Maude always says that today is the scaffold for tomorrow.

If I harness this moment today, Maude continues, then tomorrow already looks brighter because I use what I have. This is what I have. I can’t control what happened in the past, but I can work on what I have now. Making today count is so helpful to decrease the anxiety about tomorrow. I added that all of this is through the power of relationships and through connection with each other.

This week’s PRACTICE TIP:

This week let’s practice creating and/or maintaining that place of safety for our child.

For example: Are we putting extra demands on our child that we need not be doing? Let’s attune to our child’s emotional state to make sure they are not shutting down in response to us by ‘collecting before directing’, joining them in their interests and sharing joy together at their pace for as many moments of the day as we can–especially on the weekends.

Thank you to Maude for this informative podcast that really was helpful for me in understanding how to use the DIR lens in thinking about trauma. I hope that you found it as helpful as I did and will consider sharing this post on social media.

Until next time, here’s to choosing play and experiencing joy everyday!