Lucy is a 13 year old girl who was removed from her birth family at the age of 6 years after severe neglect, physical, emotional and sexual abuse. Lucy’s maltreatment was of an extreme and unusual severity. Lucy was adopted when she was 7 years old. Prior to referral to the National Adoption & Fostering Clinic, Lucy had not received a focused assessment or a formulation of her difficulties. She had received several types of supportive rather than targeted interventions from a range of therapists. Lucy was referred to us due to “trauma” and “challenging behaviour” at home.

After our assessment, we formulated the biological, psychological and social factors playing a part in Lucy’s presentation to help her and the family understand the rationale of our proposed treatment. Lucy met criteria for Post-traumatic Stress Disorder; long-standing low mood (depression) and because she was also very challenging with her family, she met criteria for Conduct disorder confined to the family context. Both her low mood and the challenging behaviour were related to the unresolved traumatic experiences.

Individual work with Lucy was offered in weekly sessions (35) over the course of nine months. Lucy identified four goals for her treatment sessions and in addition she completed validated scales for monitoring her trauma symptoms (CPSS) and depressed mood (MFQ) and both of these scores placed Lucy’s symptoms in the severe range at the start of treatment.

The first part of treatment (12 weeks) focused on mood stabilisation and emotion regulation, using a combined CBT approach with mindfulness-relaxation. The sessions focussed on helping Lucy to start to identify her emotions and the physical sensations that accompanied them.  Lucy found this difficult at first as she reported that she had “cut-off” from any emotions, a common symptom of PTSD (numbing). Therefore much of the initial sessions focussed on helping her to make sense of and identify different physical sensations and to link them to her emotions.  Emotion regulation techniques followed, as Lucy reported feeling “hyper” a lot of the time as well as reporting “explosions” where she described trashing her bedroom (hyperarousal and emotional irritability are also core symptoms of PTSD). Mindfulness relaxation exercises were introduced, which she practiced daily and reported led to her feeling a lot calmer and less irritable. 

 Once Lucy’s mood had stabilised and her explosive behaviour eased, the second part of treatment (23 weeks) focused on Trauma symptoms, in which, among other techniques, a time line of Lucy’s life was completed collaboratively and collated in her “memory book”. 

 Lucy completed the mood (MFQ) and trauma (CPSS) scales at several stages of treatment, and the gradual improvement is evident in Figure 1 mapping onto the treatment stages: first the improvement in low mood, and then, with phase two improvement of the trauma symptoms.

 Lucy‘s family were a target of much of her explosive rage, so session to help them manage and contain those in an effective and therapeutically helpful way, using an evidence based approach (a personalised social learning theory approach – see example here that was sensitive to Lucy’s mood and trauma issues.

graph lucy.jpg