Access this article by Emelina Minero on the Edutopia website at: https://www.edutopia.org/article/when-students-are-traumatized-teachers-…
Adapting SITCAP-ART: The Story of One Program’s Journey in Group Implementation for Transformative Results
This paper explores the adaptation of SITCAP-ART to fit needs and aptitudes of at risk adjudicated youth in a particular intensive after care program. After describing the program, population served, and problems with prior groups, it explores the process this therapist went through to awaken to SITCAP, and how the curriculum was designed to fit our clients and program. It specifies how we ‘sold’ the group to others, our results, outcomes, and continued challenges. It is intended to be ‘user friendly’ in the hopes that other practitioners will learn from our experience and borrow any or all ideas for their own programs and mental health treatment services.
Our program, named Reentry Services, provides intensive after care (IAC) treatment in the form of groups, individual therapy, and case management/CPST to at-risk adjudicated youth returning to the community after a residential placement for their juvenile offenses. The youth are court ordered to attend as part of their parole or probation terms and receive our services over a range of 4-8 months. The majority of youth are African American from poor neighborhoods in urban Cincinnati. They come with generational, developmental and/or complex trauma histories characterized by abuse or neglect in childhood; school behavior, truancy and academic problems; separation/abandonment from incarcerated or murdered family members, particularly fathers; poverty or financial instability; and high exposure to community violence, drugs, guns and death. They are most frequently diagnosed with PTSD or other Trauma indicators, ADHD, Conduct Disorder (D/O), Substance Abuse D/Os (marijuana being the highest prevalence of use), and often Borderline Intelligence (from low IQ scores.) Other common but less frequent diagnoses are: Reactive Attachment D/O, various Mood D/Os, and Learning D/Os. Occasionally but rarely do we have Bipolar D/O or any form of psychosis.
The youth also experience long separations from families and their communities after multiple placements that often accumulate to years, based on their repeated adjudications and probation violations. In residential placement, they are subject to group programming developed by juvenile justice (JJ) academic organizations, with very structured curriculums that are cognitive behaviorally based to correct criminal thinking, stop substance abuse, and manage anger. Occasionally mental health treatment is provided, and trauma specific therapy is rare.
In our phased, step down IAC program, youth typically attend 3 groups a week the first month, then step down to two for another two months, then remain with just individual therapy and case management for their last ‘phase’. Since the program’s inception in 2009, the three groups have varied in definition and content, with titles such as ‘Community Life’, ‘Relationship Group’, and ‘Substance Abuse’ groups. They were designed to use CBT and motivational interviewing interventions that built on the treatment concepts they learned at their placements, assisting them to internalize the skills as they transition to the community. As one of the therapists who developed the curriculums and facilitated the groups throughout the program’s first three years, we tried an array of formats, ranging from very structured to more open, client led groups. We learned that groups work best ‘in the middle’ of the spectrum, with enough structure to provide direction and focus, but loose enough to allow the client to engage in what we call ‘real talk’, honestly sharing about their thoughts, feelings, and behaviors since their return. We also had some success using creative, right-brain, fun activities to keep groups interesting and dynamic, while keeping a fast pace for fidgety and easily distracted youth.
When the youth arrive at our program, they are burnt out on groups. They are tired of just talking and doing worksheets, with lots of rules to keep behavior in check. Positively, they are equipped with CBT skills that they learned in placement, yet they have not been able to practice or use them in real life. Then typically they get exposed to real life traumatic situations anew and/or triggered upon return to old environments and, alas, they are unable to use their new found CBT skills. In other words, their prefrontal cortex is not able to work with the trauma affected, unhealed parts of the brain. So essentially, the thinking based skills go right out the window, leaving probation officers and treatment providers baffled. This restarts the punitive cycle, as triggered youth with no trauma healing go AWOL, commit new offenses, smoke marijuana, struggle in school, and ‘act out’ emotionally and physically. The courts give citations and violations, or send them to new placements. Meanwhile, we scramble to add more services, particularly high dosage of substance abuse services. We find ourselves saying things like, ‘you had all these great goals and seemed so motivated to change, what went wrong?’ Or, ‘Why aren’t you using the skills you learned in placement?’ In other words, ‘what’s wrong with you?’
Awakening to SITCAP
I remember learning briefly about CBT trauma therapy in grad school, and felt immediately after starting work at our agency, that we were missing out on addressing trauma more directly. Often I would debate with our service providers with long histories in juvenile justice, about the discomfort I had with not addressing feelings thoroughly enough, as this also is an important component of CBT I observed was consistently short changed. I also read about how the JJ residential programming and our IAC model was based on the adult criminal system, which was created for anti-social adults, emphasizing correcting anti-social beliefs and attitudes. It was missing developmental understanding, compassion for what the youth had experienced, and was not sufficiently strength based.
It was about two years ago that I was able to attend the initial SITCAP trainings. I remember thinking that finally, here is a model that has the right ‘lens’ for seeing and understanding our youth. There are interventions that fit them, focusing on healing the brain and body, and addressing more than the logical, thinking part of the mind. The whole person is addressed – mind, body, and spirit. And the fun activities we tried to fit in awkwardly to our groups are an essential part of the healing and done with intention, leading to the CBT part of reframing the story for hope, and moving from victim to survivor. We decided we would replace our ‘relationship group’ with a SITCAP/trauma healing group (as well as train our therapists and CM’s to incorporate SITCAP interventions in their practice, but this is not a subject of this paper.)
So while the overall model of SITCAP, the themes, the treatment process, and the approaches all made sense for our population, I concluded that the SITCAP-ART curriculum would not work as-is for our group. First, the language often centered on specific traumatic events, and our youth could not identify these events, indeed they don’t think of traumatic experiences as particular events, necessarily. This is because there are so many of them, they don’t remember them, or they don’t want to be directly asked about them. Second, I felt the language and pictures were too young for our youth who, though may be behind in developmental maturity, talk with more mature language, and are very sensitive about being talked to like they are young. Third, I felt the activities did not adequately reflect the black, urban culture, and that this would be key to connecting with them in a trauma group.
Thankfully, I had two ‘aha’ moments at this point. First, our agency trainer and expert in SITCAP consulted with me, and assured me that the materials were just a starting point, and that I should find a way to adapt the materials to our youth. This was liberating, I just didn’t know how! The second, ‘aha’ came when I took TLC’s online course called ‘Breathe, Rock, Draw’, by Barbara Dorrington, MBSW, MEd, CTC-S. I was fascinated by how she organized and structured activities for her classroom into three areas: breathing exercises, rhythm routines, and drawing/writing. It included positive affirmations, warm ups, and encouraged creativity in identifying the activities that could be used in the three areas. I started to think about how the exercises energized or calmed, both types being needed by our youth, covering the range that was needed to address hypo and hyper arousal. Thus began a kind of creative brainstorming over several weeks, laying out ideas and talking to others, until finally it hit! We could redesign our groups to incorporate both active and calming activities, while also addressing the model themes and providing narrative reframing.
We would structure our groups around these three categories: Mellow, Move, and Make (MMM). We would end on a positive or ‘Up’ note each group as is important for the model. Each group would have a SITCAP theme e.g. anger, hurt, victim/survivor. This way, we would be following the overall progression of the model which is so important to address the trauma themes and get to the narrative reframing, but also allow us to actively engage in emotional management, thereby reducing traumatic stress symptoms. We would have psychoeducation pieces to assist facilitators in being deliberate and aware in the healing work. We would invite speakers occasionally, to bring the themes and activities to life. We kept our group norms, but we added one to allow members to find ways to self regulate and encouraged this via the norm: ‘Find & use what you need to stay and be part of group: mandalas, doodling, stress balls, stretching’. See the attachments titled ‘Self Group Design: Mellow Move Make’ and ‘Self/MMM Group Introduction’ for more thorough descriptions.
We use a matrix approach by adding various activities in each of the three categories and for each theme. This allows flexibility for the facilitators to alter activities to fit the group, and keeps the groups from getting repetitive (as some clients end up repeating groups over time). The activities are designed to be more culturally relevant, referencing current events, contemporary African American urban culture, and common themes that reflect attitudes and beliefs we have learned over time from our youth. See the attached group example titled ‘Self/MMM Group Example – Anger/Love.’
We also kept our Community Life CBT and AOD groups, although eventually we ‘wrapped’ SITCAP around them, and continue to evolve them this way.
When we began using SITCAP in our agency, there were just a few of us practicing with one SITCAP experienced and certified trainer to assist as we gained practice using the tools and model in our own service areas. Not surprisingly, we met some resistance and skepticism in the agency, as happens with new or different approaches. I particularly felt this in Juvenile Justice. So it was important that I ‘sold’ the new group to my management in a way that assured we would be covering the critical treatment concepts, while improving the way we were doing so.
Our proposal was based on the need to solve the problem of client burnout, by creating groups that provide a new experience from what they have known. We proposed the SITCAP approach could make groups transformational and challenging, which was everybody’s goal. Importantly, we were not introducing new or contrary treatment concepts, we were simply reframing treatment concepts that we have always used, bringing them to life with SITCAP, and bringing in a couple of new concepts for trauma education and healing. We would be improving our ability to provide a safe environment that is more resilient to negative peer influences. By tackling exposure to traumatic events we proposed it would make it easier for the youth to make connections to their offending behaviors. We also could finally bring in health & wellness psychoeducation for certain topic areas that had been a stretch to add in the past, like sex education and sleep hygiene, which began our foray into the mind-body work.
We vetted the group with our agency’s trauma practitioners. We did this by having the practitioners experience being the group members, with us facilitating. This was extremely helpful, for we got some great tips, plus it helped validate our curriculum.
Our director asked for how we could sell this to the courts, and we used this: We teach our youth important skills while they are in their placements for their crimes. Many accept responsibility for what they have done and want to change. However, when they return to their stressful environments, they get triggered and/or emotionally dysregulated again. This shuts down the thinking part of the brain, so they can’t use the skills. We need to heal and regulate emotionally, calming down the brain, so that the CBT skills can be used and internalized.
We also used brief surveys the youth filled out for the end of the old groups and the beginning of the new, that confirmed positive trends needed to continue forward with implementation.
We were now ready for ‘prime time’, and started the groups in October, 2014.
A year and a half under our belts, here are our key learnings from conducting our adapted SITCAP-ART group:
- These tough, ‘street smart’ youth do the ‘corny’ sensory activities! My biggest worry was that these young men would refuse to do the activities we offer. However, we frame as asking, not demanding, asking that they just try or sit respectfully as others try, and explaining these are things we do ourselves that many adults do to take care of their stress. We are constantly surprised at how courageously these youth jump in and try activities including yoga postures, breathing techniques, guided meditation, lavender sniffing, mindfulness walks, singing ‘Hallelujah’, affirmations, and Native American chants about forgiveness.
- ‘Real talk’ has increased. Our desire has always been to allow the youth to discuss the real problems and struggles they face upon return to the community. However, we were afraid we were glorifying crime and violence, and would not allow talk of gangs or guns. With the SITCAP group, we had to accept that when we ask a youth to draw about their biggest worry or fears, these things will emerge. These are the traumatic experiences. We had to allow them to be put on the table, and honor their realities. We had to hear about what underlies the fatalistic attitudes and beliefs. We became witnesses to the struggle. So the youths drawings often show guns, contain curse words, street slang, and other disturbing things. Many of our youth write rap or record it in studios, so we invite them to share and often it is explicit, but underneath are the message we discover together about difficult life experiences and deeper feelings, like abandonment. We had to get over our own biases, and allow the youth to share their own interpretation of their experiences. Of course the goal is to get to the hopeful reframing and normalizing, which we do. But we learned to allow the time for this to happen vs. forcing it to happen on our terms.
Exposure is helpful for our youth. My prior understanding of trauma therapy was to be wary of exposure and triggering. And we do worry, and triggering does happen. However, it was happening anyway, because these traumatized and daily stressed youth were getting triggered all the time, including in our program, by for example, the tone of voice used by an aggressive Probation Officer in a team meeting. Our challenge was to provide safe containment and emotional management skills to manage and reduce their trauma reactions. Revisiting traumatic experiences was already happening sporadically in past groups, as things like shooting deaths were brought up and discussed as group members (and staff) became more comfortable. So we came up with a safe way of initiating exposure: displaying black and white images (from stock images on the internet), of various traumatic experiences that we had heard youth describe over the years. See the attached ‘Self/MMM Group – Tough Times Table’ for some of the images used. Then, when we do the ‘road map to the past’, we ask youth to visit the ‘tough times’ table and choose images that depict bad times they have experienced. If they are not comfortable, they can choose images that others might find difficult. This puts them in control and they don’t have to share their choices with the group unless they want to. We found with this technique, more traumatic experiences are revealed than we had ever heard in the prior 3 years of groups, particularly bullying and domestic violence.
- A trauma informed environment is needed. From the beginning, we designed various sensory elements into our program’s environment, like cooling wall color, welcoming décor and art, aromatherapy, and youth’s mandalas on the walls. We try to surround youth and staff with an array of sensory stimuli and activities, such as comforting food, music, hand ‘fiddles’, games, and multi-media technology. We created a relaxation room for therapy and ‘chilling’ when clients need it. We also are more attuned and aware of triggering to be able to proactively help youth anticipate and manage feelings and behaviors as they emerge. We are more often checking in on the body and reminding them of their emotional management tools, thereby promoting a sense of safety.
- The walls of anger come down. I used to hear, ‘I don’t care’, ‘I don’t have feelings’, or ‘my only feeling is anger.’ Conversation was dominated by prison and ‘street’ talk. We thought that these youth were emotionally incapable of empathy. This was incorrect, we just weren’t finding ways to open up the other emotions. Now I hear, ‘I am a loving person’, ‘I am glad to be alive’, ‘I am afraid of these streets’, ‘I worry that I won’t be able to get out of my hood and make it’. We could never get the youth to acknowledge fear previously, and now it is sometimes said, and often depicted in drawing, etc. The sources of anger are also more apparent. For example, feelings about racism, oppression, conspiracy theories, and cultural taboos, are more explored and debated. Feelings allow these youth to debate and discuss their opinions in a deeper way with each other than before. We have even been able to discuss spirituality more. One group ended with a youth who insisted, after getting permission from the group, in leading an affirmative prayer for all members.
- There is more safety and trust. You can feel it. This is subjective for us as we do not measure this directly. Beyond the improved outcomes, there is a sense that permeates the program that youth are more relaxed, less apt to lash out in anger, more able to focus, get to the ‘real talk’ and, essentially, show their vulnerability. This affects the staff as well, creating a greater sense of safety, reducing vicarious trauma. There is a greater use of humor and a sense of fun. As a result, some of our toughest youth continue to come for services, even when they are confronting death of peers, revenge urges, and drug relapses.
Youth are completing the program more successfully, in terms of mental health improvements, getting off of parole/probation, and making gains in life domains, such as education and employment. Our biggest testament is that we have more youth who don’t want to leave our services when they have completed the program. And more come back after they are done with services to attend our prosocial activities or just visit. Our program implemented outcomes tracking after the start of SITCAP, and we made several program improvements (like adding prosocial events and job readiness groups) that make it difficult to isolate the impact of SITCAP. However, we know that the CANS (Comprehensive Needs & Strengths Assessment) outcome tool we use at our agency indicates that we have been consistently reducing needs and increasing strengths for the youth who receive SITCAP interventions (group and individual therapy). We are currently in the process of adding modules to our outcome tool so that we can measure post traumatic symptom changes.
Not everything we set out to implement has happened, and there are still areas we continue to struggle. Here are the challenges and where appropriate, plans to improve:
- We are not getting to the narrative, at least not directly. It has been difficult for us to be disciplined about saving client’s work from group and individuals, taking pictures of things that cannot be saved (like clay sculpture). We get behind and then we end up with a pile of drawings, poems and pictures that are not organized. Individual therapists reframe and discuss the narrative sporadically, but not in a direct, deliberate way. In other words, we are not getting to the ‘story’ as we set out to do in our group design. The one time I was able to do this more directly, however, the results were impactful, so we need to strive for this. Our plan is to get there is two-fold: 1) implement ways to make it easier for us to save and use the work; and 2) do more direct psychoeducation and expectations setting with treatment teams (clients, families and the courts) to lay out the model in user-friendly terms. We are currently developing a set of handouts for clinicians to use during intake and initial services.
- Therapists are not always comfortable with the mind-body work. It was relatively easy for me to begin using various mind-body and other sensory interventions with clients as I am an artist, and practice yoga and mindfulness already. It was a challenge for me to adapt the practices to our adolescents, but it was just a matter of jumping in and finding the right language. I built the interventions into the group curriculum and then taught them to my co-facilitators over time. However, some therapists are simply more comfortable with talk therapy, and do not have the aptitude for the sensory interventions. For example, in group, I find I am leading guided meditation as I am more comfortable and experienced doing so. To continue moving forward, I am encouraging our clinicians to develop their own experiences and practices so that they can empower our youth to use these skills based on their own practice of the mind-body activities. I also would like to develop a half day training focused on mind-body activity learning and practice.
- Triggering, dysregulation, and victim problems still occur. Our highly traumatized youth continue to have post traumatic stress behaviors and attitudes that disrupt and derail groups. Part of this is the nature of rotating member groups, which is the way our program operates. There have been many times that group is feeling safe, cohesive, and engaged in the activities, but then a new member appears and we destabilize into chaos. Or a traumatizing event happens to a stable individual and he has a setback. A hypo-aroused, dysregulated group member can disrupt and interrupt everyone. If the group members aren’t able to resist, they all get that way. Alternatively, if we get a strong leader personality that is highly traumatized and anti-social, others get intimidated and fearful, and we don’t get to the ‘real talk’. Members suddenly begin to dredge up ‘criminally minded’ beliefs and engage in ‘street talk.’ Others disengage completely or lapse into generalized ‘treatment talk’. Sometimes an especially vulnerable youth is alienated by the group. Our solution as facilitators is to step back and focus on the group process of building cohesion, and the curriculum frankly, becomes secondary. An idea we have considered is to create a separate step down group for those ready for survivor/thriver and narrative reframing. However, we don’t have the staff or youth numbers needed to set up this group.
- Keeping sensory and self regulation materials stocked is not easy. We try to keep our supplies stocked, but things disappear or get destroyed. ‘Finger fidgets’ get deflated, objects break, silly putty goes missing, food gets spilled and wasted, markers dry out. I don’t think our youth are intentionally ruining, but these high energy, stressed out young men are especially hard on things! It’s hard to find time then to get to the dollar and craft stores to keep up with replenishing our materials. And like most non-profit agencies, we have budget constraints. It has helped to bring in outside guests to lead creative activities, as they bring supplies that we reimburse. However, this takes planning and logistics to arrange, and it has been difficult to find guests that can handle our youth in a trauma informed manner and be reliable.
After running our adapted SITCAP-ART groups for nearly a year and a half, we have learned a lot about how to engage our youth in the trauma work, that is such a critical part of their mental health and life functioning. The work is exciting and challenging. However, I believe we are about halfway to where we could be in service delivery and the organizational commitment to trauma informed care. There are so many opportunities left for us to improve our trauma sensory interventions, deliver more components of the model, and to create a safe, trauma-informed environment. As a supervisor and therapist, my passion is to continue training, influencing and encouraging those within our agency, our partners, and the broader community to embrace sensory based trauma healing.
Self Group Design: ‘Mellow Move Make’
- Review group norms & last week’s group
- Prosocial news & Announcements
- Topic of the day: Write on the board
- Mellow – relaxation exercise
- Move – physical activity (walk, get up and do something, role play)
- Make – draw, write, listen, create something related to topic of the day
- Review of group
By the end of this group, members will:
- Reduce trauma symptoms
- Reframe their story in a positive, healing way
- Be less stressed, more motivated and hopeful about life
- Manage emotions better and able to feel & express healthier emotions
Topics: seven that rotate and new member can enter at any time + 2 to 3 speakers/activities
- Values & ID
Speaker 1x/month – stories of transformation – volunteers from the community to do ‘art’ projects.
My story: 15 minute presentation in any group, after member completes the six. Can be done in individual therapy as an option. Creations from each group (and individuals) are building the story. Member works with therapist to review and assemble, maybe put together into 1 story. Options to convey: graphic novel, self portrait, poem, etc.
Group structure: Every group goes through Mellow, Move, Make, and ends on Up note. Psychoed (PE) is used to make connections at end and review before next group. These ‘buckets’ can be reordered for flow. Most groups have a second set of M’s for a different concept so there is plenty to fill up a group. If not all are addressed, make sure we end on an Up.
Facilitation: Content of each agenda item are color coded (PE orange, Think yellow, Feel blue, Act red, Up green) on index cards to allow a less intrusive and more natural facilitation of group. Content is short as it assumes facilitators are well versed and skilled at bringing the treatment concepts to life in group. Allows containment and structure for safety and interaction by being less scripted and less rigid in format. Also, allows group to create the pace and go deep if it can, or move on more quickly if the group is not ready or able to (which happens with unsafe or new/forming groups). Question using TLC/SITCAP method – third person, not interpreting. Remember, the trauma healing and emotional regulation may be happening without verbalization, as it is happening with the sensory activities.
Self/MMM Group Introduction
Why this group: Young men who have a past with juvenile crimes and placements usually have had a tough life. This group is about respecting your tough life, because it helps to move forward. For some, there has been a lot of trauma*, and this group helps with that as well.
Goals of Group: Be heard & understood on your own terms. Handle your emotions (e.g. anger) and stress better. Be more motivated and excited about life. Learn more about yourself and who you want to be.
What you should expect: There is less thinking and more doing. The skills taught happen as part of the group work. Sometimes we get corny. If you have an open mind and work at it, you will have a different experience than other groups.
Presenting your story: You will put your work in a folder with your name on it so you can remember everything you created in group. We will take pictures of those things that you can’t keep or put in the folder e.g. clay, pictures from tables. You will be asked to present your ‘story’ by the last group (11 groups). Your folder will help you do this.
A traumatic event is when something frightening or dangerous happens and the person doesn’t have control over it. Examples: death, abuse, neglect, car crash, parents separate; family member leaves; shooting; bullying. Even if the person was responsible, you can you still feel bad afterwards and it can affect you. Also includes stressful life situations, like not having enough to eat, moving all the time, changing caregivers, a parent with addiction, homelessness.
It becomes trauma for a person when the brain and body get stuck in defense mode, still reacting as if there is danger, long after the event is over. This is because hormones get released when the senses (hear, see, touch, smell) get triggered by cues from the past. The body believes it is still in danger, even if our thinking tells us otherwise. Over a really long time, we believe that danger is everywhere. No one can be trusted. Life is hopeless.
Drawing: However you draw is fine as this is not about skills at drawing, but helping to tell a story or get across your feelings in a different way than just talk. A picture tells a thousand words. Here are some drawings by other teens who agreed to allow us to share their drawings with others. You can see there are rough sketches and stick figures.
Bullseye of sharing: You may want to start out less personal – movies, books, stories, your imagination – to do an activity. Over time as you get more comfortable, we see people do more about themselves and their own experiences. We expect this. It means if you are new, you may be surprised at how much people are sharing. If you have been here awhile, you may remember where you started. We are all in different places with our stories and that is ok.
Choice: you can decide not to do something. It is up to you. We ask that you just tell the group this, then you can sit quietly.
Self/MMM Group Example – Anger/Love
- First rate anger 1-10 to yourself. Guide through a progressive muscle relaxation. This is a great way to relax before going to sleep, especially when your body is still keyed up.
- Visit the ‘tough times’ table. Pick images that make you angry and bring to table. There is also clay in front of you, as a way to take our anger out safely. Tell us what you are comfortable sharing about your pictures. May we ask questions (use third person)?
- Make a list of ‘Things that Tick me Off’ (what you are most angry, frustrated, annoyed, impatient). Take pictures. Stand up. Tear up at least 20 times. Rate anger 1-10.
- Video Spokenword about anger & frustration with the world, and a return to hope and self via LOVE. Rate anger 1-10. Take pictures of clay. http://youtu.be/BzV1FzixSmw
2.Listen to 1st half of video interview from Enquirer article ‘Avondale: breaking the cycle of revenge’. Comments, what can you relate to? Remind of clay. http://archive.cincinnati.com/article/20121028/NEWS/310280054/Avondale-Breaking-cycle-revenge
- Get up and write some graffiti on the board about your feelings of revenge. Any comments?
- This is a meditation to let go of revenge. Imagine the target of your anger or revenge: Now a white light covers this person/thing so you no longer can see them. You are now by yourself, and free of that person/thing. Let yourself feel your own freedom. Let yourself be surrounded by white light, and love.
2.Play second half of video ‘Avondale: breaking cycle of revenge’ about positive mindset and life changes
Psych Ed –
Anger is about feeling someone or something of value has been taken from you. Can be from any kind of loss – death, your childhood, trust in others. Can also come from being treated unfair, not having enough, feeling a lack of power & control. Sometimes it is about covering up other emotions: acting tough vs fearful, proving not weak, surviving. Problem is it’s like a bottle of pop. If builds up, explodes. If numb out, goes flat. Want to ease it off.
Self/MMM Group – ‘Tough Times’ Table
Since 1990, the National Institute for Trauma and Loss in Children (TLC) has pioneered strength-based, resilience-focused interventions with young people. As a core piece of these interventions, the helping adult becomes a witness seeking to understand the deeply painful experiences of traumatized children. How traumatized youth interpret themselves, their interactions with others, and their environment guide treatment. We often hear traumatized youth say:
If you don’t think what I think… feel what I feel… experience what I experience… see what I see when I look at myself, others, and the world around me… how can you possibly know what is best for me?
Childhood trauma is marked by an overwhelming sense of terror and powerlessness (Steele & Kuban, 2013). Loss of loving relationships is yet another type of trauma that produces the pain of sadness and grief. The resulting symptoms only reflect the neurological, biological, and emotional coping systems mobilized in the struggle to survive. Young people need new strategies for moving beyond past trauma, regulating emotions, and coping with future challenges.
Neuroscience confirms that trauma is experienced in the deep affective and survival areas of the brain where there are only sensations, emotionally conditioned memories, and visual images (Levine & Kline, 2008; Perry, 2009; van der Kolk, 2006). These define how traumatized youth view themselves and the terrifying world around them. Reason, language, and logic needed to make sense of past experiences are upper brain cognitive functions that are difficult to access in trauma (Levine & Kline, 2008; Perry, 2009; van der Kolk, 2006). This explains the limitation of traditional talk therapy or narrowly cognitive interventions. Therefore TLC’s Structured Sensory Interventions for Traumatized Children, Adolescents and Parents (SITCAP) starts with the lived experience of youth which drives their behavior.
SITCAP provides the opportunity to safely revisit and rework past trauma, beginning with sensory memories which youth have experienced and stored. Trauma-related symptoms can be reduced and resilience strengthened to support post-traumatic growth as youth engage in SITCAP (Steele & Kuban, 2013). The process is designed to support safety, emotional regulation, and empowerment.
With the adult as a curious witness, youth are able to take the lead and set the pace of intervention. They are giving permission to say “yes” or “no” to whatever they are asked to talk about and discover that saying “no” is honored. This genuine interest is essential to allow the youth to experience the intervention as safe and the practitioner as trustworthy. Their safety remains the primary focus. The SITCAP process helps youth identify ways their body responds to stress. Young people recognize how post-traumatic memories can be activated by current events and learn to “resource” their body to regulate their reactions.
School Memorials: Should We? How Should We?
Several students die in an “active shooter” situation or as the result of a major car accident. The school erects a permanent memorial for these students. Months later, another student dies. Should this student be included in the permanent memorial or should another memorial be created? Within the next two years fourteen more students die. Some die by violent means, others by non-violent means. Some are well liked; others are not at all liked. What should you do regarding their inclusion in the memorial?
Many administrators at schools where permanent memorials have existed for a few years are now realizing that the immediate and long-term issues they present can be larger than administrative parameters, responsibilities, and resources of their schools. Just a few of the difficult challenges include, but are not limited to the following: student and staff deaths, the causes and circumstances of their deaths, variations in their status, variations in cultural views and customs, size and location of the memorial, politically and economically influential parents who want something different for their child, and resources needed to maintain these memorials.
The only nationwide consensus regarding establishing memorials and memorial services in schools following student suicides is that memorials are not appropriate. Most accept and understand that memorializing a student who takes his/her own life communicates to those predisposed to suicide, “If you want to get noticed, kill yourself” (www.suicidology.org , Media Guidelines for Reporting on Suicide)
Beyond suicide there is no consensus about memorials. In fact, there are a wide variety of opinions and practices. These range from creating garden memorials on school property to restricting memorials to a specific time frame, size of lettering on memorial plaques to varied yearbook practices. Some policies basically say that each situation will be studied at the time and decisions made by a cross section of school representatives.”
Healing garden memorials themselves are quite varied. At Rancho Cucamonga High in California (Torrejon, 2004), rose bushes and plaques identify deceased students. Santana High School in San Diego, California (Torrejon, 2004) created a healing garden to remember what happened and “the sanctity of human life.” Some gardens honor staff. The Ashland High School (Torrejon, 2004) garden has only one plaque to honor all the students. The school did not want to start listing names fearing it would leave students wondering who would be next. Another variation is the “remembrance garden” at Lewiston High School in Maine (Torrejon, 2004) which uses bricks to identify retired staff and others who wished to be remembered for various reasons.
Memorial web sites, often designed by students, are on the rise. More often student memorials are quickly created at student lockers, parking spaces, and other areas on school property. Some districts allow memorial plaques but determine the size of the plaque as well as the size of lettering on it. There are different practices related to yearbooks; some allow poems, student letters and photos while others have a memorial page listing no more than the names of those who died. Still other schools identify the foundations that can receive memorial donations or those materials that can be purchased with donations in memory of the deceased. Recently, students are coming to school wearing T-shirts with their peer’s picture and often words on the back.
There is a general consensus that memorials provide an avenue for healing, a place to visit (National Association for School Counseling, 2004, www.naspoline.org/neatmemorials). People can come together to support one another as well express their feelings in a supportive environment. Given the acceptance that memorials serve a beneficial purpose for most, the question still remains, “Do memorials belong in schools?”
Are School Memorials Appropriate?
Should memorials, other than for suicide, be created within schools? And if so, what guidelines should be considered? To partially answer these questions it is necessary to understand the nature of trauma and, specifically, issues of exposure, as both influence guidelines for memorials.
Any situation that results in a desire to create a memorial is likely to be traumatizing for some students as well as staff (Steele & Raider, 2001). Abundant research describes the many child and adolescent manifestations of trauma (Pynoos, 1988, van der Kolk, 1996). The area of concern associated with memorials is that which deals with exposure and arousal, also referred to as “activation.”
Trauma is a state of terror in which victims feel unsafe and powerless to do anything about their situation (Steele & Raider, 2001). Trauma is also accompanied by worry; often worry about “it” happening again and “will I be next?” Arousal is a psycho-physiological and neurological state of readiness for the “next time.” Physical proximity to the actual location of the tragedy and or to visual reminders activate the arousal response (van der kolk, 1996; Rothchild, 2000). Memorials, although beneficial for many, are also activating for many, especially those already vulnerable due to their own personal trauma experiences. This constitutes a significant number of students in any facility.
Memorials can be activating because of the simple fact that they provide an ongoing visual reminder of what happened. Arousal can also lead to a decrease in cognitive function, the ability to attend, focus, retain and recall, and the ability to process information– primary learning functions. Furthermore, prolonged arousal also leads to aggressive, assaultive behaviors. From this perspective memorials in the school or on school property do pose a risk for many simply because in this “closed” environment it becomes almost impossible for students to avoid the physical reminders. There is no choice. Memorials need to be an opportunity of choice, as we all grieve differently. For some, it is healthier not to be reminded.
The concept of “exposure” or physical proximity to reminders is supported by many years of research, The memorials need to be moved out of the school environment into the community where they can either be easily accessed by those who need their comfort and benefits or easily avoided by those who are activated by the “reminders.” Community memorials provide the same benefits as school memorials while avoiding the many conflicts and challenges created when erected in closed environments such as schools.
Where will the resources come from to maintain the memorial, especially the larger memorials, like gardens? How large will the memorials be allowed to grow? In reality, many deaths can occur within a few years. From 1996 through 2003, Slippery Rock High School in the Pittsburg, Pennsylvania area experienced 23 tragic student deaths (Clark & Woodall, 2004). The numbers can grow quite rapidly. Do you really want students to be reminded daily of how many have died? What if the memorial or parts of that memorial are destroyed? Not all students will react favorably to memorials created for an individual student and vandalism can occur.
Once the practice of creating a permanent memorial begins, how will the school respond to the politically and economically influential parents in the community who insist that their child be given a separate memorial? Are schools prepared to respond to the friends and families of students with much less status or those who have been disruptive students? Sometimes people will question the value of including a “less desirable” student to the memorial. Who is going to make the value judgment as to who is included and who is excluded? Should exceptions be made for different students or different situations? School boards do fluctuate and make exceptions to the rules. (see www.splc.org/report , Student Press Law Center.)
If memorials can be a beneficial healing experience for some, while an activating experience for others, what is recommended? Many students do need that opportunity to express themselves, feel connected to others, and to let others know the value their friend brought to their lives. However, others need not be reminded. We each need to grieve in our own way, to do what is most helpful for us individually.
Based upon the knowledge of traumatic exposure as well as the complexity of school systems and school populations, it is recommend that schools do not create permanent memorials of any kind, but do in fact, look to the larger community to make the memorial a community memorial. Community memorials, such as healing gardens, mosaic tile walkways and walls, sculptured works created to represent the spirit of the deceased or the value of life, certainly are beneficial for many. Being in the community, however, the choice to visit or avoid is retained. Community memorials allow for not just students t be remembered, but staff, families and all members of that community who suffered a tragic or untimely death, as well as those who made noteworthy contributions.
Following are several guidelines based upon what is known about exposure to reminders. These practices can help those who are grieving and fulfill their need to “do something” to express themselves to others.
Memorials Can Be Temporary
A temporary memorial is one that can provide students the opportunity to express themselves and to give testimony to their peers, as well as learn how to also direct their generosity to surviving family members. The opportunity to participate in temporary activities and projects can help them come to accept the finality of their loss. Temporary memorials are very important to healing and do not create the significant problems and challenges of permanent memorials in schools. An initial memorial site where students and staff can place flowers, poems, pictures, and teddy bears, can be located in an area where those who wish not to be reminded can easily avoid that location, while others have easy access. However, it is to be temporary. A natural time to remove the materials is often following the funeral, but do so in a formal way that leads to the presentation of all these symbols of caring to the family. This provides students the opportunity to experience the tremendous help they can be to grieving family members. This is a wonderful “teachable moment” and completes the need most of us have to feel as if we have done something helpful and meaningful.
T-Shirts Picturing the Deceased
T-Shirts with a picture of the deceased student or students is a memorial itself, but one that also needs to be time limited. T-shirts are another way for students to express themselves, but because they are visible to many, some may become activated by this visual. Students wearing memorial T-shirts will need help in channeling their need to be visible and publicly associated with the deceased student. Involving these students in activities that fulfill this need, helps to diminishing the need to wear the T-shirt. Students can write notes and cards to family members for formal presentation or, better yet, be given the opportunity to meet with the family to directly communicate their thoughts and feelings to the family. They can help establish a drive to raise monies for the school foundation in memory of their friend. Depending upon the nature of the death they could organize efforts to develop recommendations related to prevention of such deaths. They could be invited by the crisis team of that school district to contribute their suggestions as to what was or would be more helpful should such a situation happen in the future. However, at some point the wearing of t-shirts, which is not part of the dress code for many schools, must end. It will be much easier if students have been involved in other related activities as well as educated to be sensitive to the way their tribute can be difficult for others. This too is a teachable moment regarding consideration for others.
The Need to Do Something
In the numerous articles about memorials posted on the Internet, not one discusses the conflict between staff and students that can be created in the first few weeks after a death, especially when administrators face the difficult challenge of saying “no” to specific behaviors and desires of students. Problems most frequently emerge when the student’s need to do something is not channeled into activities that become meaningful for family survivors, when students are not participants in determining how best to show support during memorial services. Students who continue to challenge school policy regarding memorials often have other personal issues triggered by the death of their friend. Some may need further intervention. Maintaining a dialogue and attempts to reach agreeable solutions becomes another “teachable opportunity” to develop supportive relationships with these students. Providing a range of activities for students retains their need for choice provides experiences they may not otherwise have been able to provide themselves, and communicates administrative/system support of their need to grieve and to somehow find a way to manage the wide range of emotions they experience.
School newspapers can be considered a temporary memorial. Students will expect to read about that student(s), what happened and what others have to say about the student and, in some cases, the circumstances of the death. We recommend that the guidelines established by the American Association of Suicidology regarding the reporting of a suicide be followed (www.suicidology.org). These guidelines are based upon well-documented research related to contagion and the modeling of that suicide act in order to be also publicly acknowledged. This is a difficult task for editors who must find a balance between what is helpful and what becomes a glorification. Highlighting the values the student communicated or lived by, their favorite activities and songs, but most importantly why they will be missed, constitute responsible, helpful information for those who are closest to the student. After articles in the student newspaper have been published, bring students together to discuss their thoughts, their responses, what they liked or did not like about what they read. Again, involving the students helps to defuse otherwise intense reactions. Students certainly could be asked to submit their thoughts in writing to the newspaper staff before and after, as students often identify life issues that are important, do have merit and deserve consideration.
We recommend schools establish a school-based foundation that families and students can contribute to for the purpose of funding specialized programs, services, in-service trainings, materials, and equipment. Attention therefore, is not on any one single family, student, or staff person. Foundation contributors can be listed in the yearbook and school newsletters. Materials, services, programs, etc. that are made possible through this funding can be acknowledged with, “This equipment was made possible from the families, businesses, and benefactors in our community.”
Again, it is important to involve students in the planning of memorial services when such services allow for student participation. Some students will not want to attend services. They need to be provided alternative activities. Use symbols of life that deliver positive messages and hope. Music, balloons, and candles can all be effective in focusing on our ability and strength to survive painful experiences. It is recommended that memorial services are not conducted in the school but again, at a community facility such as a church. In some communities the school gym or auditorium is the only facility large enough to hold a large group. Should the decision be made to use the school, schools should not allow media coverage. Administrators have no control over what reporters decide to communicate. Most administrators who have allowed the media to attend have regretted it. Speeches, testimonials, music, poems, and other performances, need to be previewed and approved. This necessitates that several staff and crisis team members work with the students as they prepare. Conflict can arise regarding the appropriateness of some of their material, and what they wish to do. It must be brought to their attention that their message could have an impact on the larger student population.
Following any memorial service students need to have the opportunity to talk about their thoughts and reactions one more time. This is also a time for crisis team members to normalize their reactions and talk a bit about what life will be like without their best friend. Let them know healing will take time and, should they need to just sit and talk in the future, team members will be available. Above all, those students closest to the deceased will need permission to laugh and enjoy themselves in the weeks and months to come without guilt, acknowledging that real friends want the best for one another.
There are a number of articles written about the benefits of a community memorial. The Oklahoma Memorial is somber yet a beautiful testimony to those who were killed in the bombing of the Federal Building. It certainly helps families to give some meaning to the senseless death of their loved ones. Memorials in the community simply do not present the problems such memorials in closed environments, like schools, present. When a student is allowed to speak to other students or at a school assembly problems can arise because of the diverse yet closed assembly. When that same student presents the same message in a community setting open to others to attend, the message will be heard and reacted to quite differently.
Unfortunately, there is no long-term research on the impact permanent school memorials have on its population, on its constantly changing population. However, the anecdotal information from those who have dealt with problems they never anticipated when that permanent memorial was approved does, and should, cause concern. We know that because of the disturbing effects of exposure to ongoing reminders that rethinking permanent memorials in schools is necessary.
Memorials can be very beneficial, but for some they can be very activating. Anyone who needs to, should be allowed to easily avoid the unwanted memories and fears memorials can trigger. Most school memorials today are impossible to easily avoid. In contrast, community memorials are much easier to avoid. Temporary memorials are helpful and appropriate but must be time-limited and removed from the school. Students must be involved in the planning of memorial services and activities and ultimately these students and their activities need to be directed at supporting the family of the deceased student. The nature of the death can be the beginning of efforts and campaigns to prevent similar deaths. Moments of silence are appropriate and, when death impacts a large part of the student body, a brief reminder and moment of silence on the anniversary of that death is appropriate.
Editor’s note: Should you have specific questions suggestions, guidelines that work for you, please call, email, or write the National Institute for Trauma and Loss in Children. Since 1990, the National Institute has trained well over 60,000 educators and members of crisis teams in schools across the country and have received feedback of hundreds of schools and thousands of school personnel who have struggled with the challenges that permanent memorials can create. Obviously, in an increasingly diverse world guidelines must remain flexible, yet preventative of further traumatization. Thoughts, information you pass on to the National Institute will be passed on to others by regularly updating this article. TLC can be contacted toll-free at 1-800-837-5591 or by email at email@example.com.
American Foundation for Suicide Prevention 1-888-333-AFSP www.afsp.org
American Association of Suicidology 202-237-2280 www.suicidology.org
Clark, V. & Woodall, M., Philadelphia Inquirer, April 1, 2004, Young lives, violent deaths.
Pynoos, R. & Eth, (1988) Psychological first aid and treatment approach to children Exposed to community violence: research Implications. Journal of Traumatic Stress, I, 445-473.
Rothschild, B, (2000) The body remembers, New York: W.W. Norton
Torrejon, V. 2004 High Schools Create ‘Grieving Gardens’. www.wtopnews.com May 10, 200-4:51pm
Van der Kolk, B. McFarlane, A. & Weisaeth, L. (1996) (Eds). Traumatic stress disorder: the effects overwhelming experience on mind, body, and society: New York: Guilford.
Winter 1998-99-High School Censorship: Yearbook Memorial approved after controversy, vol xx, no. 1 – pg 13. www.splc.org/report Student Press Law Center.
A study exploring the impact of early parental death has revealed the long-term damage and suffering that can be experienced by individuals in adult life if appropriate levels of support are not provided at the time of bereavement. The new research, published in the Journal of the Royal Society of Medicine, describes the low self-esteem, loneliness, isolation and inability to express feelings of some individuals who lost a parent in childhood, with the effects felt for as long as 71 years after the bereavement.