Bust Worry & Anxiety with Expressive Arts Activities

Anxiety is one of the most prevalent children’s mental health issues with the average age of onset for anxiety disorders being 6 years of age (Merikangas et al., 2010). Anxiety consists of many specific disorders including panic, OCD, specific phobias, PTSD, and social, separation, and generalized anxiety. When dealing with trauma we are often dealing with symptoms of Post-Traumatic Stress Disorder, which is an anxiety disorder. Our treatment plans will likely, at some point, need to address issues of anxiety.

Regardless of type of anxiety disorder, what matters in treatment is the process that happens, not so much the content of the worry. Whether the child is having worries about tripping in front of her class, seeing spiders, or needs to check the locks on the house six times before leaving, the mechanism at work is the same. The child is avoiding situations that: bring up feelings of uncomfortableness and uncertainty; is looking for reassurance; parents reassure and reassure again; it is not enough; and worries spiral out of control. We need to intervene to address the process, which is to empower the child to take charge of these worries. No one can do it for them.

There are many resources available to clinicians and families who are supporting children with anxiety (see resource list below this blog). One of the first steps in dealing with anxiety is externalizing the issue and relabeling anxiety (Chansky, 2004; Clark & Garland, 2009; Peters, 2013; and Wilson & Lyons, 2013). Everything from taming your worry dragons, to squishing your worry bugs, to standing up to your worry monsters, are identified as ways to help children take charge of their fears and worries that are often interfering with their day to day life (Image 1).

image 1 - worry bugs, image 2 - suzie the dragon warrior, image 3 - 7-year-old detective

For years I have been working with children, their families, and anxiety. Early on in my work, a 10-year-old girl taught me about being a warrior rather than a worrier (Image 2). This is such a great idea and one that is now in book form (Peters, 2013). In keeping with this theme, we will explore further how warriors can be supported with the arts. The following section highlights a range of expressive arts-based interventions that can be combined with a comprehensive treatment approach to dealing with anxiety in children.

Become the Experts – Detectives

Families are invited to rally against the worry by becoming experts in the tricks of worry. If we embody the detective we are not judging the child, but rather we are all on the same team supporting the child as cheerleaders believing in the power he/she has in standing up to the worries. We are all detectives, meaning we are curious; we are looking for signs of strength; for times when the child outsmarts worry; and we are looking for what makes worry become smaller or the child become more powerful. This gives the child the felt experience that he/she is not alone in what can seem like a very overwhelming world (Image 3).

Show Me the Worry

As with any presenting issue, it is important to know how the child experiences the issue from their personal point of view. This is no different than inviting children to show us the hurt, the sadness, the trauma. We invite the child to make us witness to the experience. We can then begin to see and understand from their point of view how they live with anxiety day to day.

  • What does worry look like? Feel like? How big is it compared to you? (Image 4)
  • How do you think your mom and dad see you and worry?
  • How do mom and dad see their child and worry?

image 4 - the 9-year-old picture of the worry monster who says "worries are my sunshine"

Once we have the images, we can be curious about stories that may go with the image and/or characters. We can enact the story by cutting out the characters, use puppets, or dress up. We can further bring them to life by giving voices to the characters.

Stories have the potential to lead us further into the inner world of the child and their life with anxiety. Through this process we may discover unique resources that this child could utilize in their treatment process.

Facing the Avoider

Whatever kinds of anxiety children are dealing with, the Avoider will inevitably be part of the work. The Avoider is worry’s best ally. It shows up in so many different ways, but its job is to do one thing – avoid feeling discomfort and uncertainty.

Children can also show us the Avoider. What does it look like? How do they work together? What tricks do they have up their sleeve? Create a story about worry and the Avoider. What kind of outcome do you want for this story?

Taming Tricky Thoughts

Comic strips are great ways for kids to capture tricky thoughts and to find ways to talk back to these thoughts. Images 5 – 7 show only three of ten images created by a 15-year-old boy who used his story about worry to walk through therapeutic steps needed to conquer his fears and the tricky thoughts that created the worries.

image 5, image 6, image 7

Body Chillers for Jitters

There are many videos available for children and parents to watch to help them deal with the various aspects of anxiety. “Belly Breathe” by Sesame Street is a catchy video and song and a fun way for kids to learn the art of belly breathing.

Creating their own movement sequence can also be an empowering way for children to work with their own imagination, energy, and inner knowing to create meaningful ways to calm themselves and remember their resources. The 10-year-old girl who painted the wooden box below (Image 8), identified four phrases to help her with severe performance anxiety. Her four phrases were: Be Brave, Trust Myself, You Know How to Do This, and You Can Do This. She then created a dance/movement sequence to go with each phrase to help her remember these powerful words. She would practice her sequence on the days when she would perform.

image 8, image 9

Strength Training: Building Brave Muscles (AKA Resources)

The best way to conquer worry is to build brave muscles. Kids don’t tend to know just how brave they are and how important being brave is to worry-busting. The only way to deal with worries and fears is to FACE them. The following are some ideas about how kids and families can build their brave muscles.

Play List for Warriors

Create two play lists. The first play list consists of music that calms and soothes when time outs are needed and soothing the body and mind is a priority. Sometimes warriors need a little more energy to muster up their bravery to face what they don’t want to face. Create a second play list when warriors are needing extra energy to motivate them to be brave. Work with them to identify songs that inspire, give energy, and lyrics that help them believe in their brave.

Brave Jars

Each time someone in the family sees an act of bravery they can add a stone into the jar with a word on it.

Power Figures vs. Worry Dolls

Worry dolls are commonly known and used to help kids with worries. The idea, from the Guatemalan legend, is that children tell a worry doll their worry at night and put the doll under the pillow, and the worry doll magically takes it away. What I have found even more powerful has been to create power figures. The invitation is for children to think about creating a figure that represents their power and/or strength to face their worry. For example, one child created a set of five figures (Image 9), each one represents either a part of herself (her courage, her inspiration and her wise self) or someone else who helps her develop brave muscles (her mother and her dog).

Image 10 was created by a 10-year-old boy who created Gandalf, the wizard, to remind him that he is not alone and that he too has strong inner powers to stand up to his fears. The imagination truly has no limits.

Anti-Anxiety Power Props

Sunglasses, hats, capes, and wands. Every warrior needs special combat props and each child will be different in terms of what makes sense to them. They can make a special tool box or tool belt to use to deal with a variety of worries, fears, and tricks.

Wands can be especially decked out with gadgets and powers that only a child’s mind could conjure up to help them with their unique situation (Image 11). Special glasses can be used when warriors are needing to practice looking more at the positive sides to things or when they are needing “learning to be grateful” glasses to assist them.

Whatever art modality is used, we must embed the intervention in an overall comprehensive treatment plan. There is no limit to the imagination, in particular, when we tap into the minds of children and teens, who inherently know their own strengths, but need support with creating space for those strengths and resources to emerge. It is then that children can truly embody the warrior within.

image 10, image 11

REFERENCES

Chansky, T. (2004). Freeing your child from anxiety. New York, NY: Broadway Books.

Clark, S. & Garland, J. (2009). Kid’s guide to taming worry dragons.

Peters, D. (2013). From worrier to warrior: A guide to conquering your fears. Tucson, AZ: Great Potential Press.

Wilson, R. & Lyons, L. (2013). Anxious kids anxious parents: 7 ways to stop the worry cycle and raise courageous & independent children. Deerfield Beach, FL: Health Communications, Inc.

Merikangas, K., Hep, J., Burstein, M., Swanson, S., Avenevoli, S., Cui, L., Benejet, C…Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of American Academy of Child and Adolescent Psychiatry. 49(10): 980-989. doi: 10.1016/j.jaac.2010.05.017

Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., Kendall, P. C. (2008). Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety. The New England Journal of Medicine, 359(26), 2753–2766. doi:10.1056/NEJMoa080463

RESOURCE LIST

WEBSITES:

BOOKS:

Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle and Raise Courageous & Independent Children by Reid Wilson & Lynn Lyons (2013)

Don’t Feed the Worry Bug by Andi Green

Freeing Your Child From Anxiety by Tamar Chansky (2004)

From Worrier to Warrior: A Guide to Conquering Your Fears by Daniel Peters (2013)

Mighty Moe: An Anxiety Workbook for Children http://www.cw.bc.ca/library/pdf/pamphlets/Mighty%20Moe1.pdf

When My Worries Get Too Big: A Relaxation Book for Children who Live With Anxiety (2006) by Kari Dunn Buron | FSRC
This book presents ways for young children with anxiety to recognize when they are losing control and constructive ways to deal with it.

Kid’s Guide to Taming Worry Dragons (2009) by Sandra L. Clark and Jane E. Garland | FSRC
This pocket-sized book provides an overview of taming worry dragons (types of worries, how they affect your body and thoughts, when they come around) as well as a summary of tools for “trapping & taming” worry dragons. Space is available for kids to add their own ideas.

Tools for Taming and Trapping Worry Dragons: Children’s Workbook (2008) by Sandra L. Clark and Jane E. Garland | FSRC
Workbook accompanying Taming Worry Dragons that helps children learn to handle anxiety and distress. These activities help children aged 8-12 years understand anxiety and teach them specific strategies for coping.

What to Do When You Worry Too Much: A Kid’s Guide to Overcoming Anxiety (2006) by Dawn Huebner & Bonnie Matthews | FSRC
This illustrated book guides children and parents through the cognitive-behavioral techniques most often used in the treatment of anxiety. Concepts and strategies are introduced through metaphors and illustrations, which make them easy to understand.

photos

Adapting SITCAP-ART

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.

Background

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.

The Problem

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.)

Big ‘Aha’

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.

Group Redesign

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.

The Sell

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.

Our Results

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.

Outcomes

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.

Challenges

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.

Conclusion

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’

Agenda:

  1. Review group norms & last week’s group
  2. Prosocial news & Announcements
  3. Topic of the day: Write on the board
  4. Mellow – relaxation exercise
  5. Move – physical activity (walk, get up and do something, role play)
  6. Make – draw, write, listen, create something related to topic of the day
  7. 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

  • Anger/Love
  • Worry/Fun
  • Guilt/Freedom
  • Reactions/control
  • Victim/Survivor
  • Hurt/Caring
  • 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.

*About Trauma

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

 

Mellow –

  1. 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.

 

Make –

  1. 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)?

 

Move –

  1. 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.

 

Up –

  1. 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

 

Make –

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

 

Move –

  1. Get up and write some graffiti on the board about your feelings of revenge.  Any comments?

 

Mellow –

  1. 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.

 

Up –

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

Self-Care & Creativity in the Trauma-Informed Workplace

Self-care in relationship to trauma work is an essential practice for professionals in this helping field. Without attention and connection to our own self-care, the demanding toll of aiding and supporting others in pain and distress can often leave us vulnerable to compassion fatigue, vicarious trauma and burnout. In relationship to this necessity for provider self-care, this post will focus on considerations about one’s workplace environment and the role creativity can have as a trauma-informed practice.

Laura van Dernoot Lipsky, (2009), who is author of “Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others,” identified 16 Trauma Exposure Responses that can manifest within trauma workers “as a result of exposure to the suffering of other living beings or the planet,” (p. 41). These responses can range from, but are not limited to, feelings of hopelessness and helplessness, experiencing pervasive exhaustion, an increasing incapability for empathy, and struggling with states of guilt, numbing, anger, and fear (Lipsky, 2009).

Experiencing minimized creativity in our work is also identified as a trauma-exposure response and also worth paying attention to. Using our sense of creativity in the work we do as trauma specialists is a critical, as it helps us be open to and see new ideas or solutions that can empower problem solving, growth and different ways to view situations, tasks and challenging issues with clients, co-workers and ourselves. In addition, when trauma exposure limits our ability to embrace the fresh air that creative thinking can breathe into our work, our efforts to help others may eventually feel immobilized without meaning, hope or new possibility. We also may become apathetic to working within systems, strategies and approaches that do not nurture professional growth, invite opportunities for change, or best serve the client’s needs and trauma recovery.

To support the value of creativity within the workplace, as well as offer one way to foster a healthy safeguard to decreasing the effects of trauma exposure and stress, here are some suggestions to consider implementing into your work practice and setting:

    Be mindful of the physical environment around your workspace and/or agency and how you could invite more joy, fun and creativity through the use of color, scents, sound, lighting and other sensory-based incentives. Some examples are adding a favorite, comforting piece of art, nature inspired items, plugging in a lavender air freshener, or a cheerful lamp to brighten the space.
  • Create a box or basket that includes easy, go-to comfort care items that help you engage in playfulness, relaxation, and re-energizing.
  • Establish a mandala coloring area in your staff break room or kitchen with colored pencils, gel pens or markers that you and your co-workers can use for a creative break. Print Mandalas is an online site where a variety of mandala coloring pages can be printed for free.
  • Include creativity into your agency’s staff meetings by beginning with a meaningful poem, song, story or image that relates to the organization’s values and mission. Invite staff members to take turns being responsible for this activity.
  • Support your co-workers and staff through making artsy notes of gratitude, affirmation or inspiring quotes on sticky notes and index cards to leave in workspaces or mailboxes. Use stickers, a magazine photo collage, and simple art materials to leave an expression of your appreciation, support or just for a creative hello. You could even institute an agency-wide event dedicated to this practice! Connection and encouragement from those we work with helps foster emotional resiliency and better manage work stress. Recognizing the challenges, achievements and commitment to our work in this tangible, creative form reminds us that our efforts do make a difference and have purpose.

References:
Lipsky, L. V. N. (2009). Trauma Stewardship: An Everyday
Guide to Caring for Self While Caring for Others. San Francisco, CA: Berrett-Koehler.

Resources:
Treating Trauma: Self-care for Providers
International Society for Traumatic Stress Studies

Self Care for Providers
SAMHSA’s Homelessness Resource Center

Self Care and Trauma Work
Office on Violence Against Women, National Sexual Violence Resource Center and National Sexual Assault Coalition Resource Sharing Project

Transforming Compassion Fatigue into Compassion Satisfaction
12 Top Self Care Tips

SITCAP-ART Research

This randomized controlled study assessed the efficacy of a structured group therapy for traumatized, adjudicated adolescents in residential treatment. Youth were randomly assigned to a trauma intervention (SITCAP-ART) or to a waitlist/comparison group. The intervention included both sensory and cognitive/behavioral components. Standardized trauma and mental health measures were used. Study participants demonstrated statistically significant reductions in trauma symptoms, depression, rule breaking behaviors, aggressive behaviors and other mental health problems.

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