Toxic Stress

Although some stress is normal and even healthy, toxic stress is not. Children who have experienced a trauma often feel helpless and hopeless and live in a constant state of worry and fear. This toxic stress negatively influences every aspect of the child’s development. Some of the most common experiences among children living with toxic stress include:

Hyper-vigilance
Always anticipating something bad to happen, feeling jumpy and nervous, distorted perception of others’ non-verbal body language and facial cues.

Avoidance
Shuts down easily when negative situations arise, uses food, alcohol, drugs or other addictive behaviors to numb out.

Negative cognition
Inaccurate beliefs about oneself, others and the work around them.

Emotional distress
Depressed, anxious, feelings of helplessness and hopelessness.

Health problems and somatic complaints
Stomachaches, headaches, physical health problems such as obesity and hypertension.

Difficulty with relationships
Withdraws, blames and pushes other away, does not feel worthy of love.

The online course, Healing the Experience of Trauma, was developed for practitioners to use with children who are living in a constant state of toxic stress. Instead of asking a child what happened, it focuses on their lives now. The course consists of video segments of a live presentation by Dr. Caelan Soma. $199 includes CEs.

The new “Healing the Experience of Trauma” program by Dr. Caelan Soma, includes a manual for the clinician, with step-by-step instructions to move through 9 sessions with a child, adolescent or group and one journal. Move back and forth between the themes of trauma and introduce them to feelings of connection, resilience and strength. Buy it now for $75!

Calming Corners

When students experience stress or trauma at home or are overwhelmed in school, their nervous systems respond. Some students become extremely activated while others shutdown. Activation comes in reactions such as inattention, difficulty sitting still and hyperactivity. Shut down looks like daydreaming, falling asleep in class or not responding to others bids to connect. With both activation and shut-down, cognition is impaired and learning is difficult. Calming corners can help with both. When activated, a calming corner provides an opportunity for students to reset or re-regulate and when shut down, a calming corner provides opportunity for engagement.

A calming corner is a small, designated space located within a classroom. The purpose of a calming corner is to help support self-regulation while keeping students in the classroom if they need a break from instruction time or a group activity. The use of calming corners can transform the culture of the classroom because calming corners are not consequence-based but rather used as an opportunity, driven by a student’s choice to feel better. Calming corners are private enough to allow the student to maintain dignity, however, they should be within eyesight of the educator so the student maintains a feeling of safety.

Teachers should introduce calming corners in their classrooms as safe places. They are not for students who are “in trouble,” but rather for all students in the classroom. Invite all students to “try out” the calming corner when it is implemented. At first, the calming corner will be a novelty and every student will want to try it out. This is normal. As time goes on, only the students who really need to use it will ask to do so. If there is more than one student who wants to use the calming corner, the use of timers is helpful. Typically, after 5 minutes in the calming corner, students are ready to join the rest of the class.

A calming corner can be a safe place for students to do peer lead restorative circles or to just process through issues. Classrooms can create calming corner passes or a simple signal individualized by each student to alert the teacher that student needs to process or calm down.

For school-age children, a small nook or space set apart from the rest of the room that offers privacy is perfect. Provide seating with beanbags, pillows, a small table and chairs. Some teachers use a tapestry or some sort of “roof” to cover the calming corner space. Peaceful lighting and colors are a bonus. And, post the purpose of the calming corner. As children enter middle school and high school – a small area with a desk, beanbag or comfortable chair will do the trick. Some like to call these areas “chill-out corners”.

List of items you might want to include in your calming corner:

  • Different kinds of timers
  • Squishy “stress” ball
  • Small bottles of water
  • Glitter ball or glitter jar
  • Emotional feelings sheet to help identify and record emotions
  • Mirror to help identify emotions
  • Blank paper, pens, and crayons, markers,, write a letter, or to reflect on strategies used in the peace corner
  • Hoberman breathing sphere
  • Soft, small blanket or even a weighted blanket for sensory reasons
  • Soft rug
  • Relaxation CD and player
  • Headphones
  • Books, magazines
  • Low partitions/dividers for privacy
  • Tapestry for “roof”
  • Visual calming strategies
  • Worksheets from TLC’s “One-Minute Interventions” and “Mind Body Skills for Emotional Regulation” workbooks.

The Body Holds the Truth

After 17 years of facilitating grief and trauma recovery, I recently experienced something that led me to a completely new understanding of the importance of the work we do at TLC and the programs we have developed and refined. As well as being a trauma counselor, I am also the author of the TLC/STARR Adults in Trauma program. Along the way, I have become aware of my own grief and trauma experiences. Addressing them has been instrumental in my work as a witness to others’ experiences in a therapeutic setting. Little did I know that trauma was residing just below the surface of my awareness.

In December of 2017, I found myself in a particular pose at a yoga class that unexpectedly threw me back into the memories of a trauma about which I had only been vaguely aware. Suddenly, the power of hidden trauma became very real to me. You may be familiar with The Body Keeps the Score by Dr. Bessell van der Kolk. Well, my body had kept the score. The yoga pose released a visual image and the emotions associated, immediately and dramatically.  Given her training and experience, the owner of this yoga studio was able to understand what was happening, reframe the experience in a manner I could understand, and helped return me to a relative sense of safety and control.

The best I can determine is the event that was triggered, and allowed to release, happened when I was about 7 years old. Since then, I have managed to gather a rather eclectic, unconventional team to help me address and move on from this childhood experience with which I am still in the process. At 68 years old with this experience finally revealed, I am energized to continue the flow of information regarding therapeutic practices that are available to adults who have experienced traumatic events in their childhood.

While children are the focus at TLC/STARR, there are many children of trauma who have grown up to become adults in trauma, not realizing that the traumatic events they experienced may still be present and active within their body. They are handling life well, mostly, until one day something triggers a strange and scary physical and/or emotional reaction seemingly out of context with current events. If they come to us seeking help, how do we assist them?

  • Do we help understand and assure that basic needs have been met, if necessary?
  • Do we endeavor to teach what trauma is, the effects, reactions, while normalizing it all?
  • Do we seek to offer the possibility of some action to be taken by the person, regardless of how small, that can lead to a sense of safety and control?
  • Do we focus on the many possibilities that could be at play and that may not fit neatly into a DSM V diagnosis?
  • Can we share assessment results in a manner that bolsters safety and empowers?

While we may start with a few inquiries, our priority is creating a human connection through our gaze, our voice, our words, maybe our proximity, discovering that our humanness, our caring, and our witness is enough, initially.

When I first wrote Adults in Trauma, I had no clear notion of the true reason behind the writing – that my own experience was guiding me – or the potential effect on future generations. Through the research conducted by Dr. Rachal Yehuda in epigenetics, Dr. Bessel van der Kolk, Dr. Peter Levine, our colleague Dr. Caelan Soma, and many others, I began to understand differently that unaddressed traumatic childhood experiences can have a profound effect on future generations, not only behaviorally and emotionally, but in ways that the field of epigenetics is beginning to reveal. Our focus at TLC/STARR is to educate, support, teach, and assist children and adults in understanding and moving beyond the impact of traumatic events experienced and into a place of thriving. The hope in our work lies not only in mitigating the potential long-term effects of trauma, but also for future generations in ways we may have not imagined before.

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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

Structured Sensory Interventions for Traumatized Children, Adolescents and Parents: SITCAP in Action

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.

Read more about SITCAP in action here.

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.

Download article (PDF)

Posttraumatic Stress Disorder (PTSD) Reactions

REEXPERIENCING

  • Intrusive thoughts, feelings
  • Traumatic dreams
  • Flashbacks
  • Intense psychological distress triggered
    by reminders
  • Physiological reactivity

PERSISTENT AVOIDANCE

  • Of thoughts, feelings, talking of activities, places, people associated with trauma
  • Inability to recall
  • Numbing, detachment, estrangement
  • Restricted affect
  • Foreshortened future

INCREASED AROUSAL

  • Sleep difficulty
  • Irritability, assaultive behavior
  • Difficulty concentrating
  • Difficulty remembering
  • Hypervigilance
  • Startle response

PTSD is diagnosed when reactions persist or develop four weeks beyond the initial traumatic incident and when there exists one or more reexperiencing reactions; three or more avoidance reactions and two or more arousal reactions.

PTSD Reactions in Children

  • Cognitive dysfunction involving memory and learning. “A” students become “C” students; severe reactions cause others to fail altogether.
  • Inability to concentrate. Children who once could complete two and three different tasks now have difficulty with a single task. Parents and educators often react negatively to this behavior because they simply do not understand its cause.
  • Tremendous fear and anxiety. One boy who witnessed his father kill his mother when he was seventeen-months-old is now seven-years-old. He still sleeps on the floor, ever ready to run from danger. Six-year-old Elizabeth, whose sister was killed one year earlier, is also sleeping on the floor. She did not witness her sister’s murder, yet she is experiencing this same hypervigilant PTSD response.
  • Increased aggression, fighting, assaultive behavior – these are the first reactions generally identified as a change since the trauma. Revenge is a constant theme when the incident has been a violent one.
  • Survivor guilt: Students not in school at the time of a random shooting and subsequent death of a fellow student feel accountable and experience intrusive thoughts and images. Another form of survivor guilt is the belief that “It should have been me instead” or “I wish it would have been me instead.”
  • Intrusive images (flashbacks): Two years later, teachers still notice this teenage girl engaging in a plucking motion with her hand. She was home when the beating occurred. She did not know her mother was already dead when she ran to help her. When she rolled her mother over, her mother’s mouth was filled with blood and broken teeth. The daughter began pulling the broken teeth from her mother’s mouth so she wouldn’t choke on them. Two years later, that plucking motion still occurred when she’s reexperiencing her experience.
  • Traumatic dreams: We first met eleven-year-old Tommy one year after his sister had been stabbed repeatedly in the chest/stomach area and was killed by a serial killer. His sister. He was still having dreams of his “guts” being ripped out by “Candyman ” even though he was not a witness.
  • Inappropriate age-related behavior: These include clinging to mother, bed-wetting, and other regressive behaviors. Eleven-year-old Tommy, the boy mentioned above, has started to stutter.
  • Startle reactions: After her father beat her mother to death, the police arrived to take pictures and arrest the father. Two years later, this daughter still cannot allow her picture to be taken because it reminds her of that day.
  • Emotional detachment: Fifteen-year-old Mary, whose sister was also killed by a serial killer, had made friends that her mother described as “real trouble.” Mary never even cried at the funeral. She had received help, but not trauma-specific help.

Children may exhibit the following behaviors:

  • Trouble sleeping, being afraid to sleep alone even for short periods of time.
  • Be easily startled (terrorized) by sounds, sights, smells similar to those that existed at the time of the event – a car backfiring may sound like the gun shot that killed someone; for one child, his dog pouncing down the stairs brought back the sound of his father falling down the stairs and dying.
  • Become hypervigilant – forever watching out for and anticipating that they are about to be or are in danger.
  • Seek safety “spots” in their environment, in whatever room they may be in at the time. Children who sleep on the floor instead of their bed after a trauma do so because they fear the comfort of a bed will let them sleep so hard that they won’t hear danger coming.
  • Become irritable, aggressive, act tough, provoke fights.
  • Verbalize a desire for revenge.
  • Act as if they are no longer afraid of anything or anyone verbalizing that nothing ever scares them anymore and in the face of danger, respond inappropriately.
  • Forget recently acquired skills.
  • Return to behaviors they had previously stopped, i.e. bed-wetting, nail-biting, or developing disturbing behaviors such as stuttering.
  • Withdraw and want to do less with their friends.
  • Develop physical complaints: headaches, stomach problems, fatigue, and other ailments not previously present.
  • Become accident prone, taking risks they had previously avoided, putting themselves in life threatening situations, reenacting the event as a victim or a hero.
  • Developing a pessimistic view of the future, losing their resilience to overcome additional difficulties, losing hope, losing their passion to survive, play, and enjoy life.