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Contents

Foreword

Preface

Acknowledgments

Chapter One: How Structured, Sensory Interventions Help Grieving and Traumatized Children

Was It Grief or Trauma: What Matters Most?

It Is Not the Situation

Children’s Mandate

Implications for Treatment

Subjective Experiences Matter

SITCAP’s Core Principle

Key Concepts

Practice-Based Evidence (PBE) and Evidence-Based Practice (EBP) Outcomes

Case Studies

Summary

Chapter Two: Children’s Experiences With Grief and Trauma

Subjective Experiences of Grief and Trauma

The Differences Matter

Additional Trauma-Driven Guilt Factors

“I Don’t Want to Talk About It”

Resistance, Safety, Duration, and Children’s Iconic Identity

Alicia: What Matters Most

The Private Logic Created by Experiences

Survival Behaviors Driven by Experiences

The Primary Differences

Summary

Chapter Three: Trauma-Informed Principles and Practices

Being Trauma-Informed

The Need for Sensory-Based Interventions

Storing the Implicit Memories of Trauma

Iconic Images of Trauma

Externalizing Implicit Memories by Drawing

The Body in Trauma

Actively Involving Children in Their Own Healing

Trauma-Informed Principles and Practices

Safety, Empowerment, and Self-Regulation

Integrating Implicit and Explicit Processes

Appropriate Developmental Intervention

Supporting Cultural Diversity

There Is No One Intervention

Trauma-Informed Relationships

Creating a Trauma-Informed Environment

Promoting Posttraumatic Growth (PTG) and Resilience

Summary

Chapter Four: Structured Drawing Activities

Seeing What Children See: The Meaning They Give to Their Experiences

Todd’s Drawing: Giving Meaning to How He Is Experiencing Life

Accessing, Externalizing, and Concretizing Implicit Memories

Drawing and Diversity

How Children Draw Does Not Matter

Pursuing Details Matters

Beginning the Process

What We Do With Drawings

Drawing Activities

When a Story Triggers Another Drawing

Summary

Chapter Five: Curiosity and the Trauma Questioning Process

Curiosity

Trauma-Specific Questioning

The Process: Experiencing the Lessons Being Learned

Questioning the Child’s Subjective Experiences

Summary

Chapter Six: Meeting Children in Their World

The Family: A Brutal Assault and Murder

Following Intervention

Cognitive Reframing

Summary

Chapter Seven: Incorporating SITCAP in Schools and Community-Based Organizations

Trauma’s Impact on Learning

Trauma’s Impact on Behavior

Meeting Our Immediate Needs When in Crisis

Critical Intervention Timelines

A Word About Protocol

Begin With the Least Intrusive Response: The First Three Days

Crisis Intervention: First Several Days

Classroom Presentation: First/Second/Third Day

Defusing

Staff Review

Beyond Staff Review: Support Group for the Most Exposed

Six Weeks and Beyond: SITCAP in Schools

Trauma-Informed Schools

Trauma-Informed Classroom Environments and Practices

Summary

Chapter Eight: Interventions With Parents and Guardians

The Killing of Coach Ed Thomas

SITCAP’s Adults and Parents in Trauma Program

Session One

Session Two

Session Three

Session Four

Practice History

Grandma Maddox

Tina’s Story: Grotesque Suicide

Summary

Chapter Nine: Nurturing Resilience and Posttraumatic Growth

A Bounce-Back Spirit

Preventing Trauma and Encouraging Growth After Trauma

Interactions Influencing Posttraumatic Growth

Promoting Resilience and Posttraumatic Growth

Promoting Resilience and Posttraumatic Growth Through Community

Meeting These Universal Needs Through SITCAP

Deficit-Based and Strength-Based Thinking

Trauma Integration

Michelle’s Story

Summary

Appendix A: What If? Questions

Appendix B: SITCAP Program Activity Examples

Appendix C: School Recovery Protocol

Appendix D: Resilience Resources for Teachers

About the Authors

References

Author Index

Subject Index

Praise for Working With Grieving and Traumatized Children and Adolescents: Discovering What Matters Most Through Evidence-Based, Sensory Interventions

“In the sea of rhetoric about trauma-informed care, What Matters Most delivers answers that will make a difference to young people right now. This book equips professionals working at all levels with young people impacted by trauma to do their work differently, incorporating one fundamental principle that stands above all else: this work is not about doing to children, but being with children, and empowering them in their own healing journey. From neuroscience to relational practice, this book is the most compelling and practical story about trauma treatment told to date.”

—Kiaras Gharabaghi, PhD, Ryerson University, Toronto, Canada

“This book is a page-turner, a comment usually reserved for action novels. Rich with recent neuroscience findings, the impact of trauma on the brain, case studies, and specific interventions, Working with Grieving and Traumatized Children and Adolescents is a must-have resource for anyone who works with and cares about young people of any age. As a foster care survivor and now a college professor, I am grateful for Steele and Kuban’s contribution.”

—John Seita, EdD, School of Social Work, Michigan State University

“Building on years of developing and researching structured sensory interventions, the authors share poignant stories of resilience, integrate findings from neuroscience and empirical studies, and offer simple and effective interventions that build safe and secure relationships for grieving and traumatized children and teens.”

—Anne L. Stewart, PhD, Professor of Graduate Psychology, James Madison University, and president of the Virginia Association for Play Therapy

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WILLIAM STEELE

To the resilient forces in my life: my wife, son, and daughter, our grandchildren, and the thousands of professionals I have met over the years, who continue to expect the best of themselves in order to foster the strengths and resilience of the grieving and traumatized children they are helping every day.

CAELAN KUBAN

To my daughters, Luscia and Maren, who have allowed me to experience connection, joy, and love. To my mother, Bridget, who gave me not only her sunny disposition but also her unconditional support. And to the many professionals whose time and expertise have enhanced my understanding of what matters most in our efforts to help grieving and traumatized children flourish.

Foreword

Reading Working With Grieving and Traumatized Children and Adolescents is like being blessed with having two wise, seasoned trauma therapists to consult whenever one is in need of support, encouragement, and inspiration. As Bill Steele, founder of the National Institute for Trauma and Loss in Children (TLC), and Caelan Kuban, current director of TLC, emphasize throughout this fine book, their clients have taught them much during their years of practice. Fortunately for the rest of us, the authors have decided to pay it forward by sharing these lessons of hope and resilience with readers.

What I love about this book is that the authors have created a reading experience for us that actually parallels the process of the therapeutic relationship they create with their clients. One indispensable quality of effective therapy is authenticity, and as I read the book, I encountered real people—clients, parents, teachers, and therapists—in every chapter. I was not reading the typical, traditional case studies that characterize so many books on therapy. Those case studies often strike me as formulaic, contrived, analytical, and superficial. They leave me perhaps edified, but rarely moved. Instead, in Working With Grieving and Traumatized Children and Adolescents, I experienced narratives that were told with all the vivid characterizations and dramatic power of short stories. These rich and nuanced accounts rang true in their depth, authenticity, and complexity. They did much more than demonstrate principles; they touched me, stirred my emotions, invited me to care deeply, and ultimately inspired me. By engaging us with such powerful illustrations and narratives, the authors do much more than help us understand important concepts and principles. At a deep and implicit level, we truly get it.

I also love that the book dedicates an entire chapter to the topic of curiosity and celebrates taking the stance of not knowing. As a trainer of therapists, I have discovered that students find it particularly challenging to accept not knowing as an essential condition for successful therapy. After all, aren’t they attending graduate school, studying diligently, and earning their degrees in order to become experts? Setting aside that professional mask and stepping down from that expert pedestal to encounter our clients, to learn from them, and to bear witness to their journey of healing are daunting tasks. However, once students follow the example of Steele and Kuban by taking these risks, they can engage in their own transformative experiences of being truly therapeutic—not merely doing therapy.

Another parallel between the book and the process of therapy is that each chapter of Working With Grieving and Traumatized Children and Adolescents begins and ends in a safe place—just like a successful session. Steele and Kuban also practice what they preach by following the show-and-tell method of their therapy. They first share with us the powerful drawings by clients that give expression to the raw, searing experience of their traumas. The authors then elaborate on these pictures by using words to give voice to their therapeutic narratives.

One particularly disturbing case study reminded me of the classic Harry Harlow studies (1958) on infant rhesus macaque monkeys who were separated from their mothers. Virtually every introductory psychology textbook contains stunning pictures of these poor, traumatized creatures, clinging desperately to their cloth surrogate mothers. What is little known, however, is that a later study, reported by Cozolino (2010), demonstrated that these monkeys were not condemned to a life of profound dysfunction and alienation. In fact, Harlow and Suomi (1971) developed a successful therapy, involving 12 sessions, for these deeply troubled monkeys! The therapists were other monkeys who had been raised with healthy attachments. Although these monkeys were smaller and welcoming, the isolated “clients” reacted with anxiety whenever the “therapists” at first tried to engage with them. However, the gentle touches and persistent overtures of the “therapists” won out as the “clients” began to feel safe and began to interact with them. At the conclusion of the therapy, the initially isolated monkeys successfully joined the colony. I’m willing to bet that most practitioners believed that these monkeys were hopeless cases. Steele and Kuban have dedicated their professional lives to working with similarly supposed hopeless cases and to sharing their invitational, gentle, and nonthreatening manner of drawing out the strengths and nurturing the resilience of their clients.

An unexpected bonus of this book is that readers also gain a greater understanding of neuroscience, including mirror neurons, brain functioning, neural plasticity, and neural pathways. Steele and Kuban artfully introduce neuroscience principles and research findings in the context of their dramatic narratives of trauma and triumph. As a result, instead of inflicting on us a dry treatise on brain functioning, the authors engage us in a mystery in which neuroscience is providing clues into what makes our clients—and us!—tick.

Based on the work of Cozolino (2010) and other neuroscientists, Steele and Kuban highlight how empathic attunement, which is the foundation for a safe and secure relationship, promotes neural plasticity. Such a therapeutic alliance, which activates the processes of attachment, is the optimal chemical environment for creating new neural pathways. They practice a therapy that is based on synchrony and attunement. One of the common slogans of neuroscientists is, “Neurons that fire together, wire together.” In other words, therapy invites the creative expression of previously dissociated, denied, or inhibited thoughts and feelings. This process of working through experiences builds new neural pathways.

Building on the fundamental insight that therapy is a shared here-and-now experience, Steele and Kuban have developed wonderfully creative techniques to help clients express their experiences in modalities other than verbal communication. By immersing their clients in the creative moment and expanding their awareness, Steele and Kuban have enabled traumatized, grieving children and youth to create narratives of resilience and transcendence.

I would also like to mention that the timing of this publication is fortuitous. As the publication of DSM-5 approaches, numerous articles have been written on proposed changes to the PTSD diagnosis. Ever since PTSD was entered into the official psychiatric nosology in 1980, “no other psychiatric diagnosis, with the exception of Dissociative Identity Disorder (a related disorder), has generated so much controversy in the field as to the boundaries of the disorder, diagnostic criteria, central assumptions, clinical utility, and prevalence in various populations” (Spitzer, First, & Wakefield, 2007). In Working With Grieving and Traumatized Children and Adolescents, Steele and Kuban provide a convincing argument for adding a new diagnosis, Developmental Trauma Disorder (DTD), in the DSM-5 (van der Kolk & Pynoos, 2009). The proposal of this diagnosis was based on the findings from developmental psychopathology, the clinical presentations of children and youth exposed to chronic interpersonal violence, and emerging evidence from the field of neurobiology regarding the impact of trauma on brain development. They note that the DSM PTSD criteria were not developmentally sensitive and did not capture clinically relevant symptoms for children living in chronically unsafe conditions. However, the proposed PTSD criteria for DSM-5 would result in inaccurate diagnoses for children who undergo multiple and complex traumas, especially those exposed to harmful caregiving (van der Kolk & Pynoos, 2009). The proposal for DTD was not accepted for inclusion in DSM-5, but thanks to Steele and Kuban, the discussion of the merits of an alternative classification system for children experiencing complex trauma is continuing.

Working With Grieving and Traumatized Children and Adolescents includes many “magical moments” of therapy that practitioners have described to the authors with heartfelt eloquence. Interestingly, in addition to studying the work of therapists, researchers are now beginning to investigate how stage magicians exploit neuroscience to create their illusions. In other words, magicians are just as much practitioners of sleight of mind (Macknik & Martinez-Conde, 2010) as they are of sleight of hand. Although magicians take advantage of neurological processes to trick audiences, therapists use the same processes to enhance neuroplasticity. Consequently, a magic performance can leave a spectator mystified, but therapy can leave a traumatized client transformed.

Speaking of magic, the authors pull off a great trick themselves with this book. While giving detailed instructions and excellent examples of how to help clients reframe their experiences of trauma, Steele and Kuban skillfully guide us readers into reframing our own roles as trauma therapists. By the time we finish their book, we have come to cherish the power of curiosity as a powerful therapeutic tool, to respect the transformative potential of bearing witness rather than dispensing expertise, and to focus on what’s strong rather than what’s wrong with a client. Now, that’s a magic moment!

Lennis G. Echterling

James Madison University

References

Cozolino, L. (2010). The neuroscience of psychotherapy: Healing the social brain (2nd ed.). New York, NY: W. W. Norton.

Harlow, H. F. (1958). The nature of love. American Psychologist, 13, 673–685.

Harlow, H. F., & Suomi, S. J. (1971). Social recovery by isolation-reared monkeys. Proceedings of the National Academy of Sciences, USA, 68, 1534–1538.

Macknik, S. L., & Martinez-Conde, S. (2010). Sleights of mind: What the neuroscience of magic reveals about our everyday deceptions. New York, NY: Picador.

Spitzer, R. L., First, M. B., & Wakefield, J. C. (2007). Saving PTSD from itself in DSM-5. Journal of Anxiety Disorders, 21, 233–241. doi: 10.1016/j.janxdis.2006.09.006

van der Kolk, B. A., & Pynoos, R. (2009). Proposal to include a developmental trauma disorder diagnosis for children and adolescents in DSM-5. Retrieved from www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf

Preface

The mandate coming from both grieving and traumatized children today is to spend time in their world—a sensory world without language—to see what they actually see when they look at themselves, others, and the world as a result of what they have experienced. From their perspective, if we cannot see what they see, feel what they feel, and think what they think, how can we possibly know what matters most in their efforts to remain resilient and flourish despite the troubling and traumatic situations they experience?

The following experiences, and many others, represent the kind of grief- and trauma-inducing situations; varied levels of severity, complexity, and diverse environments; and developmental ranges of children and adolescents that have taught us so much over the past 22 years:

By presenting these survivors with opportunities to bring us into their troubling and traumatic worlds, to see what they saw as they looked at themselves and the world around them, to discover what was driving their challenging behaviors, we learned to abandon traditional intervention processes for structured, sensory-based experiences that evidence-based outcomes and practice history now demonstrate are effective in reducing posttraumatic stress and related mental health symptoms and behaviors.

Advances in neuroscience clearly support rethinking our understanding of grief and trauma and the interventions we practice. The five stages of grief, for example, developed in the late 1960s by Dr. Elisabeth Kubler-Ross, have been used for years to guide the treatment of grief. Today these stages are axiomatic, no longer reflecting the reality of how grief is experienced and processed. Furthermore, neuroscience has clearly documented that trauma is not primarily a cognitive experience but a series of subjective experiences that do not respond well to our use of reason, logic, or talk-based interventions. These advances alter the way we must relate with grieving and traumatized children today.

Becoming a witness to these subjective experiences and helping survivors transform their internal grieving and trauma-specific implicit memories and sensations into concrete, tangible forms in ways that lead to the restoration of their sense of safety, empowerment, and resilience are the strategies we detail in Working With Grieving and Traumatized Children and Adolescents.

A Timely Practical Resource

The detailed, evidence-based intervention strategies we present make this a timely, practical resource for addressing the realities of today’s grieving and traumatized children, adolescents, and adults in schools, agencies, and clinical and community settings. The intervention model presented, SITCAP® (Structured Sensory Interventions for Traumatized Children, Adolescents and Parents), was developed in 1990 by the National Institute for Trauma and Loss in Children (TLC), a nonprofit program of the Starr Global Learning Network, which has been helping children and adolescents flourish for more than 100 years.

Benefiting Survivors and Practitioners in Diverse Settings

Several aspects make Working With Grieving and Traumatized Children and Adolescents unique:

For the Reader

Through the use of vivid characterizations, dramatic short stories, sequential and structured processes, and the integration of training activities used in actual training in the use of the SITCAP model, readers will learn:

We hope that the Magical Moments shared by practitioners in this text and the structured intervention processes we present on our journey into the world of the children’s stories we tell reveal that what matters most in our efforts to help is our ability to provide them with the opportunity to make us a witness to how they are experiencing themselves and their world, while teaching us what matters most to their ongoing efforts to flourish despite the significant losses and trauma they have experienced so young in life.

William Steele

Caelan Kuban

Acknowledgments

We wish to acknowledge Starr Commonwealth and the Starr Global Learning Network staff for their ongoing efforts to help us create practices that help children flourish and for affording us the time needed to prepare this work. Special thanks goes to Deva Ludwig, for all of the technical support and creative encouragement she provided, and to Sarah Slamer, whose assistance with preparing case material was invaluable. We thank Deanne Ginns-Gruenberg, owner of the Self Esteem Bookstore, for allowing us hours and hours to review and learn from the many books authored by others in the field. Naomi Chedd, Licensed Mental Health Counselor and Educational Consultant, in Brookline, Massachusettts, provided a most helpful review and critique of the manuscript. The expertise, support, and recommendations of Rachael Livsey, Senior Editor at John Wiley & Sons provided to us throughout the development and completion of this work were invaluable.

Over the past 20 years, we have had the wonderful opportunity to learn a great deal from thousands of traumatized children and their families. In many ways, they are the authors of this book. We cannot thank them enough for their inspiration, resilience, and guidance in defining what matters most in our efforts to help children heal from grief and trauma. Hundreds of dedicated professionals also volunteered their time to participate in field testing and rigorous research of our evidence-based sensory intervention programs. Their feedback ensured that the intervention processes and activities accomplished what they were intended to accomplish: significant reduction of PTSD and other mental health–related reactions while strengthening the resilience of grieving and traumatized children. We thank them for all of the valuable lessons they have taught us over the years. We also wish to acknowledge the hundreds of school districts, child care agencies, and mental health and community-based programs that have collaborated with us to bring best practices to the grieving and traumatized children, adolescents, and families they serve every day. Their efforts are making a difference.

Chapter One

How Structured, Sensory Interventions Help Grieving and Traumatized Children

This first chapter begins with a brief history of what we learned at the National Institute for Trauma and Loss in Children (TLC) while working with grieving and traumatized children who had been exposed to a variety of violent and nonviolent experiences. Established in 1990, TLC is a program of the Starr Global Learning Network of Starr Commonwealth, which has been helping children and adolescents flourish for the past 100 years. The children taught us what mattered most in their efforts to overcome their painful and overwhelming experiences, which lead to the development of the evidence-based Structured Sensory Interventions for Children, Adolescents and Parents (SITCAP) programs presented in detail in this text. The SITCAP model meets the criteria validating it as a practice-based and an evidence-based intervention model. This criteria and how it is supported by SITCAP is reviewed, as funding sources are more frequently requesting that today’s interventions meet these requirements.

In addition, a distinction is made between nonviolent and violent situations to illustrate that the subjective experiences of children, not the nature of the situation, determine whether the experiences are grief or trauma inducing. This is followed by a very simple yet profound mandate by children and a brief discussion regarding its implications for treatment. This introduction becomes essential to understanding the Core Principle and Key Concepts of SITCAP presented in subsequent chapters. These concepts describe how children’s subjective experiences are revealed and utilized to help diminish the painful, overwhelming, and terrifying reactions they can experience. Similar to Lenore Terr’s (2008) descriptions of magical moments in psychotherapy, we also introduce Magical Moments, those turning points in children’s lives that practitioners using SITCAP shared with us over the years. Magical Moments are featured in each chapter, in addition to Points of Interest, which briefly discuss a variety of subjects pertinent to helping grieving and traumatized children and adolescents. The chapter concludes with a review of two cases and their evidence-based outcomes, supporting the overall benefits experienced by those who have participated in SITCAP over the years.

Was It Grief or Trauma: What Matters Most?

Examining our experiences in the 1970s and 1980s with children, teens, and families who sought help while in crisis—or created a crisis to draw attention to their need for help—revealed what mattered most in our efforts to help. Grief was a common response to their crisis experiences resulting from the losses precipitating their crises—loss involving a loved one to sudden or accidental death, suicide, homicide, domestic violence, sexual and physical abuse, or terminal illness, or loss due to divorce, betrayal of trust in relationships, abandonment, homelessness, or exposure to catastrophic events. In the early 1980s, suicide became an epidemic claiming the lives of youth. At the core of the suicide experience is the loss of value for oneself, the loss of connectedness to any significant person, and the loss created for the family members and friends who are left behind. In the later 1980s, suicide rates remained high; however, violence claimed this unfortunate title of epidemic, reflecting the disturbing ways our children were now experiencing their worlds.

With these losses, we were observing reactions not only associated with grief but also with the posttraumatic stress disorder (PTSD) described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) (APA, 1980). Unfortunately, these criteria, as defined by the DSM-III-R, were specific to adults. The challenge we faced was helping others acknowledge that children could, in fact, experience the reactions attributed to adults at the time. This would not occur until the mid-1990s. Practitioners in the 1980s, for example, observed adult PTSD criteria in adolescent survivors of suicide as well as those who discovered the bodies of those who took their own lives. However, it wasn’t until 1993 and subsequent years that the literature began to acknowledge that discovering the body of a loved one, friend, or peer who had taken their life was traumatic (Brent et al., 1993). The term trauma was not formally assigned to children by the American Psychological Association until 1994, when they were included in the adult-designed PTSD diagnostic category in the DSM-IV (APA, 1994). This inclusion was certainly encouraged by the research that emerged in the 1980s regarding the association of PTSD with suicide and violence among children and adolescents (Pynoos & Eth, 1986; Pynoos et al., 1987).

Despite the various situations that brought children and families to our attention, so many victims showed us that grief and trauma were not necessarily separate entities; they often coexisted. Symptoms could be attributed to both grief and trauma, as we understood them at that time, but also to other disorders, making it difficult to assign treatment based on symptoms alone. What we discovered really mattered the most to those who were grieving and traumatized was not their symptoms, but how they experienced themselves, others, and life following exposure to traumatic events in their lives. TLC was founded in 1990 to develop an intervention process that would be helpful to both grieving and traumatized children and that could be initiated in clinical and community settings and also in schools, where children are the most accessible.

It Is Not the Situation

An Internet search for trauma-informed care yields more than 7 million references. It is safe to say that a great deal of information exists about the prevalence of trauma experienced by children and what constitutes trauma-informed care. The majority of articles regarding trauma consistently cite violence as the primary cause of trauma. There is no doubt that violence does induce severe trauma in children. Most would agree that at least 50% of the children in child welfare and 60% to 70% of youth in the juvenile justice system experience trauma (Hodas, 2006; Kerig & Becker, 2010). However, research began to emerge as early as the 1990s indicating that trauma can also be induced by disasters such as fires (McFarlane, Policansky, & Irwin, 1987), hurricanes (Lonigan, Shannon, Finch, Daugherty, & Taylor, 1991), boating accidents (Yule, 1992), burns, and medical procedures such as bone marrow transplants (Stubner, Nader, Yasuda, Pynoos, & Cohen, 1991). Three million people yearly are involved in car accidents; up to 45% of those injured suffer PTSD (Goodin & Abernathy, 2011). In fact, divorce can also induce trauma when the conditions of that experience leave children vulnerable (Divorce and PTSD, 2012).

We have two reasons for making this distinction between violent and nonviolent situations, which are not the result of direct intent to do harm. First, in comparison to the volumes written about the relationship between violence and trauma, we rarely read about the daily nonviolent trauma-inducing situations in children, such as homelessness. Often, trauma is not screened for in children who are exposed to situations such as a depressed parent, house fires, car fatalities, critical injuries, terminal illnesses, divorce, or victims of bullying and cyber bullying. Second, we must conclude that if both violent and nonviolent situations can induce trauma, then perhaps it is not the situation that induces trauma but how that situation is being experienced that leaves children and youth vulnerable to trauma. If this is true, then it follows that we must first know how children are experiencing what they are exposed to if we want to determine what might be the most helpful and appropriate trauma-informed response.

Children’s Mandate

If you don’t think what I think, feel what I feel, experience what I experience, and 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?

This is a simple yet profoundly wise mandate. When we can appreciate how traumatized children are experiencing themselves, others, and their lives as a result of their experiences, we can assign timely, useful, and appropriate interventions. Resilience research, for example, clearly documents that not everyone exposed to what we might consider to be a trauma-inducing incident is necessarily traumatized by that incident (Bonanno et al., 2002). Assigning an appropriate intervention dictates that we first determine how children are experiencing what they are exposed to if we are to provide an intervention that is not itself traumatizing. In fact, the primary dictate of trauma-informed care is to avoid re-traumatizing, “to do no harm” (Hodas, 2006), by not making assumptions that children must be traumatized by what they have been exposed to or, if traumatized, that all children need the same intervention (Steele & Raider, 2001).

In essence, a situation such as divorce may not be violent or traumatizing for many children. However, even in a nonviolent divorce—one void of physical abuse and threats of bodily harm—if the child’s experience of that divorce involves terror, worry, guilt, feeling powerless, and other subjective experiences associated with trauma, then that divorce may become traumatic. This is why interventions must match how children are experiencing their life events.

Implications for Treatment

The child-driven mandate presented earlier dictates that to be helpful we need to relate to grieving and traumatized children at a sensory level rather than primarily at a cognitive level. What does this mean? Today neuroscience has confirmed that trauma is experienced in the midbrain, the limbic region, sometimes referred to as the “feeling” brain or the “survival” brain, where there is no reason, logic, or language. Reason, logic, and the use of language, to make sense of what has happened, are upper brain cognitive functions that become difficult to access in trauma (Brendtro, Mitchell, & McCall, 2009; Levine & Kline, 2008; Perry, 2009; Schore, 2001; van der Kolk, McFarlane, & Weisaeth, 1996). Neuroscience also shows that “learning anything requires building new neural networks [by] being actively involved in what is being learned” (Fischer, 2012).

For these reasons, we must direct our efforts at helping children with how they are experiencing their worlds, with what they now see when they look at themselves and others as a result of their exposure to trauma. We must engage them in nonverbal, sensory-based experiences that allow them to rework their traumatic memories and their trauma-related sensations, images, and feelings in ways that also allow them to see themselves and their experience as survivors and thrivers, not victims. We must help them to see and experience others as helpful and supportive rather than threatening and unsafe, and to see and experience life as promising rather than continually painful. This goal is difficult to accomplish using cognitive-based interventions alone. If, for example, I experienced something terrifying months earlier and I am now physically safe, but elements in my environment are reminding me of that terrifying experience (my midbrain is being activated by the associated memories), then all of the verbal reassurance in the world will not calm me. I must do something that brings about a sense of safety and calms (deactivates) my midbrain responses to those past memories. Numerous examples and sensory-based activities that restore this sense of safety are presented throughout the book.


A Magical Moment
My magical moment in using SITCAP is about a 7-year-old boy. He had lovely eyes with an eagerness and innocence that shone through. Much of his little life had been filled with turbulence and trauma. He had witnessed violence in his home and had experienced neglect and emotional abuse. In our work together, we had been using many interventions from SITCAP programs. In one session, Shawn (not his real name) was telling me how he would hear his mom and dad fight a lot. I asked if he could show me how that felt in his body when he thought about it now. He drew a picture of a person with a breaking heart and said he felt sad, scared, and worried. We talked about the meaning of each feeling for him and how he experienced it in his body. Then, spontaneously, he drew an image of a worry thermometer. He exclaimed that this thermometer goes from 0 to 100, and that his worries were so big that it was more than 100 degrees, and that the thermometer broke. “That’s how much I worry!” he said.
Shawn then asked me to make a string of paper dolls. He took the paper dolls, and he drew happy faces on all seven of them and asked me to draw hearts on their bodies. He called these dolls the “worry breakers.” He paid special attention to the doll on the far right, calling it “a soldier.” He said that this soldier is the leader, and the rest of the dolls follow to help fight and break worries. As he spoke about the power of these dolls, his eyes widened and his back straightened. I could feel his own power growing as he spoke with confidence about how he might use these dolls in his life when he starts to feel worried. We then noticed the paper that was left over from cutting out the paper dolls looked like a crown. Shawn invited me to assist with drawing hearts and stars on the crown. We then stapled the ends together and, putting it on his head, he reported, “This crown helps with sad feelings!”
We talked about how he and his mom could use his powerful new resources. We walked around the room practicing how it felt to wear the crown and how that felt different in his body and could help with sad and scared feelings. Toward the end of our session, I looked at his picture of the thermometer again and asked if he could show me how he felt now. Shawn took another piece of paper and began drawing purposefully. As he put down his marker, he looked right at me, smiling with his bright green eyes and said, “This is an angel with wings. The angel is very special because it shoots love arrows to all people who need it.” There was a calm presence about him.
As a therapist, SITCAP helps us create a safe holding space, guided by clear clinical interventions. Knowing our own therapeutic map allows us to step aside and let the magic begin to take shape. This little fellow knew what he needed to do. He was following his own magic inside—the kind of magic that allows a beautiful unfolding of a child’s healing path as he journeys toward wholeness of spirit, body, and mind.
Carmen Richardson, MSW, RSW, RCAT, REAT Prairie Institute of Expressive Arts Therapy, Calgary, Alberta, CANADA T3C 0P9

Subjective Experiences Matter

It is well argued and supported by abundant research that traumatized children today are going undiagnosed and misdiagnosed. Trauma symptoms are often mistaken for depression, attention deficit problems, oppositional defiant disorder (ODD), conduct disorder, reactive attachment, and other disorders (van der Kolk et al., 2009). This is partly because of our traditional focus on using symptoms and deficits as criteria for diagnosis, as well as the current, very narrow PTSD diagnosis found in the DSM-IV-TR (APA, 2000).

In 2005 and again in 2010, Robert Pynoos, Bessel van der Kolk, and their colleagues proposed a more relevant trauma category that reflects how traumatized children are presenting today and the abundant documentation neuroscience has provided regarding trauma’s impact on the brain, the body, behavior, learning, and emotions. Although not included in the DSM-5, the proposed Developmental Trauma Disorder (DTD) presents a much more comprehensive, representative, and descriptive view of how traumatized children experience themselves, others, and the world around them as a result of their exposure to traumatic experiences (van der Kolk et al., 2009). It also puts those experiences within a developmental perspective, which is infrequently discussed in the literature. How a divorce is experienced at age 6, for example, is completely different than how it is experienced at age 16. Interventions must be different because of the developmental differences and experiences existing between these two age groups. This is also the case, for example, when a child is chronologically age 10 but developmentally more representative of a 6-year-old. At the time of this writing, the changes being made to the PTSD category in the DSM-5 include (1) a preschool subtype for children ages 6 and under—Posttraumatic Stress Disorder in Preschool Children, (2) a dissociative subtype, and (3) a six-month requirement for children for the bereavement-related subtype (APA, 2012).

Although the proposed DTD category remains under consideration, its focus on the subjective experiences of trauma is critical to appreciating what matters most in our efforts to best understand and respond to traumatized children. In listing the prescribed criteria for exposure, the proposed DTD lists the following subjective experiences of traumatized children: rage, betrayal, fear, resignation, defeat, and shame. In other words, the experiences matter. TLC has always approached trauma as an experience rather than a diagnostic category. The evidence-based SITCAPSITCAP