This is the final installment of my series on trauma gleaned from CALO’s 5th Annual Conference on Trauma, with information presented by Joseph Spinazzola, Ph.D. from JRI in Massachusetts, Steve Sawyer from NVW, and folks from CALO including Rob Gent and Landon Kirk, as well as some general information from the field (towards the end).  In Part 1, I described how trauma creates a “fight or flight” reaction to the world that is based on survival instincts centered in the brain.  In Part 2, I talked about how that overly alert perception guides behaviors, and began the discussion about how those responses should guide treatment.  In Part 3, I will discuss attachment, trauma, treatment, and the path to a healthier emotional life.

A traumatized individual can appear difficult.  Symptoms may range from oppositional behaviors, cognitive disorders, mood instability, aggression, passivity, and/or obsession.  The child may make statements that “don’t make sense” to others (What’s he talking about–that’s not what really happened!)  The child craves “unconditional love” from others, yet ironically that is on the unhealthy end of the continuum of emotional regulation!  That is, the thing they crave the most, love, is also the thing most feared in a traumatized brain.  It is vital to understand that trauma affects relationships in many ways and makes it difficult for healthy attachments to occur.  Even well-intentioned individuals may inadvertantly re-traumatize an individual (a classic example, using a rape kit to test a rape victim).  Treatment modalities for many different types of emotional, psychological, or behavioral conditions often rely on talk therapy or even phase or level systems–yet not one of these is effective with victims of developmental trauma, as the triggers can be subtle or overt, and the response inconsistent and volatile.  Trauma creates a very “in-the-moment” response–fight, flight, or freeze–and as such must be addressed in the moment, and not in a behavioral manner but in a relational (attachment centered) way.

So what does treatment look like?  When does it begin?  How long does it last?  Well, treatment for trauma looks very different from other treatments.  It should begin immediately and in the moment.  And the trauma never “goes away” magically, so effective treatment must guide the individual to build a toolkit that will likely need adjustment from time to time throughout that person’s life–but hopefully, they will be doing many of the adjustments themselves.  This is why good treatment must start immediately, and must be appropriate to trauma, not to behavior alone.

Caregivers for children with trauma need to truly be present–not just physically, but mentally as well.  They need to be ready to attune to the child and follow or lead as needed by the child.  Some might think this sounds like coddling or allowing the child to manipulate the situation, but that cannot be further from the truth–we are talking about substantive changes in brain chemistry and processing that need careful guidance to realign and re-regulate an entire system!  Change is short-lived in trauma, so behavioral interventions might last a day, a week, even a month–but a trigger can undo all that work in a heartbeat!  Thus, therapeutic trauma work is fluid, ongoing, and relational.

Because our emotions are guided by the brain (see Parts 1 and 2), we interact with the world where our brains perceive ourselves to be.  So a good therapist/caregiver must be aware of that child’s perceptions and actions in that moment.  The therapist/caregiver wants to help the child find safe places–unfortunately, the situations they are used to are actually unsafe!  So when they are in a heightened state emotionally, and their feelings are ramped up, the therapist/caregiver needs to help the child by attuning to their needs and their state right now.  Only then can the therapist/caregiver help the child ramp down.  This is not the same as simply “supporting” (Oh, I’m so sorry you feel that way.  Here’s a cookie.), it’s about hearing them and realigning their entire nervous system in the moment.

Oh, really, you may ask, so how do we do that?  We do that by building a relationship of trust and reciprocity, by getting to know them truly and deeply and helping the child get to know themselves, and by helping the child learn how to repair their responses and their relationships in a structured, safe way.  Face to face interactions help us build communication in all aspects of our lives.  It is therefore imperative that we implement communication in treating children with trauma.  Time outs, locked rooms, and isolation have the exact opposite effect and only reinforce that child’s trauma (and the same is true for excessive physical and chemical restraints).  Empathy is the antidote for shame.  A traumatized brain does not process sarcasm, competition, or even praise appropriately or well.  Praise, for example, has to be equal to that child’s self-concept or it becomes confusing and the child thinks you’re lying.

Remember, a healthy brain is relational.  It likes commitment, acceptance, security, attachment, and empathy.  But these require higher order thinking skills, something missing and/or detached in a traumatized brain.  In order to heal, the traumatized brain needs caregivers who can help that brain, slowly, patiently, and in the moment, re-regulate, calm, and realign perception–about what is happening around it as well as to it.  To be effective, care must be trauma informed and therapy trauma focused.  A child needs to develop a feeling and thinking brain connection through understanding feelings (affect literacy), relationships (relational literacy), the body and the brain responses (somatic and nervous system literacy), and nervous system management and entrainment.  Yes, they need to be aware of how their body responds to feelings and learn how to self-soothe in a healthy manner (no more head banging, cutting, or sensation seeking).  Breathing regularly, for example, is actually the best defense to calm the brain (rather than the hyperventilation one often experiences when stressed).  Finally, treatment must include something tangible for the child to hold onto, with a regimen he or she can use daily (the famous toolkit!).

There are many paths to self-regulation.  Trauma system yoga, Heart Math, Neurofeedback, Equine (or other animal) therapy are examples of excellent approaches.  But if a child is truly traumatized and in need of care, intensive treatment that may include residential placement is essential.  In the best residential setting for trauma, trauma work continues 24/7, the same time frame in which trauma is lived by that child.  A close staff to resident ratio allows the child to build at least one trusted relationship, and the opportunity to practice new skills in the moment rather than at prescribed times of the day or the week.  A strong program of any kind must also include family therapy so that the parent or caregiver can develop their own toolkit that will help them rebuild a healthy relationship with their child.

In conclusion, a parent or primary caregiver should never feel ashamed or embarrassed by seeking outside help.  After all, caring for this child can create its own trauma in the parent or caregiver as well.  By seeking help, you acknowledge that you and your child need help overcoming something bigger than both of you.  And by seeking and receiving the right care, you are preparing your child for a healthier emotional life and better relationships, and that treatment, the development of that lifetime toolkit, is priceless.

For more information, I’ve attached some sites that may be of interest to the reader.  This is intended as a guide only, and there is even more information out there!  Nor is this a specific endorsement of specific programs, although there are only a few that specialize in trauma-informed care.