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About the Author
Dr. Caelan Soma, PsyD, LMSW, Starr Commonwealth’s Chief Clinical Officer, provides oversight for all clinical operations and research at Starr Commonwealth.
Dr. Soma provides trauma assessment and trauma-informed, resilience-focused intervention for youth utilizing evidence-based practices, including Starr’s SITCAP® model programs.
She has been involved in helping with the aftermath of disasters such as Sandy Hook, Hurricanes Katrina and Rita and others. She is has authored several books, the most recent, 10 Steps to Create a Trauma-Informed School.
She is an internationally acclaimed speaker and trainer, and is the instructor for many Starr courses, including Children of Trauma and Resilience and Structured Sensory Interventions II. She received her doctorate in clinical psychology at California Southern University, where she received the 2013 CalSouthern President’s Award.
Starr Commonwealth
The Starr Professional Training and Coaching emerges from the vision that: knowledge + empowerment = impact.
Starr provides guidance and expertise to educators, clinicians, and many others who care for children from around the world in the form of research, publications, e-learning courses, in-person trainings, conferences and events, professional certifications, as well as school/organization-wide accreditation. These products and services have been developed through our three key legacy training programs: The National Institute for Trauma and Loss in Children (Starr), Reclaiming Youth International (RYI), and Glasswing (GW).
Introduction
About the Program
Questionnaires
Curriculum
Session One
Session Two
Session Three
Session Four
Session Five
Session Six
Session Seven
Session Eight
Session Nine
References
Table of Contents
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67
73
79
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Introduction
Healing the Experience of Trauma: A Path to Resilience
Healing the Experience of Trauma: A Path to Resilience builds upon and enhances Starr’s evidence based, SITCAP® (Structured Sensory Interventions for Traumatized Children, Adolescents and Parents) model programs and is the result of:
• Advancement in brain science related to the impact of stress and trauma on the developing brain
• Lessons learned from the Adverse Childhood Experiences Study (ACEs)
• Direct practice with at risk and traumatized youth
• Feedback from Starr Certified Trauma Practitioners
• Prioritized use of mind-body skills for emotional regulation
The ACE study has provided us with solid research supporting the connection between trauma and toxic stress with negative implications for both mental and physical health problems. With one out of every four children experiencing trauma and still more living with toxic stress, the ACE study confirms trauma and toxic stress as a public health crisis. It is rare for any child caring professional to meet a child who has experienced only one traumatic event. The unfortunate reality is that many of the youth trauma practitioners serve today experience trauma from multiple exposures or from living in a state of toxic stress.
As trauma-informed practitioners, we learn to ask, “What happened” to better understand a child’s experience rather than label or judge them based upon their symptoms and behavior alone. However, the answers to this question can leave even the most experienced practitioner unsure of how to help. When practitioners ask, “What happened?” stressed and traumatized children respond with answers such as “I don’t know”, “I can’t explain it” “too many things” or “nothing”. Perhaps the child recalls an exhaustive list of trauma and loss. Maybe their life, perceived traumatic to an outsider, is completely normal to them. Family secrets also keep children from sharing their stories. Others, who have experienced pre-verbal trauma, may not even remember what happened. Most children of trauma simply do not have the words to describe their terror.
One of the most important skills a trauma practitioner can have is the ability to understand how chronic exposure(s) to toxic stress shape a traumatized child’s private logic. Private logic, the
way children view themselves, others and the world around them certainly drives their emotions and behavior but does not seal their fate. In fact, trauma practitioners can interrupt the mental and physical health risks children experience following adversity when they help youth process the impact of adverse experiences while also engaging them in new experiences to uncover and create characteristics of resilience. The result is a new lens through which children view themselves and others. When youth integrate all of their experiences and use their bodies as resources for healing, they thrive.
About the Program
The
bad news is trauma is a fact;
the good news is that so is
resilience.
Levine & Kline, 2008
Healing the Trauma Experience: A Path to Resilience is for multiply and chronically stressed and traumatized children and for the practitioners who want to help. This program does not directly ask a child “what happened” but instead keeps children focused on what is happening - how they are experiencing their lives in the present. While helping children manage overwhelming feelings and sensations through activities needed for healing, the program also offers several engaging opportunities to spend time with experiences that foster strength and resilience.
Similar to Starr’s SITCAP® model programs Healing the Experience of Trauma: A Path to Resilience is a sensory-based trauma intervention program and draws from principles included in Somatic Experiencing, developed by Peter Levine. Somatic Experiencing focuses on resolving the symptoms of chronic stress and post-traumatic stress. Its major interventional strategy involves bottom up processing by directing attention to internal sensations, both visceral and musculoskeletal, rather than primarily cognitive or emotional experiences. In other words, interventions target deep brain structures that rule the central nervous system rather than the upper brain structures that are responsible for higher level thinking processes. Instead of reliving trauma experiences through drawing a picture of “what happened” in Healing the Experience of Trauma: A Path to Resilience, the child visits the impact of negative experiences by way of their body sensations and the themes of trauma, as they are experienced in the here and now. This gentle exposure helps promote safety. In addition, the practitioner does not have to ask what happened but rather maintains focus on what is happening in present time. Each session integrates exposure to the more difficult themes of trauma such as worry and anger, with mind-body skills and expressive art activities that provide the child with body based experiences of themes like hope and joy. The activities provide opportunities that allow children to be active participants in uncovering and cultivating their own characteristics of resilience including curiosity, courage, openness to relationships, the ability to set boundaries and body awareness.
Neuroscience and Psychophysiology Support this Program
If a child is living in an activated state, their body is still experiencing a flight and/or fight trauma
response. This could be because 1) they continue to live in a state of toxic stress (i.e. poverty, abuse, bullying) or, 2) the trauma incident is over but their body is still re-experiencing it as if it is still happening. In other words, the child is trying to escape or to fight and neither is working, so they remain in that activated state. Their body naturally wants to return to balance but will not do so until it senses the escape or fight is completed and genuinely experiences sensations associated with calm, safety and goodness.
If the child is living in a collapsed state, they have been trying to escape and/or fight without success – also called the “fold” response. Collapse occurs when someone who has been trying to escape or has been fighting for quite some time has now reached the point of exhaustion. Even though they were not successful in completing their escape or fight, their body shuts down but the unwanted symptoms and reactions of stress and trauma persist.
When exposed to trauma, we enter a state of “arrest”. In the arrest state, our body’s central nervous system engages because we sense that something is wrong. Perhaps we hear a loud noise, see impending danger or feel something physically hurt us. When this happens, the first thing most people (both children and adults) do is to try to get away from whatever is happening that we perceive as dangerous or frightening. We attempt to flee (flight) and if we are successful, the stress system in our body returns to balance. While we may experience some residual symptoms and reactions from the acute stress response, we usually return to our normal state within 4-6 weeks’ time. However, if we are not successful in our attempt to escape, we will then engage in the fight response. Like flight, if we are successful in our fight, the stress system in our body returns to balance. While we may experience some residual symptoms and reactions from the acute stress response, we return to our normal state within 4-6 weeks’ time.
However, if we are NOT successful with the flight and/or fight responses, we continue to try to escape or fight in an effort to resolve our alarming experience. This is why in many cases, we see a person still fighting or trying to escape even though the experience they had is over. In essence, their body continues to respond.
Flee/Flight Symptoms and Reactions
• Running away (from home, school, relationships)
• Feeling alone
• Anxiety/worry
• Not following through with plans, an activity
• Substance abuse
• Eating disorders
• Isolation
• Not sitting still
• Jumpy/nervous
• Not taking a risk
• Perfectionism
Fight Responses
• Oppositional
• Feeling stuck
• Hurt
• Destruction of property
• Defiant
• Helplessness
• Physical and verbal aggression
• Anger
• Fear
• Self-harm
If a person experiences toxic stress, they are constantly trying to escape or fight whatever is happening in life. The incident is never “over.”
In some cases, you may also see a “freeze” response. Freeze responses are also in an attempt to survive or save others and happen without intention, thought or logic.
Freeze Examples
• I will have a chance to escape.
In the wild, animals often play dead when they their survival is threatened. Prey will often move motionless animals to a safe place and return to them later after they have captured others. This gives the animal who is pretending to be dead a chance to flee or escape. A child may think, I will hide under my bed and remain as quiet and still as I can and when he goes to the bathroom, I will run.
• They cannot see me.
When motionless, animals often believe they are invisible. A child may think, if I do not move a muscle, he will not touch me.
• If the predator gets me, he will not harm the others.
A child may think, I will let him get me so my sister will remain safe. There is an analgesic effect when the body engages in the freeze response. Many will report not feeling any pain despite physical assault.
• I cannot feel it. I am numb
A child may think, I did not even feel the pain when it happened, I was bleeding, but I felt nothing.
Core Regulation Network
A network of regulatory systems, called the core regulation network (CRN), is located deep inside the CNS. The CRN consists of the limbic system, autonomic nervous system, reticular activation system and the motor system (Payne, Levine & Crane-Godreau, 2015). This system responds very quickly to arousing or threatening stimuli, with little input from higher-level thought processes. When a person is in the “arrest” state, there is emergency activation of their CRN but compromised access to decision-making or cognition. The core regulation network excels in the short term. Nevertheless, when activated for a prolonged period, it becomes dysregulated. The bottom or deep brain activates while access to higher-level brain structures is impaired.
• Limbic System
The Limbic System includes the amygdala. The amygdala acts like a smoke detector. When stimulated it signals distress.
• Autonomic Nervous System
The Autonomic Nervous System can intensify or calm the activity of the body. This system influences alterations in heart rate, blood flow, respiration rates, hormone and endocrine activity.
• Motor Cortex
The motor cortex tenses or calms muscles in response to input from the limbic and autonomic nervous systems.
• Reticular Activation System
This system involves multiple networks, which trigger arousal through sensory pathways (olfactory, auditory, etc.)
These responses should last only for a short time – but when the Core Regulation Network has prolonged engagement (more than 4-6 weeks) individuals become trapped in this space. They are always on the lookout for danger and often perceive non-threatening stimuli as dangerous. Their heart and respiration rates are high, muscles tense, and they are highly sensitive to sensory inputs.
Many will attempt to complete the loop back to balance for a long time. They will fight, run and/
or numb out. At some point however, the parasympathetic nervous system will kick on and the person will move to a state of collapse. At this point, they have reached complete defeat and exhaustion.
We used to believe there was only one parasympathetic nervous system (PNS) within our Autonomic Nervous System. However, there are actually two branches of the PNS. First, the branch that eventually leads to complete collapse and the other branch that results in feelings of goodness, calm and joy. This branch is the social engagement system (SES).
The Polyvagal Theory
We have learned how the sympathetic nervous system influences activation or arousal. The PNS is deactivating or calming. The polyvagal theory (Porges, 2007) postulates that there are actually two branches of the PNS. The branch that turns on during collapse is the well-known dorsal branch of the PNS. When a person experiences complete exhaustion it is because the dorsal branch of the PNS is activated. However, there is a lesser-known branch of the PNS called the social engagement system. The social engagement system has gained attention in recent years. When the social engagement system is active, rather than a collapse response, it provides a gentle calming response. This is great news for trauma practitioners.
The social engagement system consists mainly of the vagus nerve. The vagus nerve travels from the brain stem via the heart, lungs and esophagus to the stomach. It includes numerous branches. It controls unconscious body reactions like heart rate, breathing, sweating and loss of bladder control under stress. The vagus nerve also orchestrates relaxation, self-soothing, social interaction reactions and fight, flight and freeze responses. It acts as our “reset” button because it tells the body and brain that the threat is over and it can return to calm.
Social engagement and connection help make the vagus nerve accessible. When the muscles of the eyes, ears, throat, and viscera are stimulated so is the vagus nerve (i.e. eye contact, voice and verbal interaction). Other ways to access the vagus nerve are to draw awareness to internal sensations or body movements. For example, being curious about what you imagine to be the person’s inner state (i.e. I imagine that sweatshirt is really soft and comfortable).
The SES governs goodness and belonging. When overly activated or in collapse, it is difficult for a person to access their vagus nerve. In trauma, there is a significant need for social engagement. Nevertheless, at a time when needed, most traumatized individuals do not want to engage with others because their experiences with people have not been or are not rooted in trust or safety. When dominated by shutdown, collapse and fold, traumatized individuals are unavailable for true calming feelings of attachment and even when they are in the company of others, they often feel alone. The activities in Healing the Experience of Trauma help children “reset” their vagus nerve.
Most stressed and traumatized people focus immediately on negative inner states and this increases fear reactions. Levine encourages the drawing of attention to positive, non-aversive inner states, which help bring the Autonomic Nervous System into a less fearful state. This is why the Healing the Experience of Trauma: A Path to Resilience program includes a significant focus and time on body awareness of positive somatic markers and introductions to several relaxation opportunities and positive experiences through body-based activities.
Vagus Nerve
The vagus nerve travels from the brain stem via the heart, lungs and esophagus to the stomach. It includes numerous branches.
It controls unconscious body reactions like heart rate, breathing, sweating and loss of bladder control under stress.
n The vagus nerve orchestrates:
• Relaxation
• Self-soothing
• Social Interaction reactions
• Fight/flight/freeze responses
n Responds positively to tone quality.
n It is our “Reset Button” because it tells the body/brain that the threat is over– return to calm.
n Repeated unregulated stress/trauma freezes the reset button.
FEAR/TRAUMA EXPERIENCE(S)
First Attempt FLIGHT
If Not Successful If Successful
Will attempt to FIGHT
If Not Successful If Successful
Will continue FLIGHT, FRIGHT or FREEZE
This is meant to be a short-term response. If this becomes a long-term response, the core regulation system (CRS) will become dysregulated
The goal of Healing the Experience of Trauma: A Path to Resilience program is to regulate the Autonomic Nervous System and Core Regulation Network by decreasing sympathetic nervous system arousal and activating the social engagement system (vagus nerve) through the use of sensory interventions and mind-body skills including affirmations, journal prompts, body awareness, movement and expressive arts.
Program Format
Today I Feel
Each session begins with the child identifying an emoji that best represents how they feel at that particular time. This should be short and used as an icebreaker. However, it is also a good way to compare how the child reports they are feeling from session to session.
Session Affirmation
Affirmations are statements designed to reiterate or help shift a child’s view of self to one that is positive. Briefly state the affirmation at the beginning of each session and tell the child you will come back to it again at the end of the session. At the end of each session, you will ask the child to reflect upon what the session affirmation means to them. Listen. Validate their responses and offer a brief reflection if needed.
The affirmation acts as an anchor to the positive session theme. There is an affirmation card in each journal session that the child can color in if there is time left in the session. Alternatively, they may cut out the card, take it home with them, and color it on their own.
Mindfulness Activity
The program includes a variety of mindfulness activities including breath work, body awareness, guided imagery, journal prompts and coloring. Each session starts with a mindfulness activity. As the practices are introduced, if there is a certain activity that appeals to youth, you can repeat it during subsequent sessions either in addition to or in place of the mindfulness practice assigned in that particular session.
The best way to explain mindfulness to youth is to tell them mindfulness means paying attention to what is happening right now with kindness and curiosity. Some mindfulness for children experts like to explain mindfulness to children by taking a scientific approach. The following script or a variation of it can be helpful.
When you learn about mindfulness, pretend you are being a scientist. You study your own self and your own mind. You study your thoughts, feelings and body sensations. Like any scientist, you do experiments and you discover things by paying attention to yourself and to what you are doing. For example:
• Perhaps you will discover there is a happy or quiet place inside yourself that you never visited before.
• You might discover ways to calm yourself down and lift your mood when you are upset, angry or sad.
• You might discover ways to be kinder to yourself, others and the world.
Individual Sessions versus Group Sessions
If you are working with a child individually, you may choose only the individual mindfulness activity. However, if you are working with a group, there are group-based mindfulness activities that allow for connection and interaction among group members. You can choose to do one or more of the mindfulness activities in each session. Please note that group mindfulness activities often take more time than those done individually but are an excellent way to foster connections between group members which is another way to activate their social engagement system. The group mindfulness sessions are playful, non-intrusive and offer meaningful yet safe interactions between participants.
Body Maps
In each session, the child will check in with their body using a body map to see what kinds of signals their body gives them. The more the child practices, the easier it will become. This activity is so important that is done twice in each session. Complete each body map as indicated in each session. Each body map will focus upon a different theme and sensation to help the child pendulate between the session themes. This practice is an excellent way to reset the vagus nerve and practice body awareness. It is hard to manage emotions and behavior if children do not learn how to pay attention to the cues their body provides. Paying attention to body sensations is the foundation of body awareness. The more a child checks in and listens to their body, the easier it will be for them to regulate how they feel and act at home, in school and with friends. This practice will help.
Body awareness MUST come before emotional regulation.
Remember:
• Awareness first, and then teach regulation strategies.
• Awareness first, and then practice regulation strategies.
• Awareness first, only then can you expect to see emotional regulation
This is not a process to rush. Spending time with body awareness will be worth the time and effort.
It is important that we teach each child the difference between feelings and sensations. There is a script for this in the first session but it is always a good idea to repeat this concept as often as necessary. Here is an introduction for you.
A feeling is the name we give to describe a sensation or group of sensations we experience in our body.
An example of a feeling is SAD. An example of sensations that describe the feeling of SAD might include things like a heavy head, watery and hot eyes, a sinking chest or nauseous stomach.
There is a chart on page 13 that lists different words and icons to refer to when looking for words to label feelings. There is a chart on page 14 that lists different words and icons to refer to when looking for words to describe sensations.
