Review of Dr. Glen Saxe’s presentation on December 8, 2007 -- By Candace Saunders, LICSW
The New England Society for The Treatment of Trauma and Dissociation was honored at its December 2007 meeting to have Dr. Glenn Saxe provide the clinical presentation, “Treating Child Traumatic Stress and Dissociation: The Trauma Systems Therapy Approach.” Dr. Saxe is the Associate Chief of Psychiatry for Research and Development at Children’s Hospital Boston, where he is the director of the Center for Behavioral Science. As a medical student in Canada, Dr. Saxe trained under Dr. George Fraser, a recent recipient of the International Society for the Study of Dissociation’s Distinguished Service Award and its Pierre Janet Writing Award. Dr. Saxe also trained as a resident at Massachusetts Mental Health Center under Dr. Bessel van der Kolk with whom he published “Dissociative Disorders in Psychiatric Inpatients” in The American Journal of Psychiatry,
Dr. Saxe's current research and clinical interests are in the psychological consequences of traumatic events in children. He is the Principal Investigator in several NIMH-funded grants that support his study of post-traumatic stress disorder in children. He is an internationally sought after speaker, whose focus in his lecture for NESTTD was an innovative model of treating severely stressed children, Trauma Systems Therapy, which he and his team have created over the last ten years. This comprehensive treatment model is described in his celebrated book, Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach, co-authored in 2007 with his colleagues Heidi Ellis and Julie Kaplow.
Dr. Saxe refers to Trauma Systems Therapy (TST) as both a clinical and an organizational model of treatment. Central to Dr. Saxe’s thinking is that one cannot effectively treat a chronically stressed child without first recognizing and then bringing some change to the chronic stressors of violence, substance abuse, poverty, neglect, or oppression that impact the moment-to-moment experiences of the child and his/her family. Unique to the Trauma Systems Therapy (TST) approach is its detailed attention not only to treating the dysregulated behaviors of the traumatized child, but also to assessing and attending to the systems on which the child depends for his/her containment. Central to this model are tools for managing the accountability of the team of professionals, whose role it is to bolster this containment using micro and macro levels of intervention. The model provides clear and efficient ways that professionals from mental health, child protective, juvenile justice, and educational organizations can work as a team over time to employ evidenced-based methods of assessing and actively reducing dysregulated stress in children and their families.
Dr Saxe impressively mirrored the countless experiences of members of the audience, who have known the frustration of treating a child with complex PTSD and have felt little control over the chaotic or unattuned environment to which the child returned. It was this huge systemic treatment challenge that Dr. Saxe and his team of researchers at Boston Medical Center became motivated to address in their decade of work with urban children and families. Compared to their suburban counterparts, these families had experienced high levels of exposure to chronic stress while their access to systems of support had been historically and appallingly limited.
Dr. Saxe expounded on his team’s guiding principals for creating their socially and neurobiologically based TST model of assessment and treatment. One principal was that treatment must address amygdala-driven shifts in consciousness of children who present with complex PTSD and dissociative symptoms: it must address their movement from a state of emotional regulation to a state of emotional dysregulation. Two additional guiding principles that he stressed throughout his presentation were that treatment must address the child’s social ecology – the school, neighborhood, agencies, and other systems that impact his/her life – and that it must also address his/her systems of care-- the primary people on whom s/he depends daily for developmental containment.
In elaborating on the first guiding principal of TST, Dr. Saxe used case examples to address patterns of trauma-activated survival circuits in the body and brain, which become reactivated when a child is triggered by conscious and unconscious associations to previously experienced overwhelming stress. He reminded us, “When we think of traumatic stress, we think of survival in the moment.” With complex Post-Traumatic-Stress and dissociation, those survival moments are experienced again and again. In reflecting on his work with urban children and adolescents exposed to chronic trauma, he spoke of the importance of adults understanding children’s survival strategies as exemplified in the reality that “Often a kid who beats up another kid is in that moment fighting for his life.” Dr Saxe’s empathy for the kids he talked about and his commitment to disseminate information about his model in an effort to bring relief and change to these kids was made obvious throughout his presentation.
Dr Saxe shared a specific TST assessment tool for observing and assessing a child’s moment-to-moment experiences of moving from a state of regulation, to dysregulation, and to regulation again. This includes a path of: 1. Feeling regulated; 2. Revving up to needing to engage one’s survival modes; 3. Re-experiencing overwhelming and traumatic disorganization, at which time one’s survival modes are engaged, and one’s circuitry necessary for verbal and conscious thought is automatically shut off; and 4. Reconstitution of feeling regulated, when one’s survival modes are disengaged, and one’s circuitry necessary for verbal and conscious thought is more activated. Dr. Saxe addressed research confirming that, “Survival circuits are regulated by safe and healthy relationships,” supporting our understanding of the importance of attachment relationships in the regulation of child and adult somatic and emotional experiences. TST asks that those in attachment relationships with children pay close attention to and help children change what happens prior to and during the ‘revving up” stage of regulation change. Dr Saxe believes that “if we know the stimulus to the onset of a problem, we can work with that problem… In treatment we want to build in the child and parent capacities to use cognition between the stimulus and response and… we want to diminish the environmental stimuli that create the stress.”
Dr. Saxe invited his audience to consider, “What is it that changes between states of emotional regulation and dysregulation?” – a seemingly simple question, which demands complex considerations. In addressing his teams complex considerations, Dr. Saxe presented “The three A’s” that are central in TST to addressing two critical treatment questions, “As we listen to the description of this child’s presenting problems, what changes occurred in this child as he moved from a state of regulation, to revving up, and to dysregulation?” and “What changes need to occur in order for this child, now and more frequently in the future, to move from a state of dysregulaton to a state of reconstituted regulation?” He proposed that the answers to both questions are the same – what happens in each situation is that there are significant changes in the activity level and balance of the child’s affect, awareness, and attention, which TST calls the three elements of state regulation change – “the three A’s.” The goal of any TST treatment is to gradually help children alter the balance of their “three A’s.” Specific treatment tasks are recommended that help children and their systems of care promote an increase in frontal-lobe-driven capacities to put the breaks on amygdale-driven affect, increase self and other awareness, and pay attention to thoughts and behaviors that serve their healthy functioning and sense of emotional containment.
Unique to TST is an assessment grid with which the clinician determines the appropriate treatment protocol based on an assessment of both the seriousness of a child’s dysregulation (“Regulated, Dysregulation of Emotion, or Dysregulation of Behavior”) and the stability of his/her social environment (“Stable, Distressed, or Threatening.”) TST identifies five potential protocols/phases of treatment -- Surviving, Stabilizing, Enduring, Understanding, and Transcending -- the appropriateness of which are determined by where a child is placed on the grid. The protocols/phases of treatment recommended for two children with similar symptoms indicating dysregulation of behavior would, for example, be very different if one child’s social environment was assessed to be stable and the other’s threatening.
TST identifies seven treatment components used across treatment phases – stabilization on site, services advocacy, psychopharmacology, emotional regulation, cognitive processing, and meaning-making. The recommended inclusion or exclusion of these components within a treatment phase/protocol is determined, again, by the combination of seriousness of emotional dysregulation in the child and stability of care system on which the child depends. Cognitive processing and meaning-making modules, for example, would be excluded from the “Surviving” treatment phase/protocol in which a behaviorally dysregulated child was seen as living in a threatening social environment. Stabilization on site and services advocacy would be the initial treatment components for this child with a goal of other treatment components being possible once the child and his/her environment were stabilized.
Dr. Saxe reminded the audience of the importance of maintaining fidelity to treatment principles. Among those important to him were: staying consistently focused on the goals of treatment; being clear, honest, and direct with the family about the team’s goals; being always proactive regarding the safety of the child; and investing extensive energy in allying with the family before beginning with any treatment plan. What is extremely impressive about Dr. Saxe and his colleagues’ accomplishments in having created this model is that they have taken on the enormous challenge of creating clear and specific step-by-step recommendations not only for the child, but also for the community of adults on whom that child relies. A seeming result is that in the treatment world of chronically stressed clients, where clarity can feel illusive to both the client and professional, the TST model, when closely followed, provides much needed containment, not only for the child and his caretakers, but also for the often under-supported professionals providing the treatment. In being kept focused and accountable by a group of colleagues, professionals are given the opportunity to see changes that bring clarity not only regarding next steps in helping their clients, but also to their own sense of competence and accomplishment. A quote from his brilliantly organized book captures the final points of his presentation, “Interventions need to get to the essence of the problem and stick to it like a dog to a bone, never to let go until the work is done. Interventions must address the numerous barriers that get in the way of families accessing services. This work is not easy.” Dr. Saxe’s investment in promoting The Trauma Systems Therapy approach to make this work a bit easier was extremely compelling.