Chapter   1

Introduction

Trauma Systems Therapy (TST) for

child traumatic stress

Icons Used in this Chapter

Essential Point Academic Point Quotation Case Discussion

L E A R N I N G O B J E C T I V E S

To introduce Trauma Systems Therapy for child traumatic stress

To outline the four goals of this intervention approach

To provide a guide for the rest of this book

T R A U M A S Y S T E M S T H E R A P Y

Gerald is a thirteen year-old boy who lives with his mother and sixteen

year- old brother. His father is in prison for attempted murder of Gerald’s

mother. Gerald witnessed his father stabbing his mother two years

previously. His father was imprisoned for this episode but Gerald and his

brother had witnessed many instances of domestic violence prior to this

time. Gerald’s mother has a long history of Major Depression and is currently

quite depressed, staying in bed throughout most of the day. His brother has been

arrested numerous times for assault and for car theft. Gerald’s brother has also

severely assaulted his mother on two occasions. Gerald’s mother is terrified to

set a limit on her older son’s behavior for fear of being assaulted. Gerald and his

brother do not get along. There are frequent arguments at home that have

escalated to fist fights. Gerald has been knocked unconscious by his brother and

is perpetually in fear that his brother will “lose it” again. Gerald has frequent

intrusive memories of witnessing domestic violence, he is vigilant about being

assaulted, and has exaggerated startle response. He has poor sleep with frequent

nightmares and very poor concentration. He failed the sixth grade as he found it

hard to focus on school. He is at risk for failing the sixth grade again this year

and has told his therapist that if he fails school again he intends to kill himself.

hat do you do? What do you say? Where do you begin? If

you are like most mental health clinicians in the United

States you work out of your office or a mental health clinic.

The story of Gerald is probably very familiar to you. In your

caseload, there are probably five Gerald’s. You see him for

his first intake appointment. Perhaps you see him again for a follow-up

visit. If you end up treating Gerald his attendance is spotty. He is here

a few sessions, gone for weeks or months at a time. If he attends

regularly you are faced with the real question: HOW CAN I HELP??!!!

Does Gerald have cognitive distortions that need correcting? Does he

have serotonin receptors that need blocking? Does he have conflicts

that need interpreting? Does he have avoidance that needs exposing?

Does he have eye movements that need desensitizing? Maybe… but…

anything that you do; any distortion that you challenge; any

interpretations that you make; any medication that you prescribe; any

learning that you condition…is undermined as soon as Gerald leaves your

office. What do you do?

Gerald travels through the system. He is seen in emergency rooms,

residential programs, inpatient units, and outpatient clinics. His care

W

T R A U M A S Y S T E M S T H E R A P Y

involves mental health, education, social service, and soon the juvenile

justice systems. If you are assigned to treat Gerald than you know that

sensible treatment requires a lot of integration with each of these

systems. But who has time for that? He is hospitalized and you see him

again. His medications are changed but, for the life of you, you cannot

figure out what “they” did in the hospital. He is failing school. You’ve

gone to a few school meetings and explained about the stress and chaos

in Gerald’s life. The teachers are tired, and they have to think about

the other kids in the class. They don’t really know what to do. Gerald is

missing school. He is missing appointments. You consider “closing the

case” but just can’t bear to do it. You’ve filed a couple of reports with

the department of social services but they are “screened out”. What

do you do??

There are no easy answers

We wish it were easy. We wish there was that one medication. We wish

there was that twelve-step, eight-session therapy that would make

Gerald’s nightmare go away. We know that you wish it too. Sadly, what

has created Gerald’s nightmare is years of trauma, abuse, and neglect;

some of which is ongoing. Real intervention will require rolling up your

sleeves and helping to address the reality of Gerald’s problems. But

how?

This book is about an intervention model that attempts to address

Gerald’s needs and the tragic needs of children like him. Accordingly,

intervention needs to be complex, focused, and intensive. It must be in

the home, in the school, and in the neighborhood. 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. It requires a lot of energy on the part of

clinicians and a lot of support of clinicians from mental health agencies

and service systems. Obviously, this type of work exists in a system

that is far, far, from perfect. There are enormous public policy

concerns related to how services are delivered to traumatized children

and how the service system is organized. Nevertheless, there are

We wish it were easy.

We wish there was that

one medication. We

wish there was that

twelve-step, eightsession

therapy that

would make Gerald’s

nightmare go away. We

know that you wish it

too.

T R A U M A S Y S T E M S T H E R A P Y

existing services in place in most states that can be maximized for

effective treatment. This book is about using these existing services in

a coherent treatment model aimed at maximizing effectiveness.

This book also tries to address the realities of clinicians practice.

What are these realities?

“extra” time or resources to enhance treatment.

has few funds for the “extras” such as staff training,

supervision, outcome monitoring, or home based care.

fragmented, with insufficient communication between

departments and inadequate cross system service plans for

children with traumatic stress.

We designed our intervention model with the needs of children with

traumatic stress in mind constrained by the realities of clinical practice

in the United States at this particular time. Accordingly, we designed

this intervention using services that are available in most states.

The answers we propose are not “easy”; how can they be? We offer a

series of solutions that are in no way perfect. Service delivery takes

place in a service system that is resource poor and is problematic in

many ways. Nevertheless, we believe that the solutions we propose will

be very helpful for mental health clinicians, agencies, and possibly even

service systems as we all try to figure out what to do for children like

Gerald.

Who are we?

We are mental health clinicians, researchers, and educators at the

Boston University Medical Center, Boston’s inner city hospital.

Accordingly, the children and families we serve contend with

considerable social problems such as poverty, community violence,

parental mental illness and substance abuse, homelessness, and racism.

We designed our

intervention model with

the needs of children

with traumatic stress in

mind constrained by the

realities of clinical

practice in the United

States at this

particular time.

T R A U M A S Y S T E M S T H E R A P Y

Our hospital is a magnet for families that have immigrated to the

United States from around the world. Consequently we see many

children and families who have experienced war and political violence.

We are also a Level 4 trauma center and see most of Boston’s children

who are injured from assault or otherwise. Many of the families we

serve are highly traumatized. Ten percent of children seen in our

primary care clinic reported seeing a shooting or stabbing before they

were six years old (Taylor et. al. 1994). Sixty-two percent of

adolescents seen in our emergency room (for any reason) reported a

history of experiencing or witnessing violent physical or sexual assault

(Kassner et. al, 1999).

We have been trying to help our children and families for many years.

Our child psychiatry mental health clinic has been in operation since

the early 1960’s. We had been trying to do our best for these families

with outpatient therapy, including what is considered “empirically

validated” treatments and the highest quality psychopharmacology.

About five or six years ago, faced with the frustration of the clinician

assigned to Gerald (and a great many other children like him) we began

to ask a simple question; are we helping? We were not able to provide a

clear answer to that question. Further, we were getting burned out.

Our staff turnover rate was high. People were very frustrated. Frankly,

it was feeling like we were banging our heads against the wall trying to

help. We began to initiate a process of figuring out how we could do

better. This book is a result of that process. On the way we

investigated many different types of treatments and services for

children. We also wanted our work to be helpful to others and so have

worked with many people to try to operationalize our ideas into a useable

format.

A huge catalyst for our efforts was our funding at the end of 2001 as

an Intervention Development and Evaluation Center as part of the new

this Network is the nation’s primary response to the problem of

traumatic stress in children and provides the funding and

infrastructure to develop new treatments. After we received this

funding our efforts to develop a treatment model to approach the

We began to ask a

simple question; are we

helping? We were not

able to provide a clear

answer to that

question.

T R A U M A S Y S T E M S T H E R A P Y

clinical realities of children like Gerald was conducted as part of our

What is Trauma Systems Therapy?

Traumatic stress occurs when a child is unable to regulate emotional

states. This happens when the brains way of processing emotion is

disturbed. We will talk a lot more about this in chapters 2 and 3. For

now it is very important to know that these core problems regulating

emotional states are highly reactive to ongoing stresses and threats

within the social environment. Because clinic- and office-based

practices are removed from the social environment, they frequently

are powerless to intervene with the very factors that drive children’s

traumatic stress symptoms.

Our treatment is about interventions in what we call a Trauma System.

A Trauma System describes the failure of the natural systemic balance

between the developing child and their social environment. As has been

described for decades in the child development literature, healthy

development requires a regulatory balance or “goodness of fit” between

the child and their social environment such that the social environment

is properly equipped to help the child. When children enter service

systems this “goodness of fit” includes the system of care. A Trauma

System occurs when there is a failure of this regulatory balance

between the traumatized child and their social/environment and/or

system of care.

A Trauma System is defined by

1) a traumatized child who has difficulty regulating emotional states

and;

2) a social environment and/or system of care that is not able to help

the child to regulate these emotional states.

Trauma Systems Therapy details an approach to assessing this “fit”

between the child’s emotional regulation capacities and adequacy of the

of interacting,

interrelated, or

interdependent

elements forming a

complex whole.

The American Heritage®

Dictionary, Fourth Edition

Copyright © 2000 by Houghton

Mifflin Company.

T R A U M A S Y S T E M S T H E R A P Y

social environment/system of care to help the child and offers a

variety of treatment modules based on the outcome of this

assessment. We designed our intervention approach to help with the

severe problems in children’ environments and do this work consistent

with principles of child development and systems of care. We designed

our intervention approach with children like Gerald in mind.

Existing interventions do not offer clear approaches for these severe

social environmental problems informed by theory about the way the

social environment and the developing child-interact. As will be

described below, and repeated throughout this book, our treatment is

about helping two core problems of the Trauma System; a child with

dysregulated emotional states and a social environment/system-of care

that is unable to help the child to regulate these emotional states. Our

intervention intensively targets the Trauma System. That is why we call

Four Goals of the Development of TST

We designed our intervention approach to help with the severe

problems in children’ environments and do this work consistent with

principles of child development and systems of care. We designed our

intervention approach with children like Gerald in mind. Specifically, we

set four goals for designing this intervention:

1. Treatment must be developmentally informed.

3. Treatment must be compatible with systems of care.

4. Treatment must be disseminate-able.

T R A U M A S Y S T E M S T H E R A P Y

What does this mean??

1) Treatment must be Developmentally Informed

In order to treat Gerald you need to know certain basic

principles about child development. You need to know that

the types of interventions effective for a six year old are

very different than for a sixteen year old, and also that a

treatment of a child with developmental delays looks different from a

child without them. You must consider how such areas as attachments,

emotional regulation, identity, and cognition at different ages may be

approached in treatment.

These ideas are very important for a child like Gerald. What type of

attachment relationships might develop for a child with a depressed

mother and a very violent father and brother? What does it do to the

sense of identity of a 13 year-old boy to have a father in prison and to

have witnessed his father beating up his mother and brother? What

does it do to his sense of identity, self-esteem, and feelings of control

to have been beaten up by his father? How do these experiences, and

their influence on attachments and identity formation influence

Gerald’s ability to regulate emotion? What type of peer groups is he

likely to have? How does growing up in terror affect cognitive

development and school performance? These types of questions need

to be asked and answered in order to sensibly treat Gerald. In

chapters 2, 3, and 4, we describe the developmental principles upon

which our intervention approach is based.

The developmental principles guiding our intervention approach was

most specifically outlined in a report by the Institute of Medicine and

the Medical Research Council in 2000 called, From Neurons to

Neighborhoods: The Science of Early Child Development. This report

describes the science of child development from the earliest years.

This report integrates ideas about attachment, emotional, cognitive

development, and identity in interventions for children. In particular,

this report describes the influence of adverse environments on these

developmental areas and the critically important interacting

What does it do to the

sense of identity of a

13 year-old boy to have

a father in prison and

to have witnessed his

father beating up his

mother and brother?

T R A U M A S Y S T E M S T H E R A P Y

relationship between the environment and the developing brain. More

details about this report are provided in chapter 2.

address the social ecology. If your treatment is only in

your office you will be spinning your wheels for a very long

time. If you try to approach Gerald’s family problems by

scheduling the occasional family meeting you will probably not help very

much. Gerald’s problems require treatments on-site and which directly

address the social environmental contributors to the problem. Often

families of children with traumatic stress experience significant

barriers towards receiving appropriate care. Intervention approaches,

accordingly, must be flexible enough to surmount these barriers.

Perhaps the most successful intervention model to directly

address the social ecology is Multisystemic therapy (MST)

for conduct disorder (Henggeler et.al, 1998). MST uses

community-based interventions to specifically target areas

of a child’s environment that are theoretically related to the

development and maintenance of conduct problems. MST has

demonstrated effectiveness for aggressive children by successfully

targeting many fields in which the child interacts for intervention; "the

child and family, school, work, peer, community, and cultural institutions

are viewed as interconnected systems with dynamic and reciprocal

influences on the behavior of family members” and are, thus, engaged

in the treatment process (Henggeler et al., 1995, p. 710). MST targets

child and family problems in the multiple systems in which families are

embedded and delivers treatments in the settings in which they are

likely to have the highest impact. Services are delivered in a variety of

settings, such as home, school, and the community.

How could you approach Gerald’s mental health problems from the

distance of a clinic or office? His severe traumatic stress symptoms

are highly reactive to conflicts and threats from his brother. His

mother is too depressed to intervene or to reasonably engage in clinic

or office based treatment. The consequences of these traumatic

If your treatment is

only in your office you

will be spinning your

wheels for a very long

time.

How could you approach

Gerald’s mental health

problems from the

distance of a clinic or

office?

T R A U M A S Y S T E M S T H E R A P Y

stress symptoms severely affect school performance. Communitybased

interventions are essential for a child like Gerald.

protect him by engaging the police, the social service agencies,

relatives, or whomever may help.

that she receives treatment for depression so that she can

better protect Gerald.

other school staff about how to best teach him and help with

the construction of an individualized educational plan.

The failure of two school years, for a child like Gerald (who has normal

intelligence), is a tragedy. Chapter 4, 10, 11, and 12 offers details about

the way in which the social environment can be engaged in traumatic

stress care.

2. Treatment must be compatible with the system of care

In order to treat Gerald you must be able to clearly link his

treatment with the wider system of care. This is not easy

given how fragmented this system has become.

Nevertheless, as we will describe in chapters 4, 11, and 12

there are a number of tools that can help. Gerald, like many children

with traumatic stress, is seen in many different service systems.

Within the mental health system, children like Gerald often drift

between the inpatient, outpatient, residential, and emergency

psychiatry systems. Gerald is currently treated in an outpatient

setting. If his suicidal impulses increase he may be seen in the

emergency or inpatient psychiatry systems. If his mother continues to

be too incapacitated to protect him, the social services and residential

systems may become necessary. There is a clear and reciprocal

relationship between his emotional symptoms and his school functioning.

His traumatic stress related anxiety and poor concentration have

interfered with his performance at school. This poor school

In order to treat

Gerald you must be able

clearly link his

treatment with the

wider system of care.

T R A U M A S Y S T E M S T H E R A P Y

performance, in turn, has contributed to low self-esteem and suicidal

impulses. It is hard to imagine a sensible treatment plan that does not

fully integrate the educational system.

Clearly, there is a great need for service integration for traumatized

children. There is widespread acknowledgement of the need to create

integrated systems of care for vulnerable, especially traumatized

children. The surgeon general’s report on mental health specifically

identifies the need for services integration:

The organization of services…is the linchpin of

effective treatment…it is not just services in

isolation but the delivery system as a whole, that

dictates the outcome of treatment. Among the

fundamental elements of effective service delivery are

integrated community-based services, continuity of

providers and treatments, and culturally sensitive and high

quality empowering services (Report of the Surgeon

General, 1999)

Our overall approach has been strongly influenced by

the important national Child and Adolescent Service

System Program (CASSP) (Stroul and Friedman, 1986;

Pumariega & Winters, 2003). This initiative was

developed to guide states and communities in the development of

community-based systems of care for vulnerable children and

outlines a number of important “guiding principles” of effective

community-based intervention (Stroul and Friedman, 1986). These

guiding principles concern the need to create individualized, familyoriented

services for children which address the child’s physical,

emotional, social, and educational needs. These services are

“integrated, with linkages between child-care agencies and the

programs and mechanisms for planning, developing, and coordinating

services” and involve case management to coordinate the broad

array of services that children might receive. More details about

the CASSP initiative and systems of care are provided in chapter 4.

T R A U M A S Y S T E M S T H E R A P Y

What would an integrated and highly coordinated array of communitybased

services look like for traumatized children? How might the

specificity of trauma-related psychopathology guide the development

of this array of services? What types of problems would be most likely

to change as a result of these services? Our intervention model is

designed towards such an integrated and highly coordinated system of

services for an individual traumatized child guided by the specific

understandings of the nature of child traumatic stress.

This model views the development of traumatic stress in children as

resulting from two main elements:

1. a traumatized child who is unable to regulate emotional

states when confronted with a stressor and;

2. a social environment and/or a system of care that is unable to

adequately help the child regulate these emotional states

Our treatment is explicitly about these two core problems, a

dysregulated emotional nervous system and a social

environment/system-of care that is unable to help the child to regulate

emotion. As the social environment (e.g. family, school, peer group,

neighborhood) ordinarily has a core function of helping a child to

contain emotions or behavior, it is assumed that a child’s inability to

contain emotions or behavior means there is a diminished capacity of

one or more levels of the social environment to help the child. Similarly,

a child who is unable to regulate emotional states also implies an

inadequacy of the system of care to help the child to contain emotions

or behaviors. This is either because the child has not yet accessed the

system of care, because the child is “falling through the cracks” or

because the services the child is receiving are in some way insufficient

to help contain emotions or behavior.

What would an

integrated and highly

coordinated array of

community-based

services look like for

traumatized children?

T R A U M A S Y S T E M S T H E R A P Y

Our intervention approach can be seen as a guide for how

services and interventions ought to be put together given a

child’s emotional regulation capacities and the ability of the

child’s social environment and/or system of care to help him

regulate emotion.

3. Treatment must be Disseminate-able

In order to treat Gerald you must be able to work within

an agency or service system that supports and pays for

this treatment. It is critical that new interventions are

developed mindful of the financial and human realities of

the clinicians, agencies, and service systems that will use them. It is

relatively easy to design a “pie-in-the-sky” intervention model that is

prohibitively expensive to use. A new intervention must be

disseminate-able. It must be described in a clear way and address the

clinical realities of practice in this time and place and also incorporate

strategies for supporting clinicians in this difficult work. Chapter 8 will

review some of these strategies for supporting clinicians.

We designed this intervention model with the needs of children with

traumatic stress in mind constrained by the realities of clinical practice

in the United States at this particular time. Accordingly, we designed

this intervention using services that are available in most states. A

multidisciplinary team of clinicians assesses and treats all referred

children. This team is typical of most multidisciplinary teams of

psychiatrists, psychologists, and social workers, with three exceptions:

a. It has the capacity to deliver home and community-based

interventions in addition to clinic-based treatment,

b. It includes a child advocacy attorney who serves a key

consultative role for advocacy for services, and

c. It functions from a very specific and operationalized model of

assessment and treatment.

In order to treat

Gerald you must be able

to work within an

agency or service

system that supports

and pays for this

treatment.

T R A U M A S Y S T E M S T H E R A P Y

The enhancement of treatment with the aforementioned “exceptions”

to usual practice was chosen in a way that could be implemented with

limited extra resources.

a. Home and community-based interventions: Most states fund

short-term home based intervention. We integrated a homebased

team funded by the Commonwealth of Massachusetts

Medicaid contract with a conventional multidisciplinary clinical

team. This enhancement did not cost extra resources.

b. Child Advocacy Attorney: This critical member of our team was

paid for via “extra” grant funds. There are however, many

partnerships that could be forged between mental health and

legal aid clinics.

c. Model of assessment and treatment: Most of the rest of this

book is devoted to our description of our model of assessment

and treatment. This model is about a map for how services and

interventions ought to be assembled. Our main aim in this regard

is clinical utility.

What’s New in TST?

There are already a number of good treatments out there for child

traumatic stress. We believe our main innovation is to create an

intervention that allows clinicians to think beyond their office. When

interventions are conceived that directly address the social

environment and system of care and specifically focus these

interventions on the child’s core problems regulating emotional states

there is a much higher likelihood of effectiveness. Existing

interventions for traumatic stress do not pull the social environment

and system-of-care into treatment sufficiently. Other people have

expressed some of these ideas, in other ways, in other formats. We

believe one of our main innovations is to pull together these ideas into a

useful, focused, and testable framework for treating children with

traumatic stress. There have been many ideas that have deeply

influenced our thinking; these include:

We believe our main

innovation is to create

an intervention that

allows clinicians to think

beyond their office.

T R A U M A S Y S T E M S T H E R A P Y

As described, we have been particularly influenced by ideas about how

the social environment and the child’s developing nervous system

interact. As described, the Institute of Medicine’s From Neuron’s to

Neighborhoods Report (2000) contains very compelling ideas on this

topic. This report is reviewed in more detail in chapter 2.

Developmental ideas regarding attachment and about self-regulation

have also been very important to our approach. Frank Putnam’s (1997)

concepts about discrete emotional states in traumatized children based

on the infant developmental work of Peter Wolff (1984) are reviewed

in chapter 3. Allan Schore’s work on attachment, self-regulation and

the brain (1994, 2003a, 2003b) have also strongly influenced our

thinking as well as Robert Pynoos’ Developmental Psychopathology model

of traumatic stress (1993, 1995), Bessel van der Kolk’s ideas about

trauma and self regulation (1994a, 1994b, 1996), and Bruce Perry

(1995, 1998) and Michael DeBellis’ (1999a, 1999b) ideas about trauma

and the developing brain. Barry Zuckerman’s (1995, 2000) work on

translating developmental ideas to public policy has also been very

important.

Joseph LeDoux’ books The Emotional Brain (1998) and the Synaptic

Self (2002) have affected our thinking about how trauma influences

emotional processing. This is reviewed in chapter 2. Other influences

include Antonio Damasio (1999), Stephen Porges (1995), Jaak Panksepp

(1998), Alan Schore (1994, 2003a, 2003b), and Bruce McEwen (1994).

The Social Ecological model of mental health by Yuri Bronfenbrenner

(1979) is reviewed in chapter 2 and chapter 4 and is fundamental to our

treatment approach as is Bronfenbrenner’s extension of this model

(with Steven Cici) (1994) to the interface between the brain and the

social ecology. These ideas have been extended to traumatic stress by

Cicchetti and Lynch (1993), Mary Harvey (1995), and Anne Kazak

(1996).

T R A U M A S Y S T E M S T H E R A P Y

As described, Scott Henggeler and colleagues have been most

successful about applying this model to child services with the

development of Multisystemic Therapy (1995, 1998). This model is

pioneering and has strongly influenced the way that we operationalize

treatment.

The CASSP initiative (Stroul & Freedman, 1986; Pumariega & Winters,

2003) as reviewed above, has had a great influence on our thinking

about the interface between our interventions and child service

systems as well as how the system-of-care ought to be assessed and

assembled.

Ideas about developing empirically validated interventions for

traumatic stress are fundamental for how we have constructed our

treatment approach. This effort most notably includes the work of

Terry Keane, John Fairbank and colleagues (1989), Edna Foa (1991), and

Patti Resick (1992). This work applied to children includes the work of

Bill Salzman and Christopher Layne (2001), Esther Deblinger (1990),

Judy Cohen and Tony Manarino (1996, 2000), and John March and Lisa

Amaya Jackson (1998), and Beverly James (1988). We have been

particularly influenced by interventions aimed at enhancing emotional

regulation such as the work of Marsha Linehan (1993) and Marylene

Cloitre (2002).

We are also especially excited to include ideas on treatment initially

suggested by Victor Frankl (1959). Frankl’s books, particularly Man’s

Search for Meaning, based on his experiences as a concentration camp

survivor, are about developing psychotherapeutic approaches to trauma.

These ideas have been hugely influential in the popular culture but are

almost never discussed in academic circles. Our chapter 15 (“Meaning-

Making Skills”) is largely about operationalizing these ideas and

including them in our treatment approach.

T R A U M A S Y S T E M S T H E R A P Y

The brain is plastic. Just as adverse events can harm the brain, positive

events can help the brain. We have been strongly influenced by the

recent movement in the mental health field to consider psychosocial

interventions as possible psychobiological treatments by enhancing

brain functioning. This movement was lead by Eric Kandel (1998) in his

seminal paper called A New Intellectual Framework for Psychiatry.

Insofar as our words produce changes in our

patient’s minds, it is likely that these

psychotherapeutic interventions produce

changes in the patient’s brains. From this

perspective the biological and the sociopsychological

approaches are joined (Kandel, 1998, p. 466).

Implementation of Trauma Systems Therapy

Trauma Systems Therapy has successfully been implemented in the

City of Boston and in rural New York State. Our initial outcome study

has been published as an open treatment trial and shows very promising

effects with the initial 110 families from Boston or New York State

over six months. This outcome study showed significant decreases in

traumatic stress symptoms, emotional and behavioral dysregulation, and

an increased stability of the child’s social environment. Importantly,

sixty percent of these families started in the intensive home and

community-based treatment phases of TST; and forty percent started

in the less intense, office and clinic based phases of treatment. These

percentages were exactly reversed at the end of six months when only

forty percent needed intensive home and community-based care and

sixty percent needed office or clinic based-care (Saxe et. al, 2005).

At the time of this writing there are eight additional agencies from

across the United States that are being trained to implement Trauma

Systems Therapy. It is important to note that there is great flexibility

about how a given agency may implement TST. Agencies use broad

T R A U M A S Y S T E M S T H E R A P Y

latitude about the type of services that can fit ‘under the TST

umbrella’ and use a lot of creativity about forming partnerships and

collaborations between agencies to get the right services configuration

under this umbrella.

We believe this type of latitude and collaborative creativity is

extremely important. TST has been in development over seven or eight

years as a highly iterative process. Ideas were tried, kept, or discarded

based on their clinical usefulness. It is our sincere hope that many

different agencies will try TST and adapt it based on their own needs.

We would be very glad to learn and to try your innovations to TST. We

strongly believe that TST sets forth some valuable tools but that

utility emerges over time and with diversity of experience. That is a

long way of saying that we do not believe that TST is the final answer.

We welcome you along on our ride…

Outline of the Trauma Systems Therapy (TST) Manual

This book is to be read as a manual for implementing the

stress. The book has three sections:

A- Foundations,

B- Getting Started,

C- Doing TST.

Section A (chapters 2 through 5) describes the theoretical background

describes practical elements of assessment, treatment planning, and

(chapters 10 through 16) describes the different treatment modules

that offer a hands-on, practical approach to intervention. These

chapters are:

T R A U M A S Y S T E M S T H E R A P Y

This chapter describes the interaction between the developing nervous

system and the social environment for producing the problems of

traumatic stress.

This chapter provides an outline for how traumatic stress problems

are, at their core, a definable inability of a child to regulate emotional

states in the face of stressors.

This chapter offers an account of the various interacting levels of the

social environment including the family, school, peer group,

neighborhood, and culture. We focus on how these areas of the social

environment can serve to promote, or diminish, the self-regulation

capacities of the child and how service systems ought to work to

promote these capacities.

This chapter offers a description of the critical role of the

therapeutic relationship for traumatic stress care. This chapter notes

the importance of building a therapeutic alliance and how to use

information derived from the therapeutic relationship to guide

treatment.

This chapter outlines the ten principles that anchor TST treatment.

These principles are shown in table one:

1. Fix a broken system

T R A U M A S Y S T E M S T H E R A P Y

2. Safety first

3. Clear plans come from clear evidence

4. Don’t “Go” before you are “Ready”

5. Put scarce resources where they’ll work

6. Insist on accountability, particularly your own

7. Align with reality

8. Take care of yourself, and your team

9. Build from strength

10. Leave a better system

Table 1: Ten Treatment Principles

This chapter offers a clear approach to assessing the interface

between a child’s self regulation capacities and the social

environment/system-of-care. This assessment approach leads to the

approach to treatment planning.

This chapter offers ways of organizing treatment based on our

approach to assessment. Briefly, this is a phase-oriented treatment

with each phase corresponding to various degrees of the child’s

regulation capacities and the stability of the social environment.

This chapter describes the importance of having a multidisciplinary

team. It describes strategies for creating a supportive team

environment, the role in the team in maintaining treatment fidelity and

therapist commitment and energy.

The remaining chapters of the manual offer “hands-on” guidelines for

providing different types of interventions depending on the assessed

degree of self regulation the child displays and stability that is

contained in the child’s social environment. Chapter 8 will offer

T R A U M A S Y S T E M S T H E R A P Y

guidance on how each respective module is chosen given this type of

assessment.

This chapter discusses potential difficulties in engaging families in

treatment. It identifies 3 key areas for successfully engaging families

in treatment: Building the treatment alliance, providing education and

information, and trouble-shooting practical problems.

Building the alliance focuses on agreeing on the problem, agreeing on

the solution, and being genuine. Providing education and information

discusses why parents become motivated to bring their children to

treatment, and what information to share in order to encourage this.

Trouble-shooting practical problems describes specific logistical

problems parents face in seeking treatment (such as transportation

problems or their own traumatic stress symptoms) and discusses

concrete solutions to these problems.

describe a community-based treatment model and the way that it is

interwoven with other service modalities to provide treatment for

acutely symptomatic traumatized children. This chapter provides

clinicians with specific skills for providing treatment in the home or

community, and for coordinating with other providers. This

treatment module focuses on diminishing traumatic triggers in the

child’s social environment. The goals of the SOS are described, and

the two main treatment areas identified: Emotional Regulationfocused

SOS treatment, and Environmental Stability-focused SOS

treatment. A case example illustrates how community-based care

can remediate triggers in the social environment.

Next, practical considerations are discussed including a)

safety of the environment for the SOS team, b)immediate safety

of the environment for the child, and c)engaging the family in

T R A U M A S Y S T E M S T H E R A P Y

treatment. Key treatment tools are then presented, including an

Environmental Stability Check (a structured intervention plan for

social-environmental interventions) and on ‘On the Spot’ Decision

tree (a structured decision tree that guides a clinician’s actions in

crisis situations in the home). Special consideration is then given to

ways of communicating and coordinating treatment with other

providers.

This chapter describes a treatment approach that utilizes legal

advocacy in conjunction with traditional treatment modalities to

address instabilities in the social environment of traumatized

children. The chapter explains how legal advocacy helps clinicians

move beyond in-office therapy and psychopharmacology to assist

families in changing or overcoming environmental stressors that

impede recovery. The module describes the range of advocacy

interventions available and the mechanics of integrating legal

advocates into a clinical treatment team. This infusion of legal

advocacy into mental health treatment seeks nothing less than to

change the model and culture of care. Case examples illustrate how

Services Advocacy practically works to diminish traumatic triggers

in the social environment.

The chapter closes by offering guidelines for the successful

psycho-legal collaboration, and a discussion of the implications such

collaborations have for trauma treatment, specifically, and mental

health care, generally.

The main purpose of the Emotion Regulation (ER) chapter is to teach

the clinician specific strategies and exercises that help the family and

child to improve the child’s self-regulation skills. Specifically, the

strategies described will help children and families identify a)

traumatic triggers, b) internal and external signs that a child’s

emotional state is changing, and c) interventions to help the child

emotionally regulate.

The four domains of treatment include: Assessment, Coping and

Emotion Identification (ACE). The central treatment tool is the

Emotion Regulation Guide, which is described in detail. Specific

T R A U M A S Y S T E M S T H E R A P Y

worksheets and treatment activities are included, providing all of the

necessary tools for the clinician to fully implement the treatment

described in this module. Finally, the chapter ends with a discussion of

how to help the child transition from the Emotion Regulation module to

Cognitive Reprocessing.

The main purpose of the Cognitive Processing Skills (CPS) chapter is to

teach clinicians how to utilize specific exercises and activities that will

help the traumatized child to extinguish maladaptive responses to

traumatic reminders and to ultimately create meaning out of the

traumatic experience. The CPS chapter explains the ways in which the

therapist can assist the child in a) extending his/her repertoire of

emotion regulation skills to incorporate cognitive coping skills, b)

increasing his/her tolerance for thoughts/discussions surrounding the

traumatic event, and c) decreasing the intensity of emotion associated

with thoughts of the trauma.

discussion of how to help the child transition from cognitive

reprocessing to making meaning of the trauma.

The Meaning-Making Skills chapter is meant to provide clinicians

with skills and suggestions for helping clients to create meaning out

of their traumatic experiences. This chapter explains the ways in

which the therapist can a) assist the child in developing new ways of

thinking about the traumatic experience, b) help the child to

recognize and articulate important lessons learned from the

experience, c) help the child reinvent himself/herself and plan for

the future, and d) find ways of turning important lessons learned

from the trauma into personal expressions of hope. The four

with case examples of children who were able to make meaning out

T R A U M A S Y S T E M S T H E R A P Y

of their traumatic experiences through the use of their own

creativity and imagination.

Psychopharmacology is an integral part of TST. This chapter shows how

the use of psychoactive medications can fit within the care of

traumatized children and outlines the role of medication within an

overall treatment plan to help the child regulate emotion. The chapter

focuses on the relationship between psychopharmacology and

psychotherapy within the TST model and describes the different roles

for medication in the various phases of treatment. The chapter also

describes the role of the Psychiatric Consultant on the Treatment

Team and offers practical ideas to enhance the critical communication

between psychiatric and non-psychiatric members of the team.

The book ends with a concluding chapter that highlights the possible

roles that TST can play in the system of care and the public policy

concerns relevant to creating an effective and integrated system of

care for traumatized children.

Use of Icons

Throughout this manual we will be using icons to guide you through the

elements of our interventions. The icons should be read as symbols that

provide “at-a-glance” ideas concerning what a given section is about.

The following table describes the six icons that will be used in this

manual. Each chapter will begin with a table indicating the icons that

will be used in that chapter.

T R A U M A S Y S T E M S T H E R A P Y

Icon Key

Essential Point

An Essential Point indicates a section that

understood to master the Trauma Systems

Therapy treatment approach.

Academic Point An Academic Point indicates a section that

contains information that is interesting or

academically important but is not absolutely

necessary for mastering the Trauma Systems

Therapy treatment approach.

Quotation A quotation is a piece of writing taken from

others that we believe is very important to

illuminate the Trauma Systems Therapy

treatment approach.

Case Discussion Case Discussions are liberally used

throughout this manual to illustrate our

treatment approach. We believe case

discussions are particularly important to

understand the concepts described in the

manual.

Useful Tool A Useful Tool is used in our treatment

module sections to highlight an intervention

technique that is highly useful.

Danger

A Danger Icon indicates a potential pitfall of

practice. This icon should serve as a warning

to pay attention to the section (or skip at

your own peril !!).

The National Child Traumatic Stress Network

We would like to acknowledge the Substance Abuse and Mental Health

Services Administration (SAMHSA) for funding the development of

Trauma Systems Therapy and its The National Child Traumatic Stress

TSTwork (www.nctsnet.org) for being the setting in which many of our

ideas have developed. The National Child Traumatic Stress Network

(NCTSN) was funded by the Substance Abuse and Mental Health Services

Administration (SAMHSA) in October 2001 in order to address the

national public health concern of traumatic stress in children.

T R A U M A S Y S T E M S T H E R A P Y

The NCTSN is composed of three components: (1) the National Center for

Child Traumatic Stress, a coordinating center based at Duke University

and the University of California in Los Angeles, (2) 15 “Intervention

Development and Evaluation Centers” which are charged with “identifying,

supporting, improving, and developing treatment and service approaches for

different types of child and adolescent traumatic events,” and (3) 38

“Community Treatment and Service Centers” which are charged with

implementing and evaluating effective treatment and services in community

settings.

The NCTSN is designed to be a highly coordinated Network of programs to

develop and implement best practices for traumatic stress care in children

and to advance their standard of care, nationally. Our NCTSN Center,

Department of Child and Adolescent Psychiatry at Boston University

Medical Center is one of the Intervention Development and Evaluation

our center.

The mission of the NCTSN is “To raise the standard of care and improve

access to services for traumatized children, their families and communities

throughout the United States.”

We hope that you will find our efforts true to this mission and to help you

help all the Gerald’s in your practice.

[Return to 2007 Calendar of Events]