My colleagues and I focus much of our work where trauma has its greatest impact: on children and adolescents. Since we came together to establish the National Child Traumatic Stress Network in 2001, it has grown into a collaborative network of more than 150 centers nationwide, each of which has created programs in schools, juvenile justice systems, child welfare agencies, homeless shelters, military facilities, and residential group homes.
The Trauma Center is one of NCTSN’s Treatment Development and Evaluation sites. My colleagues Joe Spinazzola, Margaret Blaustein, and I have developed comprehensive programs for children and adolescents that we, with the help of trauma-savvy colleagues in Hartford, Chicago, Houston, San Francisco, Anchorage, Los Angeles, and New York, are now implementing. Our team selects a particular area of the country to work in every two years, relying on local contacts to identify organizations that are energetic, open, and well respected; these will eventually serve as new nodes for treatment dissemination. For example, I collaborated for one two-year period with colleagues in Missoula, Montana, to help develop a culturally sensitive trauma program on Blackfoot Indian reservations.
The greatest hope for traumatized, abused, and neglected children is to receive a good education in schools where they are seen and known, where they learn to regulate themselves, and where they can develop a sense of agency. At their best, schools can function as islands of safety in a chaotic world. They can teach children how their bodies and brains work and how they can understand and deal with their emotions. Schools can play a significant role in instilling the resilience necessary to deal with the traumas of neighborhoods or families. If parents are forced to work two jobs to eke out a living, or if they are too impaired, overwhelmed, or depressed to be attuned to the needs of their kids, schools by default have to be the places where children are taught self-leadership and an internal locus of control.
When our team arrives at a school, the teachers’ initial response is often some version of “If I’d wanted to be a social worker, I would have gone to social work school. But I came here to be a teacher.” Many of them have already learned the hard way, however, that they cannot teach if they have a classroom filled with students whose alarm bells are constantly going off. Even the most committed teachers and school systems often come to feel frustrated and ineffective because so many of their kids are too traumatized to learn. Focusing only on improving test scores won’t make any difference if teachers can’t effectively address the behavior problems of these students. The good news is that the basic principles of trauma-focused interventions can be translated into practical day-to-day routines and approaches that can transform the entire culture of a school.
Most teachers we work with are intrigued to learn that abused and neglected students are likely to interpret any deviation from routine as danger and that their extreme reactions usually are expressions of traumatic stress. Children who defy the rules are unlikely to be brought to reason by verbal reprimands or even suspension—a practice that has become epidemic in American schools. Teachers’ perspectives begin to change when they realize that these kids’ disturbing behaviors started out as frustrated attempts to communicate distress and as misguided attempts to survive.
More than anything else, being able to feel safe with other people defines mental health; safe connections are fundamental to meaningful and satisfying lives. The critical challenge in a classroom setting is to foster reciprocity: truly hearing and being heard; really seeing and being seen by other people. We try to teach everyone in a school community—office staff, principals, bus drivers, teachers, and cafeteria workers—to recognize and understand the effects of trauma on children and to focus on the importance of fostering safety, predictability, and being known and seen. We make certain that the children are greeted by name every morning and that teachers make face-to-face contact with each and every one of them. Just as in our workshops, group work, and theater programs, we always start the day with check-ins: taking the time to share what’s on everybody’s mind.
Many of the children we work with have never been able to communicate successfully with language, as they are accustomed to adults who yell, command, sulk, or put earbuds in their ears. One of our first steps is to help their teachers model new ways of talking about feelings, stating expectations, and asking for help. Instead of yelling, “Stop!” when a child is throwing a tantrum or making her sit alone in the corner, teachers are encouraged to notice and name the child’s experience, as in “I can see how upset you are”; to give her choices, as in “Would you like to go to the safe spot or sit on my lap?”; and to help her find words to describe her feelings and begin to find her voice, as in: “What will happen when you get home after class?” It may take many months for a child to know when it is safe to speak the truth (because it will never be universally safe), but for children, as for adults, identifying the truth of an experience is essential to healing from trauma.
It is standard practice in many schools to punish children for tantrums, spacing out, or aggressive outbursts—all of which are often symptoms of traumatic stress. When that happens, the school, instead of offering a safe haven, becomes yet another traumatic trigger. Angry confrontations and punishment can at best temporarily halt unacceptable behaviors, but since the underlying alarm system and stress hormones are not laid to rest, they are certain to erupt again at the next provocation.
In such situations the first step is acknowledging that a child is upset; then the teacher should calm him, then explore the cause and discuss possible solutions. For example, when a first-grader melts down, hitting his teacher and throwing objects around, we encourage his teacher to set clear limits while gently talking to him: “Would you like to wrap that blanket around you to help you calm down?” (The kid is likely to scream, “No!” but then curl up under the blanket and settle down.) Predictability and clarity of expectations are critical; consistency is essential. Children from chaotic backgrounds often have no idea how people can effectively work together, and inconsistency only promotes further confusion. Trauma-sensitive teachers soon realize that calling a parent about an obstreperous kid is likely to result in a beating and further traumatization.
Our goal in all these efforts is to translate brain science into everyday practice. For example, calming down enough to take charge of ourselves requires activating the brain areas that notice our inner sensations, the self-observing watchtower discussed in chapter 4. So a teacher might say: “Shall we take some deep breaths or use the breathing star?” (This is a colorful breathing aid made out of file folders.) Another option might be having the child sit in a corner wrapped in a heavy blanket while listening to some soothing music through headphones. Safe areas can help kids calm down by providing stimulating sensory awareness: the texture of burlap or velvet; shoe boxes filled with soft brushes and flexible toys. When the child is ready to talk again, he is encouraged to tell someone what is going on before he rejoins the group.
Kids as young as three can blow soap bubbles and learn that when they slow down their breathing to six breaths per minute and focus on the out breath as it flows over their upper lip, they will feel more calm and focused. Our team of yoga teachers works with children nearing adolescence specifically to help them “befriend” their bodies and deal with disruptive physical sensations. We know that one of the prime reasons for habitual drug use in teens is that they cannot stand the physical sensations that signal fear, rage, and helplessness.
Self-regulation can be taught to many kids who cycle between frantic activity and immobility. In addition to reading, writing, and arithmetic, all kids need to learn self-awareness, self-regulation, and communication as part of their core curriculum. Just as we teach history and geography, we need to teach children how their brains and bodies work. For adults and children alike, being in control of ourselves requires becoming familiar with our inner world and accurately identifying what scares, upsets, or delights us.
Emotional intelligence starts with
labeling your own feelings and attuning to the emotions of the people around you. We begin very simply: with mirrors. Looking into a mirror helps kids to be aware of what they look like when they are sad, angry, bored, or disappointed. Then we ask them, “How do you feel when you see a face like that?” We teach them how their brains are built, what emotions are for, and where they are registered in their bodies, and how they can communicate their feelings to the people around them. They learn that their facial muscles give clues about what they are feeling and then experiment with how their facial expressions affect other people.
We also strengthen the brain’s watchtower by teaching them to recognize and name their physical sensations. For example, when their chest tightens, that probably means that they are nervous; their breathing becomes shallow and they feel uptight. What does anger feel like, and what can they do to change that sensation in their body? What happens if they take a deep breath or take time out to jump rope or hit a punching bag? Does tapping acupressure points help? We try to provide children, teachers, and other care providers with a toolbox of ways to take charge of their emotional reactions.
To promote reciprocity, we use other mirroring exercises, which are the foundation of safe interpersonal communication. Kids practice imitating one another’s facial expressions. They proceed to imitating gestures and sounds and then get up and move in sync. To play well, they have to pay attention to really seeing and hearing one another. Games like Simon Says lead to lots of sniggering and giggling—signs of safety and relaxation. When teenagers balk at these “stupid games,” we nod understandingly and enlist their cooperation by asking them to demonstrate games to the little kids, who “need their help.”
Teachers and leaders learn that an activity as simple as trying to keep a beach ball in the air as long as possible helps groups become more focused, cohesive, and fun. These are inexpensive interventions. For older children some schools have installed workstations costing less than two hundred dollars where students can play computer games to help them focus and to improve their heart rate variability (HRV) (discussed in chapter 16), just as we do in our own clinic.
Children and adults alike need to experience how rewarding it is to work at the edge of their abilities. Resilience is the product of agency: knowing that what you do can make a difference. Many of us remember what playing team sports, singing in the school choir, or playing in the marching band meant to us, especially if we had coaches or directors who believed in us, pushed us to excel, and taught us we could be better than we thought was possible. The children we reach need this experience.
Athletics, playing music, dancing, and theatrical performances all promote agency and community. They also engage kids in novel challenges and unaccustomed roles. In a devastated postindustrial New England town, my friends Carolyn and Eli Newberger are teaching El Sistema, an orchestral music program that originated in Venezuela. Several of my students run an after-school program in Brazilian capoeira in a high-crime area of Boston, and my colleagues at the Trauma Center continue the Trauma Drama program. Last year I spent three weeks helping two boys prepare a scene from Julius Caesar. An effeminate, shy boy was playing Brutus and had to summon up his full force to put down Cassius, played by the class bully, who had to be coached to play a corrupt general begging for mercy. The scene came to life only after the bully talked about his father’s violence and his own vow never to show weakness to anyone. (Most bullies have themselves been bullied, and they despise kids who remind them of their own vulnerability.) Brutus’s powerful voice, on the other hand, emerged after he realized that he’d made himself invisible to deal with his own family violence.
These intense communal efforts force kids to collaborate, compromise, and stay focused on the task at hand. Tensions often run high, but the kids stick with it because they want to earn the respect of their coaches or directors and don’t want to let down the team—all feelings that are opposite to the vulnerability of being subjected to arbitrary abuse, the invisibility of neglect, and the godforsaken isolation of trauma.
Our NCTSN programs are working: Kids become less anxious and emotionally reactive and are less aggressive or withdrawn; they get along better and their school performance improves; their attention deficit, hyperactivity, and “oppositional defiant” problems decrease; and parents report that their children are sleeping better. Terrible things still happen to them and around them, but they are now able to talk about these events; they have built up the trust and resources to seek the help they need. Interventions are successful if they draw on our natural wellsprings of cooperation and on our inborn responses to safety, reciprocity, and imagination.
Trauma constantly confronts us with our fragility and with man’s inhumanity to man but also with our extraordinary resilience. I have been able to do this work for so long because it drew me to explore our sources of joy, creativity, meaning, and connection—all the things that make life worth living. I can’t begin to imagine how I would have coped with what many of my patients have endured, and I see their symptoms as part of their strength—the ways they learned to survive. And despite all their suffering many have gone on to become loving partners and parents, exemplary teachers, nurses, scientists, and artists.
Most great instigators of social change have intimate personal knowledge of trauma. Oprah Winfrey comes to mind, as do Maya Angelou, Nelson Mandela, and Elie Wiesel. Read the life history of any visionary, and you will find insights and passions that came from having dealt with devastation.
The same is true of societies. Many of our most profound advances grew out of experiencing trauma: the abolition of slavery from the Civil War, Social Security in response to the Great Depression, and the GI Bill, which produced our once vast and prosperous middle class, from World War II. Trauma is now our most urgent public health issue, and we have the knowledge necessary to respond effectively. The choice is ours to act on what we know.
ACKNOWLEDGMENTS
This book is the fruit of thirty years of trying to understand how people deal with, survive, and heal from traumatic experiences. Thirty years of clinical work with traumatized men, women and children; innumerable discussions with colleagues and students, and participation in the evolving science about how mind, brain, and body deal with, and recover from, overwhelming experiences.
Let me start with the people who helped me organize, and eventually publish, this book. Toni Burbank, my editor, with whom I communicated many times each week over a two-year period about the scope, organization, and specific contents of the book. Toni truly understood what this book is about, and that understanding has been critical in defining its form and substance. My agent, Brettne Bloom, understood the importance of this work, found a home for it with Viking, and provided critical support at critical moments. Rick Kot, my editor at Viking, supplied invaluable feedback and editorial guidance.
My colleagues and students at the Trauma Center have provided the feeding ground, laboratory, and support system for this work. They also have been constant reminders of the sober reality of our work for these three decades. I cannot name them all, but Joseph Spinazzola, Margaret Blaustein, Roslin Moore, Richard Jacobs, Liz Warner, Wendy D’Andrea, Jim Hopper, Fran Grossman, Alex Cook, Marla Zucker, Kevin Becker, David Emerson, Steve Gross, Dana Moore, Robert Macy, Liz Rice-Smith, Patty Levin, Nina Murray, Mark Gapen, Carrie Pekor, Debbie Korn, and Betta de Boer van der Kolk all have been critical collaborators. And of course Andy Pond and Susan Wayne of the Justice Resource Institute.
My most important companions and guides in understanding and researching traumatic stress have been Alexander McFarlane, Onno van der Hart, Ruth Lanius and Paul Frewen, Rachel Yehuda, Stephen Porges, Glenn Saxe, Jaak Panksepp, Janet Osterman, Julian Ford, Brad Stolback, Frank Putnam, Bruce Perry, Judith Herman, Robert Pynoos, Berthold Gersons, Ellert Nijenhuis, Annette Streeck-Fisher, Marylene Cloitre, Dan Siegel, Eli Newberger, Vincent Felitti, Robert Anda, and Martin Teicher; as well as my colleagues w
ho taught me about attachment: Edward Tronick, Karlen Lyons-Ruth, and Beatrice Beebe.
Peter Levine, Pat Ogden, and Al Pesso read my paper on the importance of the body in traumatic stress back in 1994 and then offered to teach me about the body. I am still learning from them, and that learning has since then been expanded by yoga and meditation teachers Stephen Cope, Jon Kabat-Zinn, and Jack Kornfield.
Sebern Fisher first taught me about neurofeedback. Ed Hamlin and Larry Hirshberg later expanded that understanding. Richard Schwartz taught me internal family systems (IFS) therapy and assisted in helping to write the chapter on IFS. Kippy Dewey and Cissa Campion introduced me to theater, Tina Packer tried to teach me how to do it, and Andrew Borthwick- Leslie provided critical details.
Adam Cummings, Amy Sullivan, and Susan Miller provided indispensible support, without which many projects in this book could never have been accomplished.
Licia Sky created the environment that allowed me to concentrate on writing this book; she provided invaluable feedback on each one of the chapters; she donated her artistic gifts to many illustrations; and she contributed to sections on body awareness and clinical case material. My trusty secretary, Angela Lin, took care of multiple crises and kept the ship running at full speed. Ed and Edith Schonberg often provided a shelter from the storm; Barry and Lorrie Goldensohn served as literary critics and inspiration; and my children, Hana and Nicholas, showed me that every new generation lives in a world that is radically different from the previous one, and that each life is unique—a creative act by its owner that defies explanation by genetics, environment, or culture alone.
Finally, my patients, to whom I dedicate this book—I wish I could mention you all by name—who taught me almost everything I know—because you were my true textbook—and the affirmation of the life force, which drives us human beings to create a meaningful life, regardless of the obstacles we encounter.
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