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“The more healthy relationships a child has, the more likely [the child] will be able to recover from trauma and thrive. Relationships are the agents of change, and the most powerful therapy is human love.”

―Bruce D. Perry, The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook

Overview of Best Practices

The Tri-Phasic Model of Recovery

As early as 1886, Pierre Janet (Van Der Hart, Brown, & van der Kolk, 1989) identified that persons in a state of distress required professionals to envision a three-phase treatment process:

• First, help a distressed person establish an inner sense of safety and stabilization, given that the nature of their past or some current stressor is causing social, cognitive, and/or emotional dysregulation. This safety and stabilization phase requires professionals to recognize that the person seeking services needs to trust the provider and trust that they are not in immediate danger before they can dedicate energy to strengthening external and internal resources needed to increase their window of tolerance for distressing thoughts, feelings, and physical sensations.
• Once the person can self-stabilize, thereby increasing their capacity to tolerate and self-regulate when encountering distressing thoughts, feelings, and sensations, the person is then ready to engage in the emotionally stressful work of articulating the traumatic events causing the distress, and work through the meaning and impact of those events. The heart of this phase is what we now describe as memory integration work, in which we encounter and rework inner positive and negative neural networks. It is the working-through process that is the heart of therapy or recovery.
• Once the person is able to remember and mourn, hence integrate, these realities in a more conscious (aware) way, they can envision how they might want to let their history inform rather than stop their life. Moving forward with a renewed sense of purpose and meaning is now more possible.

This tri-phasic model comprised of (a) safety and stabilization, (b) remembrance and mourning, and (c) reintegration or re-engagement is a foundational concept guiding trauma recovery, whether working with children or adults, and regardless of treatment model (Baranowsky, Gentry, & Schultz, 2005; Herman, 1992; Shapiro, 2018).

Two elements are of particular interest to TISP. The first is the reiteration of the role of attachment as attunement and mentoring: Once again we see best practices supporting a universal principle that when we feel seen and valued, our anxiety circuits calm down, and we are more able to learn coping skills needed to tolerate anxiety and stress. And once we have gained mastery over our internal responses to current or past traumatizing events, we are in a place to learn new ways of thinking and responding to those realities.

The second item of note will serve educators well as we seek to make sense of student responses to attachment attitudes and actions they begin to experience in the classroom: Safety and stabilization skills are designed to increase our window of tolerance for distressing memories and the associated thoughts, feelings, and sensations. …often students display a spike in dysregulated behavior when in emotionally attuned environments. While some of it is testing—”Do you really care about me?”—most of it is remembrance and mourning in code, a flushing of the injury permitted by the peroxide of care…purging the toxic residue of trauma, including negative neural networks that say they are not lovable or worthy of care and you are not trustworthy.A teacher in one of our trainings relayed an odd experience she had with a student who was displaying clear signs of emotional and social dysregulation. At one point in their interaction, the teacher simply offered the student a glass of water. The student sensed the act of attunement and was stunned, remarking that no one had ever showed her such care. It resonates with a conversation I (Anna) had where an adult, learning to receive care for the first time, declared that if he let himself feel care, he might crumble into dust and fly away. Likewise, we often see bewildering responses from children who are able to finally settle into calm, safe, and caring foster homes: Kids who seemed mild-mannered despite their trauma background suddenly display moderate to severe behavioral struggles. The intensity of those feelings—of being seen and heard, of being empathically caught and cared about—can overwhelm us with the pain of grief, allowing us to fully feel the hurt of past traumas, along with its accompanying distorted negative neural networks, laced with shame and doubt.

What this means is that often students display a spike in dysregulated behavior when in emotionally attuned environments. While some of it is testing—”Do you really care about me?”—most of it is remembrance and mourning in code, a flushing of the injury permitted by the peroxide of care. (We bet you never thought of care as peroxide!) They are not choosing to do this. And it is important to realize that the psychological motivation isn’t always about testing whether you really mean it, although your inconsistent response may lead them to learn you are not trustworthy. Rather, the vast majority of time, they are just purging the toxic residue of trauma, including negative neural networks that say they are not lovable or worthy of care and you are not trustworthy.

Psychological First Aid and Early Intervention

As mentioned in the call-out box accompanying this section, in the heyday of disaster trauma response work, mental health professionals tended to overuse new tools and misapply existing tools related to traditional treatment models, not totally aware of how to conceptualize the needs of persons and communities in the aftermath of a traumatic event (Sommers & Satel, 2006). Many persons thought that by enacting a procedure listed as PTSD preventative, we were protecting survivors from future distress. This is the equivalent of using a trauma-informed classroom strategy with the hope that it will fix our classrooms. Other mental health professionals assumed that because they work with trauma in their clinical practice on a daily basis, they could just “do what they do in the office out there in the field,” the hammer-nail problem. These professionals sought to solve valid, real problems, but were not operating from a foundation of trauma-informed knowledge, skills, and dispositions—all three of which must work together so that the strategies employed are congruent with one’s setting, context, and role.

Traumatologists had long been publishing findings indicating these nuances of difference between immediate and long-term needs of survivors, with those needs occurring along a time continuum related to pre- and post-event needs together with signs and symptoms of traumatic incident distress (Brymer et al., 2006, 2012; Everly & Mitchell, 2008; Myers & Wee, 2005; Scaer, 2005). That continuum of care recognized that recovery, at all stages, required an awareness of a person’s need for safety and stabilization (physical and emotional, and the ability to self-regulate), followed by services congruent with what was most needed at that stage and context (whether tangible physical resources such as food, shelter, and clothing, or clinical services to help recover psychologically from abuse or a traumatic event), and then access to additional resources to re-enter or re-engage life given its new realities or demands. The tri-phasic model of trauma recovery was revealing its relevance across the trauma-informed care spectrum.

As disaster mental health entered the mainstream, the trauma-informed community became increasingly aware of the need for mental health professionals to ground their response work in research and applicable techniques and strategies in a phase- and context-specific manner. (For further information, refer to the list of trauma-focused professional organizations included in the Resources for Further Reading list at the end of this chapter.) Building on the work of Everly (Everly & Lating, 2012), a group of practitioners and researchers formalized a protocol called Psychological First Aid (Brymer, et al., 2006, 2012). This program incorporated a growing consensus regarding the nature of resilience, the neurological impact of stress and trauma, and factors that maximize post-traumatic growth. It was designed for first responders, regardless of their role as medical, mental health, or citizen volunteers, as all persons serving the needs of survivors are providing a type of first aid necessary for long-term recovery.

The protocol consists of eight identified need themes of survivors, entitled Core Actions. Each of the Core Actions is accompanied by a description of the knowledge, skills, and dispositions required to enact it. The sponsors of the protocol, the National Child Traumatic Stress Network and the National Center for Post-Traumatic Stress Disorder, offer a guided tutorial in Psychological First Aid, and recommend that professional as well as citizen responders receive training in the protocol from an experienced trauma-informed trainer. See Figure 5.1 for a summary of the Core Actions, along with a link to access the online tutorial. This protocol is now the gold standard guiding all first responders, including educators responding to school-based traumatic events.

Figure 5.1: Psychological First Aid: Eight Core Actions

Figure 5.1. About PFA. http://bit.ly/2YY26nR.

 

Of interest here is not only an invitation to train school personnel in the protocol as is congruent with the needs of a trauma-informed school, but an invitation to examine the trauma-informed conceptual elements present in the Core Actions. First is the centrality of attachment. In the preceding chapters we identified the role of attunement as instrumental in helping students feel “seen,” valued, and welcome—what we mean by emotional safety. Once students know that they are safe, they can engage in self-regulation practices that further relax their stress response systems, allowing academic learning and prosocial skill building to resume. At the core of Psychological First Aid is the provision of safety—making sure a survivor knows they are physically safe, their needs and distress are seen, and help is available to them, leading to a sense of emotional safety as precursor to beginning the work of recovery.

Second, attachment is best provided within the context of one’s community. Psychological First Aid recognizes that this attunement process is best provided by connecting survivors with their community. As you dig deeper into the Core Actions, a responder is advised to recognize that they can serve the survivor best by connecting them with known, trusted others, such as the survivor’s immediate family and friends, as their relational community—their attachment base—has the greatest potential for activating their coping skills. For students, school becomes their second home base, a place where they spend a significant portion of each day.

Third, you will see that once a survivor’s stress response systems are more manageable – not necessarily calm—they need tangible “things,”—whether food, shelter, clothing, or long-term assistance. These tangible items are congruent with the nature of the traumatic injury, in this case, a recent disaster. In schools, the traumatic injury is unintegrated neural networks propelling a student to stay in a chronic state of alarm and dysregulation. Once a student metabolizes the attunement offered by the school environment, emotional-regulation skill building is the tangible thing most needed. Then, a student is not only able to engage in the academic and social challenges of the school environment, but needs these challenges and successes in order to continue on their developmental path, successes that are central to strengthening a sense of internal competence crucial to building hope and mustering the courage to envision a future.

And finally, the Psychological First Aid protocol was created in response to the vast array of trauma responders who were misapplying good strategies or employing strategies that were doing more harm than good. We see this tendency continuing today, as many settings attempt to be trauma-informed without a grounding in the knowledge, skills, and dispositions prerequisite to exercising the perceptual, conceptual, and executive skills key to safe and effective implementation.

In the school environment, attachment as attunement and mentoring is built upon the same conceptual elements as Psychological First Aid; responders offer attachment as attunement and resourcing. A trauma-informed responder is helping persons achieve a sense of safety and then providing tangible items needed to cope, all within the context of community, enabling them to re-engage in life, both its immediate responsibilities and future goals. A trauma-informed responder is helping persons achieve a sense of safety and then providing tangible items needed to cope, all within the context of community, enabling them to re-engage in life, both its immediate responsibilities and future goals.

The ARC Treatment Framework

For the past two decades, a group of clinician researchers have analyzed treatment outcomes with children who suffer the consequences of unmitigated stress and trauma. Their data mirrors the tri-phasic recovery model, and is further detailed to highlight specific tasks in each stage in the Attachment, Regulation, and Competency (ARC) treatment framework (Blaustein & Kinniburgh, 2007, 2019; Kinniburgh, Blaustein, Spinazzola, & van der Kolk, 2005). Having initially observed that optimum treatment outcomes were not necessarily tied to one therapeutic protocol over another—for example, a cognitive behavioral therapy approach versus a narrative therapy approach—the researchers learned that recovery was most influenced by providers who followed a series of trauma-informed principles or concepts. This finding is similar to literature on Common Factors, indicating that one theoretical model of therapy might not be better or worse than another; rather, it is a series of practitioner dispositions, along with practitioner perceptual, conceptual, and executive skills, that are highly indicative of successful therapeutic outcomes (Sprenkle, Davis, & Lebow, 2013).

The primary clinical population that gave rise to ARC is children who have experienced pervasive or chronic stress and abuse over the course of their lifes—what the ARC researchers call complex developmental trauma. The impact of repeated adverse events impairs development, and the effects of unmitigated stress and trauma have a compounding effect given that repeated psychological injuries pile one on top of another. What they discovered is that when children in a state of dysregulation due to trauma receive adequate attunement, they become able to respond to direction and build internal coping resources needed to self-regulate. Then, and only then, can they use higher-order cognitive functioning, a competency needed to engage in the hard work of recovery and continued growth. Regardless of a clinician’s treatment modality, when these trauma-informed concepts inform the clinician’s perceptual, conceptual, and executive skills, children show a remarkable ability to respond positively to treatment, and resume growth and development (Blaustein & Kinniburgh, 2007, 2019). The ARC model mirrors the theory and findings of those applying the tri-phasic model in other treatment settings with adults and children (Baranowsky & Gentry, 2005; Herman, 1992; Shapiro, 2018)

Recovery as Neural Network Integration

The above overview of best practices across the continuum of care shows that they all share common elements key to resilience and recovery in the aftermath of a traumatic event or unmitigated stress and trauma. Attachment, as attunement and mentoring, is a prelude to being receptive to learning the social-emotional regulation skills needed to self-stabilize. This is a prerequisite to access executive brain functions needed to continue the healing process and resume developmental challenges, all of which bolster a person’s sense of competence and self-efficacy, key themes in strengthening resilience. Attachment, as attunement and mentoring, is a prelude to being receptive to learning the social-emotional regulation skills needed to self-stabilize. This is a prerequisite to access executive brain functions needed to continue the healing process and resume developmental challenges, all of which bolster a person’s sense of competence and self-efficacy, key themes in strengthening resilience.

Each of the models reviewed above acknowledges that unmitigated stress and trauma lead to disrupted and unintegrated domains of neural processing. Revisit Figures 2.1 and 2.3 in Chapter 2. When the negative implicit memories of our left hemisphere (as described by Siegel in Figure 2.3) take root and grow into neural networks reflected in self- and other-defeating worldviews (or what Erikson called internal core pathologies, as shown in Figure 2.1), and are left unmitigated by right-hemisphere positive explicit memories crucial to self-stabilizing and counterbalancing life-enhancing worldviews (or internal strengths), we are prone to operating in the world in reaction to unintegrated traumatic experiences and other losses.

Dysregulation can be further described using Siegel’s domains of neural integration. For example, our reaction to bodily cues (Vertical domain), our Interpersonal struggles, and/or contrariness to what seems to be competing states of mind (State domain) may tip us off that we have Horizontal and Memory integration work yet to do. To work these neural systems we need to be mindful of bodily cues while reworking perspectives (internal negative and positive neural networks comprising our Narrative domain) with greater empathy and receptivity. This allows us to become more fully aware and present, as reflected in Conscious integration. As we more effectively engage in the here and now, and become able to hope for and envision our future, we are in a much better place to absorb Transpiration experiences and gently hold Temporal neural networks whose messages are always nipping at our heels in one way or another.

Summary Thoughts

Best-practice trauma-informed response models all describe a scaffolded process across multiple care settings. Most encouraging is that the ingredients required to help persons heal and grow are universal principles of care that promote healthy growth and development for all persons—children, adolescents, and adults alike.

The tri-phasic model of therapeutic recovery, Psychological First Aid, the ARC treatment model, and TISP represent four trauma-informed metaframes guiding systems of care across a variety of settings. Whether a student is expected to live a good portion of their day in a learning community while reeling from the effects of unmitigated stress and trauma, a client is undergoing the deep psychotherapeutic work of recovery, or a survivor is just now beginning to recover from a sudden traumatic event, we are hearing a consistent message: Attune to each other, and then move in with the skill building—the processes, the structure—to scaffold their next milestone in coping and recovery, with each step forward allowing persons greater access to and use of higher-order thinking processes key to resuming their life.

As you now know, unmitigated stress and trauma damage the brain, and recovery is a brain-healing process. These processes of break and repair are embedded and dependent upon relationship. Trauma-informed work does not get lost in the debate over “is it nature or is it nurture?” It is both! The remainder of this text will provide guidance on how to help repair and nurture brain structures challenged by typical and expected developmental tasks or undermined by unmitigated stress and trauma.

The Tri-Phasic Model of Trauma-Informed School Practices

Having reviewed major concepts informing trauma-informed practice, you are now better able to understand the meaning and rationale informing TISP. The Tri-Phasic Model of Trauma-Informed School Practices details the knowledge, skills, and dispositions congruent with trauma-informed educator expertise, with special emphasis on the application of these competencies within school systems, in individual classrooms, and in service to the Person of the Educator.

In many ways, the Tri-Phasic Model of TISP belongs here in our overview of trauma-informed best practices. This document provides a blueprint for the remaining sections of this text, detailing educator competencies informing teacher preparation and educator credentialing programs. It is intended to be easily accessed by schools transforming to trauma-informed programming, and higher education institutions securing qualified faculty to design and implement coursework according to these competencies. To facilitate easy access, the Tri-Phasic Model of TISP is presented in the following chapter.

Taking Inventory

In the preceding chapters, we unpacked the need for schools to re-evaluate how to respond to the academic and social-behavioral challenges of students exacerbated by unmitigated stress and trauma impairing their readiness to learn. We then provided an overview of trauma-informed concepts, detailing the nature of trauma, factors that contribute to risk and resilience, and best-practice strategies underlying all parts of the trauma-informed care spectrum.

Before we move forward, we invite you to ponder the following questions as a way of solidifying your emerging trauma-informed competencies. The first set of questions invites you to reflect on the Person of the Educator challenges we’ve introduced in this section. The second set of questions invites you to professionally evaluate what you have absorbed thus far, and to identify hopes and concerns as you move into the remaining chapters of this text.

Resources for Further Reading

• National Center for PTSD—US Department of Veterans Affairs
• National Child Traumatic Stress Network—Psychological First Aid. Follow links to participate in a free online Psychological First Aid course.
• The Trauma Center at the Justice Resource Institute. Access more information regarding the ARC treatment model, and other resources regarding responding to childhood abuse.

Trauma-Focused Professional Organizations

• Green Cross Academy of Traumatology
• International Critical Incident Stress Foundation
• International Society for Traumatic Stress Studies
• Trauma Response Institute. (2019a). Portland, OR: George Fox University