REAL LIFE HEROES Rebuilding Safety and Trust

Richard Kagan, Ph.D. Parsons Child and Family Center 60 Academy Rd. Albany, NY 12208 [email protected] Kagan (2004, 2007a, 2007b)

• Traumatic Stress – The Impact of abuse, neglect, family violence, losses, and abandonment – Core components of effective therapies for Complex Trauma – The challenge of engaging children and families

Kagan (2004, 2007a, 2007b)

• Therapy as a shared journey; a heroes’ quest – Real Life Heroes: Principles, methods, and Pilot Study – Service planning for Complex Trauma in child and family services

Kagan (2004, 2007a, 2007b)

LEGACY OF UNRES0LVED TRAUMA

CHILD `````````````````````

PARENTS

• ABUSE/ABANDONMENTS/LOSSES/NEGLECT • CRISES • NO SAFETY • PARENTS+ADULT WORLD: OUT OF CONTROL • CHILD MUST BE IN CONTROL

Kagan (2004, 2007a, 2007b)

Traumatic stress results from experiences that represent a real or perceived threat to existence and which elicit survival responses that are often reflected in long-term impairment in the ability to modulate autonomic arousal, avoidance, reexperiencing, and reenactments. Coping strategies for traumatic stress can interfere with parenting and lead to multi-generational cycles of neglect, abuse, domestic violence and impaired attachments.

Kagan (2004, 2007a, 2007b)

Parents who rage create a state of alarm in their children. Children face a paradox since they have a natural inclination to search for comfort from the source of terror. Siegel & Hartzell, 2003

Kagan (2004, 2007a, 2007b)

GROWING UP WITH FAMILY VIOLENCE; CHILDREN LEARN: – Adults who you love can sometimes: • Hurt you deep inside • Scare you more than any scary story • Make you keep secrets. • Take way your home. – So, children learn: • To believe what you see, not what they say. • In a dangerous world, children must be in charge and on guard at all times. • To look to peers for love and identity. • Use violence to gain power.

Kagan (2004, 2007a, 2007b)

Experiences shape the brain: Experiences shape the brain:

EXPERIENCES SHAPE THE BRAIN

Kagan (2004, 2007a, 2007b)

Attachments and relationships with the child’s primary caregivers in the earliest years of life play a primary role in organizing the child’s response to fear and threat and the child’s the ability to: – Regulate bodily feelings – Regulate the expression of emotion – Feel worthy of love and care – Feel free to explore the world around them – Learn to accurately appraise and cope with risk

Kagan (2004, 2007a, 2007b)

Effects of Chaotic, Disorganized Attachments Disorganized attachment is associated with physiological dysregulation and demonstrated in increased and variable heart rate, hormonal responses, and reduced immunoglobulin “Disorganized attachment is fright without solution” (van der Kolk, 2008 Symptoms include: • Affect dysregulation • Dissociation • Memory fragmentation: tactile, smell, visual, sound, narrative, affective • Poor executive functioning

Kagan (2004, 2007a, 2007b)

Maltreatment during childhood and insecure attachments leads to diminished capacity for negative affect regulation and reduced expectations of support. This serves as a pathway to psychopathological impairment in adults (Cloitre, Stovall-McClough, Zorgbas & Charuvastra, 2008). Impaired attachments have been found to be associated with anxiety, eating, mood, and personality disorders in adults (Dozier. StovallMcClough & Albus, In Press; Westen, Nakash, Thomas & Bradley, 2006). Kagan (2004, 2007a, 2007b)

Complex trauma with children or adolescents typically follows experiences of multiple or prolonged traumatic events such as early and severe neglect, emotional abuse, sexual and physical abuse, domestic violence, community violence, separations from family members, loss of an attachment figure, and inconsistent care due to caregivers’ substance abuse or mental illness. Maltreatment and trauma may lead to impaired attachments which in turn decrease emotion regulation capacity. Symptoms of complex trauma often extend beyond diagnostic criteria for PTSD and may include hyperarousal, avoidance, developmental delays in social and emotional skills as well as difficulties managing problems without emotional distress, affect dysregulation, reenactments or revictimization. (adapted from Complex Trauma Work group) Kagan (2004, 2007a, 2007b)

High Risk Factors for Children and Adolescents in Child and Family Services • Multiple placements • Little or no hope for permanency- - re-attachment • Lack of safety from repeated family violence: lack of validation lack of protection • Multiple Traumatic Stress Behaviors: hyper-arousal, on guard, impulsive, reactive to ‘triggers,’ aggressive or self-injurious behaviors, avoidance through crises or self-medication, low verbal, poor social skills, poor emotional regulation • Low verbal reasoning and verbal modulation

Kagan (2004, 2007a, 2007b)

Twice the rate of PTSD in children in foster family care than in returning soldiers Casey Family Services

Kagan (2004, 2007a, 2007b)

Behaviors tied to traumatic stress are often confused with defiance or an individual’s inner mental disorder, when these behaviors represent, in large part, coping devices developed to manage the effects of living with chaotic, disorganized attachments and adverse childhood experiences (See Andus and Fellitti, ACE Studies)

Kagan (2004, 2007a, 2007b)

Core Treatment Components for Complex Trauma (NCTSN Complex Trauma Workgroup)

1. Safety (Personal and Family)

2. Self-Regulation (Body, Emotion, Behavior) 3. Relational Engagement & Attachment (Working Models) 4. Self-Reflective Information Processing (Attention, Narrative Reconstruction—current/historical, Executive Functions— anticipation, planning, decision-making) 5. Positive Affect Enhancement (Creativity, Imagination, Pleasure, Future Orientation, Achievement/Competence/Masteryseeking) 6. Trauma Experience Integration

Kagan (2004, 2007a, 2007b)

Real Life Heroes Developed to engage children and caring adults to address core components needed for therapy for children and families with Complex Trauma, ‘Developmental Trauma Disorder’ Tested with children and families who experienced multiple forms of traumatic stress including children who lacked safe homes and secure relationships with nurturing and committed parents or guardians (Kagan, Douglas, Hornik, & Kratz, 2008)

Kagan (2004, 2007a, 2007b)

Trauma and the Heroes Quest

TRANSFORMING TROUBLED CHILDREN INTO TOMORROW’S HEROES Kagan (2004, 2007a, 2007b)

DEVELOPMENTAL PROGRESS; A JOURNEY FOR CARING ADULTS AND CHILDREN

Rebuilding Attachments Building Personal Power Reducing Traumatic Stress

Kagan (2004, 2007a, 2007b)

Components include: Rebuilding Attachments: 1. Safety 2. Attunement Personal Power 1. Affect regulation 2. Mindfulness--Centering 3. Storytelling-Meaning making 4. Re-integration: identity with family, community, cultural heritage Traumatic Stress Reduction 1. Cognitive Behavior Therapy 2. Exposure--Desensitization

Kagan (2004, 2007a, 2007b)

A Developmental, AttachmentCentered Curriculum

Engage children and caring adults by: Rekindling hope Rebuilding safety and trust En-couraging and empowering caring adults to help children overcome traumas Shared attention to child’s inner state and experience fosters attunement Enhancing family and cultural strengths

Kagan (2004, 2007a, 2007b)

INTEGRATED SERVICE PLAN • ASSESS: – ATTACHMENTS – TRAUMAS – DEVELOPMENTAL AGE – STRENGTHS (Child, Family, Culture, Community) – GOALS – TRIGGERS & TRAUMATIC STRESS REACTIONS • COORDINATE SERVICES – SAFETY – REBUILDING ATTACHMENTS – SKILL BUILDING FOR DESENSITIZATION AND SUCCESS – REINTEGRATION (IDENTITY, FAMILY, HERITAGE, FUTURE) Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

1. Safety (Personal and Family) through structured shared activities • WORK ‘CHAPTER BY CHAPTER’ WITH CREATIVE ARTS • ENGAGE CARING ADULTS AND CHILDREN TO STRENGTHEN SKILLS, FOSTER COMMUNICATION • FOCUS ON PERMANENCY: TO REBUILD, OR BUILD, NURTURING, ENDURING RELATIONSHIPS WITH CARING ADULTS COMMITTED TO PROTECTING, NURTURING, AND GUIDING CHILD TO MATURITY AND BEYOND` • REBUILD (OR BUILD) ATTACHMENTS TO MAKE IT SAFE ENOUGH TO ACCESS EMOTIONAL MEMORIES, PROCESS TRAUMAS, MODULATE AROUSAL TO ‘TRIGGERS,’ DESENSITIZE TRAUMAS, AND HELP CHILDREN REINTEGRATE AND REWRITE THEIR LIFE STORIES

Kagan (2004, 2007a, 2007b)

• Practitioner’s Manual includes Step by step guidelines, Pitfalls, Troubleshooting, and Checkpoints • Workbook format provides structure; familiar format with a beginning and an end • Safety criteria for involvement of adults in conjoint sessions while at the same time always working with children to search for or build new attachments where necessary • Use of creative arts to provide safe outlets, release and sharing • Signals for stopping

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

SESSION SUMMARY/PROGRESS NOTE

Check off (3): • Self-Check Thermometers: Knots: (1-10); Personal Power: (1-10) • ‘Safety First’: safety plans in place; before/during/after reminders for predictable crises; child’s signal and action plan if knots begin to rise; plan for practitioner to keep safe • Openings: Magical Moment: e.g. herbal tea, cookie, magic trick, skills, special rituals . . and Focusing/Centering: e.g. deep breathing, imagery, balancing, humming, bubbles . Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

Chapter pages:

• 1st: Non-verbally, select color, sketch image, tap rhythm, try out tone to match, then 2-3 note chord, enact Action Pose • 2nd: Invite child’s thoughts on their drawing, rhythm, music, and Action Pose and ask for verbal responses to questions listed on workbook page • 3rd: Highlight strengths, coping skills, and positive beliefs about child growing in strength as child shares hardships and grieves losses and challenge dysfunctional beliefs • 4th : Invite child to develop a story utilizing different modalities (music, art, movement) or to add photographs, video, or collages Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

• • •

Repeat Self-Check Thermometers: Knots: ___(1-10); Personal Power: ___(1-10) Repeat Focusing/Centering exercises if necessary If possible, share child’s work with safe, caring adult in session, or at another time, using tape recording of music and drawings; encourage attunement by adult and validation of losses, hardships, adult responsibilities . . . Other Adults Present:

•

Reassurance: thoughts or feelings to be expected as normal, how your mind is healing and becoming stronger and stronger, how to utilize bodily sensations as messages or reminders, ways to calm and self-soothe using understanding of trauma and positive self-statements; choices; caring adults to call if distressed (on safety cards); plans with caring adults and children to cope with reminders of traumas . . . Homework: fun skill and relationship building activities Time/date set for next session: Day: Date: / / Time:

• •

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

FIVE SENSES SAFETY BAG Based on child’s social and emotional developmental level Link child to caring adults (past and present) Practice use when triggered (list triggers) Five Senses Safety Plan (adapted from TARGET (Ford & Russo, 2006; DBT) Examples to self soothe/calm: Fabrics to touch with cologne Photos of child with loving relative Photo or drawing of child in a peaceful, relaxing place Jewelry or special gem from caring adult Stress ball Journal (poetry, music) Tension-relaxation exercises

Examples to energize: Messages from caring adults Photos/drawings of child succeeding (e.g. catching a fish, shooting a basket) Photos/drawings of child with caring adult in action e.g. favorite activities/sports Symbols/reminders of personal Power (pens, awards,

Kagan (2004, 2007a, 2007b)

2. Self-Regulation (Body, Emotion, Behavior)

Activities provide practice sessions for affect regulation training and exposure, strengthening positive memories of caring and detoxifying painful affect associated with hard times Children are reinforced for building skills ‘Chapter by Chapter:’ -Affect Recognition -Affect Expression with drawing, rhythm, tonality, and movement -Affect Modulation with Deep belly breathing’; balancing peacock feathers (after Macy, 2004); and guided Imagery reinforcing memories of caring -Self Monitoring with My Thermometers Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Personal Power Through Self Control and Success Challenge Children: 1. Test safety Plans 2. Build Hero Skills – Affect Recognition, Modulation, Expression – Self Control: Goals, Planning, Reasoning – Life Story: From Victim (victimizer) to Hero – Grow Positive Self Image by: • Helping Others • Developing Skills

Kagan (2004, 2007a, 2007b)

“Remember, the force will be with you”

Kagan (2004, 2007a, 2007b)

PERSONAL POWER Objective: Child becomes able to access feelings and experiences including thoughts, awareness of physiological reactions, and impulses with capacity to modulate reactions Strategies: Engage child with support and guidance from caring adults to understand stress reactions, to rekindle hope for change, and to learn and practice skills to manage stressors in more successful ways In the Heroes framework, this is work on empowerment and learning the ways of the child’s heroes: how they see the world, use their feelings, solve problems, and develop skills to succeed.

Kagan (2004, 2007a, 2007b)

Manage level of arousal and reaction Too much/too little arousal Constriction or explosive reactions Learn to sense small changes with Feeling Thermometers Learn to regulate changes with Action Caring adults as “feeling detectives” (Kinniburgh and Blaustein, 2005), models to lead the way to become aware of feelings, locate triggers, and learn to manage without dysregulation

Kagan (2004, 2007a, 2007b)

PERSONAL POWER: Managing Difficult Emotions Learn and Practice Emotional Opposites to Create New Feelings: Hatred (active, energy consuming)—Indifference Depression (stuck/passive/cycling)--Action Fear (avoidance)—Approach with strength and support Guilt/Shame (Active, Stuck, Self-abusive)— Approach, Apologize, Make amends, Accept selfimperfection as norm, then let it go, terminate interactions and self-abuse (Adapted from Marra, 2004)

Kagan (2004, 2007a, 2007b)

PERSONAL POWER: SOCIAL SKILL DEVELOPMENT Children who grew up with neglect, abuse, family violence, or chaotic disorganized attachments typically misunderstand social cues, lack effective ways to communicate, and rely on early developmental coping strategies from the past, e.g. attacking, avoiding, or denying. Skill building includes: Accurate recognition of verbal and nonverbal messages, Correction of misperceptions and ‘catastrophic thinking’ Evaluating options, consequences, personal goals Mentoring/modeling by caring adults Learning from heroes Practice communicating with eye contact, facial and hand gestures, tone and loudness of voice, and expression of verbal and nonverbal (affective messages) in different situations

Kagan (2004, 2007a, 2007b)

PERSONAL POWER: Building the Hero’s Identity Children who grew up with neglect, abuse, violence, or chaotic disorganized attachments often have developed fragmented and distorted images of themselves with little or no sense of the past or future. Help caring adults understand normal stages of development, impact of trauma on delaying development, how to work from child’s level of development, the attachment-break-re-pair cycle, and the power of attachments to promote developmental skill building and manage problems

Kagan (2004, 2007a, 2007b)

Chapter by Chapter; Stronger and Stronger

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

3. Relational Engagement & Attachment (Working Models) • Each activity provides an opportunity to repair breaks in attachment between caring adults and children; and also, in parallel, between therapists – children caring adults • Activities reinforce attunement: – In sessions – Homework practice; fun times with caring adult

Kagan (2004, 2007a, 2007b)

• Attuned communication promotes attachment and resilience in children • Learning through shared practice that negative (painful) affect does not last and can be used as clues to overcome ‘tough times’. • Neurologically, attuned communication grows the midline orbital frontal areas of the brain (Siegel, 2007)

Kagan (2004, 2007a, 2007b)

Attunement fosters integration between parents and children through eye contact, tone of voice, gestures, facial expressions, contingent responses. By emotionally attuning, parents can sense and soothe pain in their children. Caring adult- child activities build safety over time for children to share core traumas that led to breaks in attachments

Kagan (2004, 2007a, 2007b)

4. Self-Reflective Information Processing 5. Positive Affect Enhancement (Creativity, Imagination, Pleasure, Future Orientation, Achievement/Competence/Mastery-seeking) Activities include CBT components: – Self Monitoring: My Thermometers – Psychoeducation on traumatic stress: Traumatic Stress and the Heroes Challenge – Safety planning – Cognitive skillbuilding: “SOS” and “FREEDOM” from TARGET (Ford & Russo, 2006); – Cognitive reframing: “The ABC’s of Trauma” – Imagery: Accentuate positive memories and ‘safe place imagery’ – Meaning-making

Kagan (2004, 2007a, 2007b)

Mindfulness and Focused Attention Healing from “reflective functioning” (Fonaghy & Target, 1997) Openness to bodily sensations and acceptance of sensory experience as transitory, moving in and out of awareness. Opening one’s mind to experience memories fully in the safety of relationships; integrating bodily sensations, im Mindfulness involves increasing awareness through attention and care focused on the self. (Siegel, 2007) Build arousal modulation skills by “’befriending’ internal sensations, and gaining awareness of transitory nature of all sensory experience. (van der Kolk, 2007) Can use mindfulness principles to modulate how our implicit memory reactions to triggers have dominated our lives in the past.

Kagan (2004, 2007a, 2007b)

RLH Activities Promote mindfulness with attachment-centered activities shared with caring adults Helps children see how feelings shift. Accentuates awareness and reinforcement of positive experiences. Promotes practice for children and caring adults allowing perception of feelings and letting them go; getting in touch with the emotional brain to reintegrate

Kagan (2004, 2007a, 2007b)

TAKING THE SHAME OUT OF TRAUMATIC EXPERIENCES TRAUMA PSYCHOEDUCATION

Kagan (2004, 2007a, 2007b)

TRAUMATIC STRESS Tough Times start the alarm bells ringing in our bodies. That’s a good thing. We feel our stomachs get tighter, our hearts beating faster, our arms and legs get ready for action. These are like little Knots1 that wake us up to start thinking and do something to solve a problem.

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

When we have Personal Power1, we know that we are feeling worried but we also know we can think and plan and solve this problem. We are in control. We also know we can get help and friends.

from safe, caring adults

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

B u t, so m e tim e s th e to ug h tim e s a re so h o rrib le th a t o u r stom a c h s m a y sta rt to a c h e . O u r h e a rts fe e l lik e d ru m s b e a tin g fa ste r a n d fa ste r u n til th e y fe e l lik e th e y m ig h t e x p lod e ; a n d o u r a rm s a n d le g s f e e l so tig h t th e y m a y b u rn . W e m a y fe e l stu c k , h e lp le ss, n o g o o d , o r te rrif ie d . T h in g s m a y se e m e sp e c ia lly h o rrib le w h e n toug h tim e s k e e p h a p p e n in g o ve r a nd o ve r. O ur heads a n d e ve ry b o d y a n d e ve ry t h in g m a y h u rt m a y se e m un f a ir a n d rotte n. T h a t’s w h e n o u r K nots m a y g ro w b ig g e r th a n o u r P e rsona l Pow e r . T h e A la rm b e ll se e m s to g ro w

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

a n d g ro w

and Copyright Richard Kagan, 2007b

grow.

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

And, that’s when it’s easy

to ‘Blow your

and ‘Get in Top,’ ‘Lose your Mind,’ Trouble,’ even when you don’t want to. It may feel like you can’t turn the alarm off, or the bad memories about what happened, things that may seem too hard to say out loud. And, the only thing you can think to do is to Run Away,

or if that doesn’t

work to Hit, Kick,

fight someone,

or just Freeze

and try to forget

Kagan (2004, 2007a, 2007b) about everything and everybody. Copyright Richard Kagan, 2007b

That’s Traumatic Stress.

‘FREEDOM’ Heroes know that being hurt is part of real life. Bad things do happen. Sometimes good people get sick or get hurt or lose people they love. Heroes fight for FREEDOM to make sure that the bad times don’t take over what is good in our lives, so we don’t have to live with traumatic stress. Heroes use their skills to think and act, so they can make the world a little better for everyone, even when tough times seem horrible impossible to change. Heroes don’t stop thinking of a way to make things better and stopping traumatic stress from taking over. Kagan (2004, 2007a, 2007b)

Copyright Richard Kagan, 2007b Copyright Richard Kagan, 2007b

Now comes the hard part. Saying it, even writing it down, isn’t enough. You have to do it. And, just like learning to make a winning jump shot or play a guitar, it takes practice. And, sometimes, the more tough times you’ve had, the more practice and help you need. It’s like

learning to ride a bike, or shoot a basket. At first, to a little child, it seems very hard. And, even a strong boy or girl may fail if they feel stressed. But then, with a lot of practice and a helpful guide, it suddenly clicks. You can do it. Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

Heroes know that staying calm and in control is a skill that can be learned with practice. It’s very much like learning to ride a bike. It may seem hard, or even impossible at first, but then, with a lot of practice, it becomes easy. To build your skills to calm down, even in tough times, try these steps for each of your five senses1:

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

SAFETY FIRST Five Senses Self-Soothing Plan: Eyes: _______________________________________ Ears: _______________________________________ Taste buds: ___________________________________ Nose: _______________________________________ Touch: _______________________________________ Action Plan to Relax: _____________________________________________ _____________________________________________ People I can call for help: Police:________ Teacher/Principal: _________ _________ _________ Adults I trust: __________ __________ Friends I trust: __________

__________ __________ __________ __________ __________ __________

_________

__________

__________ __________ Kagan (2004, 2007a, 2007b) Copyright Richard Kagan, 2007b

Keep practicing your skill to calm down all five senses and to “SOS”. The Workbook will also give you ways you can find people to help you, people you can help, and other ways to win your “FREEDOM” from traumatic stress. Step by step, chapter by chapter, you can take on the Hero’s Challenge.

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

THE HERO’S CHALLENGE It’s hard to face traumatic stress. In many ways, it may seem easier to stay feeling trapped or stuck, not daring to change. Heroes muster the courage to heal from their wounds and use what they learn to help other people who have to face tough times.

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

H E R O E

ealing means using the pain in our lives to grow stronger.

motions are natural. Use them to grow smarter and stronger. elease the power of your own thinking. pen Up Your Options.

xperiment: Muster the courage to check out and test out

new solutions.

S ronger S ronger t

and

t

: Find your skills and make them

even stronger. Re-member who cared about you in the past and find people who care enough to help you grow.

If you are ready to work on the Hero’s Challenge, it’s time to go to Chapter Three of your Real Life Heroes book. . . . .2007a, . Kagan.(2004, 2007b)

Copyright Richard Kagan, 2007b

Life Story Work to develop a strength-based Identity (Individual, Family, Cultural Heritage)

Kagan (2004, 2007a, 2007b)

AND TRANSFORM TROUBLED CHILDREN INTO TOMORROW’S HEROES

Kagan (2004, 2007a, 2007b)

Strength to Strength; Rebuilding Hope and Courage with Culturally based Stories of Overcoming Adversity Beyond respect ; building pride with shared understanding focused on each child and family Examples with underserved groups: African American youth addressing in each community, e.g. for Albany, New York:: • Albany’s role in promoting abolition of slavery • Underground railroad sites in Albany • Local Heroes: Stephen Myers (Albany newspaper); Sojourner Truth—Ulster County; links to Harriet Tubman;

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Gay or lesbian youth: History of the Rainbow Triangle: From Nazi symbols of persecution to symbols of gay and lesbian pride Stonewall Riots: lessons in courage

Kagan (2004, 2007a, 2007b)

Heroes Library Selected books matched by age, reading level, and ethnic heritage in the Real Life Heroes Practitioner’s Manual Autobiographies of overcoming matched to a child’s cultural background: Michael Jordan on ‘rising above’ Gerald Ford, Faith Hill: achievements by adopted youths Books addressing common issues: Separation, Loss

Kagan (2004, 2007a, 2007b)

LIFE STORY WORK

• Why life story work? “memory is the way past events affect future functions.” (Siegel, 1999, p. 24) • Memory shapes how and what we learn, even without our recollection of these events • Developing an understanding of trauma through an organized narrative, e.g. a “healing theory” (Figley, 1986) facilitates transfer of affective experiences stored in the right orbitofrontal brain to the left orbitofrontal region (Schore, 2001). Kagan (2004, 2007a, 2007b)

6. Trauma Experience Integration • Modulate safe exposure to traumatic memories after development of safety by strengthening attachments and affect management skill building • Access emotional memories with art, rhythm, tonality, and movement and then integrate with verbal processing within the embrace of caring adults

Kagan (2004, 2007a, 2007b)

Trauma processing Creation of safety through safety plans, session structure and relationships Rebuild positive memories first ; practice and document Build coping skills for affect management Practice safe form of accessing emotional memory through session structure, drawing, rhythm, tonality, and movement Modulated exposure to memories and reminders of past traumas, within the “therapeutic window” (Adapted from Briere, J. (2002) Self Trauma Model)

Kagan (2004, 2007a, 2007b)

Trauma Processing in Real Life Heroes Practice safe form of accessing emotional memory through session structure, drawing, rhythm, tonality, and movement – Invitations to remember situations, feelings, perceptions, correcting misperceptions and cognitive distortions; beliefs generating expectations of danger and harm; ) – Stress differences between current safety in session, home, and school compared to the past – Counter conditioning: (repetition of) exposure to reminders of traumas while experiencing physical and emotional support, validation, attunement – Mourning losses

Kagan (2004, 2007a, 2007b)

SHARING THE JOURNEY Rebuilding Attachments: (repetition of) Attachment-breakreattachment with caring adults Growing a hero’s mind and body by re-integrating the child with a caring adult, “brain to brain” (Siegel & Hartzell, 1999) Developing stronger identities based on overcoming multiple traumas and testing new relationships With modulated exposure and practice, trauma reminders lose power to stimulate traumatic stress behavioral cycles Child and caring adult develop confidence in self-control and safety Child and caring adult develop confidence in a positive future based on ability to face and master ‘tough times’

Kagan (2004, 2007a, 2007b)

‘Healing Stories’ • Make sense out of what happened • Caring adults assume responsibility for rebuilding safety and reaching out to children • Telling the story makes it easier to feel it than trying to not feel it • Show how you’ve grown and changed and become stronger • Identify reminders and prepare for them

Kagan (2004, 2007a, 2007b)

ENGAGING THE POWER OF CARING ADULTS Caring adults work on parallel track: Understanding normal trauma reactions Developing skills for affect regulation Developing ability to detach from trauma patterns Making child’s (and caring adult’s) life different Restoring safety Restoring hope Restoring trust Showing child can count on adults to protect them from the monsters of the past

Kagan (2004, 2007a, 2007b)

CARING ADULTS LEAD THE WAY

Restore Hope, Safety, and Learning – Commitment – Self Care and Modulation – 3 R’s: Routines, Rituals, Re-attunement – Model Hero's Identity: • Helping Others • Parenting means demonstrating the courage to face the horrors of the past and to ‘Protect, Provide & Guide’ (James,1994) • Link Child to positive image within Family, Culture, Community Kagan (2004, 2007a, 2007b)

THE THREE R’S: ROUTINE, RITUAL, RE-ATTUNEMENT

Routines include: waking up, breakfast, getting to

school, getting home, after school homework and play, fun time with parents/guardians, dinner, bedtime Routines also include demonstrating to the child that their home includes consistent care including: Management of transitions and change: preparation of adults, preparation of the child Management of problems and violations of rules with consistent responses Demonstrating how caring adult and new/changed home is DIFFERENT than the past Protection from repeated traumas Kagan (2004, 2007a, 2007b)

Rituals show child each event is special ; key messages: We are a family and you are part of this family Each of us is linked to our family and cultural heritage and our community

Re-attunement after breaks in connection to child; caring adults demonstrate commitment to ‘protect, provide, and guide’ child to maturity and overcome the ‘monsters of the past’

Kagan (2004, 2007a, 2007b)

REPARENTING TRAUMATIZED CHILDREN

• Create “New/different world” • Take control by using understanding, commitment, allies • Show child can regain time: integrate past – future • Build strengths from family and cultural heritage-lessons for coping, mourning losses, connections through time • Faith-community, hope Kagan (2004, 2007a, 2007b)

Re-parenting means taking control back from child without repeating past traumas: if child continues to control with caring adults overreacting, child is usually overwhelmed with ‘threat avoidance’ work and has become overwhelming to family members and other adults Re-parenting means re-claiming by family, extended family, community (religion, school, neighborhood, ethnic heritage)

Kagan (2004, 2007a, 2007b)

Reattach at developmental level of breakdown of attachment (often, the point that child lost hope) with bottles, rocking, sandbox play, storytelling, lullabies, baking cookies, play dough . . . Child learns to trust that caring adults can see/hear/feel their pain Child learns that caring adults will help Child learns to calm self

Kagan (2004, 2007a, 2007b)

LEARN TO SUCCEED Help child identify and develop positive skills and talents Mentoring Learn and practice vs. automatic, magical skill acquisition Caring adult support and recognition Manage failures and defeat; learn from mistakes versus shame/guilt/giving up/rage

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

TABLE OF CONTENTS

• The Pledge—safety, ‘doing with’ • A Little About Me—expression and identification of feelings, affect regulation, testing safety • Heroes and Heroines—openings for hope, modeling, from imaginary to real life; developing positive ethnic heritage • People in My Life-- rebuild awareness of people who cared, open up past • Good Times—Fun, connections, resources, allies • Making Things Better—pulling together new perspectives, resources, and allies to make a difference, restitution, using what was learned

Kagan (2004, 2007a, 2007b)

• The ABC’s of Trauma and The Hero’s Quest—understanding the impact of trauma on our bodies and beliefs, accepting and recognizing bodily reaction, changing from Catastrophic beliefs to Coping Strategies, rewriting our scripts, and practice using new strategies with a low level stressful situation. • Looking Back—making sense out of past, who was there, transitions, • Through the Tough Times; desensitization to progressively more difficult traumatic memories utilizing CBT approaches and creative arts • Into the Future—open up possibilities, goals, faith

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

The ABC’s of Trauma: (Or How an “A” Can Become an “F” in 6 Fast Steps)

Tough Times can make you feel like it’s all you’re fault. Or, that nothing can change. Here’s how an ‘A’ can become an F faster than you can say A, B, C:

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

MAKING THINGS BETTER

To get out of the Trauma Pit, you’ll need to use all your power and grow stronger than all the ‘bad’ feelings that are weighing you down. To find a way out, it helps to know how you got in. It’s just like a magic trick. When you know how it works, you own the power of the magic. When bad things keep happening, you can use the Power of Thinking to make things better.

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

It takes courage to accept that: Sometimes, bad things do happen, even to good people. What you felt, you felt. Feelings are messages from you body. They are not “bad” or “good,” they are just feelings, the way your body learned to react to what happened in the past. But, what you think and what you do is up to you. You can fight failure by changing the story. **** CHANGING THE STORY You can become the director of your own story, just like the director of a movie. To change the story, release the Power of Your Thinking, the Power of your own mind. Then, you can change how the story goes. Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

You can find the script by taking a look at your beliefs: Action--What happened, happened. Drawing what happened, putting it to music, and writing it down can help take away the power of ‘tough times.’ Try this out by drawing below writing down one time that you felt was just a little bit ‘tough,’ a time when your Knots were up to a “3” or “4.” What happened?

Copyright Richard Kagan, 2007b

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

Kagan (2004, 2007a, 2007b)

RLH RESEARCH Seventeen clinicians from the Parsons Prevention (High Risk Home-based Family Counseling), Therapeutic Foster Care, Residential Services (Group Care) and Outpatient Treatment (Child Guidance) were selected and trained in the Real Life Heroes trauma treatment approach including use of the Real Life Heroes Practitioner Manual, structured session outlines, and fidelity checklists. These clinicians screened children between the developmental age of 8-12 for study inclusion based primarily on the appropriateness of the treatment intervention and anticipated length of treatment by Parsons. Forty-one children were enrolled in the study. Mean age at the start of the study was 10.5; 41% are female, 53% are members of an ethnic minority group, and 36% were living out-of-home.

Kagan (2004, 2007a, 2007b)

At study enrollment, clinicians completed the UCLA PTSD Checklist (Pynoos, Rodriguez, Steinberg, Stuber & Frederick, 1998) based on reports from caregivers, children, Departments of Social Services, and teachers: – 25% had experienced 1-2 traumatic events – 47.5% had experienced 3-4 traumatic events – 27.3% had experienced 5-6 traumatic events. At baseline, primary caretakers for children completed the Parent Report of Post-traumatic Symptoms-PROPS (Greenwald & Allen, 1999) to assess PTSD symptoms; 75.6% of the sample (31 children) had scores on the PROPS of 16 or higher, the recommended cut-off for assessing PTSD

Kagan (2004, 2007a, 2007b)

Data was collected from children, their primary caregivers, and clinicians. Children and their caregivers participated in interviews on four separate occasions: study enrollment, a four-month follow-up, at eight months, and again at twelve months. Clinicians submitted enrollment paper work, a baseline trauma screen, ratings of therapeutic alliance with the enrolled child and on-going process data regarding treatment fidelity and skill assessment of weekly Real Life Heroes sessions.

Kagan (2004, 2007a, 2007b)

Over the first four months: Children demonstrated reduced trauma symptoms on child selfreports on the TSCC (p