Step 4: Resuming behavioral routines
The establishment of behavioral competency is an important step in psychological recovery. This can occur, for example, as the child participates in physical therapy after injury. Exercises are taught, the child practices, and the physical therapist praises the child’s participation and reinforces the child’s role in his own recovery. The same can occur for children who have not been injured and for children who are experiencing chronic traumatic stress.
Encouraging the child to attend and achieve at school, to participate in school activities, and to complete chores successfully at home can help build the child’s sense of competency and self-control. The therapist can encourage the child and family to practice relaxation techniques, calming exercises, and deep breathing. The child and his family can use these skills to manage arousal and affective instability. This process further builds the engagement of the child and family in treatment and with the therapist. In addition, parents can use praise to support and reinforce their child’s competency.
Step 5: Affect exploration and identification
This step encourages the child and family to understand that trauma produces an immediate emotional response that may include fear and powerlessness and subsequent reactions such as continued fear, anger, sadness, and (possibly) shame. These emotions often occur simultaneously and can be confusing for the child and family. By identifying individual emotions and helping the child understand how each emotion is appropriate and understandable given the situation, the therapist helps the child’s emotional experience become predictable and understandable. The child learns to manage his emotions; parents have the opportunity to parent effectively, which builds their sense of control and competency. The child learns that he does not have to suppress emotion or avoid awareness of the experience.
Step 6: Supporting the supporters
The therapist creates an atmosphere of emotional support for all participants. Being involved with traumatized children can be arousing and upsetting for all involved—including the therapist. The goal for the therapist is to provide understanding and purposeful support to parents and relatives. Emotional support is also essential for first responders, hospital staff, child welfare workers, and other staff who work with traumatized children. Supervision or peer support for the therapist is an important aspect of the therapeutic process.
Step 7: Creating the trauma narrative
Organizing traumatic memories into a coherent narrative is an essential part of recovery. This helps the child appreciate what has happened and ultimately lets him master his recollections. The child is helped to recognize and cope with the anxiety attendant to recollecting the traumatic event while creating a step-by-step description of the event. One method is to encourage the child to develop an “emotion thermometer” with which to rate his level of arousal between 0 and 100. The thermometer lets the child recognize when his level of arousal is rising to a distressing level. The therapist can ask the child to stop telling the story and use relaxation skills to calm himself. When arousal decreases to an easily tolerable level, the child can begin to elaborate the trauma narrative again.
The goal is for the child to be able to tell his story and manage his arousal response. Simultaneously, the therapist strongly supports and reinforces this process. Ultimately, the child presents the trauma narrative to his parents. The parents, in turn, will need the therapist’s support to hear the story and also to encourage them to praise their child for his courage and persistence in being able to describe his experience. As the child organizes and manages his narrative, the overwhelming nature of the trauma becomes a memory over which the child has increasing control. The parents have a unique opportunity to understand, accept, and show love for their child. The resiliency of all is apparent and readily recognized.
Step 8: Making meaning of the trauma
There is always the opportunity to make unique meaning or significance of the trauma. This can be personal—through artistic expression, journal writing, or volunteer and professional activity. It can also be manifested through memorialization or efforts to improve the community (for example, through organizations such as Mothers Against Drunk Driving). National and international efforts to enhance social justice or respond to human rights abuses are also important responses to trauma. These efforts provide an opportunity for victims of trauma, as well as those who care for them, to grow.
Conclusion Traumatic experiences are common during childhood. Psychological sequelae can be persistent and can lead to further difficulties, enhanced symptoms, and poor developmental outcomes. In some children, intrinsic capacity and family response can lead to resilience and growth. By understanding the elements inherent in such resilience (eg, predictability, self-control, competence, meaningful emotional support) and working to enhance these elements in patients who have undergone traumatic stress, therapists can facilitate recovery.
Drugs Mentioned in This Article
Fluoxetine (Prozac, Sarafem)