If not Trauma Systems Therapy, then What?

In my last post, I questioned the DC Child and Family Services Agency (CFSA)'s selection of Trauma Systems therapy (TST) as a means for implementing trauma-informed practice in child welfare. I stated that this model was more appropriate for a mental health agency than for a child welfare agency as the practices it prescribes are more appropriate for therapists than for child welfare social workers. Today, I'll discuss how I would incorporate the new information about trauma into child welfare practice.

First, what is this new information about trauma? In the last few years, brain researchers have learned that trauma has long-lasting effects on the brain. In a threatening situation, the lower-level systems of the brain, led by the amygdyla, function to ensure that we survive by fighting, fleeing, or freezing. The problem is that in a child who has been repeatedly traumatized, these systems become engaged when there is no real danger. When confronted with something that reminds them of a traumatic experience, even though no danger is present, traumatized children respond by becoming emotionally or behaviorally dysregulated.¹

Trauma systems therapy, as described by its developers, is an intervention that tries to help children and their families regulate their emotions, as well as to try to decrease traumatic reminders in the social environment.² The major components of the intervention involve sessions between the therapist and the child and family. The nature and quantity of these sessions change according to the phase of treatment, but it starts out at two to three sessions per week. That is why I deem this an inappropriate modality for child welfare social workers, who are case managers, not therapists, and are already overworked.

OK, so if Trauma Systems Therapy is inappropriate for the child welfare system, then what if anything needs to change to incorporate new knowledge about trauma into child welfare practice? Clearly, some important things need to be done, if they have not been done already.

First, social workers and foster parents need to be trained in the effects of trauma on children's emotions and behavior. Social workers had already received trauma training before the adoption of TST and it was incorporated into the TST training as well. Foster parents were also trained as part of the TST roll-out. From now on, training in trauma and its effects and available treatments should be incorporated into the pre-service and in-service training received by social workers and foster parents.

Secondly, CFSA's clients are now being routinely assessed for trauma when they enter care. Any child who has been found to have experience trauma needs to be referred for trauma-informed mental health treatment. Luckily, the Department of Mental Health (DMH) has already adopted several evidence-based (unlike TST) methods of therapy, including Trauma Focused Cognitive Behavioral Therapy, for clients who have undergone trauma. Unfortunately, due to poor pay and working conditions, many DMH therapists are not well qualified to administer such therapies and those who are often leave their jobs to go into private practice or work for better pay and conditions. Because of this, CFSA and private foster care agencies already contract with private providers such as JMD Counseling and the Capital Region Children's Center. I believe that these providers also incorporate trauma into their practice.

Perhaps most important, treatment cannot be confined to the time that the client spends with the therapist. In TST, the caregiver is a crucial part of the treatment and this is true in any model of trauma-informed care, or any effective therapy. For example, in TST, the caregivers learn how to help the child manage emotions and also how to decrease traumatic reminders in the home environment. Compare this to most of CFSA's foster homes, including most of its “therapeutic foster homes,” where the foster parent never meets or talks to the therapist or attends treatment planning meetings. At a minimum, foster parents of all children who have problems of emotional or behavioral dysregulation need to work together with the therapist and the entire treatment team. Ideally, all of these children would be in truly therapeutic homes, where there would be at least weekly communication between the foster parent and the social worker and the foster parent would be responsible for carrying out the treatment plan.

CFSA's investment in Trauma Systems therapy was not a total waste. Social workers and foster parents were trained in trauma and its effect on emotions and behavior. A trauma assessment has been developed and implemented. But CFSA needs to recognize that its social workers are not therapists and should not be duplicating the work of therapists. And most importantly, CFSA needs to recognize that it is impossible for a system to become “trauma-informed” when many children are being cared for by foster parents who do not participate in their treatment. There is no shortcut or substitute for truly therapeutic foster homes.

Notes

1. See Glenn N. Saxe, B. Heidi Ellis, and Julie B. Kaplow, Collaborative Treatment of Traumatized Children and Teens. New York: The Guilford Press, 2007,
2. See Saxe, Ellis, and Kaplow.