Building Resilience to Trauma: The Trauma and Community Resiliency Models [2 ed.] 0367681749, 9780367681746

Table of contents :
Cover
Half Title
Title Page
Copyright Page
Dedication
Table of Contents
List of Illustrations
About the Authors and Contributors
Foreword by Brendan Ozawa-de Silva
Preface
Acknowledgments
Part I: The Foundation
1 Introduction, Resilience, and Perspective
2 Trauma Defined
3 The Six Wellness Skills of the Community Resiliency Model (CRM) and the Trauma Resiliency Model (TRM)
4 The Trauma Resiliency Model Reprocessing Skills
5 The Nervous System, Memory, and Trauma
6 Embodying Otherness to Us: Diversity, Equity, Inclusion, and Justice
Part II: The Community Resiliency Model in Action
7 The Community Resiliency Model (CRM) in Public Health
8 The Disaster Relief Mobilization: Community Resiliency Model Preparation Program (DRM:CRM)
9 The Community Resiliency Model (CRM) and Law Enforcement
Part III: Working with Children
10 Working with Children Who Have Experienced Trauma: A Developmental Perspective
11 Using CRM/TRM Wellness Skills with Infants, Children, and Teens
Part IV: The Trauma Resiliency Model (TRM) and Clinical Integration
12 Attachment Strategies and Adult Behavior
13 Veterans, Active-Duty Service Members, and Their Loved Ones
14 Addiction, Dependence, and Substance Use Disorder
Part V: Research
15 Research on the Community Resiliency Model (CRM): Need, Theoretical Basis, Status, Tools, and Next Steps
Index

Citation preview

Building Resilience to Trauma

During and after a traumatic experience, survivors experience a cascade of physical, emotional, cognitive, behavioral, relational, and spiritual responses that can make them feel unbalanced and threatened. The second edition of Building Resilience to Trauma explains common responses from a biological perspective, reframing the human experience from one of shame and pathology to one of hope and biology. Using two evidence-informed models of intervention that are trauma-informed and resiliency-informed—the Community Resiliency Model (CRM) and the Trauma Resiliency Model (TRM)—chapters distill complex neuroscience into understandable concepts and lay out a path for fostering short- and long-term healing. CRM develops natural leaders who share wellness skills throughout communities as primary prevention, and TRM focuses on training mental health professionals to reprocess traumatic experiences. Studies have demonstrated that the models’ use leads to significant reductions in depression and anxiety, and both models also lead to increases in well-being. The models restore balance after traumatic experiences and can be used as tools to cultivate well-being across cultures and abilities throughout the lifespan. Program cosponsors have included the United Nations, Emory University’s Center for Contemplative Science and Compassion-Based Ethics, the Victims and Survivors Network of Northern Ireland, PACES Connection, the International Transformational Resilience Coalition, the Adventist Disaster Relief Agency International, Wake County School System, and the State of Washington Police Commission. Elaine Miller-Karas, LCSW, is co-founder and director of innovation of the Trauma Resource Institute and adjunct faculty at Loma Linda University. She is an author, lecturer, consultant, radio show host, Psychology Today blogger, trauma therapist, and social entrepreneur.

Building Resilience to Trauma The Trauma and Community Resiliency Models SECOND EDITION

Elaine Miller-Karas

Designed cover image: © Getty Images Second edition published 2023 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 Elaine Miller-Karas The right of Elaine Miller-Karas to be identified as author of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2015 ISBN: 9780367681746 (hbk) ISBN: 9780367681708 (pbk) ISBN: 9781003140887 (ebk) DOI: 10.4324/9781003140887 Typeset in Goudy by codeMantra

I dedicate the second edition to three people I greatly admire and respect: To my husband, Jim Karas. His patience and unconditional love have sustained and nourished me through life’s bumpy and unpredictable journey. Without him, I could not have led the international movement of the Trauma Resource Institute (TRI). It is true that he has lived with a passionate, spunky woman with an unwavering mission and always showed me incredible grace, humor, and unwavering support. To my daughter, Jessica Karas Waterson. Since her birth, I have been amazed by her spirit, compassion, transparency, and abilities. I took her to Kenya as my assistant when she had just graduated from college. It was transformative for both of us, and it was then that I witnessed her skill in transcultural communication with African women leaders. I admire her knowledge and skill with both TRM and CRM. Her support and companionship have been immeasurable. To Michael Sapp. Through serendipitous good luck and perhaps fate, I was able to influence this young psychologist with my ideas about neuroscience and embodied healing. He could not have imagined what was in store for him - we traveled the globe together and shared so many precious moments of witnessing TRM and CRM in action. When I was ready to turn over the reins of TRI, I could not have found a better leader. His solid values of respect for all people are ones we all can aspire to in life. He has been patient and met me on this journey with humor, kindness, understanding, and compassion.

Contents

List of Illustrations

x

About the Authors and Contributors

xi

Foreword by Brendan Ozawa-de Silva

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Preface xix Acknowledgments xxi PART I

THE FOUNDATION1 1 Introduction, Resilience, and Perspective3 E L A I N E M I L L E R- KARAS

2 Trauma Defined15 E L A I N E M I L L E R- KARAS

3 The Six Wellness Skills of the Community Resiliency Model (CRM) and the Trauma Resiliency Model (TRM)31 E L A I N E M I L L E R- KAR AS

4 The Trauma Resiliency Model Reprocessing Skills53 E L A I N E M I L L E R- KARAS

5 The Nervous System, Memory, and Trauma78 M I C H A E L S A P P AND E L AI NE MI L L E R- KARAS

6 Embodying Otherness to Us: Diversity, Equity, Inclusion, and Justice100 R E E N A PAT E L AND E L AI NE MI L L E R- KARAS

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Co n t e n t s

PART II

THE COMMUNITY RESILIENCY MODEL IN ACTION115 7 The Community Resiliency Model (CRM) in Public Health117 EL A I N E M I L L E R - K ARAS

8 The Disaster Relief Mobilization: Community Resiliency Model Preparation Program (DRM:CRM)131 EL A I N E M I L L E R - K ARAS

9 The Community Resiliency Model (CRM) and Law Enforcement146 JE N N I F E R WA L L A C E

PART III

WORKING WITH CHILDREN155 10 Working with Children Who Have Experienced Trauma: A Developmental Perspective157 K I M B E R LY F R E E M AN

11 Using CRM/TRM Wellness Skills with Infants, Children, and Teens173 EL A I N E M I L L E R - K ARAS , KI MB E RLY F RE E MAN, AND SUSAN  REED Y

PART IV

THE TRAUMA RESILIENCY MODEL (TRM) AND CLINICAL INTEGRATION199 12 Attachment Strategies and Adult Behavior201 EL A I N E M I L L E R - K ARAS AND J E NNI FE R B URTON FLIER

13 Veterans, Active-Duty Service Members, and Their Loved Ones228 EL A I N E M I L L E R - K ARAS AND J AN CL I CK

14 Addiction, Dependence, and Substance Use Disorder245 EL A I N E M I L L E R - K ARAS AND J E S S I CA KARAS WATERSON

Co n t e n t s

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PART V

RESEARCH267 15 Research on the Community Resiliency Model (CRM): Need, Theoretical Basis, Status, Tools, and Next Steps

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L I N D A G R A B B E , S US ANNE MONTGOME RY, KI MBERLY F REEMAN, A N D   B E V E R LY J . B UCKL E S

Index 301

Illustrations

Figures  1.1  1.2  3.1 11.1 15.1 15.2

The Resilient Zone10 High/Low Zones11 Autonomic Nervous System34 Zones with Emojis186 Frieden’s Health Impact Pyramid 273 The CRM and TRM in the Context of the Health Impact Pyramid273

Tables  3.1 Sensations Chart36  9.1 SAI Interview Framework152  9.2 VCERT Interview Guide153 15.1 CRM Studies in US March 21 2022281 15.2 CRM International Research287 15.3 CRM Outcome Variables and Suggested Measures Used in Current and Published Research292 15.4 CRM Outcome Variables and Suggested Measures for Future Research294

About the Authors and Contributors

Elaine Miller-Karas, LCSW,  is co-founder and director of Innovation of the Trauma Resource Institute and adjunct faculty at Loma Linda University. She is an author, lecturer, consultant, radio show host, blogger, trauma therapist, and social entrepreneur. She is a founding member of the International Transformational Resilience Coalition. She has held leadership roles in international disaster-recovery projects in North America, Central America, Europe, Asia, Africa, and the Caribbean Islands. She has presented at the Skoll World Forum, the Resiliency Forum, the Centers for Disease Control, the Global Fund, the Trauma Action Network, the International Society for Traumatic Stress Studies, and the United Nations. Elaine’s book was selected by the United Nations and Taylor and Francis’s curated online library as one of the innovations helping meet the United Nations Sustainable Development Goals. https://www.taylorfrancis.com/sdgo. She is a senior consultant to Emory University’s SEE Learning program, inspired and launched by His Holiness the Dalai Lama. She also is a consultant to the Medgar and Myrlie Evers Foundation, helping to create a virtual curriculum of the US Civil Rights Movement. Her radio talk show, Resiliency Within, Building Resiliency During Unprecedented Times, is on VoiceAmerica. She has a regular blog on Psychology Today. Beverly J. Buckles, MSW, DSW, is dean of the School of Behavioral Health at Loma Linda University, LLUH vice president for Behavioral Health Education, and chair of the Department of Social Work and Social Ecology. She is the recipient of the 2010 Social Worker of the Year, California Chapter of the National Association of Social Workers. In 2006, she received the Loma Linda University Centennial Vanguard Award for her founding leadership of the University’s International Behavioral Health Trauma Team. Since 1995, the LLUH Behavioral Health Trauma Team has responded to natural disasters and conflict zones in over 60 countries around the world.

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Jennifer Burton Flier, LMFT, CEAT, CDWF, is a therapist in private practice in San Francisco and Encino. Jennifer is a Trauma Resiliency Model (TRM)® and Community Resiliency Model (CRM)® senior faculty and consultant. She has been one of the leaders contributing to the development of CRM. Ms. Burton Flier was a featured guest on the Laverne Cox podcast. She has traveled extensively in the US and to Northern Ireland to share CRM wellness skills after human-made and natural disasters, including after the terrorists’ attacks at the Pulse Nightclub in Orlando and in San Bernardino County. Jan Click, MSW, is a licensed clinical social worker who has been in practice for over 40 years. She worked at the VA for 32 years treating combat and military trauma, including military sexual trauma. She is currently in private practice in the Santa Clarita Valley. Her specialty is working with clients with complex trauma, depression, anxiety, grief, and loss. Ms. Click is an EMDR-certified therapist and an EMDR-approved consultant. She is a Trauma Resiliency Model (TRM)® and Community Resiliency Model (CRM)® senior faculty and consultant. Kimberly Freeman, MSW, PhD,  is a psychologist and social worker with over 20 years of post-licensed experience working with high-risk infants and children. Her primary area of expertise includes infant development assessments aimed at promoting parent-child attachment, identification of developmental delays, and facilitation of early intervention. Dr. Freeman is a professor and executive associate chair of the Social Work and Social Ecology Department at Loma Linda University. She serves on the Loma Linda University International Behavioral Health Trauma Team. She has been to 25 countries including Sierra Leone where she helped provide the CRM intervention to school-aged children with a history of historical and community trauma. Linda Grabbe, PhD, is a board-certified family nurse practitioner and psychiatric/mental health nurse practitioner. She received nursing’s highest honor in 2020 when the American Academy of Nurses recognized her as one of its accomplished leaders. Her expertise is in primary care and mental health care for homeless or incarcerated women and youth. She is a leader in bringing Community Resiliency Model (CRM) training to Georgia and to nurses. Her interests include the neurobiology of trauma and resilience, social justice, and social determinants of mental health. She is a clinical assistant professor at Emory University’s Nell Hodgson Woodruff School of Nursing.

A b o u t t h e A u t h o r s a n d Co n t r i b u t o r s

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Susanne Montgomery, PhD, MPH, MS, is a social/behavioral epidemiologist whose research focus is on hard-to-access, underserved populations, and health disparities from a translational behavioral health and prevention perspective. She has received NIH, CDC, Foundation, and State funding, has published over 140 peer-reviewed articles, and serves as a peer reviewer for NIH, CDC, and professional journals. She is the associate dean for research in the Loma Linda University (LLU) School of Behavioral Health. A leader in LLU research, she is also an enthusiastic member of the TRI research group, seeking to promote rigorous research on CRM. Brendan Ozawa-de Silva, PhD,  is senior lecturer at the Center for Contemplative Science and Compassion-Based Ethics at Emory University. He was the associate director of SEE Learning at Emory University and helped develop the curriculum that is now used throughout the world. His research focuses on the psychological, social, and ethical dimensions of prosocial emotions and their cultivation, with a focus on compassion and forgiveness. He also helped found the Chillon Project, a degree program at Life University for incarcerated women in Georgia, as well as the Alliance for Higher Education in Prison, a nationwide non-profit. Reena Patel, MSW, is the director of Education for Trauma Resource Institute (TRI). Ms. Patel received the NASW Emerging Social Work Leader of the Year for AZ Chapter Branch II in 2018. Ms. Patel has worked on the San Carlos Apache Reservation and with the Pascua Yaqui Tribe as a mental health therapist. Ms. Patel has taught as a faculty associate for Arizona State University School of Social and has taught courses in diversity and oppression in social work context. Ms. Patel has a deep interest in the multigenerational effects of trauma and post-traumatic growth in marginalized communities. She has traveled domestically and internationally as a Community Resiliency Model (CRM)®. Ms. Patel traveled to India with TRI as part of the SEE Learning Program launch and helped to translate media materials into Hindi. Susan Reedy, LMFT,  is a Trauma Resiliency Model (TRM)® and Community Resiliency Model (CRM)® senior faculty and consultant. She has a private practice in Arcadia, California, where she specializes in child-centered play therapy, having trained extensively with Stanley Greenspan and Serena Wieder. She enjoys working with families with children with developmental delays, autistic spectrum disorder, sensory regulation issues, and trauma histories. Susan worked for 13 years as a

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consultant at Mayfield Junior School, an independent K–8 school in Pasadena, California, where she taught parent education courses and introduced CRM skills to second-to-fifth graders. She is a member of the Association for Play Therapists and has presented multiple times at the annual Southern California Regional Play Therapy Conference. Michael Sapp, PhD,  is a licensed clinical psychologist, author, and the CEO of the Trauma Resource Institute (TRI). Dr. Sapp is dedicated to concepts of community healing through simple biological-based resiliency skills. As a Trauma Resiliency Model (TRM)® and Community Resiliency Model (CRM)® senior faculty, Dr. Sapp has helped train clinicians and non-clinical community leaders both locally and internationally. Domestically, he has provided trainings throughout the United States, including in California, as well as Florida, Georgia, Michigan, New York, and North Carolina. Internationally, he has helped provide trainings in the Philippines, Turkey, England, Nepal, Germany, Iceland, and Northern Ireland. Jennifer Wallace  has served in and around law enforcement for over 33 years. She spent most of her career in Seattle as a criminal investigator/ special agent and supervisor with the U.S. Department of Defense, Defense Criminal Investigative Service (DCIS). After retiring from DCIS in 2015, Jen worked with the Seattle Police Department (SPD) in a civilian capacity on a Human Trafficking grant prior to moving into her current role as a program manager for Sexual Assault Investigations at the Washington State Criminal Justice Training Commission (WSCJTC). At WSCJTC, Jen works with a multidisciplinary team in the delivery of the mandatory victim interviewing training. The collaborations with the Trauma Resource Institute and integration of the Community Resiliency Model® wellness skills in interviews are intended to provide further engagement and endurance by officers and victims. Jessica Karas Waterson, LMFT, is a psychotherapist in private practice in Claremont, California, specializing in the treatment of trauma, depression, and addiction. Jessica is a Trauma Resiliency Model (TRM)® and Community Resiliency Model (CRM)® senior faculty and consultant. She has traveled internationally to Kenya, Africa, where she helped with a TRM training for African leaders working to end female genital violence. She has conducted training within the United States delivering trainings in both TRM and CRM. She is a consultant for businesses interested in bringing Community Resiliency skills to their workforce.

Foreword

We all want happiness and well-being. This is something we share with all living beings. And our ability to have happiness, individually and collectively, is directly related to our ability to care for ourselves and to care for each other. For this reason, any tool or any piece of knowledge that allows us to better care for ourselves and others is precious. Unfortunately, we do not live in a perfect world. There are many things that can cause us stress and create a sense of threat, rather than safety, for our mind and body. How do we navigate this uncertainty? How do we deal with the adversity that we and others have faced in the past, or will face in the future? How do we retain hope in the face of physical and moral injury? Fortunately, as this book shows, we have many resources for resilience and well-being inside us already, including our very own nervous system. This nervous system is a remarkable thing: it allows us not only to engage with the outer world through our five senses but also to sense what is going on inside our body, a kind of “sixth sense” called interoception. If we learn to use this sense, it can give us information about our emotions, our feelings, and our level of stress and well-being. This information is just as vital as that which comes from our traditional five senses. Precisely how to do so is what is covered in this book. Learning to tap into our inborn resources by directly exploring the natural workings of our nervous system gives us agency: the ability to have a hand in how we react and respond to what is going on around and inside us. Agency means choice; it means having options; and it means being able to take actions that can directly benefit us and help us attain what we want and avoid what we do not want. Agency is the opposite of helplessness, the opposite of hopelessness. And agency and compassion are also essential prerequisites for ethics and justice in society as a whole.

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One strategy for gaining this agency is the cognitive regulation of emotions, an approach I have studied over the past two decades. By redirecting our attention to something else (intentionally distracting ourselves), by reframing our appraisal of the situation (trying to see things from a different perspective), or by taking a step back and noticing what is going on instead of being caught up in the moment (meta-awareness, or often called mindfulness), we can change our emotional response. Another strategy of increasing interest is the social regulation of emotion: we seek out a loved one or good friend, we confide in someone, we ask for a hug. Importantly, the techniques in this book employ aspects of both these strategies, but they also add a third: the somatic regulation of emotion, facilitated by interoception and the “tracking” of sensations. Remarkably, we can also affect our emotions directly and sometimes almost instantaneously by direct engagement with the body and sensations: looking at colors, noticing sounds, pushing or leaning against a wall. This is the mind-body connection in action. Learning these techniques, and sharing them with others, can sometimes feel akin to learning and practicing magic. To learn that it is merely the magic of our own nervous systems makes it no less remarkable. These discoveries have been nothing short of amazing to me, and I consider them among the most important things I’ve learned in my life. For that I am eternally grateful to Elaine Miller-Karas and her colleagues. Through my work with the SEE Learning program, a free K–12 and higher education Social and Emotional Learning program developed at Emory University, I have had the benefit of watching educators and students across the world, from Colombia to Ukraine to India and elsewhere, engage with the practices in this book to positive effect. This is because the Community Resiliency Model (CRM), explained in this book, forms the second chapter of the SEE Learning curriculum: it is the first thing taught after the initial overview chapter, because of how foundational it is for the further practices of attention, emotion regulation, and compassion for self and others that follow in the program. Indeed, Elaine is a senior consultant for the program and coauthor of this chapter of the curriculum, and through her generosity thousands of children, teachers, and counselors around the world have free access to these practices in a school setting and will grow up with greater emotional and body literacy. There are so many schools, educators, and children who have benefited, and continue to benefit, from this knowledge and these practices, but I will mention just a few examples. In Dharamsala, India, the Tong-Len school, a school and charitable institution that was set up to serve the children from

Fo r e w o r d

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the poorest areas in the region, so-called “slum communities,” has adopted SEE Learning and CRM to the extent that the school is now decorated everywhere with murals, signs, and other artistic creations of the children that teach the skills they have learned, such as a giant map of the Resilient Zone. The school children have also painted giant, colorful murals across the town of Dharamsala to share what they have learned with the community, attracting the interest of local officials and administrators from other schools. Here in the United States, I recall a story shared by one teacher implementing SEE Learning who had taught the CRM skills to her class. One day they had a test to take in class, and they asked the teacher if they could take a moment to ground and resource first, so that they would be at their best to answer the questions. She told them there was no time for that. The students protested, saying this went against everything she had taught them about the importance of regulating their nervous systems and the benefits that came from that. The teacher saw the contradiction, and changed her mind, giving the students a few minutes to put into practice what they had learned. When I hear stories like this, I am not surprised. No matter the country, so many times when students are asked how often they practice these skills, they respond “Every day.” Yet the way they integrate the practices into their daily life will be particular to them, since they have learned directly what their body wants and needs in the moment. From these travels I have come to see firsthand both the universality and the individuality of the nervous system. I’ve also come to see that learning the language of the body is not only of vital use for those who have suffered trauma, but for anyone with a nervous system, which is all of us. Direct knowledge of how our nervous system processes and experiences danger and well-being allows us not only to help ourselves but also to help others. It allows us to better manage some of the main obstacles to compassion and empathy: the personal distress that comes from seeing others suffering and in pain; the frustration of seeing problems continue when they should end; the distress that remains in our body when a moral injury has occurred. The Community Resiliency Model is also essential for another very important reason: it destigmatizes trauma and the effects of adversity, and instead provides a strengths-based model for approaching adversity that is humanizing and empowering. Children (and adults) who appear to “act out” in ways that seem inappropriate to us need not be seen as “bad” or “broken.” Rather, they may be engaging in actions that their body feels are necessary for their survival, due to a lack of perceived or experienced safety. As someone who has worked in the field of higher education in prison and criminal justice

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reform, I see CRM as promoting a shift in our attitudes that can be a crucial step forward in addressing the underlying causes of mass incarceration and a punitive justice system. CRM promotes empathy and understanding. It promotes kindness, a recognition of our common humanity, and a more compassionate world. It is thus no surprise that important elements of it have been incorporated into two widespread compassion training programs, Compassionate Integrity Training at Life University and Cognitively-Based Compassion Training at Emory University. Elaine Miller-Karas is someone I deeply admire because she is trying to make the world a happier and safer place for everyone. She is trying to decrease the suffering of others and provide them with tools for a better life. And she does so not by asking them to adopt something new, external, or foreign, but by helping them tap into something that is already innate in themselves: resilience, the natural capacity of the body to respond and adjust to adversity, and to experience well-being. I believe the knowledge contained in this book and the practices it describes have the power to change the world and help make it a safer, happier, and more compassionate place for all. One of Elaine’s favorite questions is “What else is true?” There is a profound wisdom in the simplicity of this question. We cannot and should not discount the difficulties of life and the reality of trauma. But neither should we discount or ignore the power and potential of resilience and compassion. Brendan Ozawa-de Silva, PhD Senior Lecturer Center for Contemplative Science and Compassion-Based Ethics, Emory University

Preface

Building Resilience to Trauma: The Trauma and Community Resiliency Models, Second Edition, has five sections. This edition has expanded to 15 chapters from 9 based on dynamic and innovative ideas that sprang forth from the first edition. Part I is the foundation upon which both the Trauma Resiliency Model (TRM) and Community Resiliency Model (CRM) are based. Resiliency and trauma are defined in Chapters 1 and 2. Chapters 3 and 4 describe CRM and TRM in detail. Chapter 5 is about the neuroscientific underpinnings of both models with additional updated neuroscience concepts. Chapter 6 addresses equity, diversity, and inclusion, expressing the values and beliefs of the Trauma Resource Institute. Part II describes CRM’s pertinence to public health and highlights applications with sexual assault interviews and with disasters. Chapter 7 describes CRM from a public health perspective and highlights programs implemented around the world to reduce the impacts of trauma. Chapter 8 explains the Disaster Relief Management Program and how to operationalize CRM pre-, during, and post-disaster. Chapter 9 demonstrates how one state’s police commission transformed sexual assault interviews by incorporating a traumaand resiliency-informed lens in order to not retraumatize victims, guided by CRM. Part III focuses on CRM and TRM application to working with children and caregivers. Chapter 10 addresses childhood trauma and developmental considerations. Chapter 11 contains approaches and exercises used with children at different developmental ages. Several programs are highlighted that have integrated CRM into their curricula for children. Part IV describes the clinical use of TRM and CRM in psychotherapeutic interventions. Chapter 12 focuses on clinical applications based on attachment strategies applied to adult behavior. Chapter 13 describes how to use

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TRM and CRM in working with veterans and active-duty service members. Chapter 14 addresses the application of TRM and CRM to the field of Addiction, including how to integrate CRM into Motivational Interviewing. Part V contains Chapter 15. Chapter 15 describes the theoretical basis of the research and pertinent research tools identified by the leading researchers of CRM and TRM. In addition, this chapter discusses the array of research completed showing the methods used to evaluate the effectiveness of the wellness skills of TRM and CRM.

Acknowledgments

As I approach my 70th year, I reflect upon experiences in my life that gave energy to my international mission and creation of this book. I witnessed the sea of suffering at an early age and was not afraid of it and knew suffering was part of the human experience as well as joy. I also witnessed the universality of hope and healing common to all of humanity even when faced with the deepest despair and suffering. I started the Trauma Resource Institute (TRI), which led to the writing of this second edition of Building Resilience to Trauma with the ideas of how the wellspring of hope and healing could ease the suffering in the world. Traveling to the birthplace of my mother opened up my world and led me to my international mission. There are many to appreciate and acknowledge. My beloved ancestors—my grandmother, Eva, and my mother, Elsy Pineda— gave their vision of hope in coming to a new country and sharing with me the delicious and savory culture of El Salvador. My first international journey to El Salvador at eleven years of age was transformational and left me with a searing memory of a baby held tightly in a mother’s arms. The mother was clearly malnourished. This image of innocence, injustice, and poverty stayed within my heart and spirit and sparked a desire to help the less fortunate. I have met many people across the globe who have shared the stories of their lives with me: their families, their children, their elders, their music, food, and dance. They have influenced my ideas of healing through the lens of their rich cultures. My family and friends provided support and love through the journey. My husband, Jim Karas, and my daughter, Jessica Karas Waterson, have walked the walk with me with understanding and compassion. My sister, Deenise Kosct, provided unmeasured support and love. My brother, Matthew “Bill” Miller, continues to give me guidance as does my son, Erik Karas. I acknowledge my late father, Arthur “Bill” Miller, for his unconditional love and support.

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Acknowledgments

Running a nonprofit is challenging and TRI’s board members have guided me through my leadership of the Trauma Resource with compassion: Jim Loken, Dr. Deborah Small, Cynthia Costas Cohen, LMFT, Dr. Ron Fish, Dr. Carol Michelson, and Dr. Maggie Wheeler. Karen Chatt, administrative assistant, is appreciated for her dedication to TRI from the early days. Dr. Beverly J. Buckles, the dean of Behavioral Health at Loma Linda University, has given steadfast support, guidance, and vision when we were just forming our ideas. Thank you, Dr. Kate Wheeler from Fairfield University, for your belief in my work and our mission. Dr. Susanne Montgomery, Dr. Kimberly Freeman, and Dr. Linda Grabbe— you have helped us develop our evidence base with dedication, passion, and scientific rigor. The coauthors for their time and dedication to the second edition: Jessica ­ ichael Karas Waterson; Reena Patel, LCSW; Jennifer Burton, LMFT; Dr. M Sapp; Dr. Kimberly Freeman; Jan Click, LCSW; Susan Reedy, LMFT; Dr. ­Jennifer Wallace; Dr. Susanne Montgomery; and Dr. Linda Grabbe. Dr. Geneie Everet, my friend and colleague, is deeply appreciated for our history of shared ideas. Margaret Nilsson, my friend and editor, is patient and kind. This book could not have been accomplished without you. Since February 25, 2022, when our work with the Ukrainians began, I felt an opening to a more significant part of my purpose and meaning. I have been transformed by the Ukrainian people’s courage and strength and I thank them for allowing me into their lives. I have experienced a deep connection to the universal presence of compassion and empathy. It has imbued me with an even greater purpose to share the work we are doing and create new systems to prevent mental illness and provide support for those who suffer. All my experiences have inspired me each day to keep working to bring innovative ideas to as many people as will listen and sense! You are all my teachers. My world has become so much more meaningful because my heart is now filled with every one of you.

Part I

The Foundation

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Introduction, Resilience, and Perspective Elaine Miller-Karas This chapter will: 1. Introduce the Trauma Resiliency Model (TRM)® and the Community Resiliency Model (CRM)® 2. Define Resiliency and Neuroplasticity 3. Discuss Perspective and Intersectionality As we begin our journey of hope and healing, Pandora’s story illuminates what has been known for thousands of years. Elpis was the spirit of hope. Along with the other spirits, she was trapped in a jar by Zeus and entrusted with the care of the first woman—Pandora. When Pandora opened the vessel, all of the spirits escaped except for Elpis (Hope), who alone remained to comfort humankind (Ma, 2014). As Pandora’s story reminds us, even when faced with the most challenging of life experiences, hope can be found and can fundamentally transform our life’s journey. The “elegant design” of the nervous system” offers hope. Understanding the neuroscience behind our suffering reframes our experience. We are designed to heal and create new meanings and purpose from our suffering. We have observed the same common reactions in the people of Africa, Europe, Australia, North America, South America, Asia, the Middle East, and Central America and believe they are a result of our shared biology and humanity and not a result of pathology or human weakness. We have also observed these reactions in the people we have helped who have lived in active conflict during the Russian invasion of Ukraine in February 2022. Since the beginning of the Russian invasion of Ukraine, I have led the Ukrainian Humanitarian Resiliency Project of the Trauma Resource Institute (TRI). TRI has provided almost daily support on Zoom and Facebook Live to Ukrainians in the midst of war. The following story of a young DOI: 10.4324/9781003140887-2

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woman’s experience of the Ukrainian War is emblematic of the empowerment witnessed as we listen to the immense suffering and shine a light on, “What else may be true?” A woman’s voice filled with despair shares: My house is destroyed, my office is being shelled. I have barely escaped with my life. I will never be the same. I will never experience happiness or laughter again. I am alive now but tomorrow they could kill me.

We affirmed her feelings and used the skills of the Community Resiliency Model (CRM). She realized she had been numb, but as she used the skills the numbing shock of war lifted slowly. There was a silent pause and then with a voice filled with determination, her attitude transformed, she expressed, They can take my life, my nation, and everyone I love in my family. I am actually ready to die for my country. It is the most honorable thing a person can do. I am happy that I can feel the tears, and I am thankful to you for that.

With our guidance she was able to sense and embody her courage. New meanings emerged, “I can’t share this with those close to me, but I can share here, and this is a safe space.” She returned a few days later. When we asked the entire group if there was a Ukrainian song that we could sing as a way to practice the CRM skills, she spontaneously unmuted herself and in a sweet lyrical voice, sang a Ukrainian hymn a capella. With relief in her voice, she said, “Today, I was able to sleep and eat for the first time since the war started. It is like a miracle to find this hope inside during the war” (Personal Communications on Zoom, March 1, 2022 and March 3, 2022). Until the pandemic, we responded in person with a trauma team to natural and human-made disasters after the traumatic event was over. The pandemic taught us that we could provide our CRM workshops and train teachers in our global communities remotely through platforms like Zoom or WebEx. As the war started in Ukraine, we realized we could share our interventions, provide support, and build capacity among the Ukrainians during the war. We conceptualized a paradigm shift in how our organization can respond to human suffering. Through modern technology, we had

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the capability to offer support during the war and reach far more people remotely than if we responded in person. Consequently, the Ukrainian Humanitarian Resiliency Project was created and has provided workshops and support almost daily since the war began. At this writing, we are on day 50 of continuous support, and there have been 80,000 views on EdCamp Ukraine’s Facebook Live page. How else could this approach be implemented to help support the mental health of people of all ages amid crises across the globe?

A Paradigm Shift: Scaling Worldwide Well-Being Our work internationally and in the United States has often been in areas where people live with the oppression of poverty, violence and racism, often in conjunction with the impact of natural and human-made disasters. There are not enough mental health professionals to help the number of people impacted by traumatic events. It is essential to widen our perspective when considering how we can bring relief to individuals within our community using a public health perspective. In light of the impact of the pandemic, social unrest, war, genocide, and climate change on the world population, this is of the utmost importance. The pandemic has placed an additional strain on the mental health of our global community and amplified the need to bring new vistas to cultivate individual and community well-being. The US surgeon general, Vivek Murthy, stated, Mental health challenges in children, adolescents, and young adults are real and widespread. Even before the pandemic, an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide—and rates have increased over the past decade. The COVID-19 pandemic further altered their experiences at home, school, and in the community, and the effect on their mental health has been devastating. (US Surgeon General, 2021)

Mental health interventions developed in the West are often designed for emancipated, single individuals who live separately from their families. Most of the world lives in communal cultures. Mental health counseling is often a foreign concept for many from the worldwide community. An individual seeking therapy for a problem outside the family system is not customary. In addition, many individuals, for different reasons including their cultural perspectives, mistrust of mental healthcare systems, stigma, spiritual beliefs,

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a lack of resources, or an aversion to psychological interventions, do not seek the help of mental health practitioners. Often, individuals suffer in silence because of shame. In some cultures, individuals are shunned if they have a mental health condition. What if we nourish ideas and skills of well-being among community members? What if we cultivate a non-pejorative common language when describing symptoms stemming from stressful and traumatic experiences? What if we work to destigmatize mental health disorders and instead address common human reactions to stressful and traumatic experiences? What if a triage system of support existed where natural leaders have tools to help with individual and community well-being and knowledge to refer to mental health counselors when necessary? We believe part of the answers to these questions is to bring education and skills to our worldwide community based upon the burgeoning area of neuroscience in accessible, affordable, portable, and adaptable ways. The education and skills can be delivered by natural leaders of communities as well as mental health providers. CRM and TRM are examples of innovations that can create the possible change that will be discussed in Chapters 3 and 4.

The Community Resiliency Model CRM is based on cutting-edge neuroscience and teaches six wellness skills to restore the mind, body, and spirit to well-being during or after a traumatic experience. CRM is biologically based, educating about the autonomic nervous system and how the body responds to stress. It is used for self-care for children, teens, and adults to stabilize emotions, resulting in more adaptive thinking when facing emotional and physical distress. CRM skills can be learned and used during and after stressful and traumatic events. They can be delivered in small doses through community workshops or individually. CRM can be delivered by the natural leaders of communities (ministers, teachers, first responders and more) and mental health therapists and medical practitioners. Natural leaders are individuals who may or may not have formal education in mental health or designated leadership roles but are looked to for guidance because of their embodied personal qualities of treating others with respect, compassion, and empathy. They share their wisdom with equanimity in a way that encourages and empowers their community. A person delivering CRM is called a CRM guide. CRM guides integrate psychoeducational materials about the common reactions after stressful/ traumatic events, including information about the stress response and the

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autonomic nervous system. CRM teaches that many responses are biologically based and thus are not about mental weakness. CRM has distilled the complexity of neuroscience into simple, understandable concepts. This approach helps individuals understand the common human responses to stressful and traumatic events through a lens of biology. CRM concepts and skills have been found to reduce feelings of shame and stigma in survivors. New meanings about traumatic life events can emerge with a more realistic self-appraisal. The young man had been hospitalized for nearly two years, recovering from injuries sustained in war. He had lost a leg, suffered a traumatic brain injury, and severely injured the right side of his body. He wanted to learn new ways to heal his injuries, the obvious ones and the invisible ones. He learned about the CRM skills and the importance of paying attention to sensations. He learned simple tracking, resourcing, and grounding skills. As he practiced, he slowly began tracking sensations connected to his well-being. As he paid attention, his hands came together with his fingertips gently touching one another. When he was invited to bring awareness to this movement, he suddenly stopped, and with a startled expression and tears in his eyes, he said, “I feel whole again. For the first time since the war, I feel whole again!” CRM helps individuals discern the difference between sensations of distress and well-being. Once discernment is made, a person chooses what to pay attention to—sensations of distress or sensations of well-being. Wellness skills are taught to help the person learn to read the nervous system and return to a balanced state called the Resilient Zone or the Zone of Well-Being. This results in clearer thinking and greater affect regulation. Current neuroscience has identified a concept called “interoception.” Grabbe et al. (2020) state: Conscious awareness of the body’s internal state and its perturbations, the ‘felt sense’ or interoception, is currently under study as a source of emotion regulation and resiliency. Interoception, which means ‘looking inside,’ is critical to preventing stress-related sequelae of trauma…

The Trauma Resiliency Model TRM is a mind-body approach to treating trauma consisting of nine skills that focus on sensory awareness for regulating emotions and resulting in the client’s more realistic self-appraisal and an increased sense of well-being.

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Symptoms are viewed as common biological responses rather than pathological or mental weaknesses. The TRM practitioner introduces the first six skills of the TRM (the skills of CRM) to the client for self-care. Learning these six wellness skills results in a client’s increased confidence to manage and change distressing sensations, thoughts, and feelings connected to the multisensory reminders of their traumatic experience. The ability to bring attention to sensations in the present moment can reduce the impact of the reminders. TRM educates the client about how the body’s natural survival responses can be thwarted under severe stress or a perceived inescapable attack. When survival responses are not completed, unexpected multisensory cues can remind the client of the traumatic event. TRM practitioners teach the fundamentals of autonomic nervous system dysregulation and physical symptoms of trauma responses. When the autonomic nervous system is cued, reminiscent of the traumatic event, the person can feel like the experience is happening again in the present moment. TRM practitioners use the three trauma reprocessing skills of Titration, Pendulation, and Completing Survival Responses to reprocess the traumatic experience. Clients learn that the body has an inherent but unarticulated healing capacity as the TRM practitioner gently uses the reprocessing skills. Clients understand trauma responses from a biological lens and regain their sense of an integrated self by bringing thoughts, feelings, and body sensations into alignment with each other when they receive the TRM therapy. The TRM skills can be a stand-alone intervention for self-care and trauma reprocessing, and they can also be integrated into different treatment modalities.

Defining Resiliency What does it mean to be resilient? We have asked thousands of people this question in our workshops and training around the world. We have learned to do what we call a “deep listen” to all definitions to unwrap the meaning of this word. Definitions of resilience are as varied and diverse as human beings. The definitions expressed have often been passionately described, deeply felt, poignant, hopeful, and even sacred. The definition of resilience includes empowerment. Recognizing this does not mean discounting or diminishing our softness, vulnerability and at times, our exhaustion. Some people do not find the word resilience empowering. While in Belfast, Northern Ireland, on the eve of beginning training, a community member expressed another vista about the word “resilience.” They

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shared that there was a billboard in their community cautioning community members about the word “resilience.” On the billboard was a quote by Tracie L. Washington from the Louisiana Justice Institute, and it read, “Stop calling me resilient. Because every time you say, ‘Oh, they’re resilient,’ that means you can do something else to me. I am not resilient.” In other words, being called resilient was insulting. It was minimizing one’s history and lived experience. It was the government’s way of ignoring the needs of the people. In this way, the word “resilience” had been weaponized as a term used to marginalize, oppress, or trivialize individual and community suffering. We have recently heard the same sentiment toward the word “resilience” from others in the US, including some from the BIPOC community. We have often listened to the definitions that include “bouncing back” from hardship as part of the problem with the standard definitions. “Bouncing back” to what? Oppression, poverty, systemic racism, or insecure housing? This highlights the complexity in helping communities after disasters. Disasters do not happen in a vacuum but instead often have devastating effects on marginalized communities already suffering the impact of systems that work against their well-being. It has become clear that whenever we are invited into a community to help build “resilience” post-disaster, we must walk with cultural humility and not make assumptions about the meanings of concepts like “resilience” that are commonly expressed. Such humility will help us work with a community to help leverage their strengths to recover from specific events without suggesting that the systems that work against their well-being—that were present long before the disaster—should remain unchanged. In fact, we have found that the same skills we teach to help people and communities recover from specific disasters can also be used to help individuals and communities challenge and change such destructive systems. Yet, it is essential that we have a working definition of “resilience” and that it is reflective of our world community. When we began using the word “resilience,” it was not so prominently misused. We believe it remains a powerful word, and we have witnessed how it has nourished many through its meanings rooted in a strength-based perspective. Thus, our working definition has many components that have expanded over the years. We have learned that “resilience” is not a static state but one that emerges dynamically and has an ebb and flow. Our resilient self may feel elusive and is an untapped river of well-being waiting to be experienced. My definition of individual and community resilience has transformed to include a kaleidoscope of concepts. Resilient individuals and communities are infused with an overarching stance of embodied compassion and empathy

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and cultivate well-being by remembering their assets and strengths. They appreciate culture and traditions. Resilient individuals and communities acknowledge human suffering—recent and historical. They have an openness to the experience of hope and optimism. This optimism imbues community members with solution-focused perspectives. They embrace the diversity of their community and deeply listen to divergent views. There is an attitude of adaptability and flexibility when faced with individual and community challenges. Resilient individuals embody well-being by embracing their vulnerabilities as well as their capabilities. Taking all these elements together when defining resilience is fundamentally empowering. I encourage anyone reflecting upon the ideas in this book to consider what resilience means and keep in mind the definitions of resilience elaborated upon in this book.

Understanding Resiliency in TRM and CRM—the Zones The Resilient Zone is also called the Zone of Well-Being. Children call it the Okay Zone. Every person has a Zone of Well-Being. When you are in your Resilient Zone, you can think clearly, handle feelings better, and manage the sensations inside the body. There are a variety of emotions you can experience including happiness, sadness, and anger. These emotions are naturally human. When in your zone, you can manage the emotions from the best part of yourself. As one little boy once said to one of our CRM teachers, “You mean I can be ‘Okay sad’ and ‘Okay mad’ and be Okay.” When you are in your Resilient Zone, there is a natural rhythm or flow within your nervous system; just like there is in nature with the seasons, the rising and setting of the sun, the cycles of the moon and the ocean (Figure 1.1). When traumatic and/or stressful events occur, the natural rhythm within the nervous system can be thrown out of balance. At times, all of us can be bumped out of our Resilient Zones and have challenges handling even small stressors. Because of stressful or traumatic experiences, some people may feel bumped out of their Zone of Well-Being most or all the time or even stuck in

Figure 1.1  The Resilient Zone

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one of the zones. When bumped out of the Resilient Zone, a person can be on edge (in the High Zone) and/or depressed and tired (in the Low Zone) or go between the two. Some people describe it as like being on a roller coaster. When we go back and forth between the High and Low Zones, we may have problems with our family, work, and community. CRM and TRM hold no judgment about the zones. The zones simply exist and when we become aware of what bumps us out of the Resilient Zone, this awareness can help us manage our thoughts and feelings in more adaptive and flexible ways with compassion and greater self-understanding. One of the goals of CRM and TRM is to help people identify the sensations, feelings and thoughts connected to being within their Resilient Zones and their High or Low Zones. We can learn to use our skills and strengths to return to a greater sense of well-being (Figure 1.2). To de-weaponize our language, we reduce using the word “trigger” when we refer to “reminders” or “cues” of a stressful event. Reminders or cues can be almost anything reminding a person of a traumatic or stressful event (e.g., a smell, sight, sound, touch, body position). The reminder can often be outside of awareness. These reminders are designed to alert us to potential danger to aid in our protection. The alerts are set off based on experience, which means the reminders are different for each person. For example, for some people who have been sexually abused, a certain smell, sound, or body position could be a reminder that cues a desire to flee, and the internal sensations of distress can bump the person out of their Resilient Zone. This is our nervous system working for our protection.

Figure 1.2  High/Low Zones

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Neuroplasticity: The Hope of the Nervous System Maria survived Typhoon Yolanda of 2013 in the Philippines. Afterward, though, she was stuck in the story of her traumatic experience. Her body began to shake even before she began telling her story. Maria was asked, “What helped you survive the experience?” She recounted that she and her friends had held hands in a circle, praying. When asked about her sensory experience as she recounted and emphasized this new element of the survival story, Maria took a deep breath and reported her heart rate was returning to normal. She suddenly gave new meaning to her experience. “I survived. I am okay!” she said, and she reported feeling the blood flow in her body as if she was finally really alive again. At the time of the storm, the fear of losing her life overrode the memory of what helped her get through. Maria was given time to notice the sensations connected to her survival story. As she recounted the experience, her nervous system came back into balance. She shared that she could now remember that night as the night she survived, not the night that she almost lost her life. Asking about the survival experience brings new awareness of what else happened during the traumatic event. When Maria began to weave new meanings into her life about her lived experience, she changed. She experienced greater well-being in mind, body, and spirit. Her story exemplifies the concept called “neuroplasticity,” the fact that the brain is malleable. Neuroplasticity refers to the lifelong capacity of the brain to change and rewire itself in response to the stimulation of learning and experience. Neurogenesis is the ability to create new neurons and connections between neurons throughout life. (Fernandez & Goldberg, 2009)

If the brain can change, so can challenging beliefs, feelings, and associated body sensations. Specifically, new pathways or connections between neurons can be created within the brain and body. The creation of new neuronal pathways can result in greater resilience. When a person learns to stabilize their nervous system and apply this knowledge to their activities of daily living, they are changing their brain. Davidson (2016) states that neuroscientists can measure the plasticity of the brain circuitry underlying four brain circuits that can create enduring traits of resilience, positive outlook, attention and generosity. The resilience circuit refers to the rapidity with which a person recovers from adversity. Neuroplasticity is the “hope” of the nervous system. The positive outlook

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circuit refers to the human ability to see and recognize the positive in others and the ability to savor positive experiences. The attention circuit refers to a human’s emotional well-being linked to the ability to pay attention. The generosity circuit is the human propensity to engage in generosity. This engagement activates brain circuits that support well-being, whether witnessed, received, or given reliably. The thrust of Davidson’s research is that human beings can cultivate skills that directly influence the strength of these circuits. The wellness skills of CRM and TRM correspond to these circuits.

Perspective The Dalai Lama states, “There are many different angles for every event in life.” He uses the terms “wider perspective” and “larger perspective.” These involve taking a step back to look at the bigger picture. A wider perspective moves us out of a limited self-awareness and self-interest to the possibility of a global interest. Desmond Tutu expressed the idea of a “God’s-eye perspective,” which he stated allows for the birth of empathy, which creates joy not only in the one but also in the many. This wider perspective leads to the possibility of empathy opening the door to understanding the journeys of others and can prevent us from building walls that keep us from welcoming potential friends and collaborators. Different perspectives can turn the “I” into the “we.” In our travels, we have had a window to witness the suffering and hardships of others not unlike our suffering. Desmond Tutu reminded us of the Overview Effect. He stated, Many astronauts report that once they glimpsed the Earth from space—a small blue ball floating in the vast expanse, lacking our human-made borders—they never looked at their personal or national interests in quite the same way again. They saw the oneness of terrestrial life and the preciousness of our planetary home. (Dalai Lama et al., 2016)

Helping to understand perspective is a term adapted from Kimberlé Crenshaw’s “Intersectionality.” She originally used “Intersectionality” to emphasize the cumulative way the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect, especially in the experiences of marginalized individuals or groups (Crenshaw, 1989). Our view of “Intersectionality” has expanded to express where multiple experiences and identities come together and intersect, affecting not only how others perceive individuals but how the individual perceives the world. A person’s lived experience within this “intersection” can impact how they

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experience life events biologically, manage day-to-day activities and view their common humanity. Our intersections also affect how others view us. We encourage you to reflect upon your intersections as you begin learning about our philosophy of building resiliency. I come to you as a mother, a grandmother, a sister, a wife, a friend, a feminist, a therapist, a social worker, an author, a co-founder of an international organization, an advocate, a Latinx of light-colored skin, a cis-gendered heterosexual woman, a daughter of immigrants from El Salvador and Germany, a citizen of the world, an ambassador of hope—all of which intersect and crisscross. These intersections continue to inform my journey. The intersections have given me hopeful perspectives that we must acknowledge our vulnerability and suffering, be witness to the suffering of others, acknowledge our advantages, lean into our strengths, advocate for social justice and sprinkle joy whenever possible. In addition, maintaining a sense of humor and not taking oneself too seriously can lighten the spirit while journeying through life. All my intersections have impacted my perspectives, intentions, actions and content of this book, and I welcome you on this journey.

References Crenshaw, K. (1989). Intersectionality Definition. Oxford English Dictionary. https:// www.oed.com/view/Entry/429843 Dalai Lama, Tutu, D., & Abrams, D. (2016). The Book of Joy: Lasting Happiness in a Changing World. New York: Avery, an imprint of Penguin Random House. Davidson, R. (2016). The Four Keys to Wellbeing. The Greater Good Magazine, https://greatergood.berkeley.edu/article/item/the_four_keys_to_well_being Fernandez, A. & Goldberg, E. (2009). The SharpBrains Guide to Brain Fitness: 18 Interviews with Scientists, Practical Advice, and Product Reviews, to Keep Your Brain Sharp. San Francisco: SharpBrains. Grabbe, L., Higgins, M., Baird, M., Craven, P., & Fratello, S. (2020). The Community Resiliency Model® to Promote Nurse Well-Being. Nursing Outlook, 68(3), ­324–336. doi: 10.1016/j.outlook.2019.11.002. Epub 2019 Dec 30. PMID: 31894015. Ma, M. (2014). On the Nature of Hope and Its Significance in Innovation. Psychology Today Blog, February 11, 2014. U.S. Surgeon General Issues Advisory on Youth Mental Health Crisis Further ­Exposed by COVID-19 Pandemic News Release, 12.7.21, Office of the Surgeon General, HHS.

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Trauma Defined Elaine Miller-Karas

This chapter will: 1. Describe the definitions of trauma and the global challenges of traumatic experiences 2. Define positive, tolerable, and toxic stress 3. Describe the Adverse Childhood Experiences Study and its Implications 4. Define differences between cognitive and biological approaches to treating trauma

The Global Challenge of Traumatic Experiences The impact of traumatic experiences on individual and community health is widespread. According to the World Health Organization (WHO, 2021), “Traumatic events and loss are common in people’s lives.” In a review of data from WHO surveys, the cross-national lifetime prevalence of post-­traumatic stress disorder (PTSD) was 3.9% in the total sample and 5.6% among the trauma-exposed. Half of the respondents with PTSD reported persistent symptoms. Social disadvantage—including younger age, being female, being unmarried, being less educated, having a lower household income, and being unemployed—was associated with an increased risk of lifetime PTSD among the trauma-exposed. PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment, and only a minority receive specialty mental health care. The world’s population is approximately 8 billion wherein approximately 307 million people suffer from post-traumatic stress symptoms. It is estimated that about 354 million adult war survivors have PTSD and major depression (MD). Of these, about 117 million suffer from comorbid PTSD and MD. DOI: 10.4324/9781003140887-3

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The COVID-19 pandemic has ravaged the world and impacted the fabric of our society in unprecedented ways. As of March 6, 2022, over 433 million confirmed cases and over 5.9 million deaths had been reported globally (WHO, 2022). The long-lasting impact on the physical and mental health of those who have contracted the virus is unknown. The unpredictable nature of the spread of this virus, including the emergence of new variants, has brought great uncertainty to society even as our knowledge develops about the nature, prevention, and treatment of this virus. To slow the spread of the virus, people have had to distance themselves and quarantine socially. This has interfered with everyday work and social routines, cultural and religious customs, work and leisure activities, and the availability of services. Children have had to learn differently and have been distanced from their teachers, friends, and activities. The COVID-19 pandemic has brought further attention to worldwide mental health problems, including depression, anxiety, substance use, violence, and suicide among frontline workers (Gilleen et al., 2021) and the general population (Auerbach & Miller, 2020; Shim & Starks, 2021). The Lancet Psychiatry (2021) stated that although the psychological toll of COVID-19 is already apparent, the effects will be far-reaching, and health systems will face widespread demand to address the COVID-19-related mental health needs. The UN (2020) stated, “This historic underinvestment in mental health needs to be redressed without delay to reduce immense suffering among hundreds of millions of people and mitigate long-term social and economic costs to society.” Williams and Vermund (2021) state that socially and economically disadvantaged racial and ethnic minorities have experienced comparatively severe clinical outcomes from the COVID-19 pandemic in the United States. He further says that the disparities in health outcomes arise from a myriad of synergistic biomedical and societal factors. The trauma-­ informed lens includes realizing that structural factors—housing, transportation, economic needs, mistrust of authorities and institutions, and the lack of accessible mental health treatment—compound the disease burden in Black, Indigenous People of Color (BIPOC) communities. Shim and Starks (2021) call for interventions at local and national levels to prioritize equity and justice for sustainable, collective mental health and well-being. Climate change is one of the urgent issues of our global community. Rising temperatures, heat waves, floods, tornadoes, hurricanes, droughts, fires, loss of forests, glaciers, and the disappearance of rivers and desertification cause

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great human suffering. All people feel the effects of climate change. These effects are experienced most acutely by children, women, the aged, the underprivileged, the economically marginalized, and people of color, for whom climate change is often a key factor in food and housing insecurity and social fragmentation. Extreme weather events (e.g., floods) and natural disasters (e.g., wildfires) have been previously linked to a broad range of adverse mental health outcomes. The most commonly reported mental health disorders in the aftermath of extreme weather events and natural disasters are PTSD and depression and anxiety, suicide, and substance abuse disorders (Cianconi et al., 2020). Save the Children (2021) reported that “Globally, 426 million children live in conflict zones.” This statistic was before the onset of the conflict in Ukraine. In 2021, it was estimated that 72 million children lived 50 kilometers or closer to conflicts where armed groups or forces have perpetrated sexual violence against children. Ukraine is reporting that sexual violence is being used as a weapon against children and civilians to terrorize, creating fear and intimidation for political and military gain. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), at least one in seven children have experienced child abuse and neglect in the past year in the United States, and this is likely an underestimate. Children identifying as lesbian, gay, bisexual, transgender, queer, questioning, asexual, and intersex (LGBTQAI) have particular challenges. The Trevor Project’s 2020 National Survey on LGBTQ Youth Mental Health provides critical information about LGBTQ youth mental health disparities, discrimination, housing instability, and suicide. The survey was taken by over 40,000 LGBTQ youth ages 13–24 across the United States. The key findings of the report are staggering: 40% of LGBTQ respondents seriously considered attempting suicide in the past 12 months, with more than half of transgender and nonbinary youth having seriously considered suicide; 68% of LGBTQ youth reported symptoms of generalized anxiety disorder in the past two weeks, including more than three in four transgender and nonbinary youth; 48% of LGBTQ youth reported engaging in self-harm in the past 12 months, including over 60% of transgender and nonbinary youth; 29% of LGBTQ youth have experienced homelessness, been kicked out, or have run away; one in three LGBTQ youth reported that they had been physically threatened or harmed in their lifetime due to their LGBTQ identity. The LGBTQ community faces discrimination and mistreatment, resulting in a negative impact on mental health. Livingston et al. (2020) stated that

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epidemiological data suggests that individuals who identify as LGBTQ experience trauma, including violence and victimization, at higher rates than the general population. The estimated prevalence of PTSD tends to be higher among LGBTQ individuals, with rates ranging from 1.3% to 47.6% among LGB and 17.8 to 42% among transgender and gender diverse (TGD) individuals. A World Economic Forum report supplies comparisons across noncommunicable diseases that provide information about their global economic burden. Mental health costs are the largest single source—larger than cardiovascular disease, chronic respiratory disease, cancer, or diabetes. Mental illness alone will account for more than half of the projected total economic burden from noncommunicable diseases over the next two decades and 35% of the global lost output (Bloom et al., 2011). Considering that those with mental health challenges are at high risk for developing cardiovascular disease, respiratory disease, and diabetes, the actual costs of mental illness must be even higher. Rytwinski et al. (2014) reported that about one of every two people diagnosed with PTSD also suffers symptoms of depression. A Lancet Commission Report (2018) by Patel et al. on mental health stated that mental disorders are on the rise in every country in the world. They further estimated that mental disorders will cost the global economy $16 trillion by 2030. The report also stated that the economic cost is primarily due to the early onset of mental illness and lost productivity, with an estimated 12 billion working days lost due to mental illness every year. As we recognize the scope of the problem, innovative approaches to address the impact of post-traumatic stress and accompanying mental health conditions are imperative. The TRM and CRM models are examples of interventions that can be used by mental health professionals and natural leaders of communities to address the tremendous need because they are affordable, adaptable, and accessible.

CRM and TRM Definitions of Traumatic Experiences A traumatic experience is defined as an individual’s perception of an event as life-threatening to themselves or others. An event that results in trauma for one person may not be experienced by another individual as traumatic. Even when every member of a family experiences the same event, each may have a different perspective.

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Trauma doesn’t have to be experienced firsthand. This is an important distinction because many people live in self-blame and self-criticism, wondering why they are having such a difficult time when they did not experience the traumatic event. This vicarious Trauma is often experienced by those in the helping professions and first responders, such as therapists, crisis counselors, firefighters, police officers, and medical professionals. Baird and Kracen (2006) differentiate vicarious traumatization and secondary traumatic stress. Vicarious traumatization consists of harmful changes that occur in the professionals’ views of themselves, others, and the world, as a result of exposure to the graphic and/or traumatic material of others. Secondary traumatic stress refers to a set of psychological symptoms consistent with PTSD and is acquired through exposure to persons suffering the effects of trauma. Boscarino et al. (2010) stated that therapists who work with traumatized patients also demonstrate psychological distress reactions, including symptoms of PTSD. Dr. Francine Shapiro defines two types of trauma. She categorizes one as “large-T” and the second as “small-t” Trauma (Shapiro, 1987). “Large-T” Trauma includes significant events such as natural disasters, war, sexual assaults, child abuse, or acts of terrorism. Examples of “small-t” trauma could be a dental procedure, a dog bite, a routine surgery, a fall, or a minor car accident. “Small-t” traumas are labeled as such not because the person experienced them as a minor event. The individual involved may experience something like a “large-T” event; however, we may designate it as “small-t” because family members and the larger society deem the event as being of minor significance. If you have experienced a “small-t” trauma, your friends and family may minimize its importance. Cumulative Trauma, or C-trauma, was added to our conceptualization after a world leader in humanitarian efforts and restorative justice shared the lingering impact of colonialism on the people of her home country, Kenya. In addition, others have shared similarly about the micro-aggressions of homophobia, transphobia, xenophobia, and racism, and Native American colleagues have described the collective Trauma of losing one’s culture and language due to genocide. Living with racism, for example—not knowing if others accept you or if your life could be in danger because of your skin color—can create a cascade of physical, behavioral, and emotional reactions that a person can experience daily. Those who are simultaneously dealing with multiple types of trauma are at greater risk for psychological and physiological challenges. And for those

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who have overarching cumulative Trauma that impacts their lives and their loved ones daily, their wider world community is not secure. An individual can have experiences from all three categories at the same time. This “stacking effect” may be a tipping point for a person who has experienced several “large-T” and “C-traumas,” so that when a “small-t trauma” such as a minor surgical procedure is encountered, the individual can have significant traumatic stress reactions. There is no one way symptoms of a traumatic stress reaction occur. Symptoms of traumatic stress can occur immediately following a traumatic event, or it may be months or years before symptoms appear. Symptoms can wax and wane, plague people their entire lives, or appear suddenly. Understanding this is helpful as many people often feel shame if their report of symptoms isn’t immediate. Again, perception is vital. We will now describe the different ways trauma is conceptualized in the literature, including post-traumatic stress, toxic stress, adverse childhood experiences (ACE), and historical and intergenerational Trauma.

Trauma and Stressor-Related Conditions The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the standard used to classify mental health disorders by mental health professionals in the United States. The DSM-5 classifies several traumatic stress responses, including PTSD, in a category called “Trauma and Stressor-related Disorders.” The diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. Additional criteria concern duration of symptoms, assessment of functioning, and the stipulation that the symptoms are not attributable to a substance or co-occurring medical condition (American Psychiatric Association, 2013). As mental health practitioners, we need diagnostic criteria to help guide us in diagnosis and treatment. However, there is controversy over the DSM-5, and time will tell how the DSM-5 will be incorporated into practice. Also, we have found that many of our clients prefer simple explanations that help them better understand their reactions to their life experiences. There is an intention in using the word “condition” rather than “disorder.” Condition is a value-­ neutral term. The word “disorder” can harm self-image and can cause shame for someone with a mental health challenge. Using “disorder” is another way that can pathologize individuals.

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Defining the Stress Spectrum: Positive, Tolerable, and Toxic Stress It can be helpful when discussing traumatic stress reactions to consider the definition of stress. Traumatic individual and communal experiences can result in a stress response. Stress can be described as positive, tolerable, and toxic. These descriptions are important because they refer to the stress response systems’ effects on the body, not to the actual experiences or events that were stressful. CRM and TRM recognize that the reading of the nervous system can help a person learn to become aware of the physical reactions of the stress response. This sensory awareness, also called interoception, can be a portal to self-healing that can lead to community healing. Sennesh et al. (2022) define allostasis as the brain’s regulation of the body by anticipating its needs before they arise. These internal reactions to an external stressor include activation of the stress-response systems. These are normal and adaptive responses to stress and result in physiologic stability in the face of an external challenge. These systems revert to normal baseline states after acute external stress or challenge. However, when the stressor becomes chronic and unbuffered by social supports, dysregulation of these systems may occur, resulting in pathophysiologic alterations to these responses, such as hyperactivation of the allostatic systems. Over time this dysregulation contributes to an increased risk of disease and dysfunction. This pathophysiologic response is called “allostatic load.” Positive stress is the body’s response to a mild or moderate stressor. A positive stress response includes physiological changes like increased heart rate, blood pressure, and mild elevations in hormone levels. Internal balance returns quickly. A tolerable stress response is an adaptive response to time-­limited stressors. It sets off the body’s alert systems, resulting in a greater sense of distress that is more difficult to overcome. Time-limited stress responses result in short-acting physiological reactions. This kind of stress response does not decrease without the help of a support system and other interventions. However, the balance does return after a short period. Toxic stress response refers to ongoing and relentless body responses to intense stressors. When allostasis goes on too long, it causes changes in the way the brain functions. The cumulative toll can impair a person’s physical and mental health. ACE without social support that can mitigate the impact of such incidents can result in prolonged activation of the stress response systems. ACE disrupt the development of brain architecture and other organ systems and increases the risk for stress-related disease and cognitive impairment well into adulthood.

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The ACE Study is described in detail below. Its outcome highlights the importance of creating interventions that help with affect regulation, cognitive restructuring, and biological interventions.

The Adverse Childhood Experiences Study ACE Study by Felitti et al. (1998) was a joint study by Kaiser Permanente in San Diego, California, and the Centers for Disease Control (CDC). It highlights how ACE affect the human condition throughout the lifetime. In ACE Study, researchers noted that morbidly obese adults taking part in a weight management program at Kaiser Permanente were not successful in maintaining weight loss. In delving deeper into the background of these individuals, the researchers discovered that all had histories of trauma. As a follow-up, they decided to survey several patients within their medical system to see how many had experienced childhood trauma. Researchers identified the following ten types of trauma for the survey: sexual, physical, and emotional abuse; physical and emotional neglect; and five types of family dysfunction, including having a household member who treated the person violently, abused drugs or alcohol, was imprisoned, or had a diagnosis of mental illness, or having parents who were separated or divorced. Sixty-four percent of those surveyed had experienced one or more adverse childhood events (Felitti et al., 1998). In addition, individuals were assigned one point if they had the experience, regardless of how many times they had the experience. Researchers wanted to see if there was a correlation between peoples’ ACE scores and their health care utilization. They found a strong link between ACE and adult onset of chronic illness. Those with ACE scores of four or more had significantly higher heart disease and diabetes rates than those with ACE scores of zero. In addition, in the group that scored four or higher, the incidence of chronic pulmonary disease increased by 390%, hepatitis by 240%, depression by 460%, and suicide attempts by 1,220%. Patients with ACE scores of six or more had a 4,600% increase in the likelihood of becoming an intravenous drug user, and they died nearly 20 years earlier on average than those with ACE scores of zero—they lived 60.6 years versus 79.1 years. Researchers then conducted a more extensive psychosocial assessment of patients who came into Kaiser. They followed up on the traumatic experiences that individuals had gone through and asked them about how those experiences affected them in the present. The findings were impressive: In the year

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following this short intervention, there was a 35% reduction in primary care usage, an 11% reduction in emergency room visits, and a 3% reduction in hospitalizations in this group. The results of the ACE Study support one of the critical concepts of CRM and TRM: that trauma affects individuals biologically. Since many people who have experienced trauma or highly stressful events never seek therapy, we need more portals within the public health system to address the needs of those who have trauma-related symptoms. These portals must be accessible, adaptable, and affordable. In addition, this study illustrates the importance of integrating as part of our interventions body-centered approaches like CRM and TRM that are skillsbased and incorporate knowledge of the science that explains what happens to human beings when they experience adverse experiences in childhood. Most psychological approaches are cognitively based. While sometimes using relaxation exercises, cognitive models focus on changing debilitating beliefs, providing insight, and developing problem-solving strategies. This is what is called a “top-down” approach. Although it may lead to increased understanding, it may not lead to calming the physical experience associated with stressful and traumatic experiences that are so rooted in our biological responses to stress. It’s important to note that the original ACE study is biased on sampling size as 75.8% of original participants identified as White, 11.2% as Hispanic, 7.2% as Asian/Pacific Islander, 4.5% as Black, and 2.3% as Other, and 46.4% of participants were ages 60 and over, with 39.3% having a college degree or higher. Human beings throughout the world have common reactions to stressful and traumatic experiences. The TRM and CRM models recognize this common thread among people throughout the globe while respecting our differences in ethnicity, culture, gender identity, sexual orientation, and religion. While the original ACE Study highlighted the connection between early childhood experiences and poor outcomes in adulthood, it limited the number of ACEs to ten, often focused just on household factors. There are more ACE outside of the household that might have a similar effect. In 2013, the Institute for Safe Families and ACE Task Force conducted the Philadelphia Urban ACE Study, which included additional ACE indicators such as neighborhood safety and trust, bullying, witnessing violence, experiences of racism, and time in foster care. Findings include significant increases in ACE scores when indicators include environmental stressors outside of the original ACE indicators.

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We postulate that biological interventions like CRM and TRM can help a person’s nervous system return to a balanced state. So, if children at an early age and the adults who care for them learn the TRM and CRM skills of well-being, how might that impact the effects of ACEs? The trauma-informed care approach is foundational for talking to people about what has happened to them in their lives. For example, if we work in a healthcare system, the best way to bring this forward is through a team response, where everyone on the mental and healthcare team understands this trauma-informed care approach. This creates an environment that surrounds an individual and their community that is safer, compassionate, and empowering. Education about the impacts of current and past traumas on mental health and physical health is part of the delivery of comprehensive care. The trauma-informed care approach in TRM and CRM is described as a paradigm shift. Conventional thinking states that people are bad—they must be punished. The trauma-informed approach says that we need to be sensitive to what happened to a person, and we need to create interventions that can help them with the traumas they experience. The resiliency-informed approach states that all individuals on the globe can learn skills of well-­ being and that the questions that have to be asked go beyond being trauma-­ informed. The questions can also be resiliency focused: What has helped you get through? What are your strengths? Are there people in your life who helped you during challenging times? So, the paradigm shift moves from conventional thinking to trauma-informed and then to resiliency-informed. Bethell et al. (2014) studied the impact on health and school engagement and the mitigating role of resilience in children aged 6–17. She found that the children who could stay calm when faced with a challenge reduced the negative impact of ACE. So, despite higher numbers of ACE, there were higher rates of school engagement among children who demonstrated resilience. Therefore, the importance of the study is that, since CRM and TRM help people understand and regulate their nervous systems, people can go from states of distress to states of calm. Not all children have the capacity to stay calm when faced with a challenge. We’re postulating that if they can learn the wellness skills of TRM and CRM, then even children who struggle to stay calm when faced with a challenge can learn skills to regulate their nervous systems. The biological impact of ACE has illuminated the need to redesign our approaches that help people who have experienced traumatic stress. In addition, Bonanno (2009) states that intervening with cognitive-based models during periods when individuals are in a state of recovery and resilience after a traumatic event can increase someone’s traumatic stress reactions. Interventions

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that focus on the biology of the human nervous system (­ bottom-up) rather than cognitive approaches (top-down processing) need to be included in public and mental health strategies.

Historical and Intergenerational Trauma Cumulative trauma includes historical trauma, also called intergenerational trauma. Definitions of trauma have often focused on individual trauma. They do not include the resulting trauma experienced by an entire population targeted for disenfranchisement as a result, for example, of their culture, religion, sexual orientation, gender identity, or ethnicity. Historical trauma can be related to significant events that oppressed, including slavery, genocide, forced migration, homo/transsexuality, and the violent colonization of indigenous people. Sotero (2006) brought forth a conceptual framework to describe historical trauma. She states that historical trauma originates from the subjugation by a dominant group of a population through military force, bio-warfare, national policies of genocide, ethnic cleansing, incarceration, enslavement, and laws that prohibit freedom of movement, economic development, and cultural expression. She says that although overt legitimization of subjugation may be rescinded over time, its legacy remains in the form of racism, discrimination, and social and economic disadvantage. Thus, the universal experience of this communal experience results in significant physical and psychological trauma for the affected population that can endure for generations. This trauma is not only experienced in our minds but also our bodies. The unexpressed and unaddressed grief and mental and physical health needs may not be acknowledged, continuing the legacy of suffering. Transgenerational trauma, or Intergenerational Trauma, is also used to describe a theory that suggests that trauma can be transferred between generations. The hypothesis that offspring are affected by parental trauma or stress exposure, first noted anecdotally, is now being studied empirically by data from the Holocaust and other population survivor offspring studies. Biological variations coming from stress exposure in parents could directly impact offspring, a concept referred to as “intergenerational transmission,” via changes in the gestational uterine environment. This also includes the transmission of stress to offspring via early postnatal care. Yehuda and Lehrner (2018) studied the epigenetic transmission of intergenerational trauma in the children of Holocaust survivors. Yehuda et al. (2014) discovered that Holocaust survivors and their children showed changes in the same gene, a stress-related gene linked to PTSD and depression. The sample size was small but suggested that further study is needed.

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The World Health Organization Recommendations Mental health care must be grounded in a human rights-based approach, and the community must be involved in implementation. This has been recommended by the WHO Comprehensive Mental Health Action Plan 2020– 2030 endorsed by the World Health Assembly in May 2021.WHO reported that most mental health care continues to be provided in psychiatric hospitals, and human rights abuses and coercive practices remain all too common. WHO has recommended that community-based mental health programs provide services. They include crisis support, mental health services offered within general hospitals, outreach services, supported living approaches, and support offered by peer groups. WHO powerfully state, “Until that happens, the discrimination that prevents people with mental health conditions from leading full and productive lives will continue.” The growth of CRM and its integration into community-based mental health programs has found that this approach is respectful of human rights, focuses on personal and community well-being, and is proving successful and cost-effective. The WHO released clinical protocols and guidelines in 2013 to promote effective mental health care for adults and children exposed to trauma and loss. According to a WHO report, “Mental disorders are common, disabling and usually untreated.” The report recommends that primary health care providers provide mental health care support. It also mentions Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) as two possible interventions. CBT and EMDR are both evidence-based practices that require a great deal of training on the practitioner’s part to become proficient. In addition, there is a growing body of evidence elucidating the limitations of cognitive approaches. While we applaud WHO’s report and its efforts to bring attention to the numbers of individuals affected worldwide by PTSD and depression, the sheer number of individuals who have experienced trauma would make it difficult, if not impossible, to train enough primary care providers worldwide to make a significant impact.

Conclusion Bryant et al. (2008) reported that acute physiological reactions measured during or immediately after a traumatic event had been shown to predict the later development of PTSD. Some individuals experience symptoms such as an elevated heart rate and respiration rate in the wake of a traumatic event. These symptoms cannot often be “talked away” (e.g., we would not expect

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our heart rate to slow down no matter how much we tell it to do so). However, such symptoms may be able to be sensed away if the individual can learn to track their nervous system to intercept these sensations of distress and bring attention to sensations of well-being. The nervous system can return to balance, and toxic stress reactions can be reduced or eliminated. When working during or in the immediate aftermath of disasters, it isn’t easy to assess who will be resilient and who will not. This poses important questions about how we intervene after individuals have suffered traumatic events or are currently suffering, like the Ukrainians experiencing war. Our view is that the sooner we intervene with biological interventions like TRM and CRM that help stabilize an individual’s nervous system, the more likely traumatic stress reactions can be reduced or eliminated. For naturally resilient individuals, the wellness skills are additional tools to enhance their well-being. There is a crucial difference between TRM and CRM and cognitive approaches like Psychological First Aid and CBT. This is not to say that the cognitive or psychological aspects of the trauma are not necessary; in contrast, CRM and TRM focus on the biological responses themselves as the primary entry point or portal to promote healing. The reason is simple: the trauma’s disruption of normal biological rhythms fuels the cognitive and psychological aspects of trauma. Trauma can affect the areas of the brain responsible for verbal processing and cognitive functioning. When traumas occur, the experience becomes part of a person’s narrative history explicitly, but it also becomes part of the body’s experience implicitly. Although cognitive approaches can help provide insight when reflecting on a traumatic lived experience, they may not change the nervous system’s reaction when multisensory cues set off human survival responses. CRM and TRM focus on the biological basis of threat and fear because the parts of the brain responsible for verbal processing and cognitive functioning are not as accessible during and after traumatic events. In the Mind Heart Study, Cohen et al. (2013) found that individuals with PTSD scored significantly worse on processing speed, category fluency, verbal learning and recognition, and executive functioning than those without PTSD. A ­ inamani et  al. (2021) reported that the trauma of child maltreatment seems to be related to lower working memory and executive functioning of affected children and adolescents. CRM and TRM focus on the body’s innate ability to expand the sensations associated with well-being to override the s­ urvival-based responses to threat and fear. The wellness skills, then, are aimed at nervous system stabilization.

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CRM and TRM do not assume that all survivors will develop severe mental health problems or long-term difficulties. Some individuals will have greater difficulty recovering from the traumatic event and may experience an amplification of comorbid conditions. The models emphasize the teaching of wellness skills because they benefit those who will naturally return to their baseline functioning after a traumatic event and those having more significant challenges who may not be returning quickly to premorbid functioning.

References Ainamani, H., Rukundo, G., Nduhukire, T., Ndyareba, E., & Hecker, T. (2021). Child maltreatment, cognitive functions and the mediating role of mental health problems among maltreated children and adolescents in Uganda. Child and Adolescent Psychiatry and Mental Health, 15(1), 22. https://doi.org/10.1186/ s13034-021-00373-7 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders fifth edition (DSM-5). Washington, DC: American Psychiatric Association. http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf. Auerbach, J., & Miller, B. (2020). COVID-19 exposes the cracks in our already fragile mental health system. American Journal of Public Health, 110(7), 969–970. https://doi.org/10.2105/AJPH.2020.305699 Baird, K., & Kracen, A. (2006). Vicarious traumatization and secondary traumatic stress: A research synthesis. Counselling Psychology Quarterly, 19, 181–188. Bethell, C., Newacheck, P., Hawes, E., & Halfon, N. (2014). Adverse childhood experiences: Assessing the impact on health and school engagement and the mitigating role of resilience, Health Affairs, 33(12), 2106–2115 Bloom, D., Cafiero, E., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L. R., Fathima, S., Feigl, A., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A., & Weinstein, C. (2011). The global economic burden of non-communicable diseases. Geneva: World Economic Forum. Bonanno, G. (2009). The other side of sadness: What the new science of bereavement tells us about life after a loss. New York: Basic Books. Boscarino, J., Adams, R., & Figley, C. (2010). Secondary trauma issues for psychiatrists. Psychiatric Times, 27, 24–26. Bryant, R., Creamer, M., O’Donnell, M., Silove, D., & McFarlane, A. (2008). A multisite study of initial respiration rate and heart rate as predictors of posttraumatic stress disorder. The Journal of Clinical Psychiatry, 69, 1694–1701.

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Cianconi, P., Betro, S., & Janiri, L. (2020). The impact of climate change on mental health: A systematic descriptive review. Frontiers in Psychiatry, March 6, 2020. https://doi.org/10.3389/fpsyt.2020.00074 Cohen, B., Neylan, T., Yaffe, K., Samuelson, K., Li, Y., & Barnes, D. (2013). Posttraumatic stress disorder and cognitive function: Findings from the Mind your Heart Study. The Journal of Clinical Psychiatry, 74, 1063–1070. DOI:10.4088/ JCP.12m08291 Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M., & Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, 245– 258. doi: http://dx.doi.org/10.1016/S0749-3797(98)00017-8 Gilleen, J., Santaolalla, A., Valdearenas, L., Salice, C., & Fusté, M. (2021). Impact of the COVID-19 pandemic on the mental health and well-being of UK healthcare workers. BJPsych Open, 7(3). The Lancet Psychiatry. (2021). COVID-19 and mental health. Lancet Editorial, 8 (2), 87. https://doi.org/10.1016/S2215-0366(21)00005-5 Livingston, N., Berke, D., Scholl, J. et al. (2020). Addressing diversity in PTSD treatment: Clinical considerations and guidance for the treatment of PTSD in LGBTQ populations. Current Treatment Options in Psychiatry, 7(2), 53–69. https://doi.org/10.1007/s40501-020-00204-0 Patel, V., Saxena, S., Lund, C., et al. (2018). Commission on global mental health and sustainable development. The Lancet, 392(10157), 1553–1598 Rytwinski, N., Avena, J., Echiverri-Cohen, A., Zoellner, L., & Feeny, N. (2014). The relationships between posttraumatic stress disorder severity, depression ­severity and physical health. Journal of Health Psychology, 19, 509–520. Sapiezynska, Ewa (2021). Weapon of war, sexual violence against children in conflict. Save the children. https://www.savethechildren.org/content/dam/usa/reports/ ed-cp/weapons-of-war/weapon-of-war-report-2021.pdf Sennesh, E., Theriault, J., Brooks, D., van de Meent, J., Barrett, L., & Quigley, K. (2022). Interoception as modeling, allostasis as control. Biological Psychology, 167, 108242, ISSN 0301–0511. https://doi.org/10.1016/j.biopsycho.2021.108242. Shapiro, F. (1987). What is EMDR? www.emdr.com/general-information/what-isemdr.html Shim, R., & Starks, S. (2021). COVID-19, structural racism, and mental health inequities: Policy implications for an emerging syndemic. Psychiatric Services, 72(10), 1193–1198. https://doi.org/10.1176/appi.ps.202000725

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Sotero, M. (2006, Fall). Conceptual model of historical trauma: Implications for public health practice and research. Journal of Health Disparities Research and Practice, 1(1), 93–108. Substance Abuse and Mental Health Services Administration (SAMHSA). Understanding childhood trauma. Accessed March 24, 2022. https://www.samhsa.gov/ child-trauma/understanding-child-trauma The Trevor Project, National Survey on LGBTQ youth mental health 2020. https:// www.thetrevorproject.org/survey-2020/?section=Introduction United Nations (2020). Policy Brief: COVID-19 and the need for action in mental health, executive summary. Accessed March 25, 2022. https://unsdg.un.org/ sites/default/files/2020-05/UN-Policy-Brief-COVID-19-and-mental-health. pdfhttps://unsdg.un.org/sites/default/files/2020-05/UN-Policy-Brief-COVID-19and-mental-health.pdf Williams, C., & Vermund, S. (2021). Syndemic framework evaluation of severe COVID-19 outcomes in the United States: Factors associated with race and ethnicity. Frontiers in Public Health, 9, 720264. doi: 10.3389/fpubh.2021.720264. PMID: 34616705; PMCID: PMC8488144 Yehuda, R., Daskalakis, N., Lehrner, A. et al. (2014). Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in holocaust survivor offspring. American Journal of Psychiatry, Published Online: 1 Aug 2014 https://doi.org/10.1176/appi.ajp.2014.13121571 Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: Putative role of epigenetic mechanisms. World Psychiatry, 17(3) 243-257. World Health Organization (2013). WHO releases guidance on mental health care after trauma (News report). http://www.who.int/mediacentre/news/releases/2013/ trauma_mental_health_20130806/en/ World Health Organization (2021). https://www.who.int/emergencies/diseases/ novel-coronavirus-2019 World Health Organization (2022). Weekly epidemiological update on Covid-19-8 March 2022. https://www.who.int/publications/m/item/weekly-epidemiologicalupdate-on-covid-19---8-march-2022

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The Six Wellness Skills of the Community Resiliency Model (CRM) and the Trauma Resiliency Model (TRM) Elaine Miller-Karas This chapter will: 1. Define the wellness skills of Community Resiliency Model (CRM) and the Trauma Resiliency Model (TRM) 2. Provide exercises that can be used to practice and teach the skills The Community Resiliency Model (CRM) is a set of six wellness skills. The Trauma Resiliency Model (TRM), described in Chapter 4, utilizes nine skills to treat symptoms associated with stressful and traumatic experiences. The first six skills of TRM are known as the Community Resiliency Model. The skills are used as a wellness practice and are taught to individuals to increase their capacity to manage sensations associated with trauma or stress, leading to greater affect regulation. CRM is taught in workshops or shared individually by CRM teachers and CRM guides who may be professionals or natural leaders of communities. They come from various backgrounds, which include community leaders, teachers, ministers, nurses, therapists, physicians, community health workers, and first responders. TRM practitioners teach their clients the six wellness skills as part of their therapeutic interventions.

Skill 1: Reading the Nervous System: Tracking Tracking means paying attention to sensations inside the body. A sensation is a physical experience in the body. Tracking is about learning to notice the sensations and then discern whether the sensation is pleasant, unpleasant, or neutral. The TRM practitioner and CRM teacher/guide help DOI: 10.4324/9781003140887-4

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individuals learn how to tell the difference between sensations of distress and sensations of well-being. Tracking helps individuals discover that they can decide what to pay attention to–sensations of distress or well-being, providing choice. The more the person pays attention to neutral and/or pleasant sensations, the more the state of well-being is strengthened. Pleasant sensations can include slower heart rate, deeper breathing, and relaxed muscles. Gendlin (2007) stated, “You can sense your living body directly underneath your thoughts and memories and under your familiar feelings.” Tracking sensations give us what Gendlin calls “a body sense of meaning.” Tracking can help clients bring to conscious awareness information about their life experiences using the portal of the body’s sensations. The bodily sensations connected to thoughts and feelings can be an immense ocean of untapped knowledge, which can help clients maneuver through their life experiences. The Tracking skill increases the individual’s sensory awareness—or ­interoception—to develop a greater capacity for emotion regulation and embodied states of well-being. There is a growing body of research about interoception (e.g., Paulus & Stein, 2006). Interoception is defined as observing body sensations in relation to how we think, feel, and move. The insula is a part of the brain that helps the body and mind communicate with one another. It reads physical states of the body (sensations) like pain, an itch, and temperature. Based on that information, it communicates to the cortex to take action to keep the body in a state of internal balance. Farb et al. (2015) describe interoception as the sense of signals originating within the body. Interoception is critical for our sense of embodiment, motivation, and well-being. Interoception is related to well-being as it is connected to self-regulation, helping human beings maintain homeostasis. Farb et al. (2015) further state that emotionally balanced body signals are also thought to contribute to broader mood states that support emotional balance. Helping people learn the six wellness skills and the focus of interoceptive awareness has resulted in a greater sense of well-being (Grabbe et al., 2020). The models help people learn about “interoceptive awareness” in simple ways by paying attention to physical sensations, especially those connected to well-being. The focus on body awareness is why the TRM/ CRM are called “bottom-up” models.

Tracking: Step by Step 1. Education is provided about the autonomic nervous system to help individuals understand the importance of differentiating between sensations

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connected with the sympathetic nervous system and those associated with the parasympathetic nervous system. Tracking sensations is an additional portal of information for self-knowledge and empowerment. Every thought and feeling has a corresponding sensation—pleasant, unpleasant, or neutral. When one has experienced trauma, body sensations can be sparked by multisensory reminders (i.e., smells, sounds, and images) that can derail well-being and present-moment awareness. When one learns to track and monitor those sensations, a person can bring their attention to neutral or pleasant sensations. The goal is for the individuals to learn skill 1 to become the best trackers of their nervous systems. It is helpful to use the graphic below to explain how the nervous system affects the body. For example, if a person is anxious about giving a speech, their heart rate may be elevated, and they may experience the sensation as unpleasant. When people think about their favorite place in nature that is calming, the heart rate and respiration slow down. There may be pleasant experiences during which the heart rate is elevated, and the key is to differentiate those that are pleasant from those that are distressing. Learning to track the nervous system when upset and then shift awareness to more pleasant or neutral sensations helps people learn to live more fully in the present moment (Figure 3.1). 2. To teach the skill of Tracking, the CRM teacher/guide and TRM practitioner must be able to track their nervous systems first and use the skills of Resourcing and Grounding. As empathic listeners, practitioners and teachers/guides can be knocked out of their Resilient Zones when witnessing the heart-wrenching stories of traumatic experiences. The greater the knowledge of the skills for self-care for the CRM teacher/ guide and TRM practitioner, the more a person being helped can remain balanced within their Resilient Zone. Thus, the relationship is formed not only between two minds but two bodies (Schore, 2009). When tracking, the CRM teacher/guide and TRM practitioner mirror the individual’s gestures and body postures. Mirroring can help the person learning the wellness skills feel more supported. It can be helpful to let the person being taught tracking know that you may make the same gestures that occur spontaneously. Gestures and postures change as greater well-being is experienced. Some people find it off-putting when being mirrored. If that is the case, pay careful attention while tracking the person not to mirror. Awareness of voice tone and volume is essential when guiding an individual to experience the well-being of the body as well as helping to work with sensations connected to traumatic experiences. It can be jarring

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Figure 3.1  Autonomic Nervous System Source: Permission to reprint from John Kimball, Kimball’s Biology Pages, http://biology-pages.info

when working with the body if the voice is too crisp or too loud. As a doula, I learned that softening the voice while gently guiding a woman through labor would support her in working with her body’s pain. When we help an individual track, a gentle, supportive approach with a softened tone can help the person deliver themself out of distress. 3. Bringing attention to body sensations. If working with a person individually, we begin by inviting them to set their spatial boundary. “Where would you like to sit?” “How close or far away do you want to position your chair?” are questions that can be asked. For some individuals, leaning forward can elicit a sensory experience connected to a distressing experience. Some individuals have never had the experience of “feeling safe.” Thus, asking questions such as, “Is that safer for you?” can be a helpful qualifier. Judith Herman (1992) states that “establishing safety and stability in one’s body” is one of the primary elements in helping individuals who have experienced trauma.

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The TRM practitioner and CRM teacher/guide are not directive when tracking. They stay “one-half step behind” the person by inquiring about observed movements and sensations or ones that the person reports. The person’s experience is not interpreted, but rather open-ended questions are formed to gently inquire about what the person is experiencing. Invitational questions are asked, such as, “Is the sensation pleasant, unpleasant, or neutral?” Using open-ended questions such as, “What do you notice? What are you aware of now?” is essential. The person learning Tracking is the expert on their sensory experience. The person is supported and encouraged to explore the sensations connected to feelings, thoughts, and beliefs without judgment. Supportive statements like, “Sensations are not right or wrong. You are simply learning the importance of paying attention” can encourage curiosity and reduce a person’s self-consciousness. When tracking sensations, allow time for the person to respond. It takes time for sensations to develop and for the person to be aware of what is happening inside the body, especially when they are first learning to track. Taking time means taking enough time but not too much time. Some people can feel abandoned if the silence is too long. It may take a little time to build the right rhythm to determine how long of a pause will help the person experience their sensation fully. Tips on Tracking for the TRM Practitioner: When learning how to track, some individuals have difficulty being observed, so begin with mind-body education to explain the rationale behind using a biological model. The TRM practitioner can also let the client know that they can observe sensations by not necessarily facing the client; the TRM practitioner can avert their eyes to the side—for some people, it is too much for the TRM practitioner to observe their body posture or sensations straight on. If that is the case, the TRM practitioner can track their own body, and report sensation changes to the client that may be mirroring the client’s experience. For example, when the client is using the skill of resourcing and describes a beautiful place in nature, the TRM practitioner may take a deep breath mirroring the client’s deeper breath. The TRM practitioner can say, “As you told me about your beautiful place, I took a deeper breath.” This strategy can help the client begin to notice changes within their own nervous system without feeling observed by the TRM practitioner. TRM practitioners use sensory language when helping an individual learn to track. Sensory language does not always come easily. It may take some time in terms of education and also experience for individuals to begin to tune into their internal climate. For some people, even sensing pleasant or neutral sensations may spark unpleasant, even painful memories. If a client is experiencing too

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many unpleasant sensations, the TRM practitioner can bring them back to the present moment by using some of the strategies of the Help Now! skill discussed later in the chapter. It is important to honor where your client is because not every client is able to tolerate sensory awareness. If an individual is not able to sense pleasant or neutral sensations, discontinue the TRM and use your usual ways of engaging with your client. Not every method of intervention will be helpful to every client. Tracking sensations, even ones that are pleasant, can be difficult at first. As the person gains more experience with Tracking and noticing sensations that are neutral or pleasant, it becomes easier and easier. Nervous system release is a biological process that happens automatically when the body releases held tension and comes back into balance. For example, we have common terms in our language like “shake it out,” which refers to nervous system release. These sensations can be unsettling until the person understands their purpose. Release sensations are a way that the nervous system rebalances itself even though the sensations may feel unfamiliar. If you notice any of the sensations of release, invite the person to notice the sensations. Table 3.1 can help describe what clients are noticing inside. Through practice, the client’s sensory vocabulary can expand.

Table 3.1  Sensations Chart

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Tracking Exercises Tracking Exercise 1: Sensory Walk in your Space 1. Walk around your space, find a variety of items to help you practice developing sensory language. For example, find a piece of fruit, a pillow, a pen, paperclip, a penny, a pillowcase. 2. As you touch or look at the item, describe the item using sensory language. For example, if you are touching a table, as you touch it, is it soft, hard, squishy, or something else? Does it have a temperature—is it cool, warm, cold, or hot? 3. Find something to smell (fruit, lotion, flower). As you smell it, is it fragrant or not? Is it a pleasant, neutral or unpleasant smell? Bring your awareness to how you are categorizing the sensations you are experiencing. Is the sensation pleasant, unpleasant, or neutral?

Tracking Exercise 2: Hand Rubbing Holding your hands together with palms facing each other, rub your hands together while slowly increasing the speed. As the speed increases, notice the temperature of your hands. Are your hands warming up? Now, stop rubbing your hands. What do you notice? Are your hands still warm? Are they cooling down? Are they tingling? What else do you notice?

Tracking Exercise 3: Sensory Awareness Pause: Sensory Awareness Recipe As you do your tasks of daily living, take a Sensory Awareness Pause, taking time to notice sensations. Sensory Awareness Recipe: 1. Identify a common activity or task of daily living. 2. As you carry out the activity or task, notice the sensations. 3. Are the sensations pleasant, unpleasant, or neutral? Examples can include washing dishes, taking a bath or shower, walking outside, eating your favorite meal.

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Name some of your activities or tasks of daily living: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ One example: As I wash the dishes, I sense the warm water splashing onto my hands. It is a pleasant sensation.

Skill 2: Resourcing and Resource Intensification Skill 2 is called Resourcing and Resource Intensification. Resources can be anything in one’s life that brings joy, comfort, strength, peace, or happiness. The resources can be from the client’s past, present, or from their imagination. A resource is defined as a natural feature or phenomenon that enhances the quality of human life. There are three types of Resources: • External Resources: persons, places, music, animals, skills, hobbies, spiritual beliefs, life experiences, and more. • Internal Resources: values, beliefs and personal characteristics like humor, compassion, kindness, and more. • Imagined Resources: superheroes, characters from books, TV shows, or movies or imagined people or places. The following questions can help uncover the person’s resources: • • • •

What or who uplifts you? What or who brings you peace or joy? What or who gives you strength? What or who has helped you get through difficult times?

Developing resources builds an internal sense of well-being and a renewed sense of one’s abilities and capacities. Sensory awareness of well-being associated with the resource helps to stabilize the nervous system. As individuals identify their resources, they are invited to bring attention to the pleasant or neutral sensations connected to the resource. When asked to remember a resource, the client brings a multisensory experience related to their past well-being to present-moment awareness. Resource intensification refers to asking more questions about the resource, so the description is expanded. When an individual notices the sensations

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connected to the more detailed explanation, the multisensory elements strengthen the sensory experience. Hanson (2010) states that the amygdala uses about two-thirds of its neurons (brain cells) to look for the bad news. Highly emotionally charged negative experiences are quickly stored in memory. This is called the “negativity bias” (Vaish et al., 2008). Vaish states that positive experiences need to be held in awareness for a dozen seconds to transfer from short-term memory buffers to long-term storage. Thus, to override the “negativity bias,” it is essential for the person to enhance the resource by describing it in greater detail. As they describe the resource in greater detail, the person is invited to notice the sensations. Noticing the pleasant sensations connected to the more descriptive resource creates a new template within the body. The person can then experience a greater sense of well-being. Learning to track by identifying a resource is of primary importance when being introduced to the skills. As the person begins to describe a resource, they access a positive implicit memory already held within the body.

Multiple Natures of Resources Resources can have many qualities. When describing a resource, some people can become sad or distressed because of the multiple natures connected to the memory of the resource. For example, when describing her grandmother, a participant in a CRM workshop began to cry because her grandmother had died. The TRM practitioner and CRM teacher/guide do not have to ask for a different resource but can first be present with the person’s tears and sadness. The person can be invited to notice the wetness of the tears. After a pause, the person can gently be asked to share positive memories about the resource. As the positive memories are expanded, the person becomes aware of more pleasant or neutral sensations. Most often, the person can learn to hold both parts of the resource (the sadness and the joy), which can strengthen the resource’s sensory experience. The person described above explained how her grandmother would make pancakes for her in the shapes of animals. She then smiled and took a deeper breath. She was invited to notice the change. She then reported that the experience with resourcing was the first time she could talk about her grandmother without being overcome with grief. She was relieved to experience all the powerful sensations connected to the positive experiences with her grandmother.

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Conversational Resourcing Strength-based questions can be interwoven in a conversation when a person is recounting a distressing experience. Conversational resourcing can help a person remember what else is true when relating difficult life events. There are two categories of conversational resourcing: resourcing during or after a crisis and resourcing during or after a loss. Conversational resourcing can also be used to provide what is called a “resiliency pause.” As conversational questions are integrated into a conversation, this resiliency pause can increase an individual’s ability to manage the sensations associated with a distressing or traumatic experience. When entering a conversation about a distressing event, a person often thinks they must recount every detail of the event to feel better. In TRM/ CRM, we give the person a choice of how to share their experience. A helpful initial question can be: You can tell me as little or as much as you want about the experience. As you share, it can help to pause from time to time to give your nervous system a break as the experience unfolds in your memory. Would that be okay?

Conversational Resourcing during a Crisis • Who or what is helping you the most now? • What or who gives you the strength to get through this now? • When you have experienced other difficult times in your life, what or who helped you?

Conversational Resourcing after a Crisis • Who helped you the most in the beginning? • Can you remember the moment that help arrived? • Can you remember the moment that you knew you were going to survive? Did anyone else survive? As one or more of the questions are asked, you often observe the person becoming calmer. As the person becomes calmer, they often report a fuller experience, including resources that existed at the time that helped them survive. These questions also bring attention to the present moment, helping the person access the sensations, thoughts, and feelings connected to their Resilient Zone.

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Conversational Resourcing: Using Skills during/after a Loss Some survivors will want to speak about what happened during or after a traumatic event, and some will not. If family, friends, or community members die, there may be a need to talk about their loved ones, and not many people may want to listen. The TRM practitioner or CRM teacher/guide may be the first person who has invited the bereaved to talk about their loved ones. The questions below can be integrated as a person reveals that someone they cared about died. If they witnessed death, there might be complicated feelings of wanting to save them but being helpless. They may have gone into a survival response and feel shame for fleeing or freezing. In mass casualties, they also may feel a sense of guilt because they survived, and others did not. At the same time, some survivors may feel relieved they did survive even though others did not. In TRM/CRM, we explain “neuroscience nuggets.” An example of a neuroscience nugget would be: “When survival responses of freezing or fleeing occurred–these responses are automatic and happen without thinking; this is part of the survival brain.” Education about automatic biological responses can reduce shame and blame. The bereaved are invited to share whatever they want about their loved ones. If they are in shock, you can ask if they would like a blanket or something to drink, which could start to wake up the nervous system. A resource can begin to develop that is related to the loss. Tears are often part of the experience. Remember, in TRM/CRM, we acknowledge the tears and invite the person to notice the wetness or warmth of the tears. Conversational resourcing questions after loss include the following: • Can you tell me some of your positive memories? • What did you like to do together? • What kind of encouragement would they say to you during challenging times? • If they would have known you survived and they did not, what words of wisdom would they have said to you? In China after the Sichuan earthquake, an adolescent boy who survived the collapse of his middle school was brought to us for help. He had been unable to sleep since the quake. As we began to talk about their experience, he was asked to recount the moment that he knew

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he would survive the earthquake. He began to describe the moment he was walking away from the school and saw his mother. They ran to each other and cried. He reported feeling a great sense of relief and it was at that moment when he knew he had lived. He was able to smile and laugh. We went on to talk about other elements of his experience, often shifting attention back to seeing his mother for the first time when he had difficulty with other parts of the remembrance of that day. We invited him to notice the change in his body when he remembered the moment of seeing his mother. His nervous system became calmer for the first time since the quake. Although the pain of that day will never be forgotten, his ability to remember other elements of that day helped him remember what else was true. We heard later that after the session, he was finally able to sleep. Helping individuals identify resources in a myriad of formal and informal ways can help increase the bandwidth of the person’s Resilient Zone. Some individuals because of temperament or life challenges may have a narrow Resilient Zone. Practicing the skills can help them widen their Resilient Zone.

Building Resources Exercise • A resource can be anyone or anything that helps a person feel better. • It can be something the person likes about themself, a positive memory, a person, a place, an animal, a spiritual guide, one’s faith, or anything that provides comfort. It can also be an imagined resource. Questions that can help identify resources are: What or who uplifts you? What or who brings you joy? What or who brings you peace or calm? Write down three resources. 1. 2. 3. Circle one resource. Write down three or more details about your resource that you circled.

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1. 2. 3. Now read to yourself the resource and the three details you have written down about your resource. Notice what is happening inside as you think about the resource and notice the sensations that are pleasant or neutral. Notice what is happening to your breath…heart rate…muscle tension. Stay with that for a few moments. Write down the sensations that you notice on the inside that are pleasant. 1. 2. 3.

Skill 3: Grounding Grounding refers to the relationship between a person’s body and the present moment. Gravitational security is the foundation upon which we build our interpersonal relationships, and Grounding is essential to the sense of being present in the here and now (Ayres, 2005). The sense of safety needed for positive social engagement can be compromised when a person is not connected to present time and space. Grounding helps the person be in the present moment, and when experiencing this awareness, they are not thinking of past troubles or future challenges. They are present in what is happening in the here and now. Grounding can be accomplished by sensing a part or the whole of your body in relation to a surface. Not everyone can ground sitting down, so inviting the client to choose the position to begin a grounding exercise is paramount. Individuals can ground by standing against a wall, lying down, floating in the water, or walking. Some people ground by being aware of hands, feet, or other body parts making contact with a surface. A TRM practitioner working with a client with quadriplegia helped him ground through sensing his head contacting his pillow. When working in the Philippines after Typhoon Yolanda, many individuals shared that they felt the most grounded when floating in the ocean. Thus, there are many ways to ground; therefore, the more invitational

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you can be when helping the person learn the skill of Grounding, the better, as there is so much variance in how a person grounds. The following script can be shared to help a person learn the skill of Grounding: • Find a comfortable position sitting, lying down, or standing. • Notice how your back is making contact with the chair, sofa, floor, wall, bed, and earth. • If sitting, bring attention to your seat making contact with the sofa or chair…now notice your thighs…legs…and then your feet making contact with a solid surface. • Notice the sensations that are more pleasant to you or neutral within your body…take your time…notice your breathing, heart rate, and your muscles relaxing. • If you become aware of uncomfortable sensations, bring your attention to places that feel neutral or more pleasant. • As you bring your attention to neutral or comfortable sensations, notice your breathing, heart rate, and muscle relaxation. • Take a few moments to bring your awareness to pleasant and/or neutral sensations. • As we get ready to end, slowly scan your body and bring your attention to all pleasant or neutral sensations.

Challenges with Grounding Take special care with individuals who are of shorter stature. Shorter individuals can be accustomed to their feet not resting on the ground. Their safety can increase when their feet rest on a surface that provides support. Provide pillows, books, or a platform for shorter individuals so that they can sense their feet against a solid surface. Some individuals who did not find grounding helpful have the choice to move to another skill and drop Grounding. However, once the person learns to bring more awareness to sensations of well-being through tracking with resourcing, the client may develop a greater ability to ground. An elderly man who came to one of our groups initially could not tolerate Grounding. He had prostate cancer and degenerative disc disease. He was so accustomed to focusing on the chronic pain that any attention to his body and especially his heart rate was experienced

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negatively. Once he learned to use the skill of Resourcing, he was able to learn Grounding and after that, he was able to use all three skills to reduce his pain. He shared that he was now able to manage the pain better, as he could tell his doctor with greater clarity where he was experiencing the pain. Before learning Resourcing and Grounding, he would tell the doctor he felt pain everywhere. He shared that learning to be aware of parts of the body that felt neutral or pleasant increased awareness of his entire body and that only part of his body was in pain.

Grounding Tips for the TRM Practitioner Grounding is helpful for individuals who dissociate. TRM practitioners help clients who dissociate track sensations that precede dissociation. When the client becomes aware, for example, of a sensation of floating away, the TRM practitioner can use Grounding to help the client return to an embodied present-moment awareness. At times, the TRM practitioner may notice being sleepy or not paying attention to the client. This experience may indicate the client is dissociating. The closely attuned TRM practitioner may be experiencing the dissociative symptoms of the client. The TRM practitioner can gently inquire if the client feels embodied or like they are floating away. Some clients who dissociate may need a physical sense of weight on their bodies. Weighted items like a heavy pillow, a beanbag, or a weighted blanket may be necessary for clients to sense their bodies. In addition, some clients may not be able to ground without the practitioner gently touching the person’s hand or shoulder or making contact with the feet. If the client is having trouble with dissociation, a helpful but straightforward strategy is for the TRM practitioner to place their feet on the client’s feet. Conversely, some clients will not be able to ground themselves if the TRM practitioner is too physically close to them. If this is the case, the TRM practitioner can ask the client, “How far away would you like me to be from your chair?” Sometimes, just the invitation will help the client ground. Some clients can misinterpret supportive and respectful touch. The TRM practitioner who decides to use respectful touch in their practice needs to explain the uses before using touch and let clients know they can always refuse touch. We recommend that TRM practitioners use consent forms that include touch clauses if they integrate touch into their practice. Grounding can be disquieting for some individuals, especially drawing attention to their feet and inviting pushing their feet against the floor. In TRM/CRM, the person

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is invited to notice how their feet make contact with the floor rather than instructing “pushing feet into the ground.” Some individuals who have been in high-velocity car accidents, been abused somehow, or been in combat where they experienced an explosive device, may have braced their feet when the incident occurred. Thus, inviting the person to push their feet into the ground can set off a traumatic flashback of the incident when they braced. A woman shared that she was told to push her feet against the floor when she learned Grounding with another model. This instruction set off a traumatic memory of being in school with a stern teacher who would humiliate her in front of her classmates. Thus, proceed with caution with the skill of Grounding. Some individuals will not share that the experience is distressing and may internalize that there must be something wrong with them because they don’t experience Grounding as calming. If teaching Grounding on online learning platforms, invite the person to have a blanket, pillow, or a weighted item like a purse or backpack nearby. The person can be invited to place one of the items on their lap or feet to help with Grounding.

Skill 4: Gesturing Gesturing is the fourth wellness skill. Gestures emerge spontaneously and are usually below conscious awareness. Merriam-Webster Dictionary defines gesture as a “movement usually of the body or limbs that expresses or emphasizes an idea, sentiment, or attitude and the use of motions of the limbs or body as a means of expression.” Kelly, Manning, and Rodak (2008) state that people of all ages, cultures, and backgrounds gesture when they speak. Hand movements are so natural and pervasive that researchers across many fields from linguistics to psychology to neuroscience have claimed that speech and gestures form an integrated system of meaning during language production and comprehension. Further, gestures have a special meaning to the words that they accompany. It has been repeatedly observed that individuals all over the world, regardless of their culture and ethnicity, make gestures while they speak about healing experiences in their lives. In addition, there are also gestures that are self-soothing that can be a part of an individual’s repertoire for self-regulation. Dreisoerner et al. (2021) report that being touched by others improves stress coping. However, when touch from others is unavailable, feels uncomfortable, or is not considered to be safe (as in the COVID-19 pandemic), selftouch gestures, like placing a hand on the heart, may provide an alternative way to experience less strain. Self-soothing gestures are often made without conscious awareness. As we have taught the skill of gesturing to people all

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over the world, when an individual describes a meaningful, powerful experience or talks about a beloved person, the hand is often gently placed over the heart spontaneously. The person is invited to notice the sensations connected to placing the hand to heart. Bringing awareness to the sensations deepens the experience of well-being. Individuals are invited to identify gestures that are self-soothing that can be brought into present-moment awareness to return the nervous system back into balance—back to the Resilient Zone. There are many types of self-soothing gestures and movements including the following: • Self-calming gestures: movements that bring comfort and safety (i.e., twisting a part of your hair, gently rubbing a part of your body–hand, face, beard–moving the leg in a particular rhythm). • Gestures of release: movements that represent the body coming back into balance and a sensation of something distressing leaving the body. There are colloquial expressions such as “shake it out” that are helpful reminders that the body has a wisdom of recalibrating the body’s balance when a person is distressed by releasing movements of the hands and legs. • Universal movements that represent wholeness, spiritual beliefs, or deep personal meaning (i.e., bringing your hand to your heart, gently touching your fingertips together, placing the palms of your hands together as if in prayer). • Protective movements (i.e., movement of the hands and limbs). For some individuals, drawing attention to gestures can be intrusive. Having a rationale for why you are drawing attention to a gesture can help individuals understand the value of intentionally bringing awareness to gestures. The TRM practitioner or CRM teacher/guide may say: With your permission, I will help you bring attention to comforting or self-soothing gestures that are often just under conscious awareness. From time to time, I will draw your attention to gestures that you make spontaneously to help you learn about the gestures that may help you return to your resilient zone.

While drawing attention to comforting gestures, it can be helpful to suggest slowing down the gesture as this can deepen the embodied sense of the gesture. So, the practitioner or guide can say, “I may also at times suggest that you repeat a gesture slowly to help your nervous system come into greater balance.”

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Gesturing Exercise The following exercises can help an individual sense the power of gestures: 1. To help a person identify their own unique movements, they can be invited to: ○○ Take a few seconds to think about a self-soothing gesture…count 1, 2, 3 and then make the gesture or movement. As you make your gesture or movement that is self-soothing, notice what happens inside. ○○ Take a few seconds to think about a gesture or movement of strength… count 1, 2, 3 and then make the gesture or movement. As you make your gesture or movement of strength, notice what happens inside. ○○ Take a few seconds to think about a gesture or movement of joy… count 1, 2, 3 and then make the gesture or movement. As you do your gesture or movement of joy, notice what happens inside. 2. If a person wants to expand their ability to be compassionate, for example, they can be invited to think about a movement or gesture of compassion. The person can be invited to make the movement or gesture and notice the sensations connected to a compassionate gesture or movement. The TRM practitioner or CRM teacher/guide helps the person identify gestures that support the nervous system coming back into balance. The person can be encouraged to make the movement or gesture as another method to help restore balance to the nervous system. For example, a client shared the self-soothing gesture she identified when distressed. She places her hands together and strokes her left thumb with her right thumb. When she makes the movement, she spontaneously takes a deeper breath and reports sensing a calm throughout her body. She can use this gesture now in many situations to calm herself during stressful events in her life.

Skill 5: Help Now! Strategies to Reset Now! Help Now! strategies can reset the nervous system when a person is bumped into the High or Low Zones. The ten strategies are simple and can be taught to children and adults. It is best to teach the strategies when the person is not bumped out of their Resilient Zone. However, this may not always be possible. Many teachers share with us that these skills are beneficial for children and adults. Help Now! strategies are helpful in crises to help balance the nervous system. TRM practitioners and CRM teachers/guides can also

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share the Help Now! strategies with family members who can use the skills to help themselves and help their family members during their activities of daily living when they get way knocked out of their Resilient Zones. Help Now! strategies are as follows:   1. Drink a glass of water, a cup of tea, or a cup of juice.   2. Look around the room or wherever you are, paying attention to anything that catches your attention.   3. Name six colors you see in the room (or outside).   4. Open your eyes and soften your gaze if your eyes are tightly closed.   5. Count backward from ten as you walk around the room.   6. If you’re inside or outside, touch a surface. Is it hard, soft, cool, warm?   7. Notice the temperature in the room.   8. Notice the sounds within and outside the room.   9. Walk and pay attention to the movement in your arms and legs and how your feet make contact with the ground. 10. Push your hands against the wall or door slowly and notice your muscles pushing or standing against a wall, facing forward and gently pushing your back into the wall.

Help Now! Exercise: Conversational Help Now! You can ask the Help Now!/Reset Now! strategies in a conversational way as follows: 1. It can be helpful to walk around your space and notice your feet making contact with the ground. You can also invite the person, to walk together, “Would it be helpful to go for a walk together?” 2. Sometimes, it helps to get the energy of anxiousness out by pushing against the wall with our hands or pushing our back against the wall. “Do you want to do it with me?” 3. Take a drink of water. You can ask a person who is struggling, “Can I get you a drink of water?” 4. Sometimes, it can help to look around the room and see what catches your attention. “Is there a color you like, for example?” 5. When I am not feeling like my best self, I have found it helpful to pause and pay attention to the sounds in the room. 6. If I am anxious, sometimes it helps me to count down from 20. “Would you like to try it with me?”

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7. Touch something that catches your attention as you walk around your space, inside or outside. “Is it rough, smooth, or scratchy?” 8. What is the temperature of the room or space? “Is it hot, cold, warm?” 9. I found this app called iChill, and I listen to it when I get distressed. You can download it onto your phone. Write down your top three favorite Help Now! Strategies: 1. 2. 3. In what situation could you use Help Now! strategies for yourself and others? It can be helpful to practice the Help Now! strategies when not in a state of distress so that you remember them when you might need to use them again when bumped into your High or Low Zones.

Skill 6: Shift and Stay Shift and Stay is the sixth and final wellness skill. Shift and Stay integrates all five skills learned so far. This skill emphasizes that an individual can shift awareness to one of the skills they have been practicing throughout their activities of daily living when trauma and stress-related reactions arise unexpectedly. There are many internal and external reminders that can create fear, anxiety, distress, sadness, and other emotions. The person now has learned to discern the difference between sensations of distress and well-­ being. The person can use the Shift and Stay skill to shift their attention from the distressing sensations in the body to a resource, to Grounding, to a self-soothing gesture, to a Help Now! Strategy, or simply to a place in the body that feels calmer or neutral. The client then stays with those sensations until stabilization has occurred. So, Tracking is the fundamental part of Shift and Stay. This is often referred to as the skill that encourages the person to chase their resilience and stay with the sensations of well-being.

Shift and Stay Practice Exercise This practice exercise can be a concrete way to help individuals understand how they can use Shift and Stay during their activities of daily living in between sessions.

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1. Encourage the person to integrate sensory awareness during their activities of daily living by tracking some of their activities. 2. As they track and notice sensations of distress, invite the person to try one of the wellness skills or bring awareness to a place in the body that feels less distressed or neutral. 3. Invite the person to bring attention to the sensations that shift to pleasant or neutral from distressing and continue to notice the pleasant and neutral sensations. The six skills we have just described are the wellness skills of both the CRM and the TRM.

References Ayres, J. (2005). Sensory integration and the child (25th anniversary ed.). Los Angeles, CA: Western Psychological Services. Dreisoerner, A., Junker, N., Schlotz, W. et al. (2021). Self-soothing touch and being hugged reduce cortisol responses to stress: A randomized controlled trial on stress, physical touch, and social identity. Comprehensive Psychoneuroendocrinology, 8(2021), 100091. Farb, N. et al. (2015). Interoception, contemplative practice, and health. Frontiers in Psychology, 6, 763. Gendlin, E. (2007). Focusing. New York: Bantam Books. Grabbe, L., Higgins, M., Baird, M., Craven, P., & San Fratello, S. (2020). The Community Resiliency Model® to promote nurse well-being. Nursing Outlook, 68(3), 324–336. doi: 10.1016/j.outlook.2019.11.002. Epub 2019 Dec 30. PMID: 31894015 Hanson, R. (2010, October 26). Confronting the negativity bias (Online newsletter). http://www.rickhanson.net/your-wise-brain/how-your-brain-makes-youeasily-intimidated Herman, J. (1992). Trauma and recovery. New York: Basic Books. Kelly, S., Manning, S., & Rodak, S. (2008). Gesture gives a hand to language and learning: Perspectives from cognitive neuroscience, developmental psychology and education. Language and Linguistics Compass, 2(4), 550–738. doi:10.1111/j.1749–818X.2008.00067.x Paulus, M., & Stein, M. (2006). An insular view of anxiety. Biological Psychiatry, 60(4), 383–387. doi: 10.1016/j.biopsych.2006.03.042. Epub 2006 Jun 14. PMID: 16780813.

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Schore, A. (2009). Working in the right brain: A regulation model of clinical expertise for treatment of attachment trauma (Slide presentation). Vaish, A., Grossmann, T., & Woodward, A. (2008). Not all emotions are created equal: The negativity bias in social-emotional development. Psychological Bulletin, 134(3), 383–403. doi:10.1037/0033–2909.134.3.383

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The Trauma Resiliency Model Reprocessing Skills Elaine Miller-Karas This chapter will: 1. Define the Trauma Resiliency Model (TRM) 2. Define the three reprocessing skills: Titration, Pendulation, and Completing Survival responses 3. Provide clinical examples of the integration of TRM skills into a clinical practice The Trauma Resiliency Model (TRM)® is a clinical intervention based on current research about the brain that reflects the knowledge that a biological response to stressful and traumatic events exists. The nine skills of the Trauma Resiliency Model are designed to be delivered to clients by a TRM practitioner. TRM practitioners come from various backgrounds, including Marriage-Family Therapists, School Counselors, Drug and Alcohol Counselors, Social Workers, Psychologists, Psychiatric Nurse Practitioners, Psychiatrists, Drug and Alcohol Counselors, and Professional Counselors. TRM functions as both a model for trauma reprocessing treatment and a model promoting self-care. Using a mind-body approach, TRM introduces a paradigm shift in treating trauma, whereby symptoms are treated as common biological responses rather than pathological or mental weaknesses. The TRM skills can be implemented as a stand-alone intervention, but they can also be integrated into other treatment modalities. TRM helps individuals learn to track their nervous systems and concentrate on sensations that are connected to well-being. As a person begins to pay attention to sensations of well-being, the nervous system can return to a state of balance. Learning about the neurobiology of stressful and traumatic human reactions helps people understand the design of the nervous system and make sense of the responses they have experienced because of the stresses and traumas of their lives. DOI: 10.4324/9781003140887-5

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The first six skills of TRM, also called the Community Resiliency Model (CRM), are described in Chapter 3. These six skills can help a person learn to monitor sensations. The TRM practitioner first helps the client learn the wellness skills not only for self-care but also to give the client the confidence to bring their body and mind back into balance. Once the client knows they can regulate their nervous system during distress, the TRM practitioner can focus on helping the client reprocess traumatic experiences. Three additional skills of TRM are designed to promote this trauma reprocessing. These skills are Pendulation, Titration, and Completion of Survival Responses. These three skills have been adapted from the work of Peter Levine and other pioneers in the field of somatic therapy. This chapter will discuss these three skills in detail. TRM helps individuals understand that we are not only thinking beings who can express emotions but also sensory beings. TRM integrates the three portals of human experience (Sensation, Cognitions, and Emotions) to help clients reorganize their lived experiences after traumatic events. Just as many innovations are influenced by the ideas and work of many individuals, TRM owes its foundational roots to many concepts that have been interwoven together. The concepts that follow will help in understanding the essence of the TRM.

Lamaze Childbirth Education One of TRM’s foundational roots came from a feminist perspective gained through the initial lens of Lamaze Childbirth Education and my experience as a doula. As a doula in the 1980s, I learned about the natural rhythms of the body that occur as women go through one of the most stressful biological events of their lives. The support I provided was attending, guiding, and tracking the body’s natural rhythms. As a doula, I learned to monitor the sensations of the expectant mother and help guide her as she gave birth. I learned that the natural rhythms of healing coexist with the reactions connected to painful experiences. In a similar way, TRM practitioners guide with intentional kindness and compassion. Just as a doula helps the laboring woman, a TRM practitioner gently guides their client through the pain of their traumatic experience. The client often experiences a transformational rebirth where self-compassion, healing, and forgiveness are expressed. Being present during the birth process was not about directing but about “being with” the woman as she journeyed through the birth experience.

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Similarly, when helping individuals with the sensations connected to traumatic experiences, TRM practitioners guide them to pay attention to the natural rhythms of their bodies. When the client learns they can bring attention to the sensations of well-being, the nervous system begins to change, and traumatic sensations can lessen or dissipate altogether.

Somatic-based Methods There have been many pioneers in the field of somatic therapies, including Peter Levine, Pat Ogden, Judith Herman, and Babette Rothschild. I was influenced by the work of Peter Levine (2014) and his somatic approach to healing trauma. He studied many disciplines, including stress physiology, psychology, ethology, biology, neuroscience, indigenous healing practices, and medical biophysics, to create a model of intervention that focuses on releasing traumatic shock from the body so that an individual can heal from trauma. When creating TRM, we incorporated some of the concepts from Levine’s Somatic Experiencing. There are also fundamental differences in the models. In the TRM, we begin by teaching six wellness skills to the client as a self-regulation practice, and we use the paradigm of biology as a lens to view symptoms and design interventions. We stay “a half step behind” the client and guide based on observation. We do not lead. In TRM, we ask for the client’s interpretation and personal meaning and do not interpret the client’s experience. The TRM training is offered in two modules, Level 1 and Level 2, comprising six days followed by consultation and prescribed experience integrating TRM into clinical practice, leading to TRM practitioner certification. Many somatic-based trainings take years to complete. TRM’s accessibility offers the model to practitioners who serve those often left out of innovative models because of the cost. TRM is offered through the Trauma Resource Institute (TRI).

Laws of Nature—the Elegant Design In the natural world, there are seasons, the cycles of the moon, the ebb and flow of the ocean’s waves; there are bright, sunny days as well as torrential rains. Human beings are part of the natural design, and there are rhythms within our bodies. We experience sensations of distress as well as sensations of well-being. This process is observed in the autonomic nervous system: a biological system within our body designed to give us the energy necessary to overcome threats and obstacles and then calm us down once the

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danger has passed. When we embrace the concept that we are also part of nature’s elegant design, there is hope. Human beings can learn to build shelters away from the storm: we can understand that the sensations connected to traumatic experiences can change as seasons change, and we can learn to pay attention to sensations, thoughts, and feelings connected to well-being. When we pay attention to our well-being, it expands. We use the metaphor of a garden. If we cultivate our garden, nourishing the soil, and watering the vegetables and flowers, the well-being of our garden will flourish. There still may be weeds in the garden but not as many. We don’t want to forget that the weeds exist because they may represent meaningful lived experiences that have inspired us to reshape our lives in meaningful ways.

Eugene Gendlin’s Focusing Gendlin coined the concept of the “felt sense,” which he described as a person’s internal bodily awareness. The “felt sense” is another portal of information. If a person begins focusing on the “felt sense” of an experience, ideas about the resolution of problems will unfold. Gendlin also stated that the “felt sense” changes. In TRM, we help people become aware of the “felt sense.” New meanings, beliefs, and feelings emerge spontaneously as the TRM practitioner invites the client to become aware of sensations of well-being.

Neuroscience Neuroscience helps us understand the biological underpinnings of the common human reactions to traumatic experiences and resiliency. Human beings do not have to be trapped by the thoughts, feelings, beliefs, and sensations connected to past traumatic events. Rugnetta (2020) describes neuroplasticity as the capacity of neurons and neural networks in the brain to change their connections and behavior in response to new information, sensory stimulation, development, damage, or dysfunction. It was once believed that once an area of the brain was damaged, the function provided by that area of the brain was lost forever. Although some neural processes appear to be hard-wired in specific, localized regions of the brain, other neural networks are adaptable. These adaptable neural networks can carry out specific functions, but they also have the capacity to reorganize themselves so they provide new functions. Neuroplasticity is now considered a complex, multifaceted, fundamental property of the brain. The first six skills of the TRM are designed as a wellness practice. TRM practitioners help their clients learn

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about neuroplasticity. As clients learn the skills for self-care, they have a “felt-sense” experience reinforcing a new ability to bring attention to their sensations of well-being.

Sensory Integration Theory: Ayres, Williams, and Shellenberger Jean Ayres was an occupational therapist and a neuroscientist at the University of California at Los Angeles. Her work with children who had a problem with “attending” was inspirational and served as one of the foundational pieces of TRM. She found that many children experienced the world as spinning around them. With elementary exercises that helped the children “ground” and experience safety within their bodies, they could learn better. When we think about how trauma can knock us off our feet, grounding methodologies are essential in helping individuals be fully present in the here and now. In the book How Does My Engine Run, occupational therapists Williams and Shellenberger (1996) designed simple exercises to integrate sensory awareness into the home, school, and playground. In addition, many individuals who have experienced childhood trauma have difficulty sensing their bodies in the present moment. Many describe an experience of “floating” outside the body. When clients learn to ground themselves in the present moment, their lived experience changes profoundly.

Solution-Focused Psychotherapy Solution-Focused Psychotherapy (SFP) focuses on the present and holds the foundational concept that a client knows the best solutions for their own life’s challenges. In TRM, we hold the same belief, and, as in SFP, the TRM practitioner does not make interpretations and does not confront them. By having a non-directive stance of not knowing, the TRM practitioner encourages the client’s curiosity about their internal sensory experience. TRM is strength-based, as is SFP. The TRM practitioner asks the client about a personal strength or resource, and as the client describes the strength or resource, they are invited to notice the sensations. The TRM, like SFP, expands resiliency. Similarly, a SFP practitioner joins with the client by asking about what is right about their life, and a TRM practitioner joins with the client by asking about what gives them joy, peace, or meaning. The client begins to learn that there are experiences that can be sensed and focused upon that enhance their well-being.

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Resiliency-Informed Interventions In the fields of public health and mental health, much attention is given to helping organizations and systems become trauma-informed. We believe that it is essential to be not only trauma-informed but also resiliency-­informed. How do we create resiliency-informed individuals, systems, and communities? The first goal is to deepen a person’s ability to experience their well-being fully. They are then better able to adapt to life stressors with flexibility and maneuver in healthy ways through the ups and downs of life experiences. When individuals cultivate their well-being, they are also more solution-focused in more adaptive ways to bring forth new ideas to heal individual and systemic traumas.

The Zones TRM practitioners share the concepts of the zones with their clients (see Chapter 1 for a description of the zones). Explaining the zones from a stance of non-judgment is one of the ways TRM practitioners depathologize the effects of traumatic experiences. TRM practitioners educate clients that when traumatic and stressful events occur, the natural rhythm within the nervous system may be thrown out of balance. At times, all of us can be bumped out of our Resilient Zones and have challenges handling even small stressors. TRM practitioners often ask if the Resilient Zone is the same as Daniel Siegel’s “window of tolerance.” Daniel Siegel’s (2010) “window of tolerance” is described as an area of arousal in which we can function. The “window of tolerance” pertains to any moment when we have more tolerance for some emotions and situations than others. Being outside the window is chaos: one end of the window is hyperarousal and the other is hypoarousal. The problem with the semantics of the “window of tolerance” is with the definition of tolerance. In the Oxford dictionary, tolerance is defined as the capacity to endure continued subjection to something or someone and the ability or willingness to tolerate something, particularly the existence of opinions or behavior that one does not necessarily agree with. The Resilient Zone, the zone of well-being, is a dynamic condition about the vitality existing in all human beings. It integrates sensations, emotions, and thoughts. This vitality includes a rhythm of energy where human emotions like sorrow, anger, joy, or happiness can exist with their associated sensations. The Resilient Zone is not tolerance but embracing embodied well-being. Behaviors connected to the Resilient Zone can include dynamic advocacy, as when a

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person is angry about a world condition, or organic sadness as when someone participates in a tradition remembering a beloved family member who has died.

The Trauma Resiliency Model Reprocessing Skills: Titration, Pendulation, and Completing Survival Responses The Trauma Resiliency Model is made up of nine skills. The first six skills are discussed in detail in Chapter 3. This chapter will discuss the remaining three skills focused on trauma reprocessing.

Skill 7: Titration Titration is a skill used by the TRM practitioner to help bring client awareness to smaller, more manageable sensations of sensory images that may occur when a client recounts a traumatic experience or when a multi-sensory reminder has been set off causing distress in mind and body. Sensing smaller pieces of distressing or painful sensations helps to reduce or remove the unpleasant sensations. The TRM therapist guides the client by asking questions that include: • • • • • •

“What are you noticing now?” “Is it small, medium, or large?” “Does it have a shape or color?” “Can you just go to the edge of that shape?” “Can you sense a tiny piece of that shape?” “Would it help to invite a different color onto the shape that would lessen the distress?”

These questions can help the client feel less overwhelmed by the distressing or painful sensations they often have been living with since experiencing their traumatic event. Not all individuals can describe sensations with images. In this case, the TRM practitioner can ask about the size of the sensation and inquire if the client can sense a smaller part of the sensation. A helpful metaphor to describe titration is in imagining a whole apple. If someone asked you to put a whole apple in your mouth, it would be difficult, if not impossible, to swallow and digest. However, if someone cut an apple into slices and invited you to eat the apple slice by slice, it would be easier to eat

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the apple and digest it. Thus, the TRM practitioner does not ask the client to sense the entire sensation of pain or discomfort connected to the traumatic experience, as this could overwhelm the nervous system and be intolerable. Titration allows for a gentler and more graduated approach to processing the multi-sensory experience of traumatic events. Increased confidence often develops as an individual becomes aware that traumatic sensations can be experienced in more manageable chunks and can then be released. As the sensation changes to smaller pieces, the bodily experience of the traumatic memory can be digested and released through Titration. Although we describe Titration as a separate skill, it is often used with Pendulation. When the TRM practitioner uses Titration to reduce the size of the activation within the nervous system, there is often a spontaneous organic pendulation.

Skill 8: Pendulation Like a pendulum on a clock, the TRM practitioner uses the skill of Pendulation to help shift attention between sensations of discomfort, distress, or pain and sensations that are pleasant, less distressing, or neutral. Pendulation is the movement between sensations of distress and those of greater well-being within the body. This Pendulation can be spontaneous or can be invited. The TRM practitioner guides the client back and forth between these sensations, and as the client notices the changes, the nervous system comes more into balance. Sensations of distress usually decrease or disappear entirely. When the client is experiencing distressing sensations, the TRM practitioner uses the skill of Pendulation by inviting the client to bring awareness to places within the body that are less tense, less painful, neutral, or pleasant. Ogden (2006) refers to a similar process as oscillation. She states that alternating back and forth helps clients shift their focus from traumatic activation to more resourced or present-time experiences. This natural organic rhythm can be very profound for the client to sense that there is something else happening inside besides distress. At times, the invitation can be to a small part of the body that is not distressed, and the client can be quite surprised when a greater sense of balance is experienced as they stay with the pleasant or neutral sensations. TRM is an integrated model of body and mind. When there has been activation, and it starts to dissipate through Titration and Pendulation, the TRM

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practitioner notices deeper breaths and relaxed muscles. The client then becomes more socially engaged. The TRM practitioner can ask the client about changes in cognitive meanings or emotional expression about the processed traumatic experience. Often at these moments, deep and even sacred meanings emerge as the client experiences the coherence within the body.

Skill 9: Completion of Survival Responses When human beings are threatened, there are four possible survival strategies: tend and befriend, fight, flight, and freeze. The elegant design of the human nervous system sets off survival responses when there is a perceived threat. Following an existential traumatic event, a person can be reminded of almost anything reminiscent of the event. Van der Hart and Steel (1997) identified the following cues: sensory data, time-related stimuli, daily life events, events during the therapeutic session, emotional states, physiological states, stimuli recalling perpetrators, and current trauma. Almost anything can be a multi-sensory reminder of a traumatic experience. Thus, it is essential to help clients understand cues. This information can reduce the shame and self-blame that can be a constant bedfellow for those frequently reminded of the multi-sensory cues of their traumatic experiences. Peter Levine (1997) conceptualized that massive amounts of energy are mobilized within the body for self-defense when a human being is threatened. If the person can complete the defensive response, this energy is naturally discharged. The discharge sensations can include movements, such as shaking, trembling, and deep spontaneous breaths. Levine postulates that the discharge process resets the autonomic nervous system, restoring balance. When we stop the natural release of these sensations, the energy meant for defensive responses becomes “stuck” in the body. The “stuck” energy leads to physical, behavioral, cognitive, and psychological symptoms. Levine’s methodology helps the individual complete defensive responses that were blocked during the traumatic event. One of the goals of somatic-based therapies is to release the blocked energy held in the body. When the energy is released, the nervous system can be reset and return to equilibrium. The survival response continuum can help the TRM practitioner conceptualize interventions to reprocess the traumatic experience. As the client describes the traumatic event or as they are aware of the sensations connected to the traumatic experience, the TRM practitioner can begin to assess which phase was not able to be completed.

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Phase 1: Orienting Response The orienting response refers to an automatic response in which a person reacts to new information from the environment that may or may not be threatening. The orienting response is protective and is designed to answer the questions, “What is that?” and “Am I safe?” The orienting response is an autonomic sensory motor reflex. It comes from the spinal cord and is pre-wired in the central nervous system. The orienting response emerged from Pavlov’s (1927) studies of classical conditioning in dogs. Pavlov was inspired by the work of Sechenov (1863), who first described the orienting response. External Orienting: The physical act of turning the head and the body and focusing the eyes in the direction of the novelty is part of the orienting response when focused externally. For example, during the Asian tsunami, when the wave came, people naturally looked toward it because we are attracted to what threatens our survival. It was not only the visual image of the wave but the sound of the wave, which was described as deafening. During orienting, there is increased muscular tension as well as physiological changes, including acceleration of heart rate and breathing. The orienting response happens automatically below conscious awareness. It is adaptive in helping people react quickly to events that call for immediate action. It is instinctual and important for people to increase their survival chances when faced with a threat. Internal Orienting: Orienting can also be directed inward, and there can be focused attention, for example, on sensations perceived as threatening. Some individuals become fixated upon their sensations.

A client presented with a fear of driving stemming from numerous car accidents. During the first collision, the client’s car was hit on the right side while driving on the freeway. He did not have enough time to orient to the right. It happened too fast. After the event, he was in two other accidents where he did not see a car changing lanes from the right side. As a result of the first accident, he was not orienting to the right side. His awareness expanded to orient to the right when working with a TRM therapist who helped him gently move his head from right to left until he was able to orient to the right without distress in the body.

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People may also become hypersensitive to cues that remind them of the traumatic event. In the Philippines, many individuals shared that, since the catastrophic Typhoon Yolanda, rainy days caused a fear response. Hypervigilance is an over-orientation towards a multi-sensory reminder. The response can be excessive to the external stimulus of a sound, smell, or visual image. There can often be an accompanying hypersensitivity to bodily changes and a misinterpretation of even benign changes in breathing as being potentially threatening. For example, as rapid breathing often occurs during a traumatic event, individuals can become afraid if their heart starts beating fast as a result of physical exercise. Additionally, a person may become less discerning and may not be able to distinguish whether an environmental cue is threatening or not. Thus, the individual may unwittingly place themself into situations that are dangerous because their appraisal system is not interpreting the potential threat accurately. Some clients describe symptoms of disorientation, which may manifest as having problems with concentration, being “foggy,” or experiencing the environment as being out of focus. If a client has a blocked orienting response, the TRM practitioner can use TRM skills to help the client reestablish the orienting response in the present moment. In TRM, we are working in the realm of implicit memory. Implicit memory is held in the body and has no sense of time and space. So, when we work with a traumatic image, the TRM practitioner will suggest allowing the client to slow down time in the present moment. The client can have all the time they need now to accomplish the orienting response. When we take the client through reorienting strategies in present-moment awareness, the body can have the sense of orienting now. This can reset the nervous system and bring the person back to the Resilient Zone. The full orienting response can be reestablished.

Phase 2: Mobilization to Fight, Flight, or Tend and Befriend In response to a perceived threat, cortisol and adrenaline are released, and the person feels a surge of energy to respond to the threat by fighting or fleeing. Many individuals may tend and befriend (Baumgartner et al., 2008). A surge of oxytocin makes us feel more trusting and generous toward others. Oxytocin counteracts the effects of stress, reducing blood pressure, anxiety, and fear (Patin et al., 2018). Cannon (1915) first described the fight and flight response. He described that when an animal is strongly aroused, the sympathetic division of its autonomic nervous system combines with the hormone adrenaline to mobilize

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the animal for an emergency response of “flight or fight.” He was the first to conceptualize that the autonomic nervous system stimulates changes in blood supply in order to gather the body’s resources to produce what he called a “violent display of energy.” In the TRM, we have found the fourth survival strategy—“tend and befriend”—essential in helping some clients more fully understand their reactions during a traumatic event. Taylor et al (2006) and Taylor (2007) found that women not only have the capacity to flee or fight, but they have a capacity to “tend and befriend.” Women release the hormone oxytocin, which is part of their stress response. Thus, oxytocin may override the fight or flight response and result in an individual tending to the children and affiliating with other women for protection. In addition, when an aggressor experiences a woman in this state, oxytocin may also be released in the aggressor, thereby increasing the woman’s chances of survival. As of this writing, there was no information with regard to individuals who identify as gender fluid or non-binary. Although Taylor discusses tending and befriending as being more common in women in her research, it does not preclude people of any gender identification from using the tending and befriending strategy. Peter Walker popularized the term “Fawning,” which is not the same as “tending and befriending.” Walker (2020) describes “Fawning” as the use of people-pleasing to diffuse conflict, to feel more secure in relationships, and to earn the approval of others. He goes on to say, “it is a maladaptive way of creating safety in our connections with others by essentially mirroring the imagined expectations and desires of other people.” TRM views survival strategies as responses that emerged biologically to increase not only chances of physical survival but also emotional survival. We do not say to a survivor, you are maladaptive because you tended and befriended. As is the case with fighting, freezing, or fleeing, people-pleasing strategies can lead to suffering and self-harm as well as harm to others. Still, the root cause of all these reactions is the seeking of survival. When we use this lens in a nonjudgmental way, it gives an empowering explanation of how a behavior may have started but without shaming or blaming the client. This can reframe the person’s self-interpretation and lead to changed behaviors. In addition, fawning has also been used to describe feminine characteristics. This can have the unintended and undesired effect of pathologizing reactions that may be more common in women. Some therapists use the term the “four-F’s”: Fight, flight, freeze, and fawn. In our model, we say the “Four-F’s” are fight, flight, freeze, and friend.

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Phase 3: Completion of Survival Responses In this phase, the person uses the heightened energy to fight or flee or they use the calming effect to tend and befriend. If the survival responses are completed, the nervous system returns to balance. If the person experiences extreme fear coupled with an inescapable attack, they may freeze and not be able to complete the response. The energy meant for fighting, fleeing, or tending and befriending is not released. The freeze response, or “tonic immobility,” is characterized by profound motor inhibition and occurs as the result of an inescapable threat in many species, including humans. Facing a predatory attack, some animals will freeze or “play dead.” Tonic immobility may be the best option when the animal perceives little immediate chance of escaping or successfully fighting (Korte et  al., 2005). Tonic immobility can be useful when attacks may continue as a result of movement or when immobility may increase the chance of escaping, such as when a predator believes its prey to be dead and releases it. Humphreys, Sauder, Martin, and Marx (2010) stated that the experience of tonic immobility during childhood sexual assault may play an important role in the subsequent post-traumatic stress disorder (PTSD) symptoms in adulthood. Volchan et al. (2011) found that tonic immobility reports seemed more evident for people with PTSD than with other mental health disorders, suggesting that some individuals experience tonic immobility during reexperiencing episodes in daily life.

Phase 4: Return to Resilient Zone As the survival responses are successfully completed, the nervous system returns to equilibrium, that is, back to the Resilient Zone. The person will experience nervous system releases that can include shaking, trembling, burping, and yawning as equilibrium is restored. If the survival responses are not completed, the person is at risk for traumatic stress reactions.

Completing Survival Responses Protocol Education

The TRM practitioner educates clients about the key concepts of TRM, explaining the zones and the autonomic nervous system. During the initial

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sessions, the nine TRM skills are explained. Describing the neuroscience of trauma and resiliency in simple terms is essential as the TRM Practitioner explains symptoms from the lens of biology and not from a lens of pathology. Self-Regulation

Wellness skills are taught, and the TRM practitioner assesses the client’s readiness to be able to sense pleasant and/or neutral sensations before reprocessing a traumatic experience. Many sessions may be needed to frontload the wellness skills depending on the client’s ability to self-regulate. Identify the Target

Some clients can relate their trauma experience verbally, but other clients are unable or unwilling to verbalize their experience. The client does not need to verbally share the narrative of the traumatic experience in order to heal. They can simply think about the traumatic experience, and the TRM practitioner can help the client reprocess the experience by monitoring the sensations connected to the thought or image. The TRM practitioner says, “You can tell me as little or as much about the experience as you would like.” In TRM, if the client wants to share the trauma experience, the TRM practitioner will guide the client to share the experience in a different way. As the original traumatic experience was “too much too fast” or “too little for too long,” it is critical for the client’s nervous system to have a different sensory experience in the present moment as the story is shared. The TRM practitioner will request a pause in the recounting of the story from time to time if they notice the client becoming too distressed (High Zone) or too disconnected (Low Zone). During the “resiliency pause,” the practitioner shifts the client’s awareness to one of the wellness skills to help the client’s nervous system settle in the present moment before asking the client to continue. As the TRM practitioner monitors the sensations with the client, there is a point in the retelling when the TRM practitioner will ask if there is an impulse to complete a survival response. To complete the survival response, the client must be in a heightened state of arousal. Counselors from Juarez, Mexico, reported that not sharing the details of their experience by survivors was very important for the survivors of the violence occurring in their city. Many individuals feared sharing details of their trauma because of the threat of violence to themselves or their families by drug lords. Individuals who fear retribution can still reprocess without

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telling the details. This approach has also been helpful when working with individuals who have experienced trauma from their service in the military. Individuals who serve in special forces, for example, may not be permitted to share their experiences yet suffer greatly with post-traumatic stress reactions. Many clients who seek out biological-based therapists do so as a result of having tried many other “talk therapies.” They often report that they have more insight into what happened but that it has not changed the disruptive feelings and sensations when reminded of the event. When the client learns they do not have to talk about the details of their experience, they often experience great relief. If the client does not want to recount the details, the client is invited to think about components of the story while the TRM practitioner helps the client track sensations connected to the event and stays a half step behind as the body tells the story.

Specific Survival Responses Connected to the Target The Fight and Flight Response: An individual with interrupted fight responses may be irritable, angry, and/or hypervigilant and may display aggressive behaviors. The person may have a distorted lens with regard to how they read experiences with others. They can misinterpret a person’s glance and intentions as being threatening. The person may have a short fuse and overreact to benign situations. They also can display reactions conversely and feel depressed, apathetic, and hopeless. When the client is completing a survival response, the TRM practitioner invites the client to slow down the movement so it can be fully sensed. At the time of the traumatic experience, the nervous system was overwhelmed. When the body is encouraged to do what it could not do at the time of the traumatic event, the person can experience in the present moment the completion of the survival response. The nervous system can be reset and return to the Resilient Zone. A new template can be made in the present moment in implicit memory that the person did complete the response biologically. Since we are working with implicit memory that has no sense of time or space, the nervous system can change, and symptoms connected to the traumatic experience can lessen and, in some cases, go away completely. The TRM practitioner’s tracking skills are a dynamic process when helping a client complete a survival response. Paying attention to micro-movements of the body and drawing the client’s attention to the movements can help the client sense the energy necessary to complete a survival response. The TRM practitioner tracks movements of the hands, legs, feet, mouth, jaw,

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and facial muscles. The TRM practitioner helps the client become aware of sensations connected to completing survival responses. The following invitational questions threaded into the intervention can assist with tracking the fight response: “Do you have an impulse to do something? As you sense the impulse, which part of your body would like to move first? Notice what happens as you allow your body to move now.” “Is there a movement you would like to make now?” “Sense the impulse to move and give your body all the time to organize the movement it wants to make and then notice what happens inside.” “Do your hands/arms/legs want to move in any direction? Allow the movement to come through slowly, and then notice what happens inside.” “Repeat the movement as many times as feels right to you. If you can, slow down the movement so that the movement can be fully sensed and registered by your body and mind.”

Completing survival responses may also involve sounds and/or words that were not said at the time of the traumatic event. Perhaps the person was too frightened to say what they really wanted to say, or perhaps they were scared speechless. The TRM practitioner may notice a tightening of their lips and jaw and/or a trembling in their chin. The client may begin swallowing movements, coughing, and/or clearing the throat. The client may report a constriction in the throat and difficulty breathing. These are biological reactions informing the TRM practitioner there may be words that were left unsaid. Reports of constriction in the throat can also be connected to existential events where the person thought they would die. This could be a result of being intubated during surgery, when being bullied, or verbally abused as when being shamed. It could also be a result of a physical assault when there were injuries to the throat and neck from being strangled. The TRM practitioner must respond quickly to these reactions to reduce the client’s distress. The skills of Titration, Pendulation, and Completion of Survival Responses may be implemented. Step 1 is to use Titration and inquire about the size and shape to concretize the sensation. Concretizing the sensation can often provide immediate relief. Step 2 is using Pendulation by inviting the client to bring awareness to a part of the body that is less constricted or feels more comfortable if Titration does not provide relief. It can

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also help to bring in other TRM skills such as Resourcing, Grounding, or a Help Now! strategy. As sensation changes and the constriction begins to change, the client may report the sensation is smaller or less dense. The client will often make a spontaneous deeper breath and report there is more space in their throat. Step 3 is inviting the client to Complete a Survival Response. The TRM practitioner can ask, Is there a sound you want to make or something you want to say now or not? You can make the sound out loud, or you can hear yourself saying it inside, in your mind’s eye. As you do so, notice what happens inside.

The TRM practitioner also suggests slowing down the words or sounds so that the client can fully sense the impact of saying what was unsaid. People can be surprised at the degree of their angry words and impulses. Reassuring the client that just because they have an impulse, this does not mean they have become a violent person. Completing survival responses can challenge some clients’ beliefs about their moral codes of conduct as they experience the desire to express angry words or sounds and to fight or flee. It is important to reassure the client that the responses are not about being violent or cowardly. We are helping the body complete the responses in a safe environment so that the nervous system can be reset and the traumatic stress reactions can diminish and, in some cases, remit altogether. We are working with normal biological responses and helping the body know through sensation that the traumatic experience is over.

Mary had experienced sexual assaults from her stepfather for most of her childhood. When completing survival responses during trauma reprocessing, Mary found it helpful to push against the TRM practitioner’s hands as if she were pushing her stepfather away. The TRM practitioner noticed that her chin was trembling. The TRM practitioner asked if there was something that she wanted to say or not. A tremendous amount of energy was observed, and Mary shouted, “Stay away from me! Get out of here!” She experienced a tremendous amount of release in her jaw and extremities. She said, “He will never hurt me again.” She was again invited to track her sensations connected to the new meaning. She then described an image of herself as an adult cradling the little girl that she had been and telling her she would

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survive and live a meaningful life helping others. She said, “I feel like something has left me.” The TRM practitioner asked her to notice the sensations connected to the new meanings. Mary took a deep breath and stated that her entire body and mind felt cleansed of him for the first time in her life. For some clients, it is not enough to just imagine completing the survival response. In this case, resistance can be helpful. The client may not know that the impulse to push against someone is appropriate in the therapeutic session. Thus, the TRM practitioner providing resistance options is part of helping the client complete the survival responses as it was for Mary. Some options are pushing against the therapist’s hands, pushing against a pillow held tightly in the therapist’s hands, or pushing against a wall. Some clients are so energetic that they may be afraid that they will be too physically powerful for the TRM practitioner to contain. It is important to use good posture if you are to provide resistance in order not to be injured. When working with survival responses, expanding, or contracting the image of the experience can help reduce the activation. Guiding questions and statements can be integrated into the intervention, like: “You can move as far away as you need to from the image,” or “Can you bring your awareness to just one part of the image?” This kind of invitation can also open up more options for the client as to how to respond to the threat. Statements like, “You have all the time you need now” support the client in taking time to explore survival options.

Ken had been in a skydiving accident. He survived the fall but initially could not move. He had since regained his mobility. During reprocessing of the traumatic event, when he remembered lying in the field, he was focused on the lack of movement that experienced in the aftermath and the sense of being alone. He was first asked to describe the moment when he knew he would be able to walk again. He described the day as if he had won the Boston Marathon. The TRM practitioner encouraged Ken to notice the sensations connected to that moment. He reported feeling sensations of release as he experienced a light shaking in his legs. He was then asked if he wanted to continue with the details of his experience. He again described lying in the field and was

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asked to slow down and look around the field he had fallen into. As he oriented to the field, his expanded lens was able to see people running toward him and hear the sound of the paramedics and then see the fire trucks arrive. As he was able to notice what else was true about the experience, his whole body relaxed, and he reported experiencing sensations of release within the body. He then stated, “I wasn’t alone. Help arrived sooner than I thought. I didn’t know it then, but I survived, and I can walk.” Wisdom about his survival cascaded out of Ken. Ken was invited to notice all the sensations connected to his expanded meaning of the event, and he could deeply sense the support he received after the fall and most importantly, sense into the words, “I survived, and I can walk.” People with incomplete flight response may have symptoms of anxiety, panic, and avoidance patterns and consistently have an urge to move away from any situation that is distressing or causes conflict. When they become distressed, the first impulse may be, “I’m out of here.” This attitude can make relationships challenging or cause avoidance patterns that lead to many unresolved life issues. If movement during the time of the traumatic event would have meant injury or death, the client may be reluctant to move. So, you can expand their visual field by suggesting they insert protective allies into their image or suggesting they imagine running to something that represents safety. The following questions may help: “Can you imagine running with supportive friends, protective images, or even your older self?,” or “Can you move in a direction that feels safer?,” or “If you would like, see who or what you are running to,” or “If you could imagine a safer place to run in the present moment, can you bring that image into your mind’s eye and allow your body to sense the movement in your legs?”

A veteran was having difficulty with reintegration with his family. He had many close calls in Iraq and had survived an improvised explosive device (IED) explosion in his Humvee. When we worked with him to complete the survival responses, the first comment was that the impulse was to run; however, he immediately edited himself by saying, “I would have never left my guys.” We explained to him that we were giving his

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body the opportunity to do what it could not do in Iraq and assured him that it was about the biology of his body not knowing the event was over. He then stood up, and he was able to monitor the immense energy in the body. His legs moved in place, and he stated, “This is F!!!!!!ING WEIRD! I feel like I am really there, and I am getting away this time!” He was invited to continue tracking the movement of running, and he experienced release sensations. At the end of the session, he said that it was the first time since being in Iraq that he felt like himself. As this new experience engulfed him, he was invited to sense what it was like to feel like himself again. He began to cry tears of gratitude. Freeze Response: If a person cannot tend and befriend, fight, or flee because of an inescapable attack, the person may experience a freeze response. The freeze response is the most dysregulated of all the survival responses. When a person goes into a freeze response, it is like sitting in a car with the engine running, pushing down on the accelerator with the car in park. The engine is working at high capacity, but the car is not moving. At times, as the client begins to explore sensations, the client may experience a part of the body that goes into a freeze response. This can be the result of a past physical or psychological injury. Reassure the client that this sometimes happens as people learn to pay attention to sensations. The TRM practitioner will then help the client come out of the freeze response by paying attention to movement within the nervous system. As the movement returns, there will be release sensations. Tracking the release sensations helps rebalance the nervous system. The questions below can help an individual begin to move out of a freeze response. “If your body could move just a little bit, how might it want to move first?” “Is there any place in your body where you sense even the tiniest movement?” Notice what happens inside as you allow the movement.” “Would it be all right if I touched your hand to see if you can feel the warmth of my hand?” “Can you see yourself moving in just the way you would like to move in your mind’s eye?” A respectful human touch, always with permission, may help the client’s nervous system come back to the Resilient Zone. Conversely, if a person experienced intrusion into their personal space as a result of the traumatic

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experience, a touch can be more activating to the nervous system. The key is to ask permission and let the client know that they have a choice now. When a person has experienced trauma, their choice has been taken away. Thus, using invitational questions and giving choices is integral in creating safety. A helpful invitation could be, “Would it be alright for me to place my hand on yours, or would you like me to move my chair further away from you? You can choose now.” The freeze response can be the most challenging for the client and the practitioner. When the client begins to come out of the freeze, the same terror and fear they experienced right before going into the freeze may again appear as they start to sense their body. It is critical for the client to have a sound working knowledge of the TRM wellness skills prior to working with a traumatic experience that includes the freeze response. The TRM practitioner also must continue to track themself and whether they are sensing their own distress because of the intensity of the client’s experience. Bringing awareness to the present moment by using one of the wellness skills can help the TRM practitioner return to their zone of well-being too. Insertion of Protective Allies: Some clients may need the sense of a protective ally in order to be able to experience enough energy within the body to complete a survival response. Many clients will spontaneously think of a protective ally, and the TRM practitioner can also ask, “Could a protective ally be helpful for you right now to help you do what your body wants to do?” A helpful ally can include superheroes, movie or television characters, supportive family and friends, or even the client’s adult self. The “adult self” can be imagined protecting the client now. This can be a powerful, life-changing sensed experience for an individual to feel their power and strength in the here and now against a perpetrator whom they felt powerless against as a child or as an adult. Tend and Befriend Response: If there were children or other important social affiliations involved in the traumatic experience, the adult caregiver may have a primal need to tend to the children and to draw social support together before completing a survival response of fight or flight for themself.

A woman was in a car accident that resulted in serious injury to herself and her son. During the accident, there were a few minutes when she did not know the whereabouts of her son as the paramedics took him out of the car. She was asked to notice her impulse and track her body to monitor what her body wanted to do. She said, “I need to hug my son

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and make sure he is safe.” She saw herself (in her mind’s eye) hugging her son, and this resulted in release sensations. She then said, “He survived.” She was able to cry for the first time. She stated, “I am relieved.” The TRM practitioner invited her to notice the sensations of release. She was then able to focus on herself. We started the next session by using the spontaneous resource of her son’s survival. As she remembered the moment that she knew her son had survived, her body relaxed. We then were able to begin to work with her existential experience. As we worked with Completing Survival Responses, she stated, “I would have swerved to get out of the way if I would have seen the car coming on my left side.” She was invited to do what her body wanted to do now, in the present moment. She was able to imagine orienting to the car, something she was not able to do when the accident happened. When she oriented her body and head to the car, she was able to move her hands as if holding on to the steering wheel and move her car out of the way. She experienced an enormous breath, and her hands and legs began to shake. The TRM practitioner brought her attention to the release sensations, and her body continued to reset and return to the Resilient Zone. New meaning spontaneously emerged. She said, “My son not only survived, but so did I.” The TRM practitioner suggested that the client become aware of all the sensations connected to the statement. The client began to cry, and she reported that the tears were different; the tears were of gratitude. If children or other important individuals were involved in the traumatic experience, posing questions that aid the client in completing survival strategies for them is essential before they can process the personal traumatic experience. Questions include: “If you could have, what would you have done first to protect your child and/or others?” “As you see yourself taking action to protect, what do you notice on the inside?” “As you know now in the present moment that your child and others you care about are safe, what happens on the inside?” “What would you have wanted your child and others to know at the time, if anything?” “Is there something you want to say to your child and others now or not?”

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TRM Interweaves

If the client is looping or stuck, the TRM practitioner can ask: • “When you say you feel stuck, what do you notice happening inside?” • “Is there a part of your body that feels less stuck than other parts?” • “As the thought keeps repeating, notice what is happening inside your body.” If the client begins to dissociate or has a traumatic flashback, the TRM practitioner can try one or more of the following: • If the client’s eyes are closed, invite them to open their eyes and use Help Now! strategies. • Help the client Ground. They may need something weighted to place upon their body. You can suggest placing a weighted blanket, pillow, or stuffed animal on their lap. • You can bring them gently to sensory awareness by inviting them to “Sense the wetness of the tears, noticing the temperature of the tears” or “Notice a place in your body that feels pleasant or neutral.” • The client may need more physical space, and you may need to place yourself a greater distance from the client to reduce their distress. • With consent and permission, it may be helpful to touch the client respectfully on the hand. Emergence of Meaning

The client may spontaneously report new meanings, insights, feelings, and images. The TRM practitioner can bring the client’s attention to their body so that they can track the internal changes associated with the new meanings, insights, feelings, and images. The TRM practitioner wants to link the entire sensory system to new, more integrated cognitions and feelings. Spiritual meanings often emerge. TRM practitioners often report that clients describe feeling more compassion for themselves and others; they often describe prioritizing their life in a different way and have an expanded ability to appreciate life and the people whom they love in their lives. Ending a Session

Bring the client’s attention to their whole body and invite the client to sense all the neutral or pleasant changes that have occurred since beginning the

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session. If the session time is coming to a close, allow enough time for the client to come back to their Resilient Zone by using the wellness skills. This way, the client can experience that they can work with difficult material in therapy and can come back to their Resilient Zone as they return to their tasks of daily living. This chapter has outlined the nine skills of the TRM. When using the nine skills, it is helpful to think about a TRM-skills scaffolding. A scaffolding is used to support people and hold materials that are used for construction or repair. Scaffolding promotes the safety of the workers and allows them access to areas that are difficult to reach. You can step up, down, or sideways on a scaffolding. The same is true for TRM skills. Sometimes you want to shift to a resource. At other times, you may suggest that a client complete a survival response. If the activation is too much for your client’s nervous system, you can bring the client’s attention back to grounding. As TRM practitioners, we often want a succinct, step-by-step process. When working biologically, however, we do not use a “cookie-cutter” approach. Continuous monitoring of the client’s sensations is paramount. The TRM practitioner can integrate any of the skills within the scaffolding that help the client stabilize their nervous system to come back to the Resilient Zone.

References Baumgartner, T., Heinrichs, M., Vonlanthen, A., Fischbacher, U., & Fehr, E. (2008). Oxytocin shapes the neural circuitry of trust and trust adaptation in humans. Neuron, 58, 639–650. Cannon, W. B. (1915). Bodily changes in pain, hunger, fear and rage. New York: D. ­Appleton & Company. Humphreys, K. et al. (2010). Tonic immobility in childhood sexual abuse survivors and its relationship to posttraumatic stress symptomatology. Journal of Interpersonal Violence, 25(2), 358–373. Korte, S. et al. (2005). The Darwinian concept of stress: Benefits of allostasis and costs of allostatic load and the trade-offs in health and disease. Neuroscience & Biobehavioral Reviews, 29(1), 3–38. Levine, P. (1997). Waking the tiger: Healing trauma. Berkeley, CA: North Atlantic Books. Levine, P. (2014). Somatic experiencing. www.traumahealing.org. Ogden, P. (2006). Trauma and the body: A sensorimotor approach to psychotherapy. New York: W. W. Norton & Company.

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Patin, A., Scheele, D., Hurlemann, R. (2018). Oxytocin and interpersonal relationships. Current Topics in Behavioral Neurosciences, 35, 389–420. Pavlov, I. (1927). Conditioned reflexes: An investigation of the physiological activity of the cerebral cortex. Oxford: Oxford University Press. Rugnetta, Michael. (2020). Neuroplasticity. Encyclopedia Britannica. Retrieved from https://www.britannica.com/science/neuroplasticity. Sechenov, I. (1863). Reflexes of the brain. Cambridge, MA: The MIT Press. Siegel, D. (2010). The mindful therapist: A Clinician’s guide to mindsight and neural integration. New York: W. W. Norton & Company. Taylor, S. (2007). Social support. In H. Friedman & R. Silver (Eds.), Foundations of health psychology. New York: Oxford University Press. Taylor, S., Gonzaga, G., Klein, L., Hu, P., Greendale, G., & Seeman, S. (2006). Relation of oxytocin to psychological stress responses and hypothalamic-­pituitaryadrenocortical axis activity in older women. Psychosomatic Medicine, 68(2), 238–245. Van der Hart, O., & Steel, K. (1997). Time distortions in dissociative identity. Disorder, 10(2), 91–103. Volchan, E., Souza, G. G., Franklin, C. M., Norte, C. E., Rocha-Rego, V., Oliveira, J. M., … Figueira, I. (2011). Is there tonic immobility in humans? Biological evidence from victims of traumatic stress. Biological Psychology, 88(1), 13–19. doi:10.1016/j.biopsycho.2011.06.002. Walker, P. (2020). The 4Fs: A Trauma Typology in Complex PTSD. Retrieved from http://pete-walker.com/fourFs_TraumaTypologyComplexPTSD.htm. Williams, M. S., & Shellenberger, S. (1996). How does your engine run: A leader’s guide to the Alert Program® for self-regulation. Albuquerque, NM: Therapy Works.

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The Nervous System, Memory, and Trauma Michael Sapp and Elaine Miller-Karas This chapter will: 1. Describe the neuroscience underpinnings of TRM and CRM 2. Describe Implicit and Explicit Memory A core goal of the Trauma Resiliency Model (TRM) and the Community Resiliency Model (CRM) is to provide training in biologically based skills that increase well-being (also called resiliency) and decrease the debilitating effects of traumatic stress. The models assume that responses to threats—real or imagined—are biologically based and primarily autonomic. Accordingly, the cognitive and psychological aspects of trauma are secondary to the biological response to fear. That’s not to say that the cognitive or psychological aspects of trauma are not important. They are. However, most traditional modalities of treatment focus on those two aspects as the entry points for alleviating the symptoms of traumatic reactions. In contrast, TRM and CRM focus on the biological responses themselves as the primary entry point—or portal—to promote healing. The reason is simple: Trauma’s disruption of normal biological rhythms fuels the cognitive and psychological aspects of trauma. Imagine someone who lives in a home with an electronic security system. Before they go to bed, they set the alarm, perform their nighttime rituals, and then finally climb into bed to go to sleep. As they relax and drift off to sleep, an intruder tries to break into the house and sets off the alarm. The alarm sounds, causing the intruder to leave. The alarm did its job; the threat has been averted. However, the sounding of that alarm also causes the homeowner to wake up out of a dead sleep—their heart pounding, their eyes searching the room for the intruder, their muscles tense and ready for action. At that moment, they would likely say they were “scared.” Was the DOI: 10.4324/9781003140887-6

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homeowner thinking or feeling or behaving in that way prior to the alarm sounding? No. The sound of the alarm fueled the thoughts and reactions. Now imagine what it would be like for that homeowner in the subsequent few minutes. They don’t know that the intruder has left, so the alarm continues to sound as they check each room to make sure that the house is secure. Once they confirm that there is no intruder and that they are safe, what must they do next? They need to shut off the alarm and reset it. Until that is done, trying to go back to sleep or read a book or do virtually anything would be extremely difficult. It’s very hard to focus one’s cognitive and psychological energies on anything else if the alarm continues to ring. In much the same way, traumatic events can set off a “biological alarm” that dysregulates normal biological rhythms in order to prepare us for survival. TRM/CRM skills are designed to “reset” the biological alarm and restore the natural biological rhythms of the nervous system. As that happens, the cognitive and psychological aftermath of trauma will often self-correct. Just as it would be helpful for the homeowner to understand the basics of their electronic security system, learning about the nervous system and conveying brain science in simple terms helps clients understand the biology behind their symptoms. As you can imagine, the human nervous system is a very sophisticated and complex system. However, speaking simply about it helps move individuals from perceptions of personal weakness to an understanding of biology. In TRM/CRM, we highlight certain nervous system functions that can help us understand human symptoms and behaviors and, most importantly, pathways to healing. In the most basic sense, we interact with the world through our physical bodies. We take in information from the outside world through our body’s sensory receptors. Our brain processes that information as it interacts with other sources of information from our internal world (e.g., memories, current internal sensations). We make decisions—consciously and unconsciously— based on the outcome of that interaction and then we execute those decisions through our body’s muscles and tissues. All of this is made possible through our body’s nervous system. Our nervous system has traditionally been conceptualized as having two main components: the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS consists of the brain and spinal cord and can be thought of as the “decision maker” of the body. The PNS consists of all of the nerves that collect information from the body and transmit CNS decisions to the body. Please keep in mind that although we conceptualize

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them as if they are two separate systems, they are inseparable. The mind and the body work as one. That being said, some specialized functions within the human nervous system can aid us in understanding the effects of trauma and the ability of the body to adapt to a wide range of situations. Let’s focus on the peripheral nervous system first. The peripheral nervous system is considered to have two components: the somatic and the autonomic. The somatic nervous system includes all of the nerves that enable us to control our body’s muscles. For example, you may notice that you have been sitting in the same position for some time now. The urge to shift your body to a more comfortable position is carried out when your somatic nervous system tells various muscles to actually move and reposition your body until it’s comfortable. The autonomic nervous system involves all of the nerves that control our glands and the muscles of our internal organs. For example, imagine that a breeze carries in the smell of your favorite food. Your mind may drift off to thoughts of that particular food and you may notice your heartbeat quicken and perhaps feel a slight hunger pang. These changes are largely due to your autonomic nervous system telling your heart to pick up its pace and your digestion to turn on. In this example, you didn’t actively tell your digestion to turn on; it just happened as a result of information from the outside world (a scent) interacting with information from your internal world (a memory of your favorite food). Accordingly, the autonomic nervous system is considered largely involuntary. In contrast, while there are times when the body’s muscles respond reflexively and with little-to-no control, the somatic nervous system is considered largely voluntary. For example, shifting your body to a more comfortable position involves “telling” your body to do it. These biological actions are voluntary. However, “telling” your heart to race faster or getting your digestive system to turn on is another matter. These biological actions are largely involuntary. The autonomic nervous system includes the sympathetic and parasympathetic nervous systems. During times of stress or challenge, the sympathetic nervous system (SNS) arouses and prepares the body for action. It directs the adrenal glands to release stress hormones (e.g., adrenaline and noradrenaline), readying the body to take action. The SNS causes the liver to provide extra sugar to the bloodstream in order to increase energy; it also increases breathing to provide added oxygen. The SNS diverts blood from the internal organs to the muscles, slowing digestion and suppressing the immune system. Along with increased heart rate and blood pressure, this gets the blood to the

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much-needed muscles, making it easier for the body to move and to move quickly. The SNS dilates the pupils, allowing in more light; it decreases salivation, but increases perspiration in order to cool down the activated body. This is often called the “fight or flight” response and is a wonderfully adaptive process. When a threat is perceived, your SNS does all of these things without any conscious effort in order to make it easier for you to overcome the threat. If you were to imagine the last time you faced a particularly stressful event (e.g., giving a presentation, barely avoiding a car accident), how fast was your heart beating? Did you feel on edge? Did you have sweaty palms? Dry mouth? Your SNS was readying you for action. These biological processes are adaptive. Just as a car needs both an accelerator and a brake, the body needs a counterpart to the SNS. That counterpart is the parasympathetic nervous system (PSNS), which calms the body and prepares it for rest. Once the source of stress is removed, the “rest and digest” response takes over. As the stress hormones slowly leave the bloodstream, the PSNS works to conserve energy and restore the body to a more balanced state. It slows breathing, lowers blood sugar, decreases heart rate and blood pressure, increases digestion and immune functioning, constricts the pupils, increases salivation, and decreases perspiration. As a result, the activated body becomes calm once again. These two systems work together to maintain a steady and balanced internal state within the body. The natural biological rhythm of charge (SNS) and release (PSNS) corresponds to the rhythm of the Resilient Zone. When we are in our Resilient Zone, our autonomic nervous system is in rhythm. When this rhythm is working properly, we are at our best in handling the challenges that we face. However, certain demands can be overwhelming and can cause a significant disruption in that rhythm. Demands that cause tolerable and/or toxic stress, as defined in Chapter 2, would be considered types of demands that cause the natural rhythm of the autonomic nervous system to become dysregulated. In TRM/CRM language, these types of stressors bump us out of our Resilient Zone. In such cases, we might be bumped into our “High Zone” in which we may experience something akin to SNS hyperarousal. Along with the normal sensations of SNS arousal, we may feel edgy and irritable. We may get angry easily (i.e., “short fuse”) or fly into a rage. We may experience panic, anxiety, or pain. We often become hypervigilant and overly sensitive. Or, we might be bumped into our “Low Zone” in which we may experience something that looks like a ­hyper-PSNS response. We might feel numb, disconnected from others (i.e., isolated) or from ourselves (e.g., dissociative responses). We might

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experience sadness or a depressed mood. We often feel exhausted or tired. Or we might even oscillate between being stuck in the “High Zone” and stuck in the “Low Zone.” Some have reported feeling like they’re stuck in both zones at the same time. Much like pressing on the accelerator and the brake at the same time, there is a seemingly paralyzed agitation (i.e., the engine is revving, but the car is going nowhere). TRM/CRM skills are designed to bring a dysregulated nervous system back into its natural rhythm, its Resilient Zone. When a person re-enters their Resilient Zone, there is often an accompanying biological sensation of release. Nervous system release is a biological process that happens automatically when your body releases distressing sensations and comes back into balance. Sensations of release can include, but are not limited to, trembling, tingling, stomach gurgling and/or burping (as digestion comes back online), warmth, cooling down, throat clearing, shaking, itching, laughing, crying, and yawning. Inquiring about nervous system release and bringing the client’s attention to the sensations often strengthens the release, bringing the body and mind back into the Resilient Zone. Of particular note is research on a biological response that seems to be one of the most important mechanisms for regulating the survival-related behaviors in mammals—yawning. According to Newberg (2009), yawning may be the brain’s attempt to eliminate symptoms by readjusting neural functioning. Numerous neurochemicals are involved in the yawning experience, including dopamine, which activates oxytocin production in the hypothalamus and hippocampus (i.e., areas essential for memory recall, voluntary control, and temperature regulation). Yawning may be a way to cool down the overly active cortex, especially in the region of the frontal lobe. Most vertebrates yawn, but so far it has only been found to be contagious among humans, great apes, macaque monkeys, and chimpanzees. Now let’s turn our attention to the central nervous system and specifically to the specialized functions of the brain as it relates to trauma. Keep in mind that a thorough understanding of the intricate functioning of the brain as a whole is outside the scope of this book. Instead, our aim is a simple understanding of how the brain operates in response to stress, how it interacts with the body during those times, and how the brain might function better in times of resiliency. Being able to communicate this to clients is especially important and is generally met with great enthusiasm and appreciation by clients. The nervous system as a whole is made up of billions of microscopic nerve cells called neurons. According to some estimates, the brain has more than 100 billion nerve cells and over 1 trillion supporting cells (e.g., glia cells).

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Neurons are rather simple in functioning: They either fire or they don’t. However, each neuron can have up to 10,000 connections to other nerve cells, resulting in estimates of over a quadrillion connections. The complexities of brain functioning lie in these intersecting connections. Zooming in momentarily and understanding the brain at the level of the neuron is helpful in understanding the important concept of brain plasticity. Much like plastic that has a physical structure that is both structurally sound but moldable, the brain has a physical structure that is changeable. And like plastic, any change in the brain’s shape often reflects a change in its function and vice versa. We refer to the brain’s ability to change in structure and function, especially as a result of environmental influence, as neuroplasticity. As with all things related to the brain, neuroplasticity is highly complex and involves many different processes. However, for the sake of simplicity as it relates to therapeutic intervention, we can focus on at least two processes contributing to neuroplasticity. First, is the process of tuning (Barrett, 2021). When neurons form strong connections with other neurons, they often develop into neural networks, or clusters of small workgroups. Essentially, neural networks form specialized functions based on the complex interactions among the individual neurons that make up that network. This is the “neurons that fire together wire together” principle. Accordingly, changes in behavior or thinking do not necessarily involve the formation of new neurons, but rather a change in the connections that neurons make with each other. Furthermore, neural networks then form strong connections with other neural networks. Learning anything—e.g., riding a bike, memorizing a poem—involves the strengthening of complex interactions among multiple neural networks. The principle of tuning illustrates how various life experiences affect the actual architecture of the brain. For example, Kolb and Whishaw (1998) outlined many of the landmark studies dating back to the late 1940s about the effects of different environments on brain development in rats. They noted that in some of their own studies, which compared rats raised in impoverished environments (i.e., in a cage alone and without any playthings) to rats raised in enriched environments (i.e., in a cage with other rats and plenty of playthings), the rats raised in enriched environments showed significantly healthier brain development by day 60. Of particular note was the finding that rats from the enriched environments had estimates of up to 20% more neuronal connections in some parts of their brain than the rats from impoverished environments. Positive experiences can change the actual structure of the brain by increasing the number of connections between neurons.

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In contrast, the second major process involved in brain development is called pruning. Neural connections that aren’t used weaken and often disappear— the “use it or lose it” principle. This principle is often used as a possible explanation as to why infants lose their ability to tell the difference between certain sounds depending on what language they are exposed to. For example, infants younger than six to eight months show the ability to distinguish between the sounds /r/ and /l/ regardless of culture. However, by 10–12 months, infants raised in cultures that do not discriminate between the sounds /r/ and /l/ (e.g., in Japan) show difficulty in discriminating between them. Werker and Tees (1999) noted that although these infants come preloaded with the ability to make such a distinction, their “subsequent experience functions to narrow, or ‘prune,’ their perceptual sensitivities.” Whether this ability is irrevocably lost or not (see Rivera-Gaxiola et al., 2005), these findings suggest that not only can one’s experiences strengthen neural connections, but one’s lack of experience may render some neural connections obsolete, resulting in a loss of functioning. To illustrate tuning and pruning, imagine a field that people have to travel across to get to and from their destination. As people travel back and forth across the field, paths are formed. The paths that are used more frequently are broadened and become more permanent (tuning). The paths that aren’t used as frequently become less visible and are often lost (pruning). Now, consider the well-worn paths of symptoms associated with traumatic stress. Perhaps a particular smell cues intrusive thoughts, a sense of panic, and avoidance behaviors. These pathways are well traveled and seem permanent to the client. TRM/CRM focuses on teaching skills that potentially strengthen healthier responses—i.e., healthier neural pathways. The more the skills are used, the more likely they are to develop into integrated neural networks of resilience (tuning). Likewise, the more time we spend “traveling” down paths of resilience, the less time we spend in the more well-worn, dysfunctional paths. And, if the “use it or lose it” principle holds, then the less we use those unhealthy paths, the more likely they will become obsolete resulting in a reduction of symptoms (pruning). Therefore, “from the perspective of neuroscience, psychotherapists are in the brain-rebuilding business” (Cozolino, 2017, p. 34). This explains why TRM/CRM emphasize the repeated use of wellness skills. Let’s now zoom out from the level of the neuron, past the level of neural networks to focus on the various specialized functions of certain brain networks. It can be useful to think of the brain as a three-part system (MacLean, 1990), consisting of the cortex (the “thinking network”), the limbic system

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(the “emotional network”), and the brain stem (the “survival network”). Of course, right now you might be horribly offended at the prospect of trying to boil down all of the complexity involved in a system that potentially has over a quadrillion connections to just three major networks. You may be thinking that at the very least, it’s a gross oversimplification. You’re right. It is. In addition, much has been written in critique of MacLean’s theory about the “triune brain” (e.g., Barrett, 2021). However, these critiques have focused primarily on the theory’s questionable proposition that the current physical structure of the human brain evolved over time in specific layers. Trying to explain how our brain developed in structure and complexity over millennia when compared to other animals is beyond the scope of this book. Rather, we focus on the idea that there are general functions localized to certain neural networks that also correspond to certain experiences. And talking about the brain’s interaction between three general experiences (i.e., thoughts, emotions, and survival responses) is a useful conceptualization to help therapists and clients better understand the brain’s response to trauma without having to earn an advanced degree in neuroscience. Working from the top down, the cortex or “thinking network” is the outer bark of the brain. It contributes up to 85% of the brain’s weight and each of its hemispheres can be divided into four lobes: the frontal lobe, the parietal lobe, the occipital lobe, and the temporal lobe. Visualize a boxing glove from the side and you can visualize these lobes. The “thumb of the glove” is the temporal lobe—located roughly right above the ears—and it houses the auditory cortex, which is generally responsible for processing auditory information. Just above the “wrist” of the glove is the occipital lobe—­located at the back of the head—and it contains the visual cortex, which is generally responsible for processing visual information. From there up to the “knuckles” of the glove is the parietal lobe—located at the top-rear portion of the head—and it is known for its sensory cortex, which receives sensory information from the skin and from the movement of body parts. Finally, there is the portion of the glove where the “fingers” are. This is the frontal lobe—located just behind the forehead—and it is responsible for a lot of important and diverse functions. Within the frontal lobe, there is the motor strip—roughly at the first set of “knuckles” in the glove—which is important in the planning, control, and execution of motor movements. Moving toward the “fingertips” of the glove, the area immediately adjacent to the motor strip is the premotor area, which involves the spatial and sensory guidance of movement. Clearly, both of these areas are important in the voluntary control of muscle movements.

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Then there are the anterior cingulate cortex (ACC) and the insula. Activation of both of these areas has repeatedly been shown to be associated with empathy, especially when observing pain in others (Rameson et al., 2012). We often describe people who help those who are suffering as having “a big heart.” It’s probably more accurate to assume that their ACC and insula are highly active. Regarding the insula, Paulus and Stein (2010) noted that it is responsible for our interoceptive awareness—i.e., the subjective sense of the inner body. The insula is the receiving zone that reads the physiological state of the entire body and then generates subjective feelings. The subjective sense of pain involves the activation of the insula, which likely explains its role in empathy. In addition, these subjective feelings can bring about actions that keep the body in a state of internal balance. As noted in Chapter 3, the foundational skill of Tracking is used to increase the individual’s sensory awareness—or interoception—to develop a greater capacity for emotion regulation and embodied states of well-being. The insula reads physical states of the body and communicates to the cortex to take action to keep the body in a state of internal balance. The subjective sense of mind and body, thoughts and feelings are integrated in a significant way in the insula. According to a study on loving kindness meditation practiced by Tibetan monks and repeated prayer of Franciscan and Carmelite nuns, the insula was most active in those participants who reported experiencing the deepest level of empathy and compassion (Sternberg, 2009). Sternberg further commented that the areas that were activated in the praying nuns and meditating monks were the reward circuits and the prefrontal and parietal lobes. She emphasized that those parts of the brain are important in positive emotional responses and resilience. Once the nuns and monks reached a state of peace and love, the same regions of the brain became active that are responsible for passionate and compassionate love. The participants showed increased activation of the PSNS (the “rest and digest” system) and significantly thicker insulae compared to non-meditators/non-prayers. Considering the plasticity of the brain, it is hypothesized that perhaps TRM/CRM skills actually thicken the insula, which would result in a greater capacity to be in one’s Resilient Zone. Finally, within the frontal lobe there is the prefrontal cortex, which is largely considered the CEO of the brain because areas in this region help orchestrate our thoughts and actions. When we refer to the cortex as the “thinking” network, we are for the most part referring to the prefrontal cortex. Certain parts of the prefrontal cortex are active when we reason, strategize, plan, and make moral judgments.

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It is through experience and maturity that our prefrontal cortex learns to inhibit and control subcortical (e.g., limbic system) activation, which eventually allows us to regulate our emotional experiences. In terms of neuroscience then, cognitive therapies essentially target changes in the prefrontal cortex. Focusing on helping clients identify and change maladaptive ways of thinking (cortex) with the goal of better emotional regulation (limbic system), one can conceptualize this type of intervention as a “top-down” intervention, in which the goal is to strengthen the optimal functioning of the cortex so that it can better regulate the areas of the brain “below” it. Given the role of the prefrontal cortex in emotional regulation, one can also see why such therapies can be effective. But it’s not a one-way street. There are bottom-up processes that can occur wherein our emotions and/or survival responses can hijack the “thinking” network. This brings us to the second section of the three-system model of the brain. The area just below the cortex as we move toward the spinal cord is referred to as the limbic system, or the “emotional” network. Among other things, the limbic system plays an important role in the mediation and control of major emotional activities like attachment, friendship, love, aggression, affection, and the expression of mood. This system is also very important in mediating the functions of self-preservation (i.e., fight, flight, or freeze). The limbic system is made up of multiple structures, but for the purposes of this book, we will focus on just the hippocampus, the amygdala, and the hypothalamus. The hippocampus is responsible for the processing of explicit memories (i.e., memories of facts and events). It is not a storage cabinet where we “file” such memories, but rather more like the desk we use to sort and sift them before moving them to where they will be stored. The hippocampus is also important in providing contextual cues to memories such as spatial and time information (e.g., Bonnici et al., 2012; Sekeres, et al., 2018). We will discuss the importance of this later in the chapter. The amygdala is a key component linked to aggression and fear, especially in the perception of these emotions. This part of the brain can be considered our danger appraisal system and can operate much like a fire alarm. If danger is assessed, the amygdala sounds the alarm to initiate the biological sequences involved in our survival responses. The amygdala can even assess danger without our conscious awareness (Ohman et al., 2007), which might help explain why the “hairs on the back of our neck stand up” despite any obvious reason. Finally, the hypothalamus helps to maintain a steady internal state of equilibrium by influencing maintenance activities related to hunger and thirst,

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body temperature, and sex. In addition, the hypothalamus also helps regulate the autonomic nervous system. The hypothalamus governs most of these functions by influencing the endocrine system (a system of glands that secrete hormones into the bloodstream) via the pituitary gland. As we will see later, the hypothalamus plays a key role in one of the major physiological responses experienced during times of crisis. The third and final part of the three-system model of the brain is the brainstem, or “survival” network, which begins where the spinal cord swells as it enters into the skull and is responsible for the exchange of information between the body and the brain. All information that travels from the body to the brain or vice versa goes through the brainstem. In addition, the brainstem is responsible for regulating our automatic survival functions such as breathing and heartbeat, pain sensitivity, alertness, awareness, and consciousness. Accordingly, the “survival network” often goes into survival responses (e.g., fainting, shock, and more) automatically based on perceived threats. Sitting on top of the brainstem is the thalamus, which acts as the brain’s sensory switchboard. The thalamus receives information from all of the senses except smell and sends it on to the appropriate brain areas responsible for seeing, hearing, taste, and touch. (A quick side note: The sense of smell is processed by the olfactory bulb, which sits at the front of the brain just under the prefrontal cortex. Interestingly, the olfactory bulb has a direct connection to the amygdala and the hippocampus, underscoring the fast-track effect smells often have on emotion and memory.) Back to the brainstem: The cerebellum lies at the rear of the brainstem and is responsible for processing nonverbal implicit memory and helping coordinate voluntary movements. All of the brainstem’s functions occur without conscious thought. That is, they are still active whether we are awake or asleep. Thankfully! Can you imagine having to stay awake in order to tell your heart to keep beating or your lungs to take in air? Have you ever woken up in the middle of the night to see your five-year-old staring at you? Did you ever wonder why you woke up? Because the thalamus—without your explicit permission—was still taking in sensory information (e.g., your child saying your name) and communicating to the areas of your brain that are responsible for waking you up. Ultimately, the brainstem responds to sensation and body memory and not to language and conscious thought. Now that we have the basics down, let’s turn to trauma’s effects on the nervous system as a whole. As noted, the amygdala is the appraisal system that sounds the alarm when it perceives a potential threat. At that point, the amygdala sets into motion a cascade of chemical communications involving

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the hypothalamus, pituitary gland, and adrenal glands. This is referred to as the hypothalamic pituitary adrenal (HPA) axis and is our central stress response system. When threat is assessed, the amygdala communicates to the hypothalamus to release a hormone called CRH (corticotropin-­releasing hormone). CRH travels to the pituitary gland that then releases another hormone called ACTH (adrenocorticotropic hormone). ACTH in turn stimulates the adrenal gland to produce stress hormones (e.g., cortisol and adrenaline). Cortisol and adrenaline flow through the body, causing the body to adjust heart rate, blood pressure, and breathing rate in order to ready the body for survival responses. We also have a feedback system to help regulate this process. Neurons in the hippocampus have receptors that recognize the rise in stress hormones and signal back to the hypothalamus, essentially saying, “Okay, you don’t need to release any more stress hormones.” At the same time, the amygdala’s alarm alerts a specific portion of the prefrontal cortex (the brain’s CEO) which then evaluates whether there is real danger or whether it was a false alarm. If the prefrontal cortex determines there is real danger, the alarm gets louder. If the prefrontal cortex determines that there’s been a “false alarm,” everything calms down. Imagine you are going about your nightly duties, and you hear a noise right behind you. Immediately, the alarm in your brain (amygdala) fires and communicates directly to the adrenal glands telling them to release adrenaline, bringing you to attention. At the same time, it also notifies your hypothalamus, which then gives the signal (via the pituitary gland) to release stress hormones. Accordingly, the adrenal glands flood your system with cortisol and adrenaline. This causes your heart rate to rise, your blood pressure to elevate, and your digestion and immune systems to shut down, allowing for the blood to be sent to your muscles and glucose to flood your bloodstream. You start to sweat. Sound familiar? This is the sympathetic response. You are primed to fight or flee. Now then, as you turn to orient to the sound, your body is primed to respond. But then you see your cat nonchalantly playing with the book he knocked off your desk. That’s when your prefrontal cortex kicks in and determines it to be a false alarm. Thoughts and feelings may now arise as you immediately start to wonder why you even have a stupid cat! But beyond that, having determined that the once threatening noise was just your cat, you conclude that you are not in danger. The amygdala stops firing, stress hormones stop being released, and that’s when the parasympathetic nervous system comes online, and your body starts to calm. Eventually, you may even remember how much you love your cat.

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Imagine, however, that you turn around and don’t see your cat. Instead, you see a shadowy figure pass quickly out of sight. In this case, your prefrontal cortex concludes that it isn’t a false alarm. There is actual danger. In this case, your amygdala may blare even louder, calling for more stress hormones and causing even more adrenaline and cortisol to flood your body. This is the HPA axis in action. And this is good. Having our body’s alarm system operating correctly helps us deal with all sorts of threats. It’s when these systems don’t work properly or when they don’t turn off after the threat is gone that we start to observe the types of symptoms associated with a great number of emotional difficulties. Take, for example, the many studies focusing on the amygdala and its role in psychopathology. For example, an overactive amygdala has been linked to multiple anxiety disorders (Davies et al., 2017; Etkin & Wager, 2007), unipolar depression (Barbour et al., 2020), and borderline personality disorder (Cremers et al., 2021). In contrast, individuals with psychopathy show reduced amygdala activity when exposed to stimuli that normally should spark  fear, resulting in a reduced autonomic nervous system response (see Blair, 2008). Another common finding associated with compromised brain structures is that of reduced hippocampal volume. For example, Gilbertson et al. (2002) found that combat veterans with post-traumatic stress disorder (PTSD) had smaller hippocampal volume than combat veterans without PTSD. What was particularly important about this study was that it involved identical twins—100% genetically identical “clones” made naturally. The noncombat twin of the PTSD veteran had similar smaller hippocampal volume as his twin, while the noncombat twin of the non-PTSD veteran had similar larger hippocampal volume as his twin. This suggests that smaller hippocampal volume might make one more vulnerable to developing PTSD if exposed to traumatic stress. Remember, certain neurons in the hippocampus provide feedback about the rising levels of stress hormones when the amygdala is activated and are responsible for telling the amygdala when to stop signaling for more. Perhaps the smaller hippocampal volume compromises its ability to provide proper feedback to the hypothalamus, causing an exaggerated release of cortisol during times of stress, which then might make one vulnerable to the development of PTSD. Of course, the causal factors behind the development of PTSD are much more complex than this, but such differences in brain anatomy and functioning highlight how important it is to understand the brain and its role in our response to stress. A basic understanding of memory and its function adds even more clarity to our experience of traumatic stress and can further

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help us move from perceptions of personal weakness to an understanding of biology. Memory essentially involves our ability to store and retrieve information over time. When we learn anything—a vocabulary word, our mother’s voice, the smell of a rose, how to drive a car—we are forming memories. We are loading information into our brain, storing it, and then retrieving it. Sounds simple, but here’s where it gets interesting. As noted earlier, there are functions controlled by our brain that are voluntary (e.g., raising our hand) and functions that are involuntary (e.g., heartbeat). There are conscious functions and unconscious functions. In the same way, there are two types of memory: explicit memory and implicit memory. Explicit memory is the conscious retention of information like facts and events. These memories are factual and autobiographical and have a sense of self and time (Cozolino, 2017). They are often the memories that we access intentionally (i.e., voluntarily). Explicit memory is what we generally think of when we’re asked if we have a good memory or not. If we can’t remember the capital of El Salvador or the first name of the person we just met or what we did last Thursday, then we generally conclude that we have a poor memory. However, it might be more accurate to say that we are not very good at the conscious, intentional recall of some of our explicit memories. The fact is that if you can remember your name, the shape of a square, the town of your childhood, or what a book is, then your explicit memory is pretty good. Implicit memory is the unconscious retention of information. Implicit memories often involve information that is processed or accessed without intention (i.e., involuntarily). They also involve automatic procedures and internal states—thus the original use of the term procedural memories when referring to implicit memories. Unlike explicit memory, implicit memory does not have a sense of linear time or space, or a sense of self. Instead, these memories are often memories of skills and conditioned associations unfettered from the context in which they were learned. As such, mental models can be formed from experiences that entail somatic, sensory, motor, and emotional elements without our conscious awareness of them. The example of riding a bike illustrates the differences between explicit and implicit memory. Perhaps you remember the day you first learned how to ride a bike. You may remember who taught you or the color of the bike. These are explicit memories. However, staying balanced, pedaling, using the ­handlebars—these are implicit memories. You access these skills every time you get back on a bike. Therefore, you remember how to ride a bike (implicit

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memory) even though you may not remember the details of the day you learned (explicit memory). If I asked you to tell me about the last time you rode a bike (i.e., a narrative), you would be accessing explicit memories to do so. If I were to hand you a bike and tell you to ride it down the block, you would be accessing implicit memories. This illustrates an important principle about memory as it relates to trauma. Implicit memories and explicit memories do not always accompany each other. More on this later. Further distinctions between these two types of memories are found in the corresponding networks that process them. Explicit memories are processed primarily by the hippocampus and the frontal lobes. The hippocampus helps put explicit memories in their proper perspective and place in our life’s timeline. As we noted before, because of neuroplasticity, the actual structure of the hippocampus can change in response to our experiences. For example, an interesting study found that the area of the hippocampus responsible for spatial memory was bigger in London taxi drivers the longer they spent driving taxis (Maguire et al., 2003). Stress seems to negatively affect the functioning and structure of the hippocampus. It has been found that when the amygdala is highly active, the stress hormones (e.g., cortisol) released interfere with the proper functioning of the hippocampus. This may result in a traumatic experience not being explicitly remembered or being remembered in ­fragments (Van der Kolk & Fisler, 1995). Likewise, prolonged exposure to high levels of cortisol can result in significant hippocampal damage (Kim et al., 2015). In contrast, implicit memories are processed primarily by the cerebellum and the basal ganglia (i.e., brain structures near the thalamus involved in motor movements). The cerebellum is a key player in forming and storing memories created by classical conditioning. If your mouth starts to salivate when you smell your favorite food, that’s an implicit memory that involves the cerebellum. The basal ganglia is involved in procedural memories for skills. Riding your bike down the block involves the basal ganglia. Knowing that the implicit memory system is processed differently and in a different area of the brain than the explicit memory system can help explain a lot of strange phenomena. For example, both the cerebellum and basal ganglia are developed enough prior to birth to allow for implicit memories to form even before we take our first breath. At the same time, the hippocampus is one of the last brain structures to develop (around 18–24 months), resulting in few to no conscious (explicit) memories prior to the age of three—a phenomenon called infantile amnesia. Similarly, body memories processed by the cerebellum and

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basal ganglia can include sensations associated with traumatic experiences. Because they are processed separately from the hippocampus, bodily cues can set off implicit memories without any explicit understanding. One client who was sexually assaulted in her teens reported having a panic attack in her late 30s during a routine physical therapy session. The panic attack was “uncued,” meaning that she reported no flashback or explicit memory that would have activated her panic. As she put it, “It came out of the blue.” While she was convinced intellectually that the panic attack had to be related to her assault as a teen, there was no narrative connection. Some of the TRM skills were employed to help her get back into her Resilient Zone, and a brief explanation about how the two different memory systems work was provided. It was emphasized that sometimes the body can take in sensory information outside of conscious awareness and store it as implicit associations related to the trauma. Sure enough, as she recounted again some of the details regarding this particular physical therapy session, she noted a detail that wasn’t obvious the first time she told me. She noted that an apparatus that was used to bind her ankles wasn’t clasping correctly and the physical therapist had to use duct tape to secure it. It was the sound of the duct tape coupled with the muscle memory of the binding that set off her panic attack. It was during this retelling of the episode that she remembered (explicitly) that her assailant had used duct tape to bind her ankles during her assault some 20 years prior. The implicit body and sensory memories of the event were activated without the explicit memories of the event. She was so relieved to know that she wasn’t “crazy,” and knowing about the two types of memory helped her understand why she had the panic attack. But why duct tape? It’s such a common item and yet, in this particular case under those particular circumstances, it signaled something more ominous. As you may remember, the amygdala acts as our appraisal system—our fire alarm. If an event trips the alarm, the amygdala sends out its signal to release stress hormones. These, in turn, provoke the amygdala to initiate a memory trace in the frontal lobes (explicit memory) and the basal ganglia (implicit memory), causing particular memories to have a certain emotional signature (Buchanan, 2007; Kensinger & Ford, 2020). Accordingly, templates from highly charged emotional memories are formed. Some of these templates we call flashbulb memories. Where were you on 9/11? Do you remember your first kiss? For trauma survivors, vivid memories of a traumatic event often intrude again and again. These are emotionally charged memories that seem to be recalled with great clarity. More often

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than not, we talk of emotionally charged explicit memories by focusing on the narrative of what happened. However, the amygdala can initiate a memory trace for implicit memories as well. In the example above, the original assault set off the amygdala and various emotion-related memories were formed. The body memory of being bound at the ankles and the sound of the duct tape were implicit memories that retained the signature of amygdala activation. These bits of information were seared into memory just as much as the narrative of the event was. In fact, even when such explicit narrative details escaped the client’s conscious recall initially, her “body” remembered, and the amygdala was once again activated. This is an elegant design. It is astounding when certain data from the outside world (sound of duct tape; physical contact of bindings) can interact with stored internal information (implicit memories) to sound an internal alarm system (panic attack) that causes our nervous system to go into action for our protection…even when we do not know why! It is as if the body is saying, “Last time our nervous system was presented with similar information, it did not go well for us.” And our nervous system does not have to know why the alarm is sounding before initiating a “protection protocol” that encourages survival responses. One of the key elements to understand here is the process by which the stored internal information or memories help set into motion these protection protocols. Scaer (2014) refers to compartments of memory he terms memory capsules. These memory capsules hold explicit and implicit details of past traumas and can include survival energy that has not been released. Accordingly, when a memory capsule of a traumatic event is activated, one may experience a whole litany of uncomfortable outcomes such as pain, numbness, dizziness, trembling, paralysis, nausea, palpitations, anxiety, terror, shame, anger, rage, flashbacks, nightmares, or intrusive thoughts. When this happens, the trauma is perceived as being in the present. (To be clear, there are no actual tiny “capsules” in our brain that get “popped.” The idea of a memory capsule is just a metaphor that can be used to conceptualize how sensory information interacts with memory.) Memory capsules can have external reminders such as visual stimuli (e.g., people, places, things), smells, sounds, and many more. Or they can have internal reminders—i.e., internal body sensations such as muscle tension, headache, stomach ache, elevated heart rate, and the like. This can help explain why some people who suffer from panic disorder often have panic attacks that are set off by strenuous physical activities such as exercise. The elevated heart rate, shortness of breath, and sweating experienced during

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exercise can act as an internal cue that pops the memory capsule of past panic attacks (the symptoms of which include elevated heart rate, shortness of breath, and sweating). Ultimately, memory serves to help us make sense of our world, predict the future, and alert us to possible dangers. Within the brain are a variety of different systems capable of recording and storing information about life experiences. Some networks make memories by preserving records of experience to later allow conscious recollection of the past (explicit memories). Other networks process information implicitly. Sensory processing regions in the cortex store information about certain sensory experiences. Still other networks allow learned movements (e.g., habits) to be stored. When an emotionally charged event happens, the amygdala fires, helping these brain systems to put an emotional trace on the narrative and body/ sensory memory of the event as if to say, “Remember this! Beware the next time!” However, traumatic memories may or may not be remembered in a coherent explicit memory. Some traumatic memories may appear as fragments of images and sensations or may result in flashback memories (i.e., flashbulb memories of personally traumatic events). Some traumatic memories seem timeless: The entire multisensory implicit memory may be experienced as if the traumatic event is happening in the present moment. It’s as if the explicit and implicit memories are no longer aligned, much like a video playback where the sound of the dialogue isn’t quite lining up with the movement of the person’s mouth. In fact, the multisensory implicit memory may be fully disconnected from a particular source memory, as in the example of the duct tape. This can be incredibly frustrating for clients and therapists to work with, so why consider it a good thing? Joseph LeDoux (1996) told the story of a client who had damage to her hippocampus that prevented her from forming new explicit memories. Accordingly, she was unable to recognize her physician who, each day, would greet her by introducing himself and shaking her hand. One day, he tried an experiment. He put a tack in his hand. Just like every other day, he introduced himself and shook her hand. This time she pulled her hand back in pain. The next time he introduced himself the patient refused to shake his hand but couldn’t explain why. A mean experiment, yes. But an important one nonetheless. The explicit memory could not be accessed, but her implicit memory could. This allowed the patient to sense danger without knowing why. One structure of her brain (hippocampus) wasn’t working properly anymore, but that didn’t stop other structures (amygdala and cerebellum) from trying to keep her safe. That’s an elegant design!

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Now we can see how memory can affect how we respond to what happens around us. For example, when we are presented with sensory information from the outside world, we process it through one of two systems. The slow system involves sensory input (i.e., sounds, imagery) being processed by the thalamus (the sensory switchboard). The information is then filtered through the amygdala. If the amygdala makes the appraisal that there is no threat, then the hippocampus and other cortical circuits provide further processing of the information. At this point, the information is contextualized in time and space, assigned cognitive meaning, and then sent on to other areas of the cortex. The cortex is not blocked, and the person can act with conscious thought and organized, complex survival behavior. The fast system follows the same initial steps. Sensory information is processed by the thalamus and assessed by the amygdala. However, if the amygdala appraises the information as a threat—based on past experience—then the fear response is activated (i.e., the HPA axis), flooding the cortex with chemicals that block slow thinking. The cortex is blocked, and the person acts without conscious thought. This accounts for the common survival responses of fight, flight, and freeze. These behaviors are often performed reflexively and without conscious thought. A study by Ryan Herringa and colleagues (Herringa et al., 2013) illustrates how these systems can break down because of traumatic stress. According to the study, maltreatment in childhood seems to disrupt the regulatory capacity of the brain’s fear circuit, leading to increased internalizing of symptoms by late adolescence. Brain scans showed that maltreatment predicted weaker prefrontal cortex-hippocampal connectivity in adolescent males and females, but lower prefrontal cortex-amygdala connectivity only in adolescent females. Accordingly, outcomes of childhood maltreatment for some male and female adolescents resulted in the perception that “everything is a threat,” whereas in other adolescents (females only in this study) developed a “blind spot” to any threat which essentially puts them in more danger. When one or more neural networks necessary for optimal functioning remain underdeveloped, underregulated, or under-integrated with others, we experience the complaints and symptoms for which people seek therapy. We now assume that when psychotherapy results in symptom reduction or experiential change, the brain has, in some way, been altered. (Cozolino, 2017, p. 15)

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CRM/TRM focuses on reestablishing the natural rhythm of the nervous system through the portal of sensations. One could argue that when we are in our Resilient Zone, our neural networks are well-integrated, our memory systems are synchronized, and our mind and body are working as one. Helping clients manage stress—traumatic or otherwise—by increasing their ability to be in their Resilient Zones allows them to maximize their body’s natural resilience, resulting in improved integration of the brain and body.

References Barbour, T., Holmes, A. J., Farabaugh, A. H., DeCross, S. N., Coombs, G., Boeke, E. A., Wolthusen, R. P. F., Nyer, M., Pedrelli, P., Fava, M., & Holt, D. J. (2020). Elevated amygdala activity in young adults with familial risk for depression: A ­potential marker of low resilience. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 5(2), 194–202. Barrett, L. F. (2021). Seven and a half lessons about the brain. Mariner Books. Blair, R. J. R. (2008). The amygdala and ventromedial prefrontal cortex: Functional contributions and dysfunction in psychopathy. Philosophical Transactions of the Royal Society, 363(1503), 2557–2565. Bonnici, H. M., Chadwick, M. J., Lutti, A., Hassabis, D., Weiskopf, N., & Maguire, E. A. (2012). Detecting representations of recent and remote autobiographical memories in vmPFC and hippocampus. The Journal of Neuroscience, 32(47), 16982–16991. Buchanan, T. W. (2007). Retrieval of emotional memories. Psychological Bulletin, 133(5), 761–779. Cozolino, L. J. (2017). The neuroscience of psychotherapy: Healing the social brain (3rd ed.). W. W. Norton & Company. Cremers, H., van Zutphen, L., Duken, S., Domes, G., Sprenger, A., Waldorp, L., & Arntz, A. (2021). Borderline personality disorder classification based on brain network measures during emotion regulation. European Archives of Psychiatry and Clinical Neuroscience, 271(6), 1169–1178. Davies, C. D., Young, K., Torre, J. B., Burklund, L. J., Goldin, P. R., Brown, L. A., Niles, A. N., Lieberman, M. D., & Craske, M. G. (2017). Altered time course of amygdala activation during speech anticipation in social anxiety disorder. Journal of Affective Disorders, 209, 23–29. Etkin, A., & Wager, T. D. (2007). Functional neuroimaging of anxiety: A m ­ etaanalysis of emotional processing in PTSD, Social Anxiety Disorder, and Specific Phobia. American Journal of Psychiatry, 164(10), 1476–1488.

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Gilbertson, M. W., Shenton, M. E., Ciszewski, A., Kasai, K., Lasko, N. B., Orr, S. P., & Pitman, R. K. (2002). Smaller hippocampal volume predicts pathologic vulnerability to psychological trauma. Nature Neuroscience, 5(11), 1242–1247. Herringa, R. J., Birn, R. M., Ruttle, P. L., Burghy, C. A., Stodola, D. E., Davidson, R. J., & Essex, M. J. (2013). Childhood maltreatment is associated with altered fear circuitry and increased internalizing symptoms by late adolescence. Proceedings of the National Academy of Sciences of the United States of America, 110(47), 19119–19124. Kensinger, E. A., & Ford, J. H. (2020). Retrieval of emotional events from memory. Annual Review of Psychology, 71, 251–272. Kim, E. J., Pellman, B., & Kim, J. J. (2015). Stress effects on the hippocampus: A critical review. Learning & Memory, 22(9), 411–416. Kolb, B., & Whishaw, I. Q. (1998). Brain plasticity and behavior. Annual Review of Psychology, 49(1), 43–64. LeDoux, J. (1996). The emotional brain: The mysterious underpinnings of emotional life. Simon & Schuster. MacLean, P. D. (1990). The triune brain in evolution: Role in paleocerebral functions. Plenum Press. Maguire, E. A., Spiers, H. J., Good, C. D., Hartley, T., Frackowiak, R. S., & Burgess, N. (2003). Navigation expertise and the human hippocampus: A structural brain imaging analysis. Hippocampus, 13(2), 250–259. Newberg, A. (2009). How God changes your brain. Ballantine Books. Ohman, A., Carlsson, K., Lundqvist, D., & Ingvar, M. (2007). On the unconscious subcortical origin of human fear. Physiology & Behavior, 92(1–2), 180–185. Paulus, M., & Stein, M. B. (2010). Interoception in anxiety and depression. Brain Structure and Function, 214(5–6), 451–463. Rameson, L. T., Morelli, S. A., & Lieberman, M. D. (2012). The neural correlates of empathy: Experience, automaticity, and prosocial behavior. Journal of Cognitive Neuroscience, 24(1), 235–245. Rivera-Gaxiola, M., Silva-Pereyra, J., & Kuhl, P. K. (2005). Brain potentials to native and non-native speech contrasts in 7- and 11-month-old American infants. Developmental Science, 8(2), 162–172. Scaer, R. (2014). The body bears the burden: Trauma, dissociation, and disease (3rd ed.). Routledge. Sekeres, M. J., Winocur, G., & Moscovitch, M. (2018). The hippocampus and related neocortical structures in memory transformation. Neuroscience Letters, 680, 39–53.

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Sternberg, E. M. (2009). Healing spaces: The science of place and well-being. Harvard University Press. Van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory study. Journal of Traumatic Stress, 8(4), 505–525. Werker, J. F., & Tees, R. C. (1999). Influences on infant speech processing: Toward a new synthesis. Annual Review of Psychology, 50, 509–535.

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Embodying Otherness to Us: Diversity, Equity, Inclusion, and Justice Reena Patel and Elaine Miller-Karas This chapter will: 1. Bring in ideas of how we can explore our differences and commonalities using the framework of the Community Resiliency Model to guide our conversation with compassion and empathy, guided by the principles of equity, equality, and social justice 2. Describe decolonization of our mental health interventions 3. Describe how TRM/CRM approaches can create increased sense of accessibility with inclusive and invitational language within the ­LGBTQIA2S+ community The following terms will be used in this chapter: LGBTQIA2S+ stands for Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, Asexual and Two-Spirit. “Two-Spirit” is a term used within some indigenous communities, encompassing cultural, spiritual, sexual, and gender identity. The term reflects complex indigenous understandings of gender roles, spirituality, and the long history of sexual and gender diversity in indigenous cultures. Institutional racism occurs within and between institutions. Institutional racism is discriminatory treatment, unfair policies, and inequitable opportunities and impacts, based on race, produced and perpetuated by institutions (schools, mass media, and more). Individuals within institutions take on the power of the institution when they act in ways that advantage and disadvantage people, based on race (Keleher & Lawrence, 2004). Structural racism lies underneath, all around, and across society. It encompasses: (1) history, which lies underneath the surface, providing the foundation for DOI: 10.4324/9781003140887-7

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white supremacy in this country; (2) culture, which exists all around our everyday lives, providing the normalization and replication of racism; and (3) interconnected institutions and policies, the key relationships and rules across society providing the legitimacy and reinforcements to maintain and perpetuate racism (Keleher & Lawrence, 2004). Chronic discrimination refers to the ways micro and macro aggressions can be experienced daily by people being othered by society. Everyday discrimination may contribute to stress experienced by racial/ethnic minorities and could lead to chronic illness (Gee et al., 2007).

Introduction The Trauma Resource Institute (TRI) highlights the universal experience of our biology and nervous system as a uniting thread in the human experience. People worldwide experience similar common reactions to traumatic experiences, and we all have the capacity to cultivate well-being. There are also differences that profoundly influence how we perceive ourselves and how others perceive us. Based on those perceptions, members of our communities view our potential for inclusion, empowerment, and justice. A motto has emerged within our global community that we can move from “Otherness to Us.” Our vision is to integrate the Community Resiliency Model (CRM) and Trauma Resiliency Model (TRM) skills into activities of daily living concerning historical and cumulative traumas and to acknowledge the strength and courage that has evolved within the individuals of our communities. We intend to create spaces of: • Self-awareness and skills for navigating activation caused by advantage/ privilege and oppression • Empowerment to strengthen voices within communities through ­resilience-focused and informed dialogue. TRI is committed to contributing to creating a world where people of all religions, races, ages, abilities, sexual orientations, and gender identification are equally respected and welcomed. Understanding the differences between equality and equity is essential in our discussion of equity, justice, diversity, and inclusion. We may firmly believe in equality for all not realizing equality does not translate into equitable treatment. All children have equal access to being educated in America, for example. However, the system is not always

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equitable. If a child has a learning challenge and accommodations are not made, the system is not equitable. Justice means treating people in a manner that makes things right and considers altering systems to meet the needs of people. So, the child who receives the necessary accommodations has received justice when the system changed to support their needs and ensure there is fair access to resources across all students. We all have access to the language of our biology and a framework to help understand the human experience. What does this mean? When discussing interventions and skills that promote equity and justice, we must look at access. When working with the capacity and inner wisdom of our bodies and nervous systems, we become aware of what is within reach for all individuals because that is how we are designed, embracing race, ethnicity, religion, social class, age, abilities, and gender. CRM and TRM have impacted individuals from many walks of life, in all corners of our world, with multiple, intersecting lived experiences. In this chapter, we can only address a few of those lived experiences as examples of how this framework can serve as a vehicle to share power, compassion, and respect within and between groups.

Institutional and Structural Racism: Flint Michigan After lead poisoned the water in Flint, Michigan, TRI was invited to the community to share the wellness skills of the Community Resiliency Model. The community members selected CRM Teacher Training as one of the interventions to help their community. Kevin McLeod, a CRM teacher and facilitator, was part of the training team that went to Flint, Michigan. Kevin shared: “This community had endured what can only be considered one of the most egregious acts of environmental racism and injustice as residents were constantly exposed to lead and other bacteria hidden from them by their governmental officials.” Kevin led a discussion about the discrimination and structures of racism existing in Flint during the training. Kevin stated: “The TRI team welcomed the dialogue and shared how the wellness skills could help with the toxic stress they had experienced.” Kevin shared how powerful it was to have the capacity for hard conversations about race and difference, acknowledge the stress and trauma related to these experiences, and use practical skills to maintain wellness. As skills are learned and practiced, residents of Flint have tools they can use for themselves to reduce the impact of toxic stress. As Bryan Stevenson, founder and

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executive director of the Equal Justice Initiative, a human rights organization in Montgomery, Alabama, says, “We’re all burdened by our history of racial inequality. It’s created a kind of smog that we all breathe in, preventing us from being healthy.”

The Birth of the Equity, Diversity, and Inclusion Committee In 2016, a group made up of TRI staff and volunteers gathered at the home of Elaine Miller-Karas to begin discussions of how to bring the lens of equity, diversity, and inclusion (EDI) into TRI with more intention. Reena Patel took initial leadership, and the committee was formed. A subcommittee worked tirelessly to bring greater awareness to the TRI community under the leadership of Kevin McLeod. The lived experiences of members of our EDI subcommittee brought them to the knowledge that they were part of a movement that could equip human beings with skills to help create inner balance during and after the most challenging life experiences related to racism and discrimination. Inequality, equality, equity, and justice were discussed. The CRM skills allowed for a compassionate dialogue and reflection when witnessing and listening to experiences of discrimination and racism mirroring the experience in Flint, Michigan. This embodied respect and acknowledgment created the possibility of a new pathway to healing.

From Otherness to Us: Understanding Social Exclusion and the Power of a Common Humanity Brazilian educator and activist Paulo Friere (1968) states: “Dehumanization, although a concrete historical fact, is not a given destiny but the result of an unjust order that engenders violence in the oppressors, which in turn dehumanizes the oppressed.” Dehumanization is the most powerful tool to perpetuate oppression and strengthen the concept of “the other.” Giving a life, a name, and a story to individuals who are different from each other can dismantle wars and bring nations together. The impact of social exclusion and “othering” is precarious for the future of humanity. Connecting the implications of social exclusion to our biology is essential to understanding how a biologically based intervention such as CRM or TRM can help create the lens of what is true for a person’s lived experience and begin steps towards inclusion. When a part of our brain called the anterior circular cortex (ACC) experiences discrepancies in desired goals and conflict, it signals to the body that

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something is wrong. This process of signaling the “neural alarm system” is sparked by social exclusion and isolation and has a vital role in assessing and responding to race-based discrimination. Social exclusion in race-based discrimination refers to the consequences of marginalization and exclusion from “desired social groups” and how this happens (Mays et al., 2007). Individuals who have experienced social exclusion and discrimination have a “heightened surveillance for negative social cues” that mirror race-based discrimination and social rejection (Mays et al., 2007). In the language embedded in CRM, the “heightened surveillance for negative social cues” can mean a person is bumped into the High Zone, with the foot on the accelerator of the nervous system without awareness of how to find the brake to ease the tension in the body and mind. The embodied CRM skills can help a person learn to track the sensations connected to discrimination and social rejection to learn how to put on the biological brake of their nervous system. Self-regulation can help the ACC better retain information regarding an incident of social acceptance. Without self-regulation, we are more likely to remember adverse events and social exclusion details. The challenge may be for members of the BIPOC communities and other marginalized groups to self-regulate a nervous system geared towards hypervigilance and danger for survival. The self-regulation of the ACC can be utilized to rewire cognitive appraisals of race-based discrimination, potentially preventing premature amygdala activation and unnecessary wear and tear of the body. This is essentially the role of Tracking and utilizing the wellness skills as part of our activities of daily living, a means to self-regulate and reduce the distress experienced by our mental, emotional, and physical bodies. Developing these skills can be empowering with the insight that the person can be in charge of their nervous system. As one person stated to us, “These skills are like my superpower” to help my people and me when faced with racism and discrimination. In situations where threats may be chronically present, such as race-based discrimination, inhibition of the limbic system by the pre-frontal cortex may be released resulting in hypervigilance, decreased heart rate variability, and increased blood pressure and cortisol through the stress response (Mays et al., 2007; Torres-Harding & Turner, 2015). This is a protective response that reminds us we may be in danger so that we take action to protect ourselves and our families. However, the chronic nature of discrimination can lead to toxic stress that we discussed in Chapter 2, causing mental and physical health challenges. Thus, learning biological-based skills can nourish the body and mind by accessing the parasympathetic nervous system and providing respite when navigating difficult situations.

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When we think about the impact of social exclusion on groups, we invite you to think about the challenges of connecting to others who do not look like us. In Dalai Lama et al. (2016) His Holiness the Dalai Lama and the late Archbishop Desmond Tutu discussed the necessity of understanding our common humanity to one another as essential for survival of humanity itself. We are not necessarily biologically wired to empathize with individuals who do not look like us. This begs the question of how we can create intentional actions towards others to create awareness of our shared humanity. It is not enough to exclude oneself from practices of discrimination and hatred. We must be intentional in cultivating relationships across groups. We believe that dialogue is not only possible but critical. Dialogue can occur with greater clarity when we are in our Resilient Zones. We have asked questions about how trauma has changed the way we think, feel, and experience our physical body. Although suffering varied across communities, the global responses were amazingly similar. We have also asked about what new meanings and purposes have arisen out of traumatic experiences. Universally, people have shared gratitude, increased appreciation of life, advocacy, hope, and joy. Our common humanity shows up in how we are designed across cultures and ethnicities with common lived experiences in the wake of trauma and when we experience moments of gratitude and joy.

Taking Power Back: Biological-Based Interventions and Embodied Justice Resilience is built into the cells of our bodies. Like trauma, resilience can ripple outward, changing the lives of people, families, neighborhoods, and communities in positive ways. Also, like trauma, resilience can be passed down from generation to generation. Resmaa Menakem (2017)

Paulo Freire (1968) started a movement of liberation for the dehumanized working class in Brazil. Freire’s radical act was teaching factory workers how to read. CRM and TRM teach individuals how to read their nervous systems, arguably an equally radical act, especially for anyone who has survived trauma. The manifestation of power structures is well known to many of us in the helping professions. They include unfettered corporate greed and exploitation, unfair and discriminatory legislation and laws, and commoditization of our natural environment and resources. We can show up to challenge these systems. There are additional ways power structures manifest to poison our

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waters through intimate partner violence, child abuse, neglect, sexual assault and exploitation, and discrimination. Our own wounding as helpers can prevent the dismantling of these systems. When there is no perceived way to be heard by the oppressor, we hurt one another in an act of horizontal violence in traumatized systems. In this way, learning how to read our nervous systems and regaining choice in the context of our biology is radical. Mitigating our Adverse Childhood Experience (ACE) score is radical. Empowering everyone on this planet to have tools to heal trauma is radical. When we are working in partnership with someone on a healing journey, we can view the person within the context of the manifestations of power in their life. Working with the nervous system is the essential tool, understanding how biology is impacted gives us a language to re-distribute power immediately. When we say, “We all have a nervous system,” we can take steps to equalize power differentials. We believe and empower the person to have their own answers as we guide the person to explore their embodied self.

Changing Systems of Oppression The activist and author Audre Lorde (1981) said, “I am not free while any woman is unfree, even when her shackles are very different from my own…” Reena Patel speaks from the lens of someone who has been both the provider of mental health services to traumatized and racialized individuals and as a person who has received them as a survivor of trauma. Patel’s lived experience has been a journey through survival of sexual assault, witnessing years of intimate partner violence in multiple familial relationships, xenophobia, and mitigating the crossroads of generations of conservative cultural practice in her American home. She is no stranger to the layers of power structures and their impact on the brain and body. This includes the knowledge of the assault and xenophobia endured specifically by women in her family for generations. Reena believes that the healing work is also for them, and for her children, and her children’s children. This reality lives in her biology on a cellular level. Both the imprints of suffering and the resilience that have been passed down to her are true. Reena explains she had attended therapy in many settings when entering college, and it was not until meeting a therapist who practiced the biologically based skills of the Trauma Resiliency Model that she felt relief. Working with the biology of her trauma was transformative. Other therapies were cognitive-based and these approaches did not affect the centuries of violence against women that was alive inside her body.

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As a first-generation South Asian woman, Reena Patel’s experiences with the structures of racism, sexism and inequality prompted her to seek greater understanding of their impact upon individuals and communities. She recalls one meeting in particular in which she felt attacked, being the youngest and only female clinician of color on a behavioral health team. She recounts going into a state of “freeze” in response to the situation. She expressed using the CRM skills over the next several days as a means to get back in her Resilient Zone. By regaining her resiliency and ability to function in an optimal capacity, she was able to take action responsibly and with integrity for herself and prevent a reactive response from a highly dysregulated nervous system. She states feeling empowered and in control of herself. Paying attention to her own biology brought a new awareness to her life experiences. She realized now that her initial response came from decades of feeling like the “other” in professional settings. Although perhaps her colleague had no mal-intention, she now knows perception is key and she perceived the situation as threatening. She was able to remain in her workplace, despite ongoing stressors and reminders related to the event. Using the CRM skills to help self-regulate allowed her to function at a greater capacity. She was able to continue to honor the needs of clients and herself. Most importantly, she found out after talking to several other female employees in different departments that this was an ongoing issue. Reena expressed that while she was in her Resilient Zone, she was able to write a formal complaint, advocating for herself and the work environment. Coming forward regarding her colleague’s conduct resulted in him leaving this position of power.

Conceptualizing Well-Being Community psychologists Nelson and Prilleltensky (2010) conceptualize well-being as having three essential parts—personal, relational, and communal. Personal well-being speaks to internal harmony and efforts to care for self as part of a larger entity and world. Relational well-being honors respect for diversity in identity and ability to define oneself. It includes a spirit of collaboration that invites all individuals to participate in the decision-making process to ensure fairness. Relational well-being focuses on the notion that as individuals we do not stand in isolation, and our well-being is relative to those around us. This form of well-being celebrates and affirms diversity of others, so that the individual is able to feel acceptance towards self. And ultimately, a communal well-being includes both personal and relational aspects of wellness. It transcends these two aspects of holistic health to include the environments and structures within which individuals live.

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When we experience an embodied sense of well-being, self-compassion grows as does community well-being. It is a contagion of our embodied well-being springing forth into our lives. Collective well-being promotes the creation of community structures which facilitate well-being through personal and communal goals. Collective wellness also includes social justice and accountability, as well as fair and equitable distribution of resources, especially for the oppressed (Nelson & Prilleltensky, 2010).

Bound Liberation: The Importance of Honoring Our Intersectionality The words of Lilla Watson (1985) “If you’ve come to help me you’re wasting your time. But if you’ve come because your liberation is bound up with mine, then let us work together” inspire us to look closely at our intersections and cultural humility. The decolonization of mental health interventions and approaches is critical. Using a biological-based intervention allows sharing power with those seeking help and restores hope and dignity to a narrative that may otherwise carry the weight of disenfranchisement. Decolonization also equates to designing mental health interventions that are not constructed by patriarchal systems where the therapist acts as the expert. It means sharing additional tools promoting mental health to the natural leaders, the trusted ambassadors of their communities. Decolonization includes understanding intersectionality and practicing cultural humility. Everyone comes with a unique intersection of lived experience with identities that create who they are in this world. The intersections that create our unique identity are bi-directional–how we perceive the world and how the world perceives us. A biologically based model such as CRM or TRM allows these realities to speak for themselves through the language of sensation and the body, a knowing that is far deeper than words can describe. As awareness surrounding trauma increases and becomes more mainstream, there is a burgeoning need for effective and relevant trauma interventions. For minoritized groups, trauma interventions need to be accessible, adaptable, and economically resourceful. Understanding barriers to conventional treatment for underserved and underrepresented populations must inform the future approaches to trauma treatment. Applying a public health lens to trauma interventions that address the individual and communities and families can have a much more profound and sustainable impact (Helms et al.,

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2012). A public health approach such as the Community Resiliency Model brings attention to the micro, mezzo, and macro levels of intervention. It is ideal for addressing disease and toxic stress created by stressors of larger systems that need community-wide intervention. CRM and TRM are not merely coping strategies. They promote holistic well-being not for the benefit of the oppressor but the empowerment of the oppressed. Behavioral health interventions for those affected by violence and discrimination must offer choice, personal and community safety to reduce stigma. Cognitive-based coping strategies are not enough to address the impacts of embodied trauma from micro-aggressions and discrimination. Learning CRM and TRM skills is always a choice and biologically based skills result in personal and community embodied experiences of greater safety. We destigmatize the common reactions to stress and trauma by emphasizing their biological underpinnings. The spirit of TRM and CRM is infused with values that are ideal in helping bring justice and an equity-focused lens to the discussion regarding trauma interventions that are integrated into multiple disciplines. Social problems are viewed within ecological systems that are relational and mutually influential; therefore, the larger systems of institutional and structural racism that uphold poverty and segregation are seen as perpetuating trauma not only on people of color but also on all individuals. This is relevant for the accessibility of trauma treatment for individuals and communities who seek it and to place cumulative trauma and toxic stress from racism and microaggressions as significant universal stressors that need attention and healing. Individuals who have reported race-related distress describe feeling anxiety, shame, somatic symptoms, depression and adverse impact on interpersonal relationships, amongst other symptoms (Torres-Harding & Turner, 2015). Symptom manifestations of these typical responses to traumatic stress can often be mistaken for other diagnoses not based on trauma. Biological reactions to chronic stress from discrimination are often pathologized. When people report milder symptoms of distress, they may not receive a trauma diagnosis. Milder symptoms may be experienced as a more chronic response responsible for longer-term adverse health outcomes associated with race-­ related discrimination and environments (Torres-Harding & Turner, 2015; Anderson, 2013). Whether a person receives a trauma diagnosis or experiences milder symptoms as a result of discrimination, learning wellness skills can reduce the toxic stress reactions that can manifest into serious mental and physical health conditions.

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Utilizing a culturally grounded approach requires TRM practitioners and CRM guides to keep in mind their narrative as a tool to understand power and privilege in this context further. This includes understanding our intersections and how they influence how we are seen and see the world. It is imperative to understand the cumulative impact of race-based discrimination and how it can exacerbate existing trauma experiences. Due to the indistinct definition of microaggressions, therapists may fail to notice or give appropriate significance to “how upsetting or distressing these experiences may be for some clients of color” (Torres-Harding & Turner, 2015, p. 483). Creating culturally competent and grounded helpers is essential for creating optimal therapeutic environments for all people who have been “othered.” Increasing knowledge regarding the cumulative biological impacts of racebased discrimination and micro-aggressions brings a new awareness and approach to “culturally competency” that emphasizes these experiences as daily inconveniences and toxic stress. The therapeutic relationship can be compromised between client and clinician if clients of color do not feel their “racial realities” are being honored and create distrust and avoidance of the impact quality of care for individuals (Torres-Harding & Turner, 2015; Huynh, 2012). As the biological underpinning of race-based discrimination and micro-aggressions are understood and individuals grow their interoceptive awareness through Tracking, self-healing can be deeply felt and embodied, restoring internal balance we describe as the Resilient Zone. Understanding the embodied experiences of chronic discrimination for various groups may present variations in somatic complaints, impact, and health outcomes. In addition to increasing the representation of racial and ethnic diversity of participants, including the lens of intersectionality and further dissecting cumulative trauma to specifically include the crossroads of gender, sexual orientation, religion, ability status, and class can help deepen our understanding of vulnerable populations. This conceptualization of racial injustice as embodied trauma moves from a subjective reality to a greater societal, structural, and global perspective of oppression that creates risk factors for increased adverse health outcomes in people of color. As mentioned earlier, this understanding can also be applied to various groups who experience chronic discrimination, interpersonally and structurally. The following are examples from CRM and TRM teachers and facilitators regarding their lived and professional experiences working with the LGBTQIA2S+ community.

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Language can set the foundation for entering practice with cultural humility, including the constant invitation of choice to ensure power structures are not reinforced and power is consistently shared in this space. This includes expanding our awareness of the meaning of using non-binary pronouns with those who do not identify with traditional gender identifications of male and female—respecting the choice of individuals who prefer being referred to as “they” and “them” and extending respect and acknowledgment. K (Kathleen) Thomas (2022), LPCC, NCC certified CRM teacher and TRM certified practitioner and faculty, shares: The adaptability of TRM/CRM is one of the biggest strengths these models bring with regards to inclusion of the LGBTQIA2S+ communities. Many individuals within this spectrum of identities have experienced significantly higher rates of physical, emotional, and sexual abuse than their heterosexual and cisgender peers. This can result in behavioral attempts to numb or disconnect from the body not solely as a means of coping with trauma but as a means of survival as they exist in spaces of heterosexism, cisgenderism, racism, and ableism. When traditional frameworks ask “what” and trauma-informed frameworks ask “why,” TRM/CRM ask “how.” How are you moving through this world in wellness? How are you continuing to find meaning in a world that does not accept you? How are you building community, family, and belonging around you after trauma and rejection? By moving to a place of nonjudgement and acknowledging the inherent strength of individuals and cultures through the “how,” we create space for culturally responsive and resiliency-informed interventions for the LGBTQIA2S+ community. (K. Thomas, personal communication, April 27, 2022)

Tara Smith (2022), LCSW certified CRM teacher and TRM trainer, shares: The invitational language is such an important element of this model, and a form of providing inclusion for our community. Members of our community have to come out very often, in most situations where we are meeting new people, including therapists. The invitational language allows us to have more autonomy over this process and creates safety. Also, the TRM practitioner or CRM Guide asks the participant if they are comfortable with the practitioner/guide observing them and tracking them, and the act of ASKING if the participant is ok with this is critical. Sometimes people in our community feel uncomfortable being seen in our bodies, especially those of us who are trans and/or non-binary. Asking permission to intentionally observe and track us again gives us more autonomy over our healing process. We are (of course) not a monolith and tailoring the process to each person as an individual should be the standard. Allowing us to share as much or as little of our story as we wish creates a safe environment. (T. Smith, personal communication, April 26, 2022)

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Kimberly C. Wong (2022), LCSW certified CRM teacher, TRM certified practitioner and facilitator, also highlights her personal experiences with both the TRI community and how the models have supported her values of social justice: I was immediately drawn to TRM/CRM because of the philosophy and approach, which is client-centered, empowerment-focused, and with social justice values. The models are aligned with how I work. The founder, Elaine, infuses warmth, openness, respect, and acceptance. LGBTQ folks often experience shame and invisibility that comes from oppression. Creating community is important because most of us grow up without the built-in support that comes with being connected to ethnicity, race, or spiritual/religious groups. As a lesbian woman of color, I have not always felt fully part of, seen, or accepted in either the Asian community or the broader LGBTQ community. In the TRI community I have felt a belonging and acceptance for all aspects of who I am. It is meaningful to have these two important parts of my identity acknowledged and valued. (K. Wong, personal communication, April 28, 2022)

These individuals also explain the importance of CRM/TRM bringing forward the “What also is true?” in our individual and collective narratives as a means of empowerment and wellness. In this way, understanding and honoring the complexities of our intersecting identities can hold greater compassion for others’ lived experiences. This understanding can guide us to a practice of equity and justice when implementing and practicing interventions designed to address distress and trauma. K (Kathleen) Thomas, LPCC, shares their perspective of the importance of holding both suffering and resiliency: The TRM/CRM framework creates space for the ongoing inquiry of “What else is true?” This reframing of reality from a space of nonjudgement and curiosity allows individuals from the LGBTQIA2S+ community to acknowledge both the pain and beauty of their existence. It may be true that you’ve experienced trauma and suffering, and you may have also created a community, a family, and an identity that is uniquely yours. You may have been rejected by your family of origin and you may have also discovered and developed a rich, abundant, chosen family in your adult life. This reframing helps dismantle the power trauma holds on our perspective as queer individuals. It’s a remembering of our inherent resiliency, adaptability, and vibrancy. (K. Thomas, personal communication, April 27, 2022)

Tara Smith, LCSW adds to what also is true when working with the LGBTQIA2s+ community:

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Being a member of the community is not always part of our trauma, or perhaps not part of our most significant traumas. Respecting our priorities in our healing journeys allows us to maintain our autonomy and dignity. (T. Smith, personal communication, April 26, 2022)

Conclusion CRM and TRM can provide education and wellness skills to help all individuals have access to the language or their biology and a framework for their lived experiences. From this place, individuals may be able to better advocate for change, navigate systems, and have more control over their bodies and minds. Practicing and utilizing the wellness skills can also mitigate the health impacts of adverse childhood experiences that can arise from inequities and unfair conditions that many individuals are born into. We know our zip code is more telling of life expectancy than our genetic code. Biologically based interventions acknowledge interpersonal and structural racism and discrimination of marginalized groups as experiences of toxic stress. We have an opportunity to cultivate and grow our common humanity when we show up with a willingness to deeply listen to the suffering and pain of those who have been “othered.” We are here to create a healing environment to embrace the suffering and to ask the question, “What else is true?” How can we remember the potential for joy and happiness when faced with unspeakable embodied sorrow and pain? We can have difficult conversations and at the same time nourish the embodiment of well-being. As we show up as our best selves, the possibilities are limitless. We can embody the “Us.” The words of Nelson Mandela embrace our global community with hope. No one is born hating another person because of the color of their skin, or their background, or their religion. People must learn to hate, and if they can learn to hate, they can be taught to love, for love comes more naturally to the human heart than its opposite. (Nelson Mandela, 1994)

When love is embodied, its sibling—compassion—can flow through the world.

References Anderson, K. F. (2013). Diagnosing discrimination: Stress from perceived racism and the mental and physical health effects. Sociological Inquiry, 83, 55–81.

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Dalai Lama, Tutu, D., & Abrams, D. (2016). The Book of Joy: Lasting Happiness in a Changing World. New York: Avery, an imprint of Penguin Random House. Freire, P. (1968). Pedagogy of the Oppressed. New York: Seabury Press. Gee, G. C., Spencer, M. S., Chen, J., & Takeuchi, D. (2007). A nationwide study of discrimination and chronic health conditions among Asian Americans. American Journal of Public Health, 97(7), 1275–1282. https://doi.org/10.2105/ AJPH.2006.091827 Helms, J. E., Nicolas, G., & Green, C. E. (2012). Racism and ethnoviolence as trauma: Enhancing professional and research training. Traumatology, 18, 65–74. Huynh, V. (2012). Ethnic microaggressions and the depressive and somatic symptoms of Latino and Asian American adolescents. Journal of Youth Adolescence, 41, 831–846. Keleher, T., & Lawrence, K. (2004). Chronic disparity: Strong and pervasive evidence of racial inequalities, poverty outcomes structural racism. Race and Public Policy Conference. https://www.intergroupresources.com/rc/Definitions%20of%20Racism. pdf Lorde, A. (1981, June). The uses of anger: Women responding to racism. National Women’s Studies Association Conference, Storrs, CT. BlackPast.org. https://www. blackpast.org/african-american-history/speeches-african-american-­history/1981audre-lorde-uses-anger-women-responding-racism/ Mandela, Nelson. (1994). The long walk to freedom, the autobiography of Nelson Mandela. London: Little Brown and Company. Mays, V. M., Cochran, S. D., & Barnes, N. W. (2007). Race, race-based discrimination, and health outcomes among African Americans. Annual Review of Psychology, 58, 201–225. Menakem, R. (2017). My grandmother’s hands: Racialized trauma and the pathway to mending our hearts and bodies. Las Vegas, NV: Central Recovery Press. Nelson, G., & Prilleltensky, I. (2010). Community psychology: In pursuit of liberation and well-being. New York: Palgrave. Torres-Harding, S., & Turner, T. (2015). Assessing racial microaggression distress in a diverse sample. Evaluation & the Health Professions, 38, 464–490. Watson, L. (1985). (Indigenous Australian) United Nations decade for women conference in Nairobi.

Part II

The Community Resiliency Model in Action

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The Community Resiliency Model (CRM) in Public Health Elaine Miller-Karas This chapter will: 1. Discuss mental health conditions as a public health issue 2. Define Cultural Humility 3. Describe the Community Resiliency Model (CRM) Teacher Training program A Haitian survivor of the devastating earthquake in Port au Prince in 2010 shared that she hoped the Trauma Resource Institute would continue to teach people worldwide about how to restore well-being. She believed that CRM could change the world. The hopes of our Haitian CRM teacher have become a reality—the Community Resiliency Model has become an intervention that can be used as a public health strategy to address the mental health needs and well-being of individuals worldwide. We have seen CRM expand across the globe in unimagined ways. The CDC Foundation (2022) describes public health as the science of protecting and improving the health of people and their communities. This work is achieved by promoting healthy lifestyles, researching disease and injury prevention, and detecting, preventing, and responding to infectious diseases. Overall, public health is concerned with protecting the health of entire populations.

The field of public health fundamentally tries to prevent people from becoming ill by promoting wellness and healthy behaviors. Identifying mental health as a public health issue is imperative to building healthier and more productive communities. When we are physically ill with an infectious disease, it affects every aspect of our life. At the very least, it interrupts our ability to do our work and influences our interactions with others. In the same way, challenges with mental health also affect every aspect of a DOI: 10.4324/9781003140887-9

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person’s life–their ability to conduct the activities of daily living connected to school, work, and family responsibilities. Unrecognized and untreated mental health conditions can lead to social isolation, problems with the criminal justice system, and behaviors that can compromise mind and body health. A report by Tulane University School of Public Health & Tropical Medicine (2021), stated: Public health professionals play a key role in tackling the factors that adversely influence mental health. Addressing a community’s well-being requires a comprehensive approach. To promote mental health, public health professionals find ways to prevent mental disorders, improve access to mental health services, support recovery, and lower the rate of death, disease, and disability among those with mental illnesses.

Using interventions that promote mental health is part of the public health response to the global mental health challenges. CRM’s strength is as an intervention that contributes to mind and body health. The skills open up inner wisdom and knowledge of individual and collective strengths that promote well-being. On many occasions, people have asked, “Looking through the lens of public health, can we create meaningful change individually and within society through the integration of the CRM wellness skills?” With greater interoceptive and exteroceptive awareness, we can manage our nervous system and feel whole in mind, body, and spirit. Damasio (1999) stated that the “core self is the summation of extero- and interoceptive stimuli that form the experience of the self as one integrated entity.” When an individual experiences the sense of being whole, they become more solution-focused on solving the challenges in their own lives and their communities. So, our answer is a resounding yes—we can create change in the individual and in our communities and the wider society. In the field of public health, there are different categories of prevention which help in conceptualizing interventions to reduce risks to health and well-being. CRM has been integrated into primary, secondary, tertiary, and quaternary prevention strategies.

Primary Prevention Primary prevention targets healthy individuals, recommending activities that limit risk exposure. From a primary prevention perspective, the goal is to protect healthy people from developing or experiencing mental health issues. Programs that have integrated CRM as a well-being practice for children and adults now exist in schools, community mental health organizations, parent support networks, and organizations that promote mind and body health.

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Secondary Prevention Secondary prevention emphasizes early illness detection, and its target is healthy-appearing individuals. When implementing secondary prevention, the focus is on helping a person who has been diagnosed with a mental health condition so that their symptoms are decreased or even eliminated. Individuals who have been diagnosed with anxiety and depressive conditions are being introduced to the key concepts and skills of CRM to help to reduce or eliminate their symptoms in individual psychotherapy and in therapeutic groups.

Tertiary Prevention Tertiary prevention is aimed at helping people manage complicated, longterm mental health problems while maximizing overall quality of life. Tertiary prevention targets both the clinical and outcome stages of a condition. It is implemented in symptomatic individuals and aims to reduce the severity of the condition and any associated sequelae. Individuals who have chronic and persistent mental illness have also been introduced to the concepts and skills of CRM to help reduce their symptoms and enable them to still complete the activities of daily living.

Quaternary Prevention Quaternary prevention is an action taken to protect individuals from medical interventions that are likely to cause more harm than good. Quaternary prevention is aimed at helping people with a mental health condition not be over-medicated. A program initiated in Grady Hospital in Atlanta is creating Life Care Specialists to reduce the likelihood of patients developing opioid addiction post-surgery. They do so by educating patients on how to wean off of opioids and teaching CRM concepts and skills to help them learn new strategies to deal with pain management. See Chapter 14 for a longer description of this program.

The Community Resiliency Model in Action Surprisingly, the pandemic’s tragedy and challenges brought a vista to the Trauma Resource Institute (TRI) that expanded the accessibility and

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affordability of bringing CRM workshops and CRM Teacher Training to our world community. CRM skills were needed more than ever, and we were able to design effective and dynamic training online, using platforms like Zoom and Webex. Since writing the first edition of this book, I have been inspired and encouraged at all the ways CRM has been used in the world. Some of the projects that have been accomplished and are underway are highlighted in this section to give a greater understanding of what is possible. Health care systems led by a cadre of nurses, psychiatric nurse practitioners, chaplains, social workers, physicians, and psychologists have brought CRM concepts and skills into medical clinics and hospitals. De Kock et al. (2021) report that frontline healthcare workers are at risk of significant psychological distress as a direct result of the COVID-19 pandemic, and published studies suggest that symptoms of anxiety, depression, insomnia, distress, and OCD are found within the healthcare workforce. Sun et al. (2021) state that there is a need to quickly establish programs that provide timely psychological counseling and intervention to alleviate anxiety and improve general mental health. The research being conducted on CRM by Duva et al. (2022) and Grabbe et al. (2020) demonstrates the effectiveness of CRM in reducing anxiety, depression, and traumatic stress at statistically significant levels for nurses and other frontline workers. Steve Nuanez, LCSW is the director of the Employee Well-Being Department at the University of New Mexico Hospital (UNMH). The UNMH Employee Well-Being team launched CRM as one of the wellness programs for the hospital staff during the COVID-19 pandemic. Since being trained in April of 2021, they have conducted 19 workshops for their staff and the evaluations indicate that their program has been well-received. Nuanez noted that participants in the trainings have appreciated how CRM helps them understand and normalize their stress response as well as adopt skills that they can use to re-center themselves and “get back in the zone” during challenging work situations (Nuanez, S., personal communication, May 6, 2022). There were four Health Resiliency Workforce Awards (HRSA) granted in 2022 to organizations that included CRM as one of the modalities they will research, including Emory University, Children’s Hospital, Los Angeles, University of Alabama, and the University of New Mexico. HRSA awarded the funds to be used over three years to reduce burnout and promote mental health in the health workforce. These awards, which consider the needs of rural and medically underserved communities, will help health care organizations establish a culture of wellness among the health workforce and will

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support training efforts that build resiliency for those at the beginning of their health careers. Other projects have been launched by other hospital systems, including Loma Linda University, Emory University, Grady Hospital in Atlanta, and Children’s Hospital Los Angeles. Chapter 15 highlights the research that has been done with nurses and first responders demonstrating the effectiveness of CRM. New Hanover County in North Carolina has created new systems, building well-being through their community engagement integrated with CRM concepts and skills. In the aftermath of Hurricane Florence, I was contacted by Carey Sipp from Paces Connection requesting an introduction to CRM for the community. Shortly thereafter, their resiliency task force funded a CRM Teacher Training to reduce the trauma and stress from the hurricane. As they began integrating CRM into their community, their vista widened, and they embraced the idea of CRM as one of the foundations of expanding well-being throughout their community. CRM workshops have been offered throughout New Hanover County across ages, abilities, and ethnicities. Chapter 8 describes their county’s efforts that grew out of the destruction of Hurricane Florence. Our work in the Philippines after Typhoon Haiyan was first to provide CRM Teacher Training to a variety of NGOs working with survivors through the impacted areas in Tacloban and Ilo Ilo. Once the skills were learned by the community organizers, the organizers realized the effectiveness of CRM for other societal issues within the Philippines. They created PhilActs to spread CRM through their networks. Rosario Sequintin (2022), professor of social work, shared, “The Philippine Association of Community Resiliency Model Trainers (PHILACTS) does not have a physical office since the pandemic but there is constant communication between members through group chats. We have been sharing CRM skills with our students (bachelor and graduate school, social workers, government employees, migrant workers, traffic enforcers, disaster respondents, and Covid-19 responders). We have reached over 2,000 community members (Sequintin, R., personal communication, March 27, 2022.) Arizona State University (ASU) announced that in 2021 the School of Social Work received a five-year grant from the U.S. Substance Abuse and Mental Health Services Administration, funding the new National Center for Community Health and Resiliency, which will train hundreds of community health-care workers from across the country. The center, which opened in the Fall of 2021, will serve community health workers who are seeking specialized training to deliver culturally responsive interventions to

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children and families experiencing traumatic stress. These interventions are specific to children, youth, and families belonging to communities of color, emphasizing Native Americans and the Latinx populations. The National Center for Community Health and Resiliency (CCHAR) will train thousands of community health workers across the nation. Goals for CCHAR include training 500 community health care workers as certified teachers of CRM. ASU’S Office of Community Health Engagement and Resiliency entered a cooperative agreement with the Centers for Disease Control and Prevention on August 31, 2021, to begin the $8 million, four-year national COVID-19 study. The office will use the funds to examine the effectiveness of different approaches community health workers use to build public health infrastructure and address health disparities, including access to COVID-19-related services in underserved communities. The study includes 68 local and state public health agencies, tribal nations, and U.S. territories. There is overlap between the two projects, and CRM teachers will be used in the CDC project as well. At the time of this writing, the African nation of Angola has embarked on a project called the Safeguard Young People program. This program is a four-year regional project of the United Nations Population Fund financed by cooperation from the Government of the Netherlands. It is part of the South-to-South cooperation UN Initiatives which are key to reducing indicators of inequity in the region. The overall objective of the Safeguard Young People program is to contribute to achieving universal access to sexual and reproductive health and realizing the reproductive rights of young people in five provinces of Angola by accelerating efforts to reduce adolescent pregnancies and unwanted pregnancies among young women. This is a multilayered intervention that will also target strengthening health services. TRI has been invited to provide and evaluate the effectiveness of our CRM Teacher Training (i.e., train-the-trainer) as one intervention inside the larger objective of empowering adolescents and young people with knowledge, skills, and agency to make informed decisions and positive actions about their bodies, their lives, and their world. TRI will deliver a CRM Teacher Training to 50 Angola-based UNFPA trainees to disseminate the CRM Curriculum (through formal CRM Workshops) to 180 Young Adult Social Mobilizers (YASM). These YASMs will help the UNFPA trainees deliver one-to-two-day CRM workshops in conjunction with other training, as needed, to people in their regions and are expected to reach 6,000 youth/young adults over four years. TRI has enlisted a team

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from Loma Linda University to evaluate the effectiveness of the intensive five-day CRM Teacher Training on (1) the ability of the UNFPA trainers to disseminate the CRM curriculum to YASM, (2) YASM’s subsequent integration of the CRM model into the service delivery of various youth development programs, and (3) the use of the CRM model for personal resiliency development and distress regulation by both Angola-based UNFPA trainers and YASM. Sam Habimana (2022), MPH, is the executive director of the Rwandan Resourcing and Grounding Organization (RRGO). He started RRGO to address the long-term effects of the 1994 genocide as a result of being trained to be a CRM teacher in a project co-sponsored by TRI in Rwanda. Sam states, CRM has been introduced in Rwanda as a community-based response to the mental health crises. CRM has contributed to building resilience and healing in Rwanda and has also been a key program in bringing together survivors and perpetrators to live in greater harmony, peace, and compassion.

He shared the transformation that can occur in the following story of a woman in Rwanda, I was the lone genocide survivor in a family of 12 people in Kibeho. I did not know that I had anything that could make me happy in my life until I participated in CRM skills training in the Huye district. CRM skills training helped me discover that a simple cow that I was raising is my resource and makes me feel free and calm on the inside. Since then, I have started personal forgiveness and then forgave my neighbors (who perpetrated the genocide). (Habimana, S., personal communication, May 5, 2022)

Sexual Assault Investigations have been transformed by the Victim-Centered Engagement and Resiliency (VCERT) training created by the Washington State Criminal Justice Training Commission (WSCJTC). The WSCJTC’s dedication to treating sexual assault survivors with the intention not to retraumatize them as they conduct their detailed sexual assault interview has led to the integration of CRM into their training program and into the interviewing process. They now have a cadre of CRM teachers made up of law enforcement, prosecutors, and client advocates. Their program is described in detail in Chapter 9, which is now a required part of the State of Washington’s law enforcement training. CRM has been brought into prison systems and victim support programs in different parts of the world. An example is Northern Ireland, where the

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justice minister appoints the Prisoner Ombudsman. The current Prisoner Ombudsman is Rev. Dr. Lesley Carroll, a CRM teacher who first brought CRM to Northern Ireland. The Prison Ombudsman Office, Northern Ireland, has sponsored CRM workshops. In addition, the Victims and Survivors Network of Northern Ireland has a robust CRM program for its staff and clients. They also have a cadre of CRM teachers working within their community. In addition, CRM teachers have brought CRM Skills into the Juvenile Justice systems in Georgia and California. Likewise, workshops have been given at California Institute for Women and at adult prisons in Georgia. Programs supporting children, caregivers, and teachers have integrated CRM in innovative ways within schools. In addition, programs supporting “at-risk” youth and unhoused youth like Covenant House, Atlanta (see below), and Fighting Back Santa Maria are using CRM as a foundational intervention. Other programs like Aspiranet, one of California’s largest and most successful social service organizations, have the mission of providing children, youth, and families with a foundation of support to thrive at home, school, and in their communities. Aspiranet has integrated CRM into their workforce, with daily support breaks called “CRM Minutes” where resiliency skills are practiced and reinforced. Chapters 10 and 11 describe how to use CRM with children, teachers, and caregivers and highlight an array of programs that have integrated CRM. Covenant House Georgia, an organization working with unhoused youth, has received a three-year grant from the Department of Health and Human Services, Family and Youth Service Bureau, to extend its outreach to rural Georgia. The target group is 18- to-21-year-olds and their families. Todd Wilcher (2022), the director of Youth Engagement for Covenant House, Georgia, shared, The foundation of all my work with this grant is staff training in CRM. CRM has changed my perspective on a career that has covered over 30 years. The youth are so receptive along with our staff. CRM’s trauma informed and resiliency-focus has created paradigm shifts in our staff and in our clients. (Wilcher, T., personal communication, April 22, 2022)

There are more integrations than we have space for, and we are inspired at the innovation that CRM is sparking around the globe. You can go to www. traumaresourceinstitute.com or listen to Resiliency Within on VoiceAmerica to learn about more programs infused by CRM.

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Cultural Humility—the Lens of the Community Resiliency Model One of the reasons that CRM has been incorporated into so many organizations throughout the world is because it has embraced cultural humility. A public health lens includes knowledge of cultural humility. Our CRM Teacher Training takes into consideration diverse perspectives. Cultural perceptions about mental health are key to developing culturally aware programs and services accessible to members within all communities. Culture is expressed through religion, law, music, language, art, health beliefs, and customs. Culture is transmitted formally and informally to succeeding generations and influences what we eat, how we work and play, how we raise our children, how we celebrate life events, and how we view and respond to traumatic events (Mead, 1928). In conceptualizing a nonprofit organization dedicated to bringing healing to our world community, cultural humility is in the fiber of our organization and embedded in our roots. CRM teachers are invited to contextualize CRM to their community, using their unique cultural and linguistic lens. The National Association of Social Workers (NASW) (2015) defines cultural humility as “the attitude and practice of working with clients at the micro, mezzo, and macro levels with a presence of humility while learning, communicating, offering help, and making decisions…” Cultural humility also leads with respect in communicating with individuals and communities and acknowledges the worth of people of all ages, abilities, gender identifications, sexual orientations, religions, and ethnicities. Individuals, families, and communities interpret traumatic events and the presentation of mental health conditions through a cultural lens. Culture and experience shape notions about causality. Each culture has a wide array of folk illnesses and remedies that guide perceptions of “why” symptoms occur and ways to treat symptoms. For example, the “evil eye” (one of the most widely held beliefs across cultures) causes an imbalance inside the body, disrupting health. Some Latinx believe that a “susto” (sudden unexpected fright) or “coraje” (angry feelings) cause an imbalance within the body that leads to illnesses. Many cultures believe that ghosts from people who died can invade the human body and cause illness and weakness. Some cultures believe the spirits of those who have passed remain to guide their families on a pathway of healing in the aftermath of tragedies. Each culture has its own array of folk remedies to cure the effects of folk illnesses. Addressing mental health issues through the lens of cultural humility does not require a

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“re-education” about the “scientific” (i.e., Westernized) cause and nature of mental health challenges, but rather respects and works within the cultural beliefs and framework that already exist. CRM teachers respect long-held cultural beliefs by affirming and respecting people’s customs and practices. Many of our CRM teachers come from diverse cultural and ethnic backgrounds and help us understand the important cultural nuances in cross-cultural information sharing. We have made missteps and have asked with humility how we could do or say something different to improve. When invited to a new country, we have an open mind and heart and accept feedback with gratitude to better serve. Community members have welcomed us and helped us learn how to understand their culture. We also have learned not to overgeneralize cultural information because, within one culture, there can be many variations. We have trained people who have a broad range of religious practices. Although there can be a “crisis of faith” after experiencing traumatic events, one’s faith is often the only thing that sustains the human spirit. Asking open-ended invitational questions like, “Who or what is helping you the most right now?” can spark an abundance of responses. In Haiti, a Christian woman answered this question by saying, “I have Jesus right here in my heart!” as she placed her palm on her heart, and took a spontaneous deep, relaxing breath. In China, after the Sichuan earthquake, a woman responded to the same question, saying, “The teachings of Buddha are helping me now,” as she took a deeper breath and her muscles relaxed. Thus, we have observed throughout the world that as people describe deeply held spiritual beliefs, there is a universal response of a deep parasympathetic breath accompanied by muscle relaxation. When awareness is brought to the sensation connected to one’s beliefs, the experience is strengthened and felt more deeply. Like cream rising to the top, individuals will spontaneously generate new meanings like, “With God’s help, I will make it through this.” The internal locus of control and empowerment that springs forth is remarkable when considering the hardship of people’s lives. If a person has lost their faith due to their traumatic experiences, we ask additional resiliency questions like, “Who is helping you the most now?” and “Is there anyone you can help right now?” Often a spark of hope can be ignited when reminded of help received and given. While implementing the Ukrainian Humanitarian Resiliency Project (UHRP) the issue of historical trauma was brought into the conversation during one of the daily support meetings. The CRM Teacher leading the group touched upon post-traumatic stress and pivoted to the strength she

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had observed in the Ukrainian spirit. One of the Ukrainian participants poignantly spoke of her ancestors’ courage and compassion in their oral family histories through World War I, World War II, the Great Famine, and now the present war. She shared the strength in knowing what her family has endured through the ages, and her belief that it was in her DNA to have strength and courage, and this would be passed to her daughter and daughter’s daughter. The expression of her cultural heritage at that moment resonated, and many of us had tears in our eyes as our gratitude abounded for the wisdom and courage of our own ancestors. When orienting people within one African-American community to the CRM workshops, our team visited a dedicated group of ministers and deacons. On the first day of the training, we had about five people in attendance. On the second day, we had close to 25. After the class size grew, I inquired if the group had the wrong day for the start of the training. One of the community leaders approached and said, We were not too sure what you were up to with CRM. You know we will have none of that yoga or mindfulness in our churches here, and we had to make sure you were not going to do anything like that.

The group decided that we could return and bring the CRM Teacher Training to their community. I appreciated her honesty and realized that she and others had decided that CRM was not in opposition to their beliefs. This example underscores the need to design interventions that consider the “one size does not fit all” perspective. For instance, although research shows mindfulness practices to be beneficial, they will not always be well received. Some people believe mindfulness is Buddhism and reject the practices for that reason alone. In addition, it was also clear that the ministers and deacons read scripture to make sure that CRM skills were in alignment with their Christian beliefs. Loistine Herndon, one of the activists from the African-­ American Christian community, contributed to our training materials by sharing scripture that supports the CRM skill of Resourcing: Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is ­admirable—if anything is excellent or praiseworthy—think about such things. Whatever you have learned or received or heard from me or seen in me—put it into practice. And the God of peace will be with you. (Philippians 4:8)

As individuals learn the skills, trainees make CRM more relevant to their community, by incorporating their unique cultural lens. Ben Romero, who

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was then an active-duty Marine at 29 Palms in California, asked me if he could “Marine-ize” the CRM slides. In the same way, a group of young Mayan women in Solala, Guatemala, redesigned the Resilient Zone using Lake Atitlan, a magnificent body of water central to the villages and towns of that region, as a metaphor. When it is calm, the lake is the Resilient Zone; the lake on stormy days is the High Zone, and during times of drought, when the water recedes from the shore, it is the Low Zone. These young women who are community trainers helped families understand how they can reduce stress and stabilize their nervous systems using Lake Atitlan as the metaphor for the key concepts of CRM. The young Mayan women were encouraged to adapt CRM concepts to their culture. The exuberance of the young women as they described the riches of their culture through the lens of the CRM was transformative and inspirational. Culture is believed to give birth to language, so translation and culture are intricately connected. Meanings of English words are profoundly affected by their cultural context. The CRM workshop materials have now been translated into many languages. Finding translators has not been an easy task as we have attempted for the translated CRM materials to express the meaning of the key concepts and the skills within the country’s cultural context. Translations at their best are not literal but breathe the spirit of the CRM into the language of the target culture. Also, many countries have different dialects and languages within their borders. For example, in our offering to help Syrian refugees on the border of Turkey, we discovered that we needed translations in Arabic, Turkish, and Kurdish. We have learned that the word “sensation” is not so easily translated, and some languages do not have a word but rather an expression of words that describe sensation. The individuals we have trained have shared that they appreciated the translations into their native tongue and the images on the materials that represent the people of their culture. It is received as a sign of respect. TRI is dedicated to making the materials accessible by providing culturally infused materials approved by the people of each country.

Community Resiliency Model Teacher Training TRI offers the CRM Teacher Training Certification program (CRM TT) as a public health intervention. CRM TT creates CRM teachers from people within a community. Thus, the concepts and skills are better received and scaled. CRM TT has a 40-hour training format and follow-up consultation for one year. Upon successful completion of the 40-hour training, the trainee becomes provisionally certified as a CRM teacher and can then teach their

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own CRM workshops. Post training, senior faculty of TRI are available for consultation. Consultation meetings are held monthly for the first three months and quarterly thereafter for the first year after training or as needed. Additional requirements are completed by the provisionally certified CRM teacher post-training, including a Take-Home Assessment of CRM knowledge and evaluations from one CRM Workshop. Recertification is required every two years by taking an online recertification workshop. The CRM Teacher Training program is a combination of lecture, discussion, practice, and student teaching. During the course, the trainees learn the key concepts of CRM, the biology of traumatic/stressful reactions, the skills of CRM (see Chapter 3), and teaching methods to enhance their teaching abilities. CRM training also includes information about how to access one’s community mental health system, if there is one. Since the pandemic, CRM TT has been offered on Zoom. This has afforded greater accessibility to the CRM TT. You can learn more about becoming a CRM teacher by contacting the Trauma Resource Institute at www.traumaresourceinstitute.com.

Conclusion As a world community, we must look at innovative interventions that can be scaled not only to build a prevention infrastructure for healthy members of society who desire to cultivate their well-being but also for those with mental health challenges. Compassion, empathy, and empowerment are embedded within CRM. The knowledge that as a world community, we are designed in the same way not only by our common reactions to traumatic experiences, but also by how we are designed to heal. We must not only have models that can provide professionally guided individual and group therapies, but also c­ ommunity-based models that are peer-to-peer. When we are guided by the principles of cultural humility, our concepts and skills become more accessible. Fundamentally, we have learned that when we bring awareness to the inner wisdom of our bodies, well-being can grow. Even in times of great suffering, moments of gratitude can be seen and sensed. And this is true for people of all ages. Children have inspired us on our journey with CRM. A young boy, who grew up in a slum in India, shared this experience after he learned the skills of CRM. When I become very sad thinking of my brothers who no longer live with me, it is hard for me to concentrate on my studies. I now read the reactions in my body that are linked to my sadness. My arms become very heavy. I use a Help

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Now! strategy and in seconds, I can sense the heaviness slowly drift down my arms and out my fingers. My sadness leaves me enough so I can go back with my schoolmates and learn again. I feel strength on the inside.

References CDC Foundation. (2022). Accessed 4/14/22, https://www.cdcfoundation.org/ what-public-health Damasio, A. (1999). The feeling of what happens: Body and emotion in the making of consciousness. New York: Harcourt College Publishers. De Kock, J., Latham, H., Leslie, S. et al. (2021). A rapid review of the impact of COVID-19 on the mental health of healthcare workers: implications for supporting psychological well-being. BMC Public Health 21, 104. https://doi. org/10.1186/s12889-020-10070-3 Duva, I. et al. (2022). A nurse-led, collaborative public health intervention to promote well-being using the Community Resiliency Model [Manuscript accepted for publication]. American Journal of Public Health 112, S271_S274. https://doi. org/10.2105/AJPH.2022.306821. Grabbe, L., Higgins, M., Baird, M., Craven, P., & San Fratello, S. (2020). The Community Resiliency Model® to promote nurse well-being. Nursing Outlook, 68(3), 324–336. doi: 10.1016/j.outlook.2019.11.002. Epub 2019 Dec 30. PMID: 31894015. Mead, M. (1928). Coming of age in Samoa. New York: William Morrow & Company. NASW (2015). Standards and indicators of cultural competence in social work practice, https://www.socialworkers.org/LinkClick.aspx?fileticket=PonPTDEBrn 4%3D Sun, P., Wang, M., Song, T., Wu, Y., Luo, J., Chen, L., & Yan, L. (2021). The psychological impact of COVID-19 pandemic on health care workers: A systematic review and meta-analysis. Frontiers in Psychology, 12, 626547. https://doi. org/10.3389/fpsyg.2021.626547 Tulane University, School of Public Health and Tropical Medicine (2021). Understanding Mental Health as a Public Health Issue. accessed 4/14/22, https://publichealth.tulane.edu/blog/mental-health-public-health/

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The Disaster Relief Mobilization: Community Resiliency Model Preparation Program (DRM:CRM) Elaine Miller-Karas This chapter will: 1. Describe the four phases of the Disaster Relief Mobilization (DRM): Community Resiliency Model (CRM) 2. Describe the components of the Basic Module of a CRM workshop pre-/ post-disaster 3. Describe the “culture of resiliency” built in New Hanover County, North Carolina, after Hurricane Florence. The Disaster Relief Mobilization: Community Resiliency Model (CRM)® Preparation Program (DRM:CRM) can create a trauma-informed, resiliency-focused prevention program in preparation for a community disaster. DRM:CRM can also provide a structure to reduce the impact of traumatic experiences during and after a disaster. The United Nations Office for Disaster Risk Reduction (2022) describes disaster as a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts.

DRM:CRM grew out of the Trauma Resource Institute’s experiences as we were invited to places around the globe after disasters to provide our CRM workshops and Teacher Training Program to community members. We have been humbled and inspired by individuals around the world when they have reached into the best part of their humanity with courage and strength to help themselves, their families, and wider community during and after the most difficult life experiences. DRM:CRM’s approach when asked to respond

DOI: 10.4324/9781003140887-10

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after a disaster is to guide the community members to remember the inner strength and resources they have so they can better begin to recover and rebuild. After the terrorist attack of December 2, 2015, in San Bernardino, California, we were asked to provide community support meetings. One agency was especially hard hit as one of the workers had lost her husband in the attack. With the lens of our strength-based perspective, we invited the employees to first share what or who, if anything or anyone, was helping them in the aftermath. One participant, Maria, shared an experience of returning home after the attack. She was overcome with grief, crying on the couch when her four-year-old daughter came into the room and said, “Mommy, are you sad?” Maria responded, “Yes, honey. Mommy has had a hard day.” Her little girl responded, “Mommy, I can make you feel better? I can sing for you!” and she began to sing “Let it Go” from the movie, Frozen. Maria and the group gave a collective sigh and the “sweet tears of gratitude” filled the room. Maria and her co-workers smiled as a wave of calm swept over the room. This is an example of Conversational Resourcing and demonstrates how we can in subtle ways remind people to cultivate their well-being and calm their nervous system by simply remembering their resources that coexist with suffering. At the end of the meeting, the co-workers mobilized in positive ways, sharing ideas about how to make the work environment safer and how they could support each other in the days ahead. His Holiness the Dalai Lama et al. (2016) say, “Joy is the silver lining of suffering.” Teaching skills to help individuals calm their internal experience of distress during and following a disaster helps individuals reorganize to carry out the activities needed for restructuring their lives and for their community. It can also awaken feelings and sensations connected to wellbeing like joy that can become shrouded because of catastrophes. It is a quality seen throughout the world—the ability of human beings to remember what else is true during unspeakable times. A poignant example comes from a man we met in Tacloban after Typhoon Yolanda in the Philippines. He had lost his entire family and he shared with one of our CRM teachers his optimistic perspective etched in his grief. He said, See my friend over there, he lost his family, too. We decided we would create a new family together and will always honor the memory of our beloved family members and we must continue to live even with our grief.

Over time, we put together a systemic response for how to bring CRM into disaster settings. We also realized that if we could train community members

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to be CRM teachers prior to a disaster as part of their disaster planning, they could initiate CRM workshops throughout their community. This approach is a preparation and prevention strategy so when a natural- or ­human-made disaster inevitably comes to a community, there would already be “boots on the ground” able to meet the biopsychosocial challenges faced by communities. Community disaster programs often focus on the essentials of physical survival: temporary housing, food and water distribution, community services that can help in finding longer-term housing, governmental agencies like FEMA and other city, county, and state agencies. Although mental health delivered by mental health professionals is also a part of planning, a community wellness model can contribute to widespread community well-being. In addition, when there is widespread destruction and loss of life, there are not enough mental health providers, even in developed countries. It is essential that community wellness be incorporated in the response. CRM is one of the few models that are accessible across the lifespan that can be used conversationally by first responders and can be learned in workshops directed toward community members, delivered by natural leaders of communities. Strategies that help restore physiological balance are essential during times of crisis. The goals of DRM:CRM are as follows: 1. To decrease the impact of traumatic stress, anxiety, and depression that occur in populations through conceptualizing a mobilization plan to address the mental health challenges occurring during and after disasters. 2. To share with community members the CRM skills that can be used across the lifespan, ability levels, and cultures. 3. To mobilize the community by creating a cadre of CRM teachers made up of professional and natural leaders of communities who bring in their own cultural lens to CRM workshops. This can be done in community preparation for disasters as well as after disasters. 4. To link community members and survivors with community-based programs and governmental entities that support prevention strategies, mental health, resiliency, and reconstruction. 5. To build on individual and community strengths to minimize retrau­mati­zation. CRM is at the core of DRM:CRM. There are many groups and agencies that have incorporated CRM as part of their disaster response. For example, the Adventist Disaster Relief Agency (ADRA) International’s Trauma Team

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uses CRM as their primary intervention after disasters worldwide. The Red Cross funded the Trauma Resource Institute’s response to the fires in Butte County, California. Later, a community foundation provided funding in Butte County to create their own cadre of CRM teachers. New Hanover County, North Carolina, implemented CRM throughout their community in the aftermath of Hurricane Florence and it is now integrated into ­county-wide systems that have built a “culture of resiliency.” The natural leaders are often the first responders helping community members during and after the disaster. When CRM workshops are delivered by these natural leaders of communities who have become CRM teachers (e.g., lay persons, ministers, law enforcement, teachers, first responders), there can be a greater impact in reducing the suffering of individuals throughout the impacted area. Natural leaders know their community and have a cultural lens that enables them to best support their community. A “CRM guide” is a person who learns the skills of CRM after reading about CRM or taking a CRM Workshop. This person is not certified and, through their own edification, has decided to guide individuals in learning CRM skills. CRM guides cannot certify CRM teachers. DRM:CRM has four phases: Phase 1: Prevention/Community Preparation Phase 1 focuses on creating coordinated community goals for strategic planning in preparation for potential disasters and to create a common language. 1. Identify community stakeholders to create a community coalition if one does not exist. Community Stakeholders include faith-based coalitions, public health, mental health, schools (public and private), first responders (fire, law enforcement), and nongovernmental organizations (e.g., Red Cross, Catholic Charities, and Boys and Girls Clubs). 2. Identify systems already in place usually led by local city and county disaster preparation teams. 3. Trauma Resource Institute or certified CRM teachers provide CRM Orientation to community stakeholders to identify community members who want to become CRM teachers. Identify sponsoring agency that funds CRM Teacher Trainings. 4. Trauma Resource Institute conducts CRM Teacher Trainings to create a local cadre of CRM teachers. 5. CRM teachers begin to conduct CRM workshops throughout their communities as part of a strategic plan.

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Phase 2: Immediate Engagement (Post-Disaster) Phase 2 focuses on providing coordinated emergency response during or in the immediate aftermath of a disaster (e.g., climate-change event, war). 1. CRM teachers are invited to meet with community stakeholders to discuss how CRM workshops can be integrated into programs to address the biopsychosocial challenges that occur post-disaster. 2. CRM teachers are involved with community stakeholders to assess the training needs of the community (e.g., workshops could be offered in different languages like Spanish when there is a high concentration of Latinx). 3. CRM teachers provide CRM workshops/orientations throughout the community. One goal would be to identify community members interested in becoming CRM teachers. 4. Once community members who want to become CRM teachers are identified, the CRM teachers or the local agencies contact TRI to provide the virtual CRM Teacher Training course. 5. After the CRM Teacher Training course is completed, the community agency sponsoring the CRM Teacher Training designates a DRM:CRM coordinator for the deployment of CRM teachers into the community. 6. Online webinars can be offered if the internet has not been compromised. A larger group of individuals can be taught when online learning platforms are used. Phase 3: CRM Wellness Workshops Phase 3 focuses on providing CRM workshops throughout the community. The more individuals who can attend workshops, the more communities have the opportunity to reduce the psychological impact of human-made or natural disasters. If DRM:CRM is implemented into a community prior to a disaster occurring, the people will already have skills that can assist during and after the disaster to mitigate the biopsychosocial toll. Workshops can be offered to the network of community stakeholders working with individuals across the lifespan. When strategizing about implementing CRM workshops throughout a community, the following factors need to be carefully planned and considered:   1. Membership. a) Who will make up the group? Is the group open to the entire community or would it be better to offer CRM workshops to different

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subsets of the community? For example, would a specific group for teens be better received by young people than offering a group for the entire community? b) After a disaster: Membership may include an entire community or individuals more directly impacted by the disaster. For example, after a major terrorist attack, an organization decided to have a group meeting for the specific subgroup agencies of the county. One group was for members of the school district, and another was for the employees of a golf course where the medical triage center was set up in the aftermath of the attack.   2. Structure. There are a variety of ways CRM workshops can be structured. Some organizations offer an “appetizer” CRM orientation providing a shorter overview of the key concepts and the skills and then a longer, more in-depth training for those interested. This enables a wider group to learn something about the skills while those interested in learning more can take the longer training to learn all six skills. During the beginning days of the Russian invasion, four CRM workshop webinars were offered to Ukrainians, describing the skills and key concepts, were offered daily for one and one-half hours for four days.   3. Content. The content of CRM workshops will vary in response to the needs of the group. If CRM workshops are being offered as a prevention strategy, the content would be somewhat different than in a workshop offered after a disaster where there has been mass destruction and loss of life. Content can change depending on the amount of time allocated for the CRM workshop. However, in order for it to be called a CRM workshop, the basic three skills of Tracking, Resourcing and Grounding must be included.   4. Size of Workshop. a) Closed Group: Consider a CRM workshop for a smaller group working for a particular agency who are learning the skills for prevention in preparation for disasters. For example, first responders may prefer a group made up of only first responders. This can be true for workshops designed to respond during or after a disaster as well. b) Open Group During or Post Disaster: If in person, the group may consist of anywhere from two or three members of a community to a larger group of 100 members or more. In a larger group, it can be helpful to have CRM guides present to break up the group into smaller pods to facilitate communication and to respond to questions. If using Facebook Live or YouTube Live, people may listen during or after the live broadcast. Placing referral numbers for support in the chat or in responses in Facebook Live can provide more support.

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  5. Schedule. Some groups meet regularly on a specific day and time for several weeks. Some organizations with open group formats may have one group meeting where all skills are taught within a short period of time and then offer ongoing drop-in booster sessions to continue to practice the skills and respond to questions. Flexibility is important in scheduling meetings. Some groups may only be able to meet in the early morning, evening, or at lunchtime. After the fires in Butte County, the community stakeholders suggested we provide in-person workshops in the morning before people went off to work, during the day, and in the evenings. This afforded people who were working on recovering during the day to benefit from the CRM wellness skills, making the workshops more accessible. When using platforms like Zoom and/or Facebook Live, individuals do not have to be present during the live broadcast to benefit from the workshops and meetings. They can watch 24 hours per day if there is internet access.   6. Booster Sessions or Huddles. Some groups want to keep meeting after learning the skills to practice and increase their ability to use the skills in the activities of their daily living. This is called a booster session or in some systems, huddles. Daily meetings after the introduction of the skills can respond to the immediate biopsychosocial needs. For example, after the launch of the Ukrainian Humanitarian Resiliency Project that provided CRM workshop webinars to teach the CRM concepts and skills, daily Zoom support meetings followed. Questions from the Ukrainians included: “How do you deal with someone having a panic attack in the shelters?” “How do you help people calm down when you can hear the bombs exploding?” “How can we help the children in the shelters who are afraid?” “How can there be a God to cause such suffering to children?” “I am terrified of being raped and tortured, what can I do?” As CRM teachers can be natural leaders and mental health professionals, the answers to the questions can be triaged to different members of the team depending on the complexity of the question and provide much needed support and guidance. It is important to have mental health professionals as part of CRM workshops and access to referrals for people who need mental health treatment.   7. CRM Workshop Group Leader. The group leader must be well versed in the wellness skills. Tracking the members of a group is essential in order to help people learn the skills and to be available if a group member is having difficulty. A co-leader and other CRM guides are suggested if you are sharing skills with a large group. We suggest that even with a small, closed group that a co-leader assists with the workshop, if possible. If there is not a mental health provider who is a CRM teacher or guide, the group leader can provide referrals to mental health providers in the community. In addition, the group leader can invite a mental health provider to the workshop for additional support.

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  8. Group Agreements. Group agreements help a group of people work together with compassion and respect. Each organization may have its own guidelines about conducting workshops. The workshop leader can lead a discussion at the beginning of the CRM workshop to help set the group agreements with input from the members. For example, the issue of confidentiality is important as individuals may work in the same setting or live in the same community. Since there is no confidentiality possible on Facebook Live, that fact must be explicitly expressed. If using Zoom or WebEx, a private breakout room can be  provided if a person needs to talk confidentiality to one of the CRM teachers, CRM guides, or a mental health professional. Group agreements can create a safer space to share skills and engage in discussion.   9. Referral to Mental Health Counseling. When conducting a CRM workshop, some participants will share the depth of their struggles. Having a list of mental health referrals available is important for community members needing additional help. 10. Location. The group leaders and members of the community will have to decide where the CRM workshop will take place. Platforms like Zoom and WebEx have given more accessibility to individuals who live in rural communities, for example. In addition, as long as the pandemic continues, many individuals will only feel comfortable in learning environments that have social distancing or are meeting online. After a disaster, in-person workshops may be feasible as there may not be access to the internet. Phase 4: Triage Phase 4 is designed to connect community members to community stakeholders for additional evaluation, support, and resources. 1. CRM teachers are trained to recognize warning signs indicating the possibility of more serious mental health conditions. 2. CRM teachers triage community members to other community stakeholders, public and private, for further services. 3. CRM teachers provide CRM Booster/Huddle sessions to reinforce CRM wellness skills. 4. CRM teachers collaborate with community stakeholders to integrate CRM workshops into public and private offerings. 5. Designated CRM teachers continue to create collaborative relationships with community public and private stakeholders.

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6. Community stakeholders continue to meet with CRM teachers to create stronger systems to support community well-being. 7. CRM teachers can help communities set up additional CRM Teacher Trainings to create greater capacity within their community.

DRM:CRM Introducing a CRM Workshop The CRM approach does not press survivors to share their trauma experience. Such pressure can amplify a survivor’s distress and retraumatize them. Instead, we invite the survivors to say as much or as little as they would like to share about the experience. Strength-oriented questions are asked to encourage the expression of the survival parts of their experience. This approach can help survivors begin to sense their well-being as they focus on the survival elements of their story. This view is not an opposition to listening and witnessing the traumatic parts of the story. The CRM approach focuses on what else is true about the experience, reminding survivors of their strengths. As one woman in the Philippines shared with one of our CRM teachers in the aftermath of Typhoon Yolanda, “Thank you for reminding me of what I once knew but had forgotten.” The following script is provided as an example of a structure to introduce a CRM workshop during or post disaster by a CRM teacher: 1. We have been invited to come to support community members during this difficult time. We want to give you an opportunity to share what is in your hearts and in your minds right now. We are here to listen and provide support. We want to give everyone who wants an opportunity to speak. For some it is helpful to share and for others it may be more helpful to listen. If you want to listen and not speak, just say “pass” when it is your turn. 2. We have a set of wellness skills to share. The skills have been found to be very helpful for survivors. As we start, let us know what or who, if anything or anyone, is helping you get through right now? Other questions that can be integrated into the conversation, include: 3. Can you remember the moment you knew you were going to make it through? Who or what helped you or is helping you? There are a number of ways to engage the group as the workshop begins. One consideration is determining the approach depending on the size of the group. Group discussions can be more easily facilitated with smaller groups. When the group is larger, it helps to have additional

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CRM guides to break the larger group into smaller pods. Options to begin workshops include: A. Popcorn style: Would anyone like to share as we start? B. We will start to my right and go around the room, inviting everyone to take a turn. Remember that you can share as little or as much as you want, or you can just pass. C. We will start by sharing some information that may be helpful for you as we begin. We would like to share a few key concepts to give us a common language. The participants can be introduced to CRM concepts in a conversational way, and the concepts can be intertwined into the discussion. For example, if someone reports feeling anxious all the time since the event, you can acknowledge this can be a common reaction after events such as shootings, tornadoes, and hurricanes. We call this the High Zone and it is not uncommon to be bumped into the High Zone after such an experience; however, it is problematic if we get stuck there. We can also feel sad and depressed at times and this is called the Low Zone. The skills we want to share can help you get back to what we call the Resilient Zone, the zone of well-being. There are some situations where the above introduction and group process may take the whole time. Consequently, the key concepts of CRM and the skills would be introduced more informally. CRM teachers can ask questions using the framework of the CRM model. This approach is called conversational resourcing. While people are discussing their distress, you can interweave the concepts of the zones into the conversation. Some survivors want to talk about every gruesome detail of the traumatic story. This can be very difficult for other survivors within the group and can cause more distress. As the person expounds about the details, you can interweave more strength-focused questions. For example, “As you have shared this much, could you share with us the moment you knew you were going to survive?” You can also weave in, “Can you remember when help arrived?” Survivors will often begin to remember other aspects of survival connected to remembering people who were supportive and compassionate. It can also be helpful to introduce the elements of CRM in a more formal way. See Chapter 3 for more information about the CRM skills. Over the past few years as more research is being conducted about CRM, it has been found that workshops of short duration (one to three hours) improve well-being and reduce traumatic stress symptoms as well as secondary traumatic stress. (See Chapter 17 to read research about CRM).

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A Community Example: New Hanover County, North Carolina The implementation of DRM:CRM is highlighted in the experience of New Hanover County in North Carolina. The residents of New Hanover County went into action after the devastation of Hurricane Florence in 2018. Their efforts with the CRM were initiated in their attempts to find a well-being approach that had the potential for scalability within their county. Their initial efforts blossomed into a solid preparation and prevention strategy for the entire community that is now in place for when future climate-change events and other challenges occur. In 2021, New Hanover County received an Achievement Award from the National Association of Counties in the category of Training and Professional Development for their “New Hanover County Culture of Resiliency” program. They have trained over 5,000 people in the CRM skills. Their resilience perspectives were brought into the county in a systematic way which could be replicated in other parts of the United States and the world. The information that follows was taken from a report entitled New Hanover County Culture of Resilience—Training and Professional Development by Bo Dean, senior human resources analyst, New Hanover County, Human Resources. He is also a certified CRM teacher.

New Hanover County Culture of Resilience—Training and Professional Development Hurricane Florence was a storm that lasted for an extended period of time and had a number of lasting impacts on the community and organizations. Governmental officials stated, To say that there were post-storm-related issues for employees would be an understatement. Burnout and anxiety resulted, and there were needs that were uncovered for what we could do differently moving forward to live out our commitment to public service.

Utilizing one of the county’s strategic partnerships, New Hanover County’s Resiliency Task Force, originally formed to address the needs of children, began looking at the issue of what makes for a resilient community. One marker of a resilient community that the county

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identified was that it had to have residents who had a set of skills that, in the event of a major issue or in times of stress, could help themselves and others navigate through those times, make good choices, and take care of themselves in healthier ways. The task force received a grant to fund a CRM Teacher Training for community leaders within New Hanover County. Individuals trained were members of nonprofits, caregivers of children, first responders, and local government employees. In order to ensure the best for New Hanover County’s community, they realized that a resilience practice would not only have to meet a need for ongoing issues of daily response as a public service, but that it would also be needed to enhance emergency response and for creating a culture of resilience for their entire community. The human resource senior analyst for the county formed a work group of resilience-trained employees and designed a 90-minute course for all part- and full-time employees. The course included an introduction to resilience, the concepts of CRM, a look at trauma and stress modified specifically to relate to New Hanover County, and an application with the first three skills of the CRM Model to share and practice. At the end of the 90-minute course, employees and staff were encouraged to attend a deeper dive into the subject matter. Each month for that first year, an eight-hour training was offered to staff to create CRM guides. CRM guides were able to apply the CRM skills and work with them to help others. The Emergency Management team of the county identified potential CRM guides during emergency staffing plans to ensure that emergency shelters and other critical places of service had employees who could integrate the skills for fellow staff and for the public. In addition to the monthly eight-hour training, monthly “lunch and learns” for those who went to the eight-hour courses were held so that staff could further develop the ideas around what was being discussed in the resiliency trainings. This turned into what is now the ongoing monthly meeting of the Resiliency Working Group (RWG). As they continued to train on resilience, they learned that across the enterprise, there were employees who were trained in Peer Support (Fire Services), Trauma-Informed Leadership Team (TILT-Social Work), Chaplaincy (Sheriff), Critical Incident Stress Management (911), and others. Many of those employees wanted to integrate the

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CRM skills and work together. As a result, they decided to form a larger resiliency working group which was a combination of all employees trained in resilience throughout the county who would be brought together under one umbrella. They currently meet on MS Teams to deploy information, share resources, address the needs of staff, and create more awareness for what can be done to assist those in need. As of April 2021, they had 81 CRM guides. To date, the Resiliency Working Group has over 97 employees in the county available to support their entire staff. To ensure more retention of the training, CRM guides and teachers worked with facilities management to place posters of the CRM skills in break rooms and bathrooms to keep the ideas and concepts fresh. They also have laminated versions of the skills and some of the practices in their emergency areas. These resources have supported their employees during the COVID-19 pandemic at call centers and outreach sites. These images and reminders have also been placed in first responder vehicles and with school resource officers as reminders of the eight-hour trainings they received. To ensure all New Hanover County employees receive this training, new employees receive a 90-minute training video, and the basic three skills are provided in onboarding materials on the first day of orientation. Resiliency is discussed and demonstrated throughout orientation as a part of New Hanover County’s shared values of stewardship and accountability. Further, they also developed a presence on their internal website, Shorelines, where an employee looking for resources only needs to look at the interweb to find a button that says “resilience” on the main page. Once clicked, there are dozens of resources that include a peer support list of fellow employees, local mental health services, a library of resources, articles, videos, and more. Resilience as a practice is integrated in every New Hanover County training, learning and development in some way or form. In their supervisor training, professional development curriculum, change management, safety, emergency management, and compliance, there is intentionality as they believe that if they work from a place of resilience, if they address stress, and are able to be focused through practices that encourage well-being, they will be better able to serve their community (B. Dean, personal communication, 2021).

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Conclusion In 2010, the Haitian people taught us that even in the worst of times, human beings have the capacity when asked to lean into their well-being, to embrace their community with joy and hope. The Haitians, like many of the people we have met around the world, have shared that CRM skills not only helped them in the wake of the earthquake of 2010 but continue to help them through the many storms of life experienced including the political unrest, hurricanes, and the earthquake of 2021. Dr. Agathe Jean Baptiste, a Haitian physician we met in 2010, who now works for the Global Fund in Switzerland, recently shared that the CRM skills provided “seeds of light” that grew during a time of despair after the 2010 earthquake. We have witnessed people’s capacity for joy and well-being even when faced with great suffering. An experience in Haiti that demonstrates this capacity is an unforgettable moment. It is hot and muggy as we travel through the broken streets of Haiti. Our driver negotiates around the rubble to bring us to our destination where more than 100 Haitians huddle underneath a corrugated metal roof in a makeshift camp waiting for our arrival. The camp emerged in one of the many neighborhoods in Port au Prince after the January 2010 earthquake. We ask to exchange a song, as sharing music and dance brings our two worlds together. A woman moves forward from the crowd and begins to sing and soon everyone joins in, rising from the wooden benches, gathering together in song and dance. The laughter and singing resound through the camp and are contagious as more people join us—men, women, children, the old and the young. A moment of reprieve from the harsh realities…a reminder that joy can still exist. In simple ways, we begin to teach the survivors about the biology of the human nervous system—the biology of traumatic stress reactions and ideas to cultivate well-being during these devastating times. We share the basic skills of CRM and demonstrate how they can help one another by integrating the simple skills into their activities of daily living as they rebuild. The survivors share with us physical symptoms—insomnia, palpitations, sensations of the earth moving when it is not, stomach aches and headaches, weakness in the limbs, and sadness. We share that we have seen these symptoms all over the world after catastrophes like the earthquake. This is biology, not human weakness. We then ask, “What or who is helping you now?” The crowd shouts out, “Jesus, my family, my friends!” We demonstrate and practice the basic CRM skills. “Remember your resources,” we say. There is chatter and agreement in words. “Yes, yes, we will,” we hear in Creole. As we get ready to leave, the Catholic nun who leads the camp comes toward us enthusiastically, and through our Creole translator, takes my hands in hers and says, “This is the first time since the earthquake that I have felt joy.” We have witnessed firsthand that joy truly is “the silver lining of suffering.”

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References Dalai Lama, Tutu, D., & Abrams, D., (2016). The Book of Joy: Lasting Happiness in a Changing World. New York: Avery, an imprint of Penguin Random House. Dean, B. (2021). New Hanover County Culture of Resilience: Training and Professional Development, County of New Hanover County, Human Resources, www. NHCgov.com, [email protected] United Nations Office for Disaster Risk Reduction, accessed online, 3/12/22. https:// www.undrr.org/terminology/disaste

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The Community Resiliency Model (CRM) and Law Enforcement Jennifer Wallace This chapter will: 1. Describe Sexual Assault Investigations, Victim-Centered Engagement and Resiliency (VCERT) training offered by the Washington State Criminal Justice Training Commission (WSCJTC). 2. Describe how trauma-informed and resiliency-informed and focused approaches using the wellness skills of the Community Resiliency Model can be integrated into investigations with the goal of minimizing the retraumatization of victims/survivors. “You’ve made resiliency real,” said Dr. Kimberly Lonsway (personal conversation, November 17, 2021). Dr. Lonsway had just observed the interviewing exercises featured in the Sexual Assault Investigations, Victim-Centered Engagement and Resiliency (VCERT) training offered by the Washington State Criminal Justice Training Commission (WSCJTC). Dr. Lonsway presides over research for End Violence Against Women International (EVAWI), an organization setting national and global standards for training content for gender-based violence investigations. Her statement rang true to me, as I considered the attention and effort placed on integrating wellness into police officer training on sexual assault victim interviewing. We began blending the Community Resiliency Model (CRM) skills into interviews after sending interviewing subject matter experts to the CRM Teacher Training since the inaugural VCERT course in November 2018. Since then, close to 550 officers in Washington state have been introduced to CRM as part of victim interviewing. Seeking strategies to keep victims engaged with these investigations, many of the officers laud the inclusion of these skills. The VCERT class educates officers about the benefits of assisting victims with nervous system regulation while they inquire about the details of the crime(s) committed. They are learning how memory and DOI: 10.4324/9781003140887-11

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behaviors can be impacted by trauma and how and where CRM skills can aid recall and resiliency. Without a victim’s detailed account of the incident or their continued participation in the criminal justice process, offender accountability is much less likely. There are high recidivism rates among sexual offenders not held accountable for their crimes. When mandating the VCERT course for police officers “who regularly conduct adult sexual assault investigations,” the Washington state legislature considered the impacts of trauma and challenges of the justice system in establishing criteria for the WSCJTC training in the Revised Code of Washington (RCW), 101.43.272, Section 2; The training must: Be based on research-based practices and standards; offer participants an opportunity to practice interview skills and receive feedback from instructors; minimize the trauma of all persons who are interviewed during abuse investigations; provide methods of reducing the number of investigative interviews necessary whenever possible; assure, to the extent possible, that investigative interviews are thorough, objective, and complete; recognize needs of special populations; recognize the nature and consequences of victimization; require investigative interviews to be conducted in a manner most likely to permit the interviewed persons the maximum emotional comfort under the circumstances; address record retention and retrieval; address documentation of investigative interviews; and educate investigators on the best practices for notifying victims of the results of forensic analysis of sexual assault kits and other significant events in the investigative process, including for active investigations and cold cases.

By including these components in the mandate for trauma-informed, ­victim-centered sexual assault investigations training, officers are encouraged to bring more awareness, sensitivity, and overall consideration of the impacts of trauma to the process of eliciting evidentiary information during practice interviews. As we evaluated trauma-informed interviewing courses available for law enforcement, we found that many of these trainings included information about trauma and concepts for working with individuals under its influence, but none of the trainings included tools for addressing physiological activation during the interviewing process. CRM, with its simplicity, adaptability, and versatility, offered us a way to highlight the importance of understanding and tracking the victim’s state or capacity. As part of the VCERT course, we established a five-part framework for interviewing that was based on content from other trauma-informed interviewing models. What sets the VCERT interviewing model apart from others is the

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integration of the CRM wellness skills. Officers practice the application of suitable or selected CRM skills at moments of activation, or when a victim gets bumped out of the Resilient Zone. Many officers are likely already using some of these tools, but may not be relying on the same terms or understanding of the nervous system or trauma in their current application. For instance, suggesting that an individual being interviewed take a sip of water (a CRM Help/Reset Now skill), is fairly common – something that I remember as a retired federal agent including in investigative interviews in the 1990s. Having an understanding of how this can bring the interviewee into their sensations and back to the moment would have reinforced this practice. Another example of a commonly referenced concept (but never emphasized in interviewing training) is establishing rapport with the interviewee. With the twist of connecting rapport building to the CRM skill of Resourcing, this can offer the interviewer the chance to connect with the interviewee on a neutral or pleasant topic, assess their baseline, and ease nervous system activation around the sensitivities and formalities of the interview. With an understanding of the physiological impacts of trauma or traumatic events and the integration of these simple techniques to help regulate and stabilize an individual through this process, there is a stronger likelihood of a more detailed recollection and continued participation with the investigation or prosecution. We encourage officers to build rapport/resource at the beginning and conclusion. With this practice, officers not only have a better chance of connecting to the victim but also can further influence a victim’s confidence and resiliency in their pursuit of justice and healing. This offering of care to the victim while retrieving evidentiary information is perspective shifting in that it starts with a trauma-informed approach that, with the inclusion of CRM skills, evolves into being resiliency-focused.

The Creation and Framework of the VCERT Interviewing Model As the course was being developed, we sent two subject matter experts (SMEs) and the WSCJTC program manager (PM) to CRM to evaluate the potential of incorporating these skills into victim interviewing. These SMEs were originally hesitant, but soon came to understand and later advocate for the value of bringing CRM into interviewing. Soon after the CRM Teacher Training, we held a stakeholder summit attended by Elaine Miller-Karas to learn what content was important to these stakeholders and to identify course instructors. The CRM skills were also introduced to stakeholders by

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the SMEs, PM, and Miller-Karas during this summit. We studied various interviewing models and developed a framework for officers to follow in their interviews with victims. This framework blended CRM skills with features already known to officers (i.e., situational and self-awareness and rapport building). WSCJTC’s Child Abuse Interviewing and Assessment course inspired us to include interviews with professional actors, giving officers a chance to practice the new or familiar skills in a training setting. Over time, we added more CRM teachers to the training cadre. These CRM teachers come from an array of backgrounds and include individuals from mindfulness teachers to detectives and prosecutors. We’ve included CRM guides in the interviews along with the facilitator with the law enforcement background. In the three-plus years since starting the training, it has evolved into a smoother, more organic blend of wellness with information retrieval We introduce the officers to the skills via the iChill app during their pre-course assessments. They’re asked to download the app and then answer several questions about the CRM skills to familiarize themselves with CRM terms and utility. The CRM skills taught to officers include Tracking, Resourcing, Grounding, and Reset Now. More recently, we’ve added Shift and Stay. All members of the training team who have not completed the CRM Teacher Training are asked to attend a CRM workshop. There is a dual purpose to this request: to offer wellness skills to training team members and to familiarize the team with course content (particularly actors, who are not only asked to be in the vulnerable role of victims, but who may also be guided in these skills during practice interviewing). Once the class begins, officers are provided with an overview of these skills in Victim Recall and Resiliency, which is followed by the all-encompassing interviewing section of the training. The Victim Recall and Resiliency section includes a description of the neurobiology of trauma with the CRM skills so officers are able to grasp why and how these skills might be used in potentially highly charged interactions. The Interviewing section more specifically highlights the utility of these skills during various phases of the interview. Below is a summary of our step-by-step process being shared as a possible blueprint for law enforcement officer interactions or interviews in your communities:   1. Two SMEs in criminal justice interviewing and the WSCJTC PM completed CRM Teacher Training (Note: a contract was secured with TRI to utilize CRM materials in the VCERT training.).

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  2. The PM hosted a stakeholder meeting as the training was being developed to get input on course content and to identify topics and instructors. The two SMEs, the PM, and Elaine Miller-Karas informed the stakeholders of the CRM skills and their potential benefits to sexual assault victims during law enforcement interviews.   3. Trauma-informed interview models were researched and a five-part interviewing framework incorporating various concepts or practices included in the other interviewing models and integrating the CRM skills was developed.   4. Training team members identified for the course were required to attend the VCERT training prior to obtaining contracts as instructors or interview facilitators for the course. Early on, this also meant they learned about the CRM skills and how they were to be integrated into the interviewing exercises with actors.   5. The actors involved in VCERT were provided with an overview of the CRM skills while they were also learning their roles and scenarios for the training.   6. CRM trainings for members of the VCERT training cadre continued as the course evolved and more CRM teachers were sent to TRI for the training.   7. TRI sent a CRM teacher to assess and provide guidance to the PM on the inclusion of CRM in VCERT.   8. VCERT sent therapists working as instructors or consultants for VCERT to TRM training. Professional mindfulness facilitators were also sent through the CRM Teacher Training for their roles as CRM facilitators. These therapists and mindfulness facilitators are also resources for training team members.   9. VCERT now sends all training team members to CRM workshops. 10. With an emphasis on a multidisciplinary team in the VCERT course, advocates and attorneys were also sent through the CRM Teacher Training. 11. As the number of certified CRM teachers increased in VCERT, and after assessing the benefits of including CRM facilitators with the law enforcement facilitators during practice interviews, the interviewing exercises began including individuals in each role. 12. Given the potential for anxiety going into the interview practices (observed by peers), CRM facilitators start the interviewing exercise with a resourcing activity as part of introductions and nervous system regulation. 13. CRM and law enforcement (LE) facilitators encourage interviewing officers to apply CRM skills when actors become activated during these exercises. 14. CRM facilitators may also review the CRM skills and provide feedback on efforts or opportunities to rely on these skills.

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The following are the CRM skills that are emphasized during the practice interviews in the VCERT course: · Tracking – Foundational not only to the other CRM skills, but also to officers, who are trained and conditioned in situational awareness. · Resourcing – Included as part of rapport building, assessing an emotional baseline, and establishing a connection to the victim through a neutral or pleasant topic. Officers can enhance resources through sensory questions, which are encouraged as part of the interview about the assault incident as well. · Grounding – Asking victims to direct their attention to a part of their body (usually hands or feet) that has contact with a surface to guide a victim back to the present moment with the officer. · Shift & Stay – When CRM skills are employed, Shift and Stay can occur throughout an interview. Whenever a victim’s nervous system is activated in the retelling of the traumatic incident (assault), the officer can guide the victim to a more neutral or pleasant experience, or the present moment, with any of the skills. By asking questions about the sensations related to a resource, Grounding, or one of the Reset Now skills, the officer can enhance the victim’s focus on sensations that are neutral or pleasant and re-engage them in providing information related to the investigation. · Help/Reset Now – Suggested as a tactic to redirect a victim when there is sudden and extreme nervous system reaction as they provide the narrative of the assault. Like Grounding, this can also be an effective tool to bring the victim back into the room and restore executive functioning.

The interviewing exercises are typically the highlight of the VCERT course, as officers get to apply information and skills learned in sessions leading up to the interview. The course, which is primarily a victim interviewing class, is structured to include interview considerations on the first two days of training, interview exercises on the third day of training, and investigation, prosecution, and officer wellness on the final day of training. Also included are the interview reference materials provided to officers prior to the interviews. While the “SAI Interview Framework/Sample Questions” card (Table 9.1) is provided for officers to rely on during interviews, the “VCERT Interview Guide” (Table 9.2) is intended for the interview facilitators to rely on as they evaluate the practice interviews. At the end of the VCERT training, once the officers have a sound understanding of applying the CRM skills in their interviews with victims or witnesses, we shift the emphasis to officer resiliency – their well-being. In addition to hearing a presentation from a TRM-trained therapist with

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Table 9.1  SAI Interview Framework

Source: Reprinted with permission from the Washington State Criminal Justice Training Commission

substantial experience working with trauma and first responders, course participants are also reminded of the benefits of CRM skills and the application to their own well-being. This section of the training is being expanded with a journaling exercise in furtherance of officer’s memorializing and acting on aspirations of prolonged wellness. Invariably, officers reference the CRM skills and interviewing as their class takeaways. Quotes responding to the question, “What is your number one takeaway from this class?” from the last three VCERT classes (November, December, and January) are included below. Victim-centered interviewing. Thinking about word choice and providing tools for individuals in crisis. While this class was centered around interviewing/interacting with survivors, I believe these are useful tools that can be integrated into many different interview situations. The word choice, specifically – saying “How did your body respond?” instead

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Table 9.2  VCERT Interview Guide

Source: Reprinted with permission from the Washington State Criminal Justice Training Commission

of “How did you respond?” or making sure to avoid potentially triggering words, “Just breathe,” or “Tell me your story.” The science of the brain that causes biological reactions to trauma, which manifests in various ways, and how to handle the behaviors in a way that produces the best information for the criminal investigations and is the least traumatizing for the victim. The CRM skills and how they have been implemented into our everyday conversations–we just didn’t have a term to put them under. Working off the basic skills we use already and adding in the extra step to obtain details to better investigations.

Recently, a detective in Washington state who has been applying the CRM skills to interviewing practices since taking the class over two years ago, asked about prosecutors in his county attending VCERT and related the following: I sing your (and your team’s) praises whenever I talk about training and how this was one of the best – if not THE BEST training I have received in 20 years in law enforcement.

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I had an interview yesterday and used Grounding to help the victim get through a difficult account of what was so traumatizing she waited eight months (with counseling) to come forward to law enforcement. In the interview I used so many of the tools and stories from your class to help her process the incident and to stop her from blaming herself. Your training helped me help a victim through a difficult process.

We encourage other police training facilities and departments to coordinate workshops or teacher trainings with TRI and implement these practices.

References Revised Code of Washington (RCW), WSCJTC training, 101.43.272, Section 2 Washington State Criminal Justice Training Program (August 2021 Rev.). Sexual Assault Investigations, Victim-Centered Engagement and Resiliency Tactics.

Part III

Working with Children

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Working with Children Who Have Experienced Trauma: A Developmental Perspective Kimberly Freeman This chapter will: 1. Describe how the Trauma Resiliency Model (TRM) and the Community Resiliency Model (CRM) can be used to help children who have experienced trauma 2. Describe how TRM/CRM is an excellent approach for implementing primary, secondary, and tertiary prevention programs within school and community settings 3. Describe child development and attachment in relationship to using TRM/CRM 4. Describe how to use CRM with children during war Children and adolescents exposed to trauma are at risk for developing longterm behavioral, health, and social problems. Research examining the effects of trauma on the brain found that during early development, childhood maltreatment can physically alter the biological structure and functioning of the brain, resulting in lasting behavioral and physical health problems across the lifespan (Teicher, 2000). These and related findings have led to the search for resiliency factors that mediate or even reverse the development of these adverse consequences (see Zolkoski & Bullock, 2012). Resiliency, viewed early on as a fixed personality trait used to manage and adapt to stress and trauma, was once thought of as a characteristic that an individual was either born with or without (Asendorpf & van Aken, 1999; Hart, Hofmann, Edelstein, & Keller, 1997). Although this may be partly true in that resiliency has some innate biological influences, we now know that it also develops and is strengthened over time in the context of positive individual, environmental, and social supports. In support of this view, a DOI: 10.4324/9781003140887-13

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recent meta-analysis found that enhancing protective factors such as self-­ efficacy, positive affect, and social support is effective in building resiliency within an individual (Lee et al., 2013). This perspective shift has led to more modern definitions of resiliency such as “an individual’s and community’s ability to identify and use individual and collective strengths to live fully in the present moment and thrive while managing the tasks of daily living” (Miller-Karas, 2013). By building on a child’s “individual” and “collective” strengths, we build resiliency and change the trajectory of the child’s life. There is also growing evidence to suggest that just as adverse events can reorganize brain functioning to respond in maladaptive ways, building resiliency in a child can “remodel” the brain to respond in more adaptive ways, and this remodeling can endure into adulthood (Sroufe, Egeland, Carlson, & Collins, 2005; Sroufe & Siegel, 2011). It is this type of positive neurological change referenced above, aimed at restoring balance to the mind and body following trauma, that is a primary focus of both the Trauma Resiliency Model (TRM) and the Community Resiliency Model (CRM). These models specifically promote resiliency in that they focus on connecting with and intensifying specific positive memories or resources, while also attuning to body sensations in such a manner that allows the child’s distress to be released. Within these models, children are also taught to regulate their nervous systems by learning to recognize when they are bumped out of their resiliency zones and how to use the TRM and CRM wellness skills for coping with future stressors. In this respect, the models, which include a skills-based wellness program, are designed to be used by behavioral health professionals (TRM) to provide clinical treatment for trauma, and by any community member who is faced with stress (CRM). Recognizing the potential to bring CRM wellness skills to an entire community, “CRM for Georgia’s Children,” an initiative within the “Bridges to Therapy Framework,” was launched in 2022. Bridges to Therapy will help to address Georgia’s staggering behavioral health outcomes; in 2021, Georgia was ranked 49th for access to mental health services. Georgia-certified CRM teacher, Jordan R. Murphy, PhD, RN, CPNP, and chief executive officer of the Center for Interrelational Science and Pediatrics, stated, “Most of my patients were on a 3–4 month waiting list which often led to crisis-level intervention. The Bridges to Therapy framework and CRM training will help to meet the Georgia Department of Behavioral Health and Developmental Disabilities goal for a System of Care that will ultimately improve pediatric behavioral health outcomes in the state. I’m really excited to promote CRM as a first-line wellness intervention which can be used at all levels

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(prevention to crisis-level) to bridge our healthcare gaps and eventually, provide universal access to wellness skills” (Murphy, J. personal interview, 3/20/22).

Prevention Because of its focus on wellness, the TRM/CRM is an excellent approach for implementing primary, secondary, and tertiary prevention programs within the school and community settings where children spend a majority of their time. From a primary prevention perspective, the goal is to protect healthy people from developing or experiencing mental health issues. Because the CRM can be easily taught to individuals such as parents, teachers, and daycare workers within the community, specific educational programs can be designed to teach children about the biological effects of stress and trauma and the importance of skills such as Resourcing, Grounding, and Tracking. When a person learns to read their nervous system, they can return to their Resilient Zone when they get bumped out. We believe that this ability can help prevent the impact of traumatic experiences. In one elementary school setting, the CRM wellness skills were taught to a third-grade classroom as part of a wellness stress prevention program. Not long after the training there was one young boy who became mad and disruptive in the classroom. Recognizing that the child was distressed, the teacher asked the class what they would do if they “were mad,” and the students came up with several CRM resourcing and Help Now! skills, such as, “Think of your favorite thing to do; that’s what helps me,” “Go for a walk and get a drink of water,” and “Count backwards from 100 and see if it gets better.” The beauty of this example is that the suggestions came directly from the children themselves based on their knowledge of how the body responds to stress, and the children were able to help this young boy without ostracizing him. Once children understand the body’s natural response to stress and learn what they can do about it, they are in a much better position to understand when someone is having a stress reaction and to use the skills to manage their own responses to stress. When implementing secondary prevention, the focus is on helping a child who has been traumatized so that his symptoms are decreased or even

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eliminated. An example of the secondary prevention approach is demonstrated by one of our CRM-trained counselors in a school district. She indicated, On Monday I sat on the floor in the hallway talking with a fourthgrade student who was deeply distressed. She had experienced a nighttime of wakefulness, hearing domestic violence down the hall and having to escape from a furious dad who chased them down the road as they tried to flee (to grandpa’s where they arrived safely). She expressed fear and deep grief over the loss of her home and the relapse of her dad. She needed to tell some of the story, and it was easy to help her build a resource around the sense of safety she felt when she reached grandpa’s house. She easily tracked her body— smiling, relaxing, and breathing slower—and told me that she’s taught her mom about resourcing, too. After another round of becoming activated and resourcing again, she decided she’d like to try and make it through the school day and she thought she could if she could remember to resource. Yesterday I learned that she’d made it through the day.

Because the teacher was trained in CRM, she was able to reach out to the student in need and reduce the risk of the student developing further trauma symptoms while also promoting resiliency. The importance of the skills to the child is reflected in her comment about teaching the resourcing skill to her mother and in her ability to continue on with her school day. Tertiary prevention is aimed at helping people manage complicated, longterm mental health problems while maximizing overall quality of life. An example of tertiary prevention is seen in the treatment of a 13-yearold resistant adolescent who was being seen for self-harm, depression, and emotional dysregulation. She also had a number of risk factors including being financially disadvantaged, having a father who was an alcoholic and emotionally unavailable, and having a history of emotional abuse. In treatment, she was initially resistant as she anticipated being forced to talk about her problems. She demonstrated visible relief when she was told this would not be the case and when asked, she was open to noticing her physical sensations in the current moment and to discussing her resources, which centered on experiences with her best friend. By tracking her body sensations, utilizing resources,

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and pendulating from uncomfortable sensations to more pleasant or neutral sensations, this young teen gradually learned how to regulate her nervous system. She was subsequently able to deal more effectively with her daily stresses and she stopped self-harming very shortly into treatment. This non-invasive approach that does not require or force the person to retell the narrative of their traumatic experience is a key principle of the TRM/ CRM and is ideal for working with adolescents, who are often distrustful of adults and do not like to talk about their problems. In this particular case, the adolescent did eventually want to share some of her trauma stories but did so on her own terms and in a manner that allowed her to work with small increments of arousal while interweaving the TRM skills. This approach allowed her to have a new and different experience in that she was able to share her experiences while releasing the survival energy from the trauma that was stored in her body. Toward the end of her therapeutic work she stated, “I feel like I can deal with my family, like I’m in control of myself…I am stronger and can use my skills whenever I need them. My mom is even trying to use them.” As evidenced in the examples above, the TRM/CRM skills offer a powerful prevention tool for children and adolescents who experience typical daily stressors, who are at risk for developing mental health problems, and who have significant mental health issues. Although the TRM is designed to be used by mental health professionals, the CRM shares six of the basic skills and can be used by individuals in the community. In this respect, the most important people in the child’s life, such as parents and teachers, can reinforce the use of the skills with a child in multiple settings, across various situations. This is a feature that is missing in most other treatment approaches that require intensive professional training to implement. By increasing the child’s use of the skills in this more generalized manner, the Resilient Zone is widened, thereby resulting in an improvement in the child’s overall quality of life.

Developmental Considerations Although conceptually identical to the TRM/CRM for adults, there are a number of developmental factors and teaching adaptations that need to be considered when using these approaches with children. Of foremost importance and the overarching principle is the inclusion of the parents or

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caregivers in the skills-learning process. When the skills are taught to both the parent and the child, the parent can model the skills and, when balanced, be more effective in helping the child. Further, by learning the skills, parents become more attuned to and are able to track their child’s nervous system responses and redirect the child to a resource when they observe the child escalating or withdrawing. Focused attention on the parents or caregivers cannot be overemphasized, as research consistently shows that an important predictor of positive outcomes for children is the coping ability of significant adults (Gewirtz, Degarmo, & Medhanie, 2011; Silva et al., 2000). The Trauma Resource Institute launched a new program in 2020 called the Family Resiliency Program so that caregivers of children can learn how to bring the skills into their homes, neighborhood centers, schools, and the wider community. An emphasis of the Family Resiliency Program is the importance of using the skills for caregiver self-care. Additionally, other developmental factors that warrant attention and impact how a child responds to trauma include the role of memory, temperament, attachment, and the presentation of post-traumatic stress symptoms.

The Role of Memory Although brain functioning and memory are discussed in depth elsewhere in this book, child-specific information is presented here to highlight the effects of trauma on preverbal children, as it is often mistakenly thought that because young children may not have words to express their traumatic experiences that they are not affected by these events. Evidence of preverbal memories is demonstrated in what we now know about the development of implicit and explicit memory (Paley & Alpert, 2003). With regard to trauma and memory, the literature is generally consistent in showing that young children do not maintain clear explicit memories for traumatic events over time. However, this is not the case for implicit memories. Tulving, Schacter, and Stark (1982) found that implicit memory tends to survive and even influence responses long after the ability to retrieve information explicitly. For most implicit memories, this is a good thing as it allows us to engage in many routine activities automatically. With regard to trauma, though, these unwanted memories get “stuck” in the body, resulting in ongoing fear, dysphoria, anger, and/or dissociative responses that are difficult for children to manage and understand. The fact that the TRM and CRM allow clinicians and trainers to work with the child’s physiological responses and do not require a retelling or even verbal knowledge of the

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trauma highlights another reason why these models are so useful for helping traumatized children. Types of nonverbal memory such as visual memory and somatic-sensory memory include automatic responses such as freezing or dissociating in response to direct trauma or to a traumatic cue (e.g., a traumatized child vomiting or dissociating when walking into a school where she was bullied). Nonverbal memories, generally expressed immediately following traumas, tend to be accurate and continue to be expressed well into adulthood in the form of behavioral, visual, and somatic-somatosensory memory presentations. Although visual and verbal memories were also present, they were found to fade and vary over time (Paley & Alpert, 2003). Understanding the role of implicit memory in trauma reactions has been incorporated as a key principle of the TRM/CRM. Specifically, the models take into account an understanding of how preverbal children and individuals who cannot remember aspects of the trauma still experience reactions to the event. In order to effectively help someone who has been traumatized during childhood, it is necessary to process the associated implicit memory, which gets stored in the body’s sensory, motor, and emotional memory.

Child Temperament Regardless of trauma history, children come into the world neurologically different in their adaptability and responsiveness to their environment. When asked, mothers will readily tell you just how different two children can be when they have one child who rarely cries and who eats and sleeps on a regular basis, and another child who seems to cry constantly, is irritable, and has unpredictable daily habits. These characteristic patterns in which children respond to and interact with their environment are referred to as temperament (Thomas & Chess, 1989). Temperament is thought to be mostly biologically determined and is believed by many to play a significant role in later personality development. In their original study, Thomas and Chess examined individuals from infancy through adulthood by rating them along nine different dimensions of temperament. Their results indicated that most children fit into one of three types of temperament patterns: the easy child, the slow-to-warm-up child, or the difficult child. Characteristics of the easy child, which made up 40% of children in the sample, included having regular, positive responses to new stimuli; easy adaptation to changes in their environment; and generally positive moods and emotions. The slow-to-warm-up children constituted 15% of the sample and were described as having a low

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activity level, slow adaptation to new situations, and a tendency to withdraw from new situations and people. Finally, 10% of the children in the sample were described as difficult in that they tended to be unpredictable in their daily habits, overly emotional, irritable, and fussy, with generally negative responses to new stimuli. Notable is that 70% of the difficult infants received psychiatric treatment as adults, whereas only 18% of the easy infants did so. The above findings suggest the possibility that a child with a difficult temperament may present with more severe symptoms following a trauma than a child with an easy temperament. In this respect, the child’s therapist should be aware of the child’s developmental history and should make adaptations to the skills as necessary. For example, a highly reactive and sensory-sensitive (consistent with a difficult temperament) child who is reactive regardless of trauma history is likely to benefit from Resourcing as opposed to Grounding techniques, which may result in increased activation especially in the beginning of treatment before the skills are learned and practiced. Further, it is also important that these children learn to shift their attention away from the parts of their body that are activated to somewhere in the body that is more neutral or calm. This is likely to be a new experience for the child who has always been overly sensitive to his environment. Although the child’s sensitivity to the environment is not likely to change because of the innate nature of temperament, how the child manages and responds to sensory information can be greatly enhanced through use of the TRM/CRM skills. Knowing that children present with different temperament patterns provides one explanation for the variability in neurological reactions to trauma often seen in children despite their limited life experiences. There is substantial evidence to suggest that some children are naturally more sensitive to environmental stimuli and in some cases may be more prone to being bumped out of their Resilient Zones even when the stress is minor. In turn, the TRM/ CRM approach is adaptive and sensitive to each child’s unique presentation and allows the child to take the lead in determining the meaning and impact of a trauma. In this way, two children who experience the same trauma but who have different temperament styles may present very different symptom profiles such that a child who is considered highly reactive may have a much more intense reaction to a trauma as compared to a child who is moderately reactive. Also, the knowledge of temperament supports the need for a preventative approach for all children but especially for children with more difficult temperaments. As discussed previously, by frontloading these at-risk children with wellness skills, we can do much to reduce the potential effects of stress and trauma and can also widen the often narrow resiliency zone that is frequently present in children with difficult temperament styles.

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Attachment and Trauma “Attachment describes an emotional bond that serves to promote and preserve closeness between a young child and a small number of adult caregivers who are responsible for comforting, supporting, nurturing and protecting the child” (Breidenstine, Bailey, Zeanah, & Larrieu, 2011). Bowlby (1980), the developer of attachment theory, believed that infants are biologically designed to form a close intimate relationship with a caregiver in order to ensure survival. As such, early on infants exhibit proximity-seeking behaviors such as crying, smiling, following, and clinging in order to attract the attention of their caregivers. The development of a healthy attachment occurs over several years and moves from seeking the attention of any potential caregiver (birth to 8 weeks), to showing a slight preference for his caregiver but still interacting freely with others (2 to 7 months), to showing a clear preference for familiar rather than unfamiliar adults with separation protests and stranger wariness (7 to 12 months), to showing a clear preference for his caregiver (12 to 18 months). At this point, the child begins to explore his environment while using the caregiver as a secure base to return to when frightened or distressed. In the final attachment phase (18 months and older), parents and children continually balance and adjust the need for autonomous functioning with the need for reliance on the caregiver (Boris, Aoki, & Zeanah, 1999). In most situations, the caregiver is generally responsive to the child’s needs and the attachment process results in a securely attached child who prefers the caregiver to strangers and seeks comfort from the caregiver when frightened. Further, when children are frightened, they learn to rely on and trust that the caregiver will be responsive to their needs. However, when there are repeated failed episodes of seeking comfort from the caregiver (e.g., the caregiver is unresponsive, inconsistent, or abusive) one of three patterns of child insecure attachment develops, including avoidant, resistant/ambivalent, or disorganized. Children with an avoidant attachment pattern tend to adapt by avoiding closeness and emotional connection with their caregiver, whereas ambivalent children never know what to expect from their parent so they tend to be anxious and insecure. Children with a disorganized attachment are often frightened by their parents and are often left feeling confused, traumatized, and overwhelmed. Each of these insecure attachment types is associated with a higher risk for child psychopathology, with the disorganized attachment pattern being the most severe (Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1990).

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When working with a child who has an insecure attachment, it is important to remember that they are likely to experience fear and to be unresponsive in their interpersonal relationships. As such, it is critical that the TRM therapist create a safe environment by being fully present and attuned to the child’s behavioral responses. One way this can be demonstrated is through tracking responses to let the child know that they have your full attention. Example responses may include, “I see you just took a deep breath,” and “I noticed that you are smiling.” When working with children, tracking responses should be used much more frequently than with adults in order to teach, model sensory language, and to show your attention. Also, adult TRM/CRM questions that require long verbal responses such as, “What do you notice?” should be limited with young children under 12, as they tend to reduce rapport and decrease participation. Better techniques include either providing them with verbal choices of likely responses or having a series of pictures or words that they can choose from. When the child experiences changes in their body from fear to safety within the context of a caring therapeutic relationship, the child’s ability to function more fully in their social environment is strengthened in a manner that promotes resiliency, positive growth, and change. The inherent reciprocal nature of the caregiver/child relationship highlights the need for intervention strategies that target both caregivers and the child when attachment problems occur. TRM therapists working with children need to be especially attuned to attachment patterns and the possibility that the child’s problems are rooted in the parents’ inability to form a caring, secure relationship with their infant. Too often parents bring their children to treatment expecting the therapist to fix the problem without realizing their own pivotal role in their child’s progress. In fact, research shows that when parents have unresolved past traumatic experiences—as demonstrated by non-integrated emotional reactions, disorientation, or dissociative-like responses—their children’s attachment to them is likely to be disorganized (Breidenstine et al., 2011). This indicates that in some cases the parent needs to be a primary focus of treatment if relationship change is to be successful. Similarly, it makes theoretical sense that when the child, the caregiver, or both are continuously bumped out of their Resilient Zones, the attachment process is disrupted and the risk for developing an insecure attachment is increased. If the parent is able to process any past traumas with the TRM skills, they are better able to be present when other treatment components such as parenting skills and psychoeducation are being administered. Parents can also apply their knowledge of wellness skills such as Tracking, Resourcing, Grounding, and

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Help Now! in working with their child and thereby provide the necessary level of attunement and emotional support to strengthen the relationship with their child.

PTSD Symptoms in Children Because trauma has such a profound impact on a child’s physiological and environmental functioning, it is the contributing factor in the development of post-traumatic stress disorder (PTSD), particularly when the balance of risk factors for a child outweighs the number of protective factors (Blank, 2007). When a trauma reaction occurs, the child’s nervous system reacts and prepares for life in a fearful world, and hormones and chemicals within the brain are released in defense of a perceived threat even when no apparent danger exists. In other words, the traumatic experience “re-sets” the child’s baseline state of arousal such that even when no external threats or demands are present, the child will be in a physiological state of persistent alarm. Even a relatively small stressor can instigate a state of fear or terror. This process also blocks the brain’s ability to think rationally in a conscious and organized manner. Over time traumatized children can present as irritable, impulsive, hypervigilant, disconnected, numb, and/or fearful, and they generally function far outside of their Resilient Zones. Although a child can survive in this state, their nervous system is dysregulated and there is a high cost to the child’s physical and mental well-being. The fact that there can be multiple presentations and combinations of PTSD symptoms over time, and that PTSD can include unknown or unreported trauma, makes diagnosing PTSD in children challenging. Compounding this issue is the way in which PTSD symptoms overlap with symptoms from other childhood disorders such as attention deficit hyperactivity disorder (Perry, Pollard, Blakely, Baker, & Vigilante, 1995). Specifically, symptoms common in PTSD, such as difficulty concentrating, poor attention, exaggerated startle response, and hypervigilance can make the child appear hyperactive and/or inattentive. Misdiagnosing a child can have a negative impact on the child’s ability to cope with the trauma, can lead to the use of inappropriate and/ or ineffective treatments, and can result in unrealistic expectations for the child’s behaviors given his trauma history. As such, clinicians are cautioned to assess for trauma history and to be aware of other risk factors that may increase the likelihood of being diagnosed with PTSD such as having a difficult temperament, a disorganized attachment, and/or behavioral reenactments of trauma. The Fifth Edition of the DSM (DSM-5) includes a new developmental subtype of PTSD called post-traumatic stress disorder in preschool

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children. As the first developmental subtype of an existing disorder, this represents a significant step for the DSM taxonomy. For full diagnostic criteria go to: https://psychiatry.org/psychiatrists/practice/dsm

Children in War Children in many places in the world are living with the hardships of war, losing their homes, schools, community, and even their loved ones. The situations in Syria, Iraq, Afghanistan, Ukraine and many parts of the world challenge caregivers to help the children in their care with their trauma and grief. Understanding how to respond and help children in accordance to their developmental age can help caregivers learn how to create a greater sense of safety. There are no simple solutions to help children feel safer when there is killing and destruction around you and them. As children react to their caregivers’ emotional and physical states, the more caregivers can stay within the Resilient Zone the better. The following guidelines to support children faced with these difficult life experiences may be helpful: Birth to preschool age: Children do not understand the meaning of what is going on but will react to the emotions and behaviors of those around them. Children need reassurance through physical contact and simple comforting verbal communication Helpful techniques: • Grounding through holding and rocking. • Sometimes, reducing stimulation can help calm a distressed infant. • Caregivers can express words of comfort like, “I am here; we are safer right now.” • Provide the child’s resources (stuffed animal, blanket, book, for example.). Preschool to age six: Children’s understanding of events is still limited. They need short, simple explanations. Children at this age still need physical closeness and as much reassurance of safety as possible. They will also benefit from engaging in normal activities. Helpful techniques and sample statements: • Caregivers can express statements like, “There are dangerous things happening and this is what we need to do to stay as safe as possible; We are safer right now. I am with you.”

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• Children at this age express their emotions through play. • CRM-based play includes drawing, pretending, grounding like a tree, music. Age six to ten: Children in this age group may have a partial understanding of what is going on but often create their own interpretation of events. They often need facts and clarification. They want to feel safe. Helpful techniques and sample statements: • Caregivers can say,

There is fighting in our country. This can be scary and dangerous, but we are doing everything to keep us safer. There is much we do not know now but if you have questions, I will try and answer them.

• Look for opportunities for the child to engage in normal activities such as games and schoolwork. • Help Now! strategies can be practiced when in the High or Low Zones. • Limiting exposure to TV, social media, adult talk, and radio is most important at this age due to the children’s partial understanding of events. More than ever, children are looking and watching for our reactions. Preadolescents and adolescents: Within this age group, youth may attempt to keep their feelings inside. They understand what is going on and have their own thoughts and perspectives. Adults need to be available and watchful but also realize that adolescents may prefer to talk to their peers. Helpful techniques and sample statements: • It is important that adults stay involved and direct this energy in productive ways that build their sense of well-being and maintain safety. • This may include the youth offering to help others with tasks. • They can be encouraged to take part in more self-help activities such as journaling, and/or sharing the CRM skills with their peers. • Monitor their social media as the images of war may be too overwhelming and amplify their distress. • Teens can engage younger children in games and play. • If the internet is available, and caregivers are not opposed to social media, creating TikTok and positive messages laced with hope or with the CRM skills can help reinforce the skills. • Music can be a major resource for teens.

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Conclusion In closing, the past 25 years of research demonstrate that there are many windows of opportunity to promote well-being in children (Lee et al., 2013; Zolkoski & Bullock, 2012). The TRM/CRM skills are grounded in our current understanding of how trauma is stored and processed in the body, and they can be used in different variations by therapists and community members, and as a prevention and self-care program. This adaptability makes the skills easy to teach to parents and teachers and to integrate into and use with other treatment approaches. Although research using comparative and randomized controlled trials is still ongoing, outcome research has demonstrated significant pre- and post-treatment improvements (Freeman et al., 2021; Grabbe, 2021). Specifically, reductions in depression, hostility, anxiety, and somatic symptoms as well as increases in somatic well-being and friendly indicators were observed in a diverse group of high-risk youth and adults. These early findings along with overwhelmingly positive results from TRM practitioners, CRM teachers, child and adult clients, and community members around the world speak to the healing power of the TRM/CRM programs and suggest that they are powerful tools for helping children overcome trauma.

References Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum. Asendorpf, J. B., & van Aken, M. A. G. (1999). Resilient, overcontrolled, and undercontrolled personality prototypes in childhood: Replicability, predictive power, and the trait-type issue. Journal of Personality and Social Psychology, 77(4), 815–832. Blank, M. (2007). Posttraumatic stress disorder in infants, toddlers, and preschoolers. BC Medical Journal, 49(3), 133–138. DOI:10.1016/j.burns.2009.06.033 Boris, N. W., Aoki, Y., & Zeanah, C. H. (1999). The development of infant-parent attachment: Considerations for assessment. Infants and Young Children, 11(4), 1. Bowlby, J. (1980). Attachment and loss. New York: Basic Books. Breidenstine, A. S., Bailey, L. O., Zeanah, C. H., & Larrieu, J. A. (2011). Attachment and trauma in early childhood: A review. Journal of Child and Adolescent Trauma, 4, 274–290.

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Freeman, K., Baek, K., Ngo, M., Kelley, V., Karas, E., Citron, S., Montgomery, S (2021). Exploring the usability of a community resiliency model approach in a high need/low resourced traumatized community. Community Mental Health Journal. DOI:10.1007/s10597-021-00872-z Gewirtz, A. H., Degarmo, D. S., & Medhanie, A. (2011). Effects of mother’s parenting practices on child internalizing trajectories following partner violence. Journal of Family Psychology, 25(1), 29–38. Grabbe, Linda, Higgins, Melinda K., Baird, Marianne, & Pfeiffer, Katherine M. (2021). Impact of a resiliency training to support the mental well-being of front-line workers, Medical Care, 59(7), 616–621. DOI: 10.1097/MLR.0000000000001535 Hart, D., Hofmann, V., Edelstein, W., & Keller, M. (1997). The relation of childhood personality types to adolescent behavior and development: A longitudinal study of Icelandic children. Developmental Psychology, 33(2), 195–205. doi:10.1037/0012-1649.33.2.195 Lee, J. H., Nam, S. K., Kim, A., Kim, B., Lee, M. Y., & Lee, S. M. (2013). Resilience: A meta-analytic approach. Journal of Counseling & Development, 91(3), 269–279. doi:10.1002/j.1556–6676.2013.00095.x Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 121–160). Chicago, IL: University of Chicago Press. Miller-Karas, E. (2013). The Community Resiliency Model 2014 edition (PowerPoint presentation). Paley, J., & Alpert, J. (2003). Memory of infant trauma. Psychoanalytic Psychology, 20(2), 329–347. doi:10.1037/0736–9735.20.2.329 Perry, B. D., Pollard, R. A., Blakely, T. L., Baker, W. L., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation and “use-dependent” development of the brain: How “states” become “traits.” Infant Mental Health Journal, 16(4), 271–291. Silva, R., Alpert, M., Munoz, D. M., Singh, S., Matzner, F., & Dummit, S. (2000). Stress and vulnerability to posttraumatic stress disorder in children and adolescents. American Journal of Psychiatry, 157(1), 1229–1235. doi:10.1176/appi. ajp.157.8.1229 Sroufe, L. A., Egeland, B., Carlson, E., & Collins, W. A. (2005). The development of the person: The Minnesota study of risk and adaptation from birth to adulthood. New York: Guilford Press.

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Sroufe, L. A., & Siegel, D. J. (2011, March–April). The verdict is in: The case for attachment theory. Psychotherapy Networker. www.psychotherapynetworker.org/ magazine/recentissues/1271-the-verdict-is-in Teicher, M. H. (2000). Wounds that time won’t heal: The neurobiology of child abuse. Cerebrum: The Dana Forum on Brain Science, 2(4), 50–67. doi:10.1038/ scientificamerican0302–68 Thomas, A., & Chess, S. (1989). Temperament and personality. In G. A. ­Kohnstamm, J. E. Bates, & M. K. Rothbart (Eds.), Temperament in childhood (pp. 249–261). ­Oxford, England: John Wiley & Sons. Tulving, E., Schacter, D. L., & Stark, H. A. (1982). Priming effects in word-­ fragment completion are independent of recognition memory. Journal of Experimental Psychology: Learning, Memory, and Cognition, 8(1), 336–342. doi:10.1037/ 0278-7393.8.4.336 Zolkoski, S. M., & Bullock, L. M. (2012). Resilience in children and youth: A review. Children and Youth Services Review, 34(1), 2295–2303. doi:10.1016/j. childyouth.2012.08.009

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Using CRM/TRM Wellness Skills with Infants, Children, and Teens Elaine Miller-Karas, Kimberly Freeman, and Susan Reedy Promoting wellness in our children is an essential and often overlooked part of child development. By learning effective resiliency skills, children are better able to manage the stressors and daily hassles often faced in the course of growing up. These skills also provide a protective factor by improving overall mental and physical health and in some cases even reverse the impact of trauma when it occurs. Given the importance of this topic, this chapter will: 1. Highlight five programs integrating CRM/TRM wellness skills into their programs for children and their caregivers 2. Provide activities about how to apply CRM/TRM wellness skills directed towards children 3. Provide links to more CRM activities online Community Resiliency Model (CRM) teachers worldwide have shared their creativity and innovative ideas with the Trauma Resource Institute (TRI) in order to adapt and effectively teach the wellness skills of CRM to children and their caregivers. CRM teachers, many of whom were identified as “at risk youth” in their childhoods, have challenged the semantics of how we speak of children who face challenges. Reggie McNeil (2022), founder of the organization Transforming Youth Movement, challenges the negative bias of terminology such as “at risk” by calling the youth he works with “at opportunity” youth. CRM teachers share this hopeful perspective, believing that each child on this planet has inherent value and when given tools and opportunity can contribute to society in profound and meaningful ways. Many of our CRM teachers are living proof of this ethos. (McNeil, R. personal communication 2/7/22)

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Programs The five projects highlighted are the Family Resiliency Program (FRP) of the Trauma Resource Institute, the SEE Learning Program through Emory University, Atlanta Georgia, Fighting Back Santa Maria, in Santa Maria, California, Wake County School District in North Carolina, and the Sierra Leone, FaSCET Program—a collaborative project between Loma Linda University and the Sierra Leone CRM team. The FRP of the Trauma Resource Institute was launched in 2020 to help caregivers learn the CRM skills for self-care and to share ideas of how to bring the wellness skills into homes, schools, and communities. Some of the FRP activities are incorporated into this chapter. As CRM was being developed, it was intended to be offered to people across the lifespan, including children. When caregivers learn the skills for themselves, they can interact with their children, even during times of great stress, from their zone of well-­ being. As caregivers approach the challenges of childrearing from the best part of themselves, they model for their children compassionate parenting. We now have brought the skills to thousands of children and their caregivers around the world and are humbled in witnessing how children can learn the skills and concepts so well. A young girl of 10 being interviewed about the CRM skills shared her wisdom that it was difficult to be compassionate when not in her Okay Zone, and she learned that as she worked on watering her sensations of well-being through practicing the CRM skills, her compassion and happiness could grow. The SEE Learning Program is developed through Emory University’s Center for Contemplative Science and Compassion-Based Ethics. Guided by a vision for education of both heart and mind inspired by His Holiness the Dalai Lama, SEE learning conveys a universal, non-sectarian, and science-based approach to social, emotional, and ethical learning, which includes biologically based skills for promoting well-being. CRM teacher, Dr. Brendan Ozawa Silva, who became the Associate Director of SEE Learning, contacted Elaine Miller-Karas and invited her to come to Emory to meet with the staff of the Center for Contemplative Science and Compassion-Based Ethics. She became a Senior Consultant to the program and wrote Chapter 2 of SEE Learning based upon the Community Resiliency Model key concepts and wellness skills. She was invited to go to New Delhi, India, in 2019, for the launch of the SEE Learning program, hosted by His Holiness the Dalai Lama. Building upon the best practices in social-emotional learning, SEE Learning expands the focus to include key elements such as attention training,

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the cultivation of compassion for self and others, trauma-informed resiliency skills, systems thinking, and ethical discernment. Go to https://seelearning. emory.edu/node/5 to enter their portal and receive their free curriculum for ages K–12. Lindy Settevendemie (2022), a certified CRM teacher, was the project coordinator for SEE Learning as it was launched at Emory University. She recounted a story about bringing skills to a local school. She said, I asked if anyone had a special movement or technique they already use to help regulate or calm themselves. One boy, an energetic sixth grader, Sam, who was sitting on the floor, raised his hand. Then he wrapped his arms around his knees and rocked back and forth. He said, ‘This is what I do when I’m feeling nervous. It helps calm my brain.’

This is an example of how children can use the skill of Gesturing, which includes movements that self-calm. Lindy applauded Sam knowing how to help himself. Sam then wondered out loud why the principal yelled at him when he rocked. Lindy kindly shared with Sam that many adults don’t know this information yet and how the strategies we are learning can be used to take care of ourselves. (Settevendemie, L. personal communication 2/28/22) Lindy Settevendemie (2022) sends a message to all educators when she states, There is much learning needed for adults too, in terms of understanding how the nervous system works, how teaching body awareness and selfcare promotes autonomy and how all of this understanding can help us take care of ourselves and others. Learning the CRM strategies and other techniques could be revolutionary if happening in classrooms around the world. When combined with culturally responsive teaching, CRM skills can be empowering, liberating, and healing all at once. (Settevendemie, L. personal communication 2/28/22)

Fighting Back Santa Maria Valley was organized by a coalition of concerned organizations and community members. The Coalition was alarmed by the negative impact of drugs and alcohol on the youth and families of the Santa Maria Valley. Fighting Back provides direct services focusing on developing resiliency through a child’s relationship with a caring adult. This one-on-one connection allows Fighting Back to fight against drugs, alcohol, gangs, and other negative influences, one child at a time. Edwin Weaver, the executive director, is a CRM teacher and his staff are trained as CRM teachers. They have integrated CRM wellness workshops throughout Northern Santa Barbara County, training school administrators,

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teachers, law enforcement, community leaders, and youth. Of particular note is their Fighting Back Santa Maria Valley’s Youth Action Group, comprising local junior high and high school students who are motivated about taking a stand against violence, drugs, and alcohol in their schools and community. The Youth Action Group is focused on providing peer-to-peer support around issues that teens face in their community. They continually work to address such issues by raising awareness through youth rallies, Town Hall meetings, Public Service Announcements, and many other projects. They have hosted prevention and intervention programs to combat problems that youth face and have helped peers build wellness skills while promoting healthy choices. An example of Fighting Back’s work in Santa Maria, California, comes from Alexis Nshamamba (2022), director of Housing & Quality Assurance at the Good Samaritan Shelter in Santa Maria, when she shared the following experience after being trained in CRM skills: Upon having my first CRM workshop I was apprehensive as to whether or not the skills actually worked because it seemed too simple. However, I soon learned that they did in fact work and are life changing. About a week after that initial training, I got a call from staff at the Emergency Shelter in need of support in dealing with a child who was very upset and throwing wood chips and screaming and crying. My first reaction was that the staff should have called our mental health department, not me. However, at the time I oversaw the youth program, so they insisted I come to support. Upon arriving at the shelter, I quickly realized there was no talking to this young man (about 11 years old) through his frustration. I decided to try one of the Help Now! strategies because I had no other ideas on how to help him. I quietly walked next to him and started pressing on the wall next to where he was. He looked at me puzzled. I then quietly said, ‘Sometimes when I’m mad, I just push on the wall.’ After another long minute of silence, he dropped the wood chips in his hands and stood next to me pushing the wall. About two minutes of silent wall-pushing later he looked at me and said, ‘I’m ready to get my shoes on and go now.’ Several months later, while I was supervising other kids on the shelter playground, this same young man from months before came running by me. When he saw me, he stopped and said, ‘Hey! I remember you! You helped me when I was mad. Sometimes I still push on walls when I’m mad and it helps!’ and ran off before I could even respond. From that moment on, I believed that CRM changes lives. (Nshamamba, A. personal communication 2/15/22)

Many school districts and independent schools have integrated CRM into their programs and curriculum. Some school districts had a systematic approach starting with the teachers and administrators, then training the parents and then the children. Wake County Schools in North Carolina with initial leadership from CRM Teachers, Dr. Marius Pettiford, senior director,

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Counseling & Student Services, and Drew Pledger, LCSW, spearheaded this approach in their district. When CRM is brought to an entire district, the potential capacity to scale student, teacher, administration, and caregiver well-being expands. Dr. Pettiford (2022) reported the following: We first learned about the Community Resiliency Model (CRM) during a grant meeting for recipients of the Elementary and Secondary School Counseling Program Grant (ESSCP) in 2015. We chose CRM because of the connection to neuroscience and how the body naturally responds to trauma. The skills were easy to teach and actually empowering. There is security and hope knowing that you have the ability to deal with any of life’s challenges. After meeting the Trauma Resource Institute and seeing examples of CRM in individual schools, we provided CRM training for a small pilot group of the four elementary schools in the ESSCP grant and two alternative schools. We invited the Principals, Assistant Principals, and student services staff of all six schools along with the leaders of the Counseling & Student Services Department to participate in this training. (Pettiford, M. personal communication 3/21/22)

Dr. Pettiford (2022) further reported that after getting CRM started in the pilot, they were able to train the first cohort of CRM teachers in 2017 and staff have applied for CRM Teacher Training every subsequent year. They just completed their 5th cohort in the Fall of 2021. When school closed in March 2020 due to the COVID-19 pandemic, they began offering CRM Awareness Sessions for all staff and added Family and Community Wellness sessions after work hours and on weekends. They were able to add two fulltime district CRM teachers to expand the support for the over 401 CRM guides and 45 CRM teachers in their district. Dr. Pettiford (2022) emphasized that as Wake County School District moves forward after the pandemic, CRM will continue to be the foundational model used for their Trauma Informed Practices work. He states, What I have learned during the pandemic is that in order for staff/adults to give grace (seeing the humanity in each of us) during these trying times, we have to be our best selves and be in our resilient zones. Grace cannot be achieved outside the resilient zone! (Pettiford, M. personal communication 3/21/22)

Based on the CRM, the Families, Schools, and Community Engaged Together Program (FaSCET) was initially developed by Zephon Lister and Kimberly Freeman from Loma Linda University and their Sierra Leone CRM Partners. The program grew out of a long-term sustainability plan initiated by the Loma Linda University International Behavioral Health Trauma Team (LLUIBHTT) aimed, in part, at providing CRM training to 22 Sierra

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Leoneans following the 2014 Ebola crisis. These individuals successfully reached out to nearly 1,000 community members resulting in increased resilience and significant reductions in PTSD symptoms, depression, and overall distress. Given the success of this program, the Sierra Leone team, over the years, was asked to provide CRM services within the Waterloo Adventist Hospital system where they established themselves as a valuable community resource including serving local orphanages and assisting adults and children in need of coping and wellness strategies. Wanting to expand their services to children in a more broad and systematic way, the Sierra Leone team in 2019 reached out to LLUIBHTT to request assistance in further developing a training to be used within the school system. This joint effort resulted in the FaSCET Program. Given the degree of historical war trauma, abuse, and domestic violence in the community, the FaSCET Program was specially aimed at providing CRM along with education on family communication, boundaries, discipline, and conflict resolution. It was believed that providing this program to the most important individuals in the child’s life would result in more long-lasting change for the system as a whole. The children and teachers instantly engaged the CRM and the hands-on learning strategies. The skills became immediately relevant and relatable to them in a manner that transcended cultural barriers and changed how things were done in the classroom. An additional aim of the project was to provide needed data for a National Institute Mental Health grant submission to expand the FaSCET Program throughout the local and regional school system. Some of our preliminary results show a significant decrease in the use of and attitudes regarding corporal punishment, an overall significant improvement in family communication, and a significant improvement in emotional regulation in both parents and teachers. Although this project is ongoing, there have been many positives that warrant noting. Our Sierra Leone CRM team has moved toward full financial sustainability of a core group and has become a trusted and valued part of the health and school systems. There are also notable changes in disciplinary practices and attitudes for individuals receiving the FaSCET program along with improved emotional regulation and better communication in families. Finally, there are now resources and CRM training available to children and families who are suffering within this community where there was once none. Taken together, these changes have had and continue to have a positive impact on the lives of so many and a growing number of individuals in Sierra Leone.

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CRM as a Valuable Human Resource With the combination of the pandemic, social unrest, war, and the storms of life common to growing up, children across the globe have experienced high levels of disruption. Because children often express their distress differently from adults, adults may believe that children are either unaware of and/or unaffected by traumatic experiences. Behavior that may be labeled as lazy or apathetic may be a child’s way to protect themselves from disappointment and grief. Behavior labeled as acting out and disrespectful may be a child’s way to defend themselves against a perceived threat in their environment. It is not uncommon to see a child who has experienced traumatic and stressful situations happily playing one moment while becoming tearful and irritable the next, as children tend to grieve and express emotions in spurts. Children may also be reluctant to express their true feelings and thoughts about trauma and stress because they receive subtle cues from adults that the topic is uncomfortable and they want to protect their parents and other family members from being sad. Given that caregivers, family members, and teachers often underestimate children’s reactions to traumatic events, teaching the CRM wellness skills to children offers them valuable resources during times of stress. The section below provides age-sensitive techniques for teaching the six wellness skills (as developmentally appropriate) to infants, young children, and teens. The skills include Tracking, Resourcing, Grounding, Gesturing, Help Now!, and Shift and Stay.

Wellness Skills for Infants When working with traumatized infants who are preverbal, the wellness skills of Tracking, Resourcing, and Grounding can be utilized. Because infants remember and store traumatic events in their bodies, caregivers can use specific techniques to help the infant remain in or return to their Resilient Zone. The wellness skills are informed by what is known about infant development and can be utilized as a prevention program to promote infant wellness or as part of a larger therapeutic approach designed to assist families who have experienced trauma and who may have developmental challenges. Townley Saye (2022), assistant chief in the Early Start and Health Services of the Department of Development Services of the State of California, stated the following: In my work with families and providers in Mendocino County, the Community Resiliency Model (CRM) provided a foundation to support evidence-based parenting and early intervention/prevention programs

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designed for children and families. The neuroscience nuggets and wellness skills obtained through CRM teachings enhanced the social and emotional development of children while improving the self-efficacy of parents and caregivers. Early intervention and prevention programs for children allow a child to receive services in order to mitigate any developmental delay or disability. However, finding out your child has a delay or disability can be devastating and generate sensations that send the nervous system into either shock, anxiety, or depression. These sensations are often difficult to metabolize, so parents and caregivers may not be responsive in the understanding of or consenting for intervention services for their child. The wellness skills and neuroscience sound bites offered by the Community Resilience Model can expedite a parent’s ability to regulate these sensations, so they are able to make the best service decisions for their child in a timely manner in order to reduce delays and assist any disabilities. Embedding the Community Resilience Model (CRM) wellness skills into early intervention programs can provide the best buffers for both children and families. Moreover, any evidence-based program can benefit from having CRM as the foundation for how the program is supported and implemented. Vested within neuroscience, CRM creates invitational and actionable language for practicing wellness skills that are useful for providers, families, and children. (Saye, T. personal communication, 3/1/22)

Tracking Dr. Peter Wolff and Professor Heinz Prechtl found that infants have six different states of arousal or wakefulness that are associated with different behavioral responses (Shelov, et al., 2004). These states include quiet sleep, active sleep, drowsiness, quiet alertness, active alertness, and crying. Trauma can affect the amount of time infants spend in different states. For example, an infant in a home with frequent parental fighting may resort to controlling their environment by putting them down to sleep as a means of reducing the stimulation. However, when a caregiver is able to track or pay attention to the subtle changes within their infant’s nervous system, they are better able to meet the infant’s needs and are more likely to have a positive experience with their infant and strengthen the development of a secure bond. Both the quiet and active sleep states provide the infant and caregiver the opportunity to recharge and do not require response from the caregiver. However, by observing an infant during the sleep state, one can track two

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distinct sleep patterns. During quiet sleep, the infant will appear very still with a relaxed face and a steady heart and respiration rate. When an infant is in a state of active sleep, caregivers can observe rapid eye movements under the infant’s eyelids along with changes in facial expression and occasional arm and leg movements. During the drowsiness state, the infant is either waking up or falling asleep and may appear somewhat dazed. Picking them up or talking softly to the infant will likely bump them up to the waking states (Shelov et al., 2004). In the quiet, alert state, an infant is at their most responsive, providing the best opportunity for parent/child interaction. In this state, the infant will look directly into the parent’s eyes and will pay close attention to the parent’s words and actions. The newborn only spends a few minutes each day in this state, but this period of interaction and play significantly expands each day. In the active alert state, the infant will begin to move their arms and legs as a form of communication and may look away from the caregiver to indicate that they have had enough and need a small break from interaction. Sometimes an activity that was fun in the quiet alert state can become overwhelming for the infant in the active alert state indicating that the infant is done playing and may be tired, hungry, or fussy. Crying is the last state and is the infant’s way of telling the caregiver that something is not right or a way of releasing tension (Shelov et al., 2004). The first essential ingredient for all caregivers of infants and children is to learn to be in the Resilient Zone as one begins interacting with an infant or child. Tracking an infant’s state can help caregivers learn how to better respond. For example, if a parent attempts to play with the infant during the active, alert state, they may find that the infant’s nervous system becomes overwhelmed, and the baby might begin crying. The stimulation of the parent’s play attempts may bump the active alert infant out of their Resilient Zone. To avoid this activation, parents can track nonverbal cues that indicate that the infant needs a “stimulation break” or is becoming stressed. These cues include the infant looking away, yawning, coughing, sneezing, increased arm and leg movements, hiccups, and crying. Caregivers can then transition to more soothing and less stimulating interactions. When infants are in the quiet, alert state or Resilient Zone, they welcome their parents’ playful interactions. These back-and-forth circles of playful communication are vital for deepening attachment and promoting healthy brain development. Engagement cues that a parent can track—indicating it is time to play—include the infant making eye contact, cooing, smiling, and reaching. For most parents, learning to read their infant’s cues comes

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naturally but for some parents, especially those who have experienced trauma themselves or who feel unprepared for parenthood, these skills will likely require practice and in some cases professional intervention. The benefits of early intervention to teach wellness skills and help caregivers read their infant’s cues cannot be underestimated. By learning the skill of Tracking, parents can improve their ability to read and respond to their infants’ behaviors in a way that promotes parent/child connection, synchronicity, responsiveness and attachment.

Resourcing Infants are born with immature nervous systems that rapidly develop over the first few years of life. During this developmental period the most important resource or sense of comfort for the infant is the caregiver. Infants need support from their caregivers to regulate their nervous systems, as they have few self-coping mechanisms at this early age. Crying is the first way that infants communicate their needs, and most parents quickly learn to distinguish between different types of cries for hunger, fatigue, pain, boredom, or the need to discharge frustration. This latter type of crying typically occurs toward the end of the day and can last for several hours. It is often referred to as colic, which is characteristic of the first three-to-four months of life. Attempting to console a child who has been crying for hours, especially when the caregiver is also exhausted can be frustrating and highly stressful for parents who desire to calm their baby (Brazelton & Sparrow, 2006). Infants are also born with different types of responsiveness to their environment. The overall quality of a baby’s cry and the ability of the newborn to be soothed offer insight into a baby’s temperamental style and the amount of “work” the parent must do to bring the baby back into the Resilient Zone (Brazelton & Sparrow, 2006). For example, a less sensitive baby may be able to take in much more stimuli (e.g., noise, light, and/or touch) and self-soothe when upset by sucking a thumb or fist or by turning away from the stimulation, whereas a very sensitive baby may become upset and overstimulated by too much sensory input and be very difficult to soothe. During times of infant distress, caregivers can keep the following principles in mind when resourcing or providing comfort to their child: 1. Most caregivers do too much when an infant is crying. During these times of activation, less is more. Talking, rocking, and eye contact may be too much. Crying usually calls for reduced stimulation and sensory input but can in some cases indicate under-stimulation as well.

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2. Start with less invasive forms of comforting in order to learn how much help the infant needs to be comforted. Parents or caregivers may want to give the infant a brief moment to see if the infant is able to self-soothe, but children should not be left to “cry it out.” 3. A crying baby can easily bump a parent or caregiver into the High Zone. As such, it is important that the parent tracks their own body, noticing when they are bumped into their High or Low Zone. They can use wellness skills to bring themselves back into their Resilient Zone while caring for the infant. By doing this, the parent is able to not only coregulate with their infant but also begin the lifelong process of modeling skills of well-being. To assist parents in managing their child’s crying behaviors during the first four months of life, several techniques have been developed to help calm the infant. Some of the most useful approaches are described below. Before using these techniques, the parent should ensure that the infant’s crying is not caused by hunger, needing to be changed, being too hot or too cold, or pain. If at any point it is believed that a medical condition exists, the child’s pediatrician, family practice doctor, or nurse practitioner should be consulted.

• Talk softly in a steady voice in a quiet area. • Allow a pacifier or let the infant suck their thumb. (Sucking calms the nervous system.) • Swaddle the infant in a blanket or cloth so their arms and legs are supported (https://www.youtube.com/watch?v=vKIz0HYuLTg). • Hold the infant against your body (skin-on-skin) as physical support can calm the infant. • Hold the infant in a rounded position with the infant’s back against your chest and one hand on the chest and the other hand supporting the bottom. This simulates the womb, and the rounded position calms the nervous system. • Use vertical rocking in a steady, slow, up and down motion. • Reduce the stimulation in the environment. Dim lights, turn the infant away from visual stimulation. • White noise can be helpful for children. There are white noise machines that can be purchased.

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Being able to comfort their infant is empowering for caregivers and promotes confidence in their parenting ability while also strengthening the connection between the parent and child. The infant also implicitly learns to trust that the parent will respond to the infant’s needs. From a developmental perspective, the formation of this trusting relationship builds resiliency and is a foundational task of infancy that can have lifelong implications for how the infant responds to and manages his social environment.

Grounding Grounding techniques are likely to be helpful for traumatized infants who are highly activated and can include anything that helps provide physical support and helps regulate the infant’s body. In this respect, many of the comforting techniques discussed in the above section such as swaddling and skin-to-skin contact with the caregiver can provide the infant with the support they need when experiencing stress. During periods when the infant is not distressed, parents can promote a sense of Grounding or connection to the environment by laying the infant on their back and moving their legs in a bicycle motion, Allowing the infant playtime on the floor is important, as too often infants are kept in carriers for much of the day. Another way to promote connection with the environment is by providing child-safe objects for the infant to hold in their hands and explore. As part of exploring, the infant is likely to look at the object and bring the object to the mouth. These types of sensory experiences are how infants learn about their world and should be allowed. When possible, taking a baby outside to lie on their back to notice the leaves of a tree overhead, the sounds of the city, of nature or other children, to possibly feel a breeze or some sunshine on their skin, can also provide them with a sense of connection to their world. Taken together, these techniques provide the infant with a sense of support and connection with their social and physical environment and therefore promote well-being.

Wellness Skills for Children Play is the central activity for young children and is a necessary component in teaching children the wellness skills. Play relieves sensations of stress, deepens connections with others, and helps children practice skills and roles necessary for survival and growth. By including drawing activities, games,

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storytelling, and music in the learning process, children become engaged and are able to learn through doing. In this respect, the TRM practitioner and CRM teacher are “Speaking the child’s language.” When teaching the TRM/CRM wellness skills to children, the first step is to explain the different zones. Once the zones are explained at an age-­ appropriate level, the child’s resources can be established and intensified. Tracking is taught alongside developing the resource, followed by the skills of Grounding, Gesturing, Help Now!, and Shift and Stay. In teaching the skills, the TRM practitioner or CRM teacher guides the child in how to use the skills when knocked out of the Resilient Zone or Okay Zone. The goal is for children to learn to recognize body sensations associated with being in the High or Low Zones and to develop awareness that they can use the skills to get back into their Resilient Zones. When working with the child, the TRM practitioner interweaves the wellness skills with periods of activation, which acts to reset the natural balance of the nervous system. For children needing therapy, the TRM offers additional therapeutic techniques aimed at reprocessing the traumatic experience.

Helping Children Understand the Zones The Resilient Zone or the Okay Zone as it is called for children is an internal space of adaptability, flexibility, and general well-being. When functioning within this zone, children are able to navigate the ups and downs of daily life. When bumped out of this zone, they can become easily overwhelmed and respond from a reactive place. Some children come into the world with a wider Resilient Zone and can manage many stressors, and some have a very narrow resilient zone and it only takes a small stressor to activate them. One of the benefits of learning the wellness skills is that the practice of the skills can help a child who has a more narrow Resilient Zone widen their zone and feel more successful in navigating difficult situations. Regardless of the size of a child’s Okay zone, life can present traumatic or stressful events that bump a child out of their Resilient Zone. Children can become overwhelmed by these life experiences. They may become stuck in their “High Zone” and respond to everyone around them as if they are a danger or a threat, either attacking or responding with extreme panic or fear. They may also get stuck in their “Low Zone,” experiencing extreme depression, withdrawal, or even dissociation. Children who lack resiliency skills often turn to other sources of comfort when they feel unable to utilize their own abilities to regain a calm and organized state. Alcohol, drug use,

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and unhealthy relationships can provide short-term comfort to the nervous system but pave the way for longer-term difficulties. Bethell et al. (2014) defined resilience in children as “Staying calm and in control when faced with a challenge.” She further stated: Children aged 6–17 who stayed calm when faced with a challenge reduced the negative impact of adverse childhood experiences. Despite higher numbers of adverse childhood experiences, there were higher rates of school engagement among children who were able to stay calm when faced with a challenge.

When children are empowered to pay attention to their nervous systems, they can with intention calm themselves when necessary in order to walk through their lives as their best selves in mind, body, and spirit (Figure 11.1). Zones and Tracking Activity: The Cloth Game can be a fun and educational game to help children understand and experience different sensations connected to their zones. This “felt sense” experience also introduces them to the concept of Tracking. In leading the Cloth Game, select a cloth size that is appropriate for the number of participants (large tablecloths or sheets work well) and invite everyone to stand around the cloth and hold onto the edge of the cloth with both hands. Ask the participants to very slowly move the cloth up and down together as a group.

Figure 11.1  Zones with Emojis

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Continue in this slow and gentle rhythm for a minute or two, and then pause and ask sensory questions such as, “Is your heart beating fast or slow?” “Is your breathing fast or slow?” “Does your body have energy or is it calm?” If the children do not initially respond, the adult can model their own sensory responses, or if a child reports an emotion such as boredom, the leader can ask, “Where in your body do you sense boredom?” Older children may not require as much prompting and can simply be asked, “What do you notice inside?” Take time to explain how this can be similar to the Low Zone when our body sensations are very slow, but when we are in the Low Zone, we might feel much worse. Give examples of the Low Zone (e.g., feeling sad, having no energy, crying, not wanting to get out of bed). Once everyone has had a turn to share (children should not be required to share), invite the group to begin to move the cloth more quickly up and down together as a group. After a period of time, pause and ask the series of sensory questions again. “Is your heart beating fast or slow?” “Is your breathing fast or slow?” “Does your body have energy or is it calm?” Explain how this rapid movement can be like being in the High Zone when our heart is beating fast and it is hard to listen, but in the High Zone we might feel much worse. Provide examples of being in the High Zone (e.g., can’t sit still, feeling scared or angry). Share with the group that it is common for some children to have difficulty and find it unpleasant in their bodies when moving the cloth rapidly. Let children know they have a choice of whether or not to participate and invite them to notice that it is okay to let go of the cloth and move away if the sensations in their body become unpleasant. If a child takes a break, use the opportunity to let the child know that they were reading and responding to their nervous system. While the goal of the Cloth Game is to invite children to notice their different body sensations and teach them about the zones, it is also an opportunity to offer children permission to listen to their bodies in regard to participating and taking breaks. To end the activity, have the group raise the cloth over their heads and say hello to the participants on the other side of the cloth before setting the cloth down and taking a seat in a circle around the cloth. While sitting in the circle, the leader can offer suggestions of moments throughout the day in which the children may find themselves in the different zones (e.g., “If I am jumping up and down and not listening to my mom, what zone might I be in?” “If I am eating my favorite ice cream after winning a baseball game, what zone might I be in?” “If I found out that my best friend was moving to a different school and I didn’t want to get out of bed in the morning, what

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zone might I be in?”). Remind the children that it is a normal part of being human to be bumped into different zones, and that there are skills that can help them to get back into their Okay Zone, so they don’t get stuck in either their High Zone or their Low Zone.

Resourcing Once children understand the concept of the Resilient Zone and have a basic understanding of the body sensations associated with the different zones, the first skill to teach them is Resourcing. Bringing attention to their individual resources helps children learn how to track pleasant and neutral sensations in their bodies. Over time, practicing the skill of Resourcing helps to widen a child’s Resilient Zone so that they have more capacity to navigate the ups and downs of life. TRM practitioners or CRM teachers need to spend sufficient time building and intensifying the child’s resource and not rush this skill. Sensations take time to develop, and it is important to let more pleasant or neutral sensations unfold so that they can be sensed by the child. To intensify the resource, ask the child details about their chosen resource. For example, if a child is drawing and says, “My resource is my dog Sam,” you would reflect this back by saying, “You drew a picture of your dog Sam.” Reflection typically results in the child naturally adding more to the story, but if not, follow up with at least two more questions such as, “Tell me about your favorite time with Sam,” and “What do you like most about Sam?” As the child tells you about the resource, track any observable sensations. For example, “I notice that you are smiling as you talk about Sam.” or “I noticed that when you told me about Sam’s soft ears, you took a big breath.” Then ask the child what sensations they notice inside their body. If it is challenging for them to spontaneously share what is happening on the inside, offer prompts as needed. For example, “What happens with your heart rate, breathing, stomach, or temperature when you talk about Sam?” Take note of any sensations that the child reports are more pleasant or neutral and invite them to spend a few moments noticing those sensations. Children are encouraged to think about their resources any time they find themselves bumped out of their Resilient Zones. When they bring their resources to mind during a time of stress, they can focus their attention on the accompanying pleasant or neutral sensations, becoming aware of all the shifts that happen in their body as they come back into their Resilient Zone.

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Resource Activity: Draw a Resource or a Symbol of a Resource Supplies: crayons, paints, colored pencils, markers, and paper 1. Invite the children to draw personal resources together. If they want to write words around the drawing, this is okay, too. They can draw the colors, vistas, smells, sounds, and textures of their resources. 2. When a resource is identified, deepen the experience of the resource by asking three or more additional questions about the resource. 3. As the child or children share about their resources, ask them to notice what happens on the inside. 4. Reinforce the importance of paying attention to body signals. Do they notice whether they are smiling? Do they feel anything inside their bodies that feels pleasant or neutral? What do they notice about temperature, heart rate, muscles, and breathing?

Tracking Tracking, which is initially introduced through the resourcing exercise, involves teaching children to pay attention to their sensations. For most children using sensory words will be a new experience and will require learning and practice. Taking the time to talk about the meaning of different sensory words and posting the words or meaningful pictures on the wall before doing the activities is beneficial and ensures greater participation. Tracking Activity: The Tactile Box Game is another way to teach sensory language and can be done with individuals or with a small group of children. Up to six small objects of different textures are placed inside a small box, then a large sock is stretched completely over the container. This will allow the child to put their hand in the sock to feel the object inside the container without seeing what is inside. If socks are not available, a paper bag can be used, but note that children will likely look into the bag or pull the objects out before it is time to do so. Before the child starts the game, provide and review a list of sensory words. Next, tell the child the following rules: (1) Pick one object to hold in their hand while keeping their hand inside the sock; (2) Describe the object using three sensory words from the list without guessing or saying what the object is; (3) After listing three or more sensory words, try to guess what the object is and then take it out of the sock. If working with more than one child, have the children take turns. Sometimes the child will want the TRM practitioner or CRM teacher to play as well.

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Grounding Grounding is noticing how the body is supported by the ground or something else like a chair, sofa, bed, floor, or the wall. There are a variety of ways to be supported by a surface, so children do not have to be lying down or sitting up in order to practice the skill of Grounding. Grounding can be interrupted when a child is sitting in a chair which is too tall to allow their feet to connect with the earth. It can be very helpful for some students to put a stool or a thick book underneath their feet while they are sitting so that they have a sense of connection through the soles of their feet.

Grounding Activity: Grounding Like a Tree • Invite each person to stand or sit and begin to imagine that they are a tree with roots holding them firmly into the ground. (Use invitational language, allowing participants to choose whether they would like to keep their eyes open or closed and if they would rather be standing or sitting. Allowing for choice gives children more opportunities to sense into their bodies and notice what feels best for them.) ○○ Imagine you are your favorite tree. Imagine what type of tree you are. Are you a tree of your own design that no one besides yourself has ever seen? Are you tall or short? Imagine what your tree looks like and what you sense on the inside as you become your tree. ○○ Imagine your body becoming your favorite tree. Notice where you want your arms to be—either in the air or by your side. ○○ Notice the trunk of your tree and how your trunk is connected to your feet. ○○ Notice your feet making contact with the ground. You can notice the roots of your tree coming from your feet into the ground. ○○ If you want, you can move your arms slowly into the air as your roots hold you firmly to the ground. ○○ Notice what it is like on the inside to be your favorite tree. Are there places inside that feel strong, happy, kind, or another feeling or thinking word? Bring your attention to the part of your tree that you like the most and notice the sensations. Invite each person to share what they became most aware of as they created their tree and noticed the sensations, thoughts, and feelings.

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While engaging in a grounding activity, it is important to continually be tracking and reading the body’s sensations. Tracking allows the child to not only notice their current sensations but also any changes that have occurred since they began the activity. If the child notices a pleasant or neutral change, invite the child to notice the change and sense the pleasant or neutral sensations.

Gestures and Movements Gestures and movements are already used by children to calm and enhance pleasant sensations. We often make gestures or movements unconsciously when we are happy, joyous, sad, or angry. The skill of gesturing involves bringing conscious awareness to gestures or movements already being used by the child to help their nervous system to calm down. Encouraging them to explore these gestures with mindful attention and intention provides an opportunity to amplify movements that bring joy, happiness, confidence, strength, and peace. To introduce the skill of Gesturing, explain what is meant by a gesture by giving an example of how some children might twirl their hair when they are anxious, some might rub a fingernail, others might put a hand over their heart or rock slowly side to side. Each of these gestures helps to calm their nervous system so that they can remain in their Okay Zone. Children may have a gesture or movement that people have shamed them for doing, like bouncing their leg quickly. Inviting the child to notice the movement of the leg along with all the sensations connected to the movement can be very illuminating and affirming for the child. Explaining these movements as a wellness skill can also be educational to adults who often ask children to stop the movement.

Gesturing Activity 1 Take a few seconds to think about a self-soothing gesture. If you cannot think of one, ask your family members if they have noticed a movement or a gesture that helps you calm down. a. Invite the children to think of a gesture or movement that calms them. b. On the count of three 1…2…3 invite them, with intention, to make their self-soothing gesture.

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c. Ask them what happens on the inside when they make the movement or gesture. Is it pleasant, unpleasant, or neutral? Gestures and Movement Activity 2: The Animal Game allows children to engage in large muscle movements and also connects characteristics such as strength with pleasant body sensations. In this simple game, take turns asking the children to choose and then act like a fast animal, a slow animal, a strong animal, and a powerful animal. Spend time exploring the movements each animal might make and track body sensations after a few moments of acting out the animal. The game can be enhanced by having children draw an animal that makes them feel strong, cut out holes for the eyes, and wear the animal mask while pretending to be the animal. Throughout the game, track sensations, asking “Is it pleasant, unpleasant or neutral?”

Help Now! or Reset Now! Help Now! skills are taught to children and family members for use when the child is well outside of their Resilient Zone. They are designed to help when the child is either stuck in the High Zone or stuck in the Low Zone. In working with children, it is important to practice the skills so that using them becomes automatic in times of stress. It is helpful to explore all the skills during times when the child is in their Okay Zone so that they can determine which of the skills is their favorite. Teachers worldwide have shared that these strategies are very helpful as children can learn to regulate their own nervous systems and feel equipped to better respond to the inevitable bumps of academic and social challenges. Children often feel empowered as they learn to manage their sensory experience which leads to better emotional regulation and clearer thinking. It is also helpful for teachers, parents, and other caregivers to learn Help Now! Strategies to more quickly return to their Resilient Zones if the child’s behavior has bumped them out. See Chapter 3 for more information about the Help Now! strategies.

Help Now! Activity 1: Place the Ten Help Now Strategies around your space. 1. On ten pieces of paper, draw or write down the ten Help Now! strategies, one on each piece of paper. Place each station around your space. 2. Invite the group to walk around the space and spend time at each station, practicing the skill. When you are practicing each skill, track the

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body and notice if the sensations in the body are pleasant, unpleasant, or neutral. 3. Ask the children to identify their “Top 3” Help Now! strategies and think about times in life when they might come in handy (for example, when fighting with parents about homework, during a sporting event when someone is rude or the referee is bad, before a test in your hardest subject, when a friend or sibling hurts your feelings or says something rude that bumps you out of your Zone). 4. Ask how they might like to be reminded of their favorite Help Now! strategies when they get bumped out of their Okay Zone. Invite them to identify someone who can remind them of their favorite Help Now! Strategy when they are bumped out of their Okay Zone. Shift and Stay: Shift and Stay involves the child shifting attention from sensations that are unpleasant to sensations that are neutral or pleasant and keeping their focus there. Shift and Stay is the skill that combines all the elements of the Community Resiliency Model into one simple but effective tool. The skill of Shift and Stay provides the child with many different options. They could be invited to shift from the unpleasant sensation in their body to a place in their body that feels more pleasant or neutral. They could also be invited to notice any place in their body that feels more supported by a surface. Or the TRM practitioner or CRM teacher could ask them a question about their resource and invite them to notice any pleasant or neutral sensations they become aware of while thinking of or talking about their resource. If a child is able to observe shifts in their body, the practitioner or teacher can invite them to stay as long as they would like with those more pleasant or neutral sensations while continuing to notice any other shifts that occur. Invite the child to use Shift and Stay throughout the day whenever they feel they need to shift attention away from something that is unpleasant to sensations that are either neutral or pleasant. Encourage them to simply stay right there with those pleasant sensations until they feel more balanced in their nervous system.

Shift and Stay Activity: A Treasure Box, Bag, or Jar of Wellness 1. Brainstorm: a) Spend time talking about the skills that are most helpful for each child. Notice how each person has individual preferences for skills

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that they find helpful. By sensing into our nervous systems and asking questions about the well-being of others, we can understand and learn to respect both our own and others’ sensory preferences. b) Identify individual resources for each person that help them get back to their Okay Zone. c) Gather items such as paper bags, jars, cardboard or wooden boxes, popsicle sticks, slips of paper, index cards, or other craft items. Scissors, glue sticks, markers, crayons, and paint can be used for decoration. 2. Create the Treasure Box, Bag, or Jar of Wellness. a) Invite each child to decorate their box, bag, or jar. b) After decorating the container, choose either popsicle sticks, slips of paper, index cards, or other craft items to identify the wellness skills. c) Invite each child to write or draw three to ten wellness skills onto the popsicle sticks, slips of paper, or index cards. Various other items can also be used as symbols for the wellness skills, such as stickers, pipe cleaners, small tokens, rocks, leaves, charms, items from nature. d) All sticks, slips of paper, and tokens are placed into the Wellness Container. 3. Practicing Skills when in the Okay Zone a) Adults model practicing the skills by periodically picking a wellness strategy out of their Wellness Container and practicing it. After practicing it, be sure to share what you are noticing on the inside that is more pleasant or neutral. b) Children are encouraged throughout their day to choose an item and practice the strategy either by themselves or with their caregivers. c) If children are hesitant to practice, invite them to pick a skill from the Wellness Container and observe their caregiver practicing that skill. 4. Accessing skills when bumped out of your Resilient Zone. a) Place the container in an area that can be easily accessed. b) Once the adult or child becomes aware of distress, they are encouraged to pull a slip of paper or stick from the container and engage in the chosen strategy. 5. Notice sensations. a) When engaging in the strategy, if another person is present, they can encourage each other to notice pleasant or neutral sensations that help them return to their Resilient Zone.

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b) Adults and children can learn to ask the questions, “What do you notice on the inside?” “Is the sensation pleasant, unpleasant, or neutral?” Technology opens up additional resources. When schools were closed during the pandemic, one school district created a wellness room online through a google document, with different portals representing the wellness skills including Resourcing, Grounding and Help Now!—for example, animals, scenes in nature, sporting activities, and music. Children can be encouraged to create their own wellness room representing the skills of CRM on Google. The portals can then be individualized for each child. This allows the child the freedom to engage in these activities as needed.

Wellness Skills Specific to Teens The CRM wellness skills activities used for adults can also be helpful for teens. However, each teenager will have a different level of maturity and interests, so many of the ideas presented in this chapter for children will also be enjoyed by teenagers. Adolescents are in an intense phase of brain development and are exploring challenging constructs about the world around them politically, environmentally, socially, and spiritually. Relationships are central to their well-being, and relational challenges can often be highly distressing and activating to their nervous systems. When adolescents present in a place where “everything sucks,” gently introducing a resiliency pause and inviting them to notice “What else is true?” can be helpful in slowing down the story of distress and inviting attention toward a small thing of pleasure, such as the feeling of a breeze on their face, the softness of the inside of their sweatshirt, or the funny way their cat slid across the kitchen when it heard the can of food open. It is important when introducing a resiliency pause to first acknowledge the reality of the part of life that “sucks.” By inviting students to move their attention towards “What else is true?” practitioners and caregivers are not attempting to diminish the weight of challenging life experiences but are offering the brain and body the space to come back into their Resilient Zone so that the teen can face the day as their best selves. Educating a teen about the brain and the negativity bias of the amygdala can also generate curiosity and provide buy-in for adopting these wellness strategies as part of their daily habits. If a teen is in crisis, resourcing questions are also helpful for restoring balance to the nervous system. Often the first question we ask a distressed teenager is

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“What’s wrong?” or “What happened?” And while telling their story may be an important part of the journey back to well-being, sometimes retelling the narrative can intensify the body’s experience of distress. Some r­ esourced-based questions that can help in the midst of a difficult time include: • What or who is helping you get through right now? • What has helped you get through hard times in the past? Taking a resiliency pause to ground can also be helpful during the telling of a difficult story: • Sometimes when you are telling a hard story, it can help to pause and notice something that is offering you support in the present moment. • Is there anything that you would like to touch that would bring you a sense of comfort? • Would you like to pause to take a sip of water? When teachers and caregivers can offer teens the opportunity to speak about “What also is true?” they are expanding awareness to sensations that may feel more pleasant or neutral and allowing the body to gently move back toward the Resilient Zone. While the challenging situation may still continue, the student is also moving forward with new thoughts, feelings, and ideas as they experience sensations in their body that are less distressing. Another way to effectively engage teens in learning wellness skills is through the creative arts– working with music, art, drama, and technology. Many teens have become highly adept with social media and platforms like TikTok or Instagram, and these platforms can be creatively used to showcase videos of their favorite skills. Sharing skills with others is a powerful way to deepen the use of skills for themselves.

Skills Activity: Media Resourcing Using Writing, Art, Video, and Photography 1. Invite the teen to pick their favorite skill. If they picked Resourcing, invite the teen or a group of teens to think of one resource and give the choice of telling about it by writing a narrative about it, creating a video, creating a skit, or drawing a picture of it. If they have a smartphone, you can ask them to open their favorite photo on their phone that is resourceful to them. This exercise can be used with each of the CRM wellness skills.

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2. As the teen(s) share their creations, track sensations by observation (“I notice smiles and laughter …”) and by asking the teens what they notice inside their bodies. Remind the teens that they can go back to thinking about their resource any time that they feel bumped out of their Resilient Zone. 3. You can use this as a group activity by dividing the group into dyads or triads and invite the teens to share their favorite wellness skills with one another. Invite the teens to pay attention to sensations as each teen takes turns. Educate them about the questions, “As you share with us, what do you notice on the inside? Has your breathing, heart rate, or muscle tension/relaxation changed?”

Conclusion This chapter is intended to help TRM practitioners and CRM teachers and guides understand how to use the TRM/CRM wellness skills with children within the context of developmental considerations. It also provides age-­ appropriate activities to aid in teaching the wellness skills to this population. While this chapter does not provide an exhaustive list of TRM/CRM adaptations needed for working with children, it does provide a valuable foundation for understanding how children can benefit from and be empowered by this strength-based approach.

References Bethell, C., Newacheck, P., Hawes, E., & Halfon, N. (2014). Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience. Health Affairs, 33(12), 2106–2115 Brazelton, T. B., & Sparrow, J. D. (2006). Touchpoints birth–3: Your child’s emotional and behavioral development (2nd ed.). Cambridge, MA: Da Capo. Shelov, S. P., Trubo, R., & Hannemann, R. (2004). Caring for your baby and young child: Birth to age 5 (4th ed.). New York: Bantam Books.

Part IV

The Trauma Resiliency Model (TRM) and Clinical Integration

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Attachment Strategies and Adult Behavior Elaine Miller-Karas and Jennifer Burton Flier This chapter will: 1. Describe attachment strategies related to adult behaviors 2. Define Steven Porges’ Polyvagal theory and its importance to the treatment of trauma 3. Describe the multi-step approach of TRM treatment for adults: Creating Safety, Family Integration, Trauma Reprocessing, and Wellness 4. Discuss Disorganized Attachment and treatment of individuals with Dissociative Parts For infants, the primary influence on healthy development involves the relationship between the child and their primary caregiver. The emotional bond that forms between child and caregiver early on in life—the attachment relationship—profoundly shapes an individual’s behaviors and the way they interact with their environment throughout childhood, adolescence, and adulthood. The therapist’s consideration of the client’s attachment strategies learned in childhood can provide insight into how their nervous system responds when developing secure and adaptive/insecure attachment patterns. Accordingly, integrating our understanding of the effects of attachment strategies on the nervous system with current TRM concepts and methods helps the practitioner learn new ways of integrating TRM methods into treatment, especially in helping clients with dissociative symptoms. Attachment theory’s primary tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally (Bowlby, 1973). Attachment behaviors are identified as attempts made by a child to gain proximity to their primary caretaker in times of stress. The theory suggests that the quality of the infant’s attachment relationship can be classified according to specific observable attachment strategies and these strategies form in response to the many DOI: 10.4324/9781003140887-16

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interactions an infant has with their caregiver over time. The categories of observable attachment strategies are especially salient in the infant’s behavior during periods of separation and reunion with the caregiver (Ainsworth et al., 1978). Furthermore, these patterns of attachment can create enduring templates that guide an individual in interactions with their environment throughout their life. The basic patterns of attachment can be divided into secure and insecure attachment. The insecure attachment category can be further subdivided into insecure-avoidant and insecure-ambivalent. There are some who would add disorganized as a third category of insecure attachment. However, we argue that it is a stand-alone category because unlike secure and insecure patterns that are marked by fairly consistent and organized patterns of behavior, the behaviors observed in individuals with disorganized attachment are inconsistent and unorganized—thus, the name of the category. Poole-Heller (2019) uses the term “attachment adaptation” which are strategies other than secure attachment strategies. She writes, As babies, we need our parents to survive; we don’t have any choice in the matter. We adapt according to whatever capacities they possess or lack. On a foundational level, we respond and grow according to whatever works and doesn’t work.

This is a respectful and resilient way to view people’s relational issues, without pathologizing them. We tend to have predominantly one attachment style. It is helpful to view these styles on a continuum. As such, we can move in and out of these adaptations depending on what is happening in our lives. The attachment strategies, or adaptive patterns, applied to adult behaviors—through the lens of TRM—are as follows:

Secure Attachment People with secure attachment likely had primary caregivers who offered attuned, reciprocal, somatic, and verbal communication in response to their needs as a child. They trust others, have lasting relationships, high self-­esteem, are comfortable sharing their feelings, and will seek out social support when in distress. Regulatory areas in their prefrontal cortex support social engagement and access to the Resilient Zone through the regulation of the autonomic nervous system, allowing them to accurately evaluate risk, danger, and life-threatening situations.

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Insecure-Ambivalent Attachment People with insecure-ambivalent attachment likely had primary caregivers who were often inconsistent and had unpredictable responses (e.g., were either overly intrusive or non-responsive) to their needs as a child. They may become overly preoccupied with and worried about interpersonal relationships. For example, the person may worry whether their partner loves them or whether their friendship networks accept them. These individuals seek social engagement and co-regulation but have difficulty being soothed or calmed within a relationship. There is simultaneously a desperate need for the other and a fear that their needs will never be met. Ambivalently attached adults have difficulty self-soothing and have a tendency to be stuck in the High Zone, with increased emotional reactivity.

Insecure-Avoidant Attachment Adults with avoidant attachment patterns likely had primary caregivers who actively blocked efforts to be physically close and/or appeared indifferent to their needs as a child. While they may want social and/or romantic relationships, they invest little emotion in them. They have difficulty sharing thoughts and feelings with others as well as difficulty perceiving others. They may even have difficulty recalling their childhood. Thus, they are highly reliant on logic and tend to have reduced sensory awareness and reduced capacity to experience positive or negative affect. They may have a limited ability to experience pleasant and/or neutral sensations and may describe feeling numb; they are often stuck in the Low Zone. They may have learned to regulate their nervous system by engaging in solitary activities, given their primary caregiver’s rejection of proximity. It is also important to distinguish avoidant attachment patterning from someone who may be neurodivergent, as some neurodivergent traits may look like avoidant attachment, but are not necessarily part of this category.

Disorganized Attachment Individuals with a disorganized attachment pattern likely had a childhood marked by traumas including neglect, physical, and/or sexual abuse. It is likely they were abused or neglected by their caregiver, which created a dilemma of the caregiver as both the source of fear and the source of reassurance. Poole-Heller (2019) asserts that the main contributor to disorganized

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attachment is when parents are the source of fear. As such, by age one, these individuals tend to display mixed avoidant and resistant behaviors that can continue into adulthood. An adult with this pattern can have significant difficulties with a coherent sense of self. Beebe et al. (2010) demonstrated that one year of disorganized attachment during infancy contributes to dissociative behavior. Schore (2009) stated that early abuse and neglect generate disorganized-disoriented attachment, which endures into adolescence and adulthood, and acts as a risk factor for later psychiatric disorders. He further elaborated that from a developmental neuroscience viewpoint, early abuse and neglect have immediate impact on critical growth periods that results in an immature right brain with a limited capacity to regulate intense affective states. In the most severe cases, the person can experience fragmentation, meaning they develop multiple “parts” of their personality. The individual with parts may display erratic behaviors with fluctuations between Low and High Zones. They may not be aware of ever being within the Resilient Zone. Secure attachment eventually helps establish a sense of “self” and the ability to experience safety in interpersonal relationships. In contrast, insecure attachments can have long-lasting repercussions resulting in challenges to one’s sense of self and to forming healthy interpersonal relationships. However, these attachment patterns are not fixed. Though they may be resistant to change given their basis in enduring patterns of interpersonal interactions, they are not set in stone. They can change. TRM skills, especially the first six skills when practiced alone or with a trusted partner or therapist, can greatly aid in stabilizing the nervous system and helping a person sense into and reinforce secure attachment. Applying Polyvagal Theory to the attachment strategies can help us use the lens of neuroscience to create treatment plans that consider the human being’s elegant design and capacity to regulate the nervous system to change lifelong patterns. In recent years, Polyvagal Theory has come under some criticism; however, we have found Porges’ contribution to be both valid and helpful in further understanding the autonomic nervous system. Employing knowledge of Polyvagal Theory assists the TRM practitioner in deepening their application of TRM skills while also providing valuable psychoeducation to clients, thus further reducing shame for their biological responses to real and perceived threat. Porges (2021) writes that the Polyvagal Theory has provided a testable model of how the autonomic nervous system reacts to threat and safety. The theory gives voice to the personal experiences of individuals who have experienced chronic threat (i.e., trauma and abuse) and structures an optimistic journey toward more optimal mental and physical health.

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Polyvagal Theory Stephen Porges (1995) posits in the Polyvagal theory that the autonomic nervous system is a complex and hierarchical system responding directly to environmental challenges. The vagus nerve is the longest cranial nerve, and it is the main component of the parasympathetic nervous system. The vagus nerve is not a single nerve, but rather a bundle of nerves inside a sheath that travels from the brain stem to the heart and stomach and upward to the face by connecting to the other 11 pairs of cranial nerves. The vagus works bidirectionally sending communication between the body and the brain. As such, 80% of its fibers are sensory (afferent), from the body to the brain, while only 20% are motor (efferent), sending action information from the brain to the body (Dana, 2018). This is essential information for TRM practitioners and can be a wonderful piece of psychoeducation for clients. If we aren’t tracking the body, we are missing a very large piece of the puzzle. Polyvagal Theory describes three different subsystems: 1. Parasympathetic ventral vagal system (social engagement system) 2. Sympathetic system (in charge of fight/flight responses) 3. Parasympathetic dorsal vagal system (in charge of immobilization/shutdown and freeze/dissociative states) This hierarchical system works in such a way that the most evolved ­response—social engagement—is utilized first. The social engagement system stimulates psychological states that promote social behavior, communication, and social bonding. This allows for flexibility and adaptability to the environment. Individuals with secure attachment patterns are able to socially engage to develop relationships with others and have a stronger sense of self. In the TRM, we call this being in the Resilient Zone. Dana (2018) shares that the ventral vagus influences our heart rate, slowing during exhalation and speeding up during inhalation. The vagal brake works “by suppressing the heart rate to approximately 72 beats per minute through its influence of the heart’s pacemaker, the sino-atrial node.” Much like the hand brakes on a bicycle, as the brake is released, we can accelerate, and when the brake is applied, we slow down—energizing and then calming; this is an optimal sympathetic (while inhibiting the release of cortisol and adrenaline) and parasympathetic response and helps us navigate the ups and downs of a regular day. Again, in TRM terms, as we move smoothly through daily transitions, the vagal brake maintains ventral vagal regulation, or the wave, in the Resilient Zone.

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When a person is impacted by trauma, the vagal brake is affected, and a person can be pulled quickly into a survival response. These clients missed the co-­ regulation from caregivers in childhood needed to exercise the vagal brake. As such, the loss of the vagal brake causes the sympathetic nervous system to take control, followed by the dorsal vagal system—either moving back and forth between the High and Low Zones, or getting stuck in the High or Low Zone. This is evidenced in clients who have predominantly anxious-ambivalent, anxious-avoidant, or disorganized attachment patterns. Using TRM skills of Pendulation and Titration can assist clients in exploring the safer engagement and release of the vagal brake (Payne, Levine, & Crane-Godreau, 2015), thus aiding the client in both sensing into and deepening the Resilient Zone. Chitty (2013) states that if trauma and stress occur repeatedly in childhood, the individual as an adult may be unable to access the social engagement system when stressed and may instead respond from one of the other two systems. That is, if social engagement fails, the individual will proceed to the sympathetic system and finally to the most primitive—the parasympathetic dorsal vagal response. Thus, the insecure-avoidant, insecure-­ambivalent, and disorganized attachment strategies likely develop as a response to the more primitive sympathetic system or the parasympathetic dorsal vagal system. In TRM language, trauma impacts the availability of the social engagement system, narrowing the bandwidth of the Resilient Zone. Without intervention, a person will exhibit difficulty self-regulating, often vacillating between being stuck in the High and Low Zones. This vacillation and becoming stuck in either zone can make it difficult to form lasting, healthy social relationships and to have a secure sense of “self.” Accordingly, a person with disorganized attachment primarily responds to his environment via his parasympathetic dorsal vagal system. When the dorsal vagal system is triggered by past trauma, an individual sees his world through the lens of past memories, resulting in a potentially inaccurate assessment of the current environment. This is evident particularly in reference to danger or safety. Porges (2011) calls this “faulty neuroception,” which can result in a person perceiving danger in a safe situation, or conversely, perceiving safety in a dangerous situation. Now for the good news: If someone has not experienced secure attachment in childhood, they can achieve and “learn” secure attachment through other relationships in which there is security, allowing for healthy attachment to develop, often referred to as “earned-security” (Roisman, Padrón, Sroufe, & Egeland, 2002). This capacity is part of the elegant design of the nervous system and is a testament to neuroplasticity and our ability to “rewire” our

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nervous systems. When individuals learn to become aware of pleasant and/or neutral sensations connected to attuned relationships, new neuronal pathways are created, and nervous system stabilization results. The person is less likely to go into dysregulated states that lead to physical and emotional distress. New possibilities and hope abound that open up portals for greater self-awareness and compassion for self and others.

Impact of COVID-19 on the Nervous System—a Polyvagal Perspective During the global pandemic, the need for social distancing has inhibited our opportunities to connect, be present with one another, and experience compassion. A study conducted on 1,600 responders in the United States looked at the correlation between people’s current autonomic state and their response to the pandemic (Kolacz et al., 2020). The study showed that participants who experienced increased defensive reactions in their autonomic nervous system related to the COVID crisis also expressed increased fears about health, finances, and increased feelings of social isolation. It also showed clearly that participants with trauma histories and post-traumatic stress disorder (PTSD) symptoms expressed higher COVID-related worry. The experience and expression of compassion is a shared feeling state that both increases our sense of trust and dampens defenses. This is the social engagement system, or ventral vagal system, in action—the very thing we were all told to avoid. When the threat/stress response is activated in the nervous system in our attempts to avoid contracting COVID along with our inability to fulfill the biological imperative to connect with others to feel safer and calm, this creates competing demands neurophysiologically. Porges (2021) states, “Avoiding being infected triggers a chronic mobilization strategy that downregulates our capacity to calm through social communication and connectedness.” The resources many of us use to feel settled became dangerous, thus furthering the threat response in the system. While the use of telehealth and other computer options has assisted in accessing co-­regulation, therapists and clients have had to make a lot of adjustments for this shift in conducting therapy. The disembodied nature of screens mainly used for streaming, scrolling, or other sources of entertainment have become essential to remaining connected to one another as well as being a necessity for conducting therapy. Recognizing the challenges is helpful in navigating this new landscape, as we are adjusting our neuroception and refining for vocal tone, facial expression, and head gestures.

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For the TRM practitioner, Tracking our own nervous system has become even more essential when conducting telehealth sessions. The more the TRM practitioner is grounded and in the Resilient Zone, the easier it is for the client to be in their zone as well. When conducting telehealth sessions, the TRM practitioner also needs to be more aware of transitions—hellos and goodbyes—as our ability to make a more gentle transition from the waiting room to therapy office has been removed. Helping the client track their nervous system in relation to their proximity to the screen increases the likelihood of the client coming into their Resilient Zone at the beginning of a session. If the client is at home during a session, provided there are resource spaces available, the TRM practitioner can also invite the client to locate resources in the environment and/or move themselves to a place in the home that is most comfortable for them. Given that we are at times conducting sessions with a client in their own office or car, similar Resourcing and Tracking can help increase the therapeutic alliance, deepen the Resilient Zone, and thus bring the client into the ventral vagal system. Finally, it is important to note that some clients who identify as neurodivergent might not experience the same feelings of isolation due to the pandemic need for social distancing, as the internal sense (neuroception) of safety or connectedness is experienced through solitary activity and not through social interaction. The TRM practitioner needs to remain attuned to this possibility by remaining a half-step behind and inquiring how each client experiences connection. A multi-step approach will be utilized to highlight how to use TRM skills in the context of clients’ attachment strategies. Nijenhuis et al. (2004), van der Hart et al. (2006), and Poole-Poole-Heller (2019) support a multi-step approach. We have added a fourth step: family integration. The multi-step approach will be divided into two sections: (A) insecure-ambivalent and insecure-avoidant attachments and (B) disorganized attachment.

Insecure-Ambivalent and Insecure-Avoidant Attachments: Step-by-Step Step 1: Creating Safety Creating safety by learning to experience sensations connected to attunement and pleasant and/or neutral experiences in the present moment is critical for those who have experienced insecure-ambivalent and insecure-avoidant attachments. Many individuals who seek treatment have had insecure attachments. When the TRM practitioner assesses that secure attachment did not exist, stability and safety within the nervous system can be established

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through the relationship with an attuned therapist and through bringing the client’s awareness to safer personal relationships with, for example, a teacher, spiritual leader, family member, friend, or co-worker. The TRM practitioner uses the skill of Tracking to monitor the autonomic nervous system of the client, similar to the way an engaged parent monitors the reactions of an infant. Healthy attachment that was lacking in childhood can be created in the present moment, paving the way for increased connection and social engagement. The adult client is invited to sense the pleasant and/or neutral sensations connected to being safely socially engaged. There may be safer relationships within the client’s social network, but the client’s tendency to be stuck in the High Zone or Low Zone may make the person unaware of those relationships. Tracking pleasant and/or neutral sensations connected to interpersonal relationships is a key element in helping the individual learn there is a way to gain greater security. As the person becomes aware of sensations connected to an attuned presence, their nervous system can come into balance increasing the client’s ability to bounce back to their Resilient Zone more readily. It is the attuned therapist who provides the gateway that can then be generalized to other relationships. Cognitive models of intervention can be useful in understanding how parental lack of attunement resulted in problematic behaviors for the client. However, this knowledge does not necessarily translate into changed behaviors and nervous system regulation. Integrating the vocabulary of sensation can begin to change long-held patterns as the client becomes aware of sensations connected to attunement— something that was missing in childhood. A client with a trauma history, including being abandoned as a baby and having traumatic experiences in his adoptive family, identified with being stuck in the Low Zone frequently, which he described as being “frozen” in public and social situations. He had trouble with his wife, feeling alternately disconnected and wishing for connection, which led to explosive arguments. Key concepts of the TRM were explained and he was introduced to Tracking through Resourcing. He was able to build resources fairly quickly and use them daily to assist with the “frozen” sensations. However, whenever he perceived a lack of attunement by the therapist, he would “move away” from treatment, missing sessions and feeling anger toward the therapist. Beginning with the therapy relationship and extending out to friendships, family, and ultimately his marriage, he could sense the urge to either pull away or fight (stuck in a fight/flight response). The therapist helped the client

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understand the attachment strategy that he used as a child to survive. In addition, the therapist, understanding this attachment dynamic, remained constant and continued to support the client with sensory awareness, education, and wellness skills. As the client learned to better track his sensations and distinguish between sensations of well-­ being and positive attachment versus those that bumped him out of his Resilient Zone, the bandwidth of his Resilient Zone expanded. He incorporated wellness skills into his activities of daily living. His relationships deepened, and he reported increased awareness as well as an elimination of the sensations connected to freezing in social settings.

Step 2: Family Integration Integrating family therapy into the treatment plan can help untangle behavioral patterns that are causing distress within the family system. Without conscious awareness, individuals may choose a partner with similar characteristics to a parent’s ambivalent or avoidant parenting patterns. When clients are educated about the autonomic nervous system and the survival brain being set off by the amygdala, they can gain a biological perspective to behaviors that may not make logical sense. Helping individual family members learn to track their own nervous systems in order to learn to come back to their Resilient Zones when bumped out can reduce the stress experienced by other members of the family. As the ability to track one’s own nervous system expands, family members can also help others in the family return to their Resilient Zones when they notice they are bumped out. Individuals within the family learn to change old patterns by Tracking sensations connected to long-held beliefs, thoughts, and feelings, and by learning to track sensations connected to more adaptive ways of interacting. Additionally, teaching family members about the Resilient, High, and Low Zones can provide both a common language as well as a shorthand way to communicate with one another about what they are experiencing. Katherine initiated therapy to work specifically on childhood trauma, but she presented with significant difficulty in her activities of daily living, including organizing her busy schedule with two young children as well as communicating with her husband. Prior to any trauma reprocessing, it was clear that Katherine would need to be educated about the six wellness skills as well as biological responses to trauma and stress. As she

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learned the wellness skills, she requested her husband be taught them as well to help them communicate. Once in the therapy room, it became evident that while Katherine had an insecure-ambivalent attachment style, her husband had an insecure-avoidant one, and this was at the core of their communication issues. She was more often stuck in the High Zone when triggered, and he would become stuck in the Low Zone in response, causing her to feel abandoned. Both were educated in the wellness skills and encouraged to track their nervous systems and use skills of Grounding and/or Resourcing before engaging in important conversations. Subsequently, they reported that having the common language of the Resilient Zone reduced the criticism and blame in their interactions. This paved the way for them to learn about their attachment styles and find ways to meet one another’s needs in more healthy ways, which, in turn, deepened the Resilient Zone of the whole family system.

Step 3: Reprocessing Trauma Some clients may not be able to identify anyone in their lives who has provided a sense of safety and may find it difficult to track their nervous systems. Their experience with adult caregivers was so inconsistent and lacking that Tracking even pleasant sensations can trigger a numbness (stuck in the Low Zone) or agitation (stuck in the High Zone). The practitioner can suggest identifying a nurturing and supportive resource from characters in books or movies, or from the client’s imagination. The TRM practitioner can begin by asking the client to name the qualities of nurturing and supportive people. Once the client develops one or more nurturing resources, the TRM practitioner can gently suggest that the client notice the sensations connected to thinking about the resource and the qualities that are nurturing. This will intensify the resource, and the more that the client can bring their awareness to this presence in between sessions, the more they can begin to experience their Resilient Zone. The more time spent in the Resilient Zone, the more opportunities for social engagement that can begin to transform the client’s interpersonal relationships.

Step 4: Wellness Clients will begin to share an increased ability to manage the activities of daily living with less distress and greater capacity to manage the challenges

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of their lives. Interoceptive awareness and learning to track sensations connected to old patterns open a new perspective of biological states. These states can lead to behaviors that do not serve the clients’ lives in adaptive and constructive ways. This new awareness also opens the portal to sensations linked to wellness and growth. The client is encouraged to continue to cultivate the sensations connected to well-being by practicing the CRM/ TRM wellness skills.

Disorganized Attachment (Distinct, separate states that may exist within one person will be called “parts.”) The person with a disorganized attachment pattern can be incongruent—at times demonstrating excellent decision-making and reasoning and at other times acting in ways that are in direct opposition to healthy functioning at home and in the workplace. They can alternate between shutting down and hyperarousal. Poole-Heller (2019) further identifies that someone might present as “disorganized avoidant,” where high stress or threat cause fear and withdrawal, or alternately someone might present as “disorganized ambivalent,” where stress or threat cause extreme clinginess, excessive need for reassurance, and intense worries of abandonment. People with a predominantly disorganized attachment pattern tend to have a more narrow Resilient Zone, and often initially in treatment will report an inability to sense their Resilient Zone, but have a fairly good awareness of the High and Low Zones. Affect regulation is also particularly difficult for individuals who have experienced disorganized attachment. Blizard (2003) states that disorganized attachment may result from several parental behaviors, including abuse; neglect; a frightening, intrusive, or insensitive manner; and disrupted affective communication. She goes on to state that according to longitudinal research, disorganized attachment in infancy predicts dissociation in childhood and adulthood. Liotti (2006) states that disorganized attachment is in itself a dissociative process and predisposes the individual to respond with tertiary structural dissociation to later traumas and life stressors. Tertiary structural dissociation applies to individuals with three or more parts. The parts can have individualized senses of self, including their own names, genders, and specific preferences. In such cases, childhood traumas become stuck and are not integrated in the person’s life narrative. As a result of the unprocessed childhood trauma, the personality becomes divided into “parts” that remain fixated on the traumatic experiences. Therefore, dissociation is part of the elegant design to protect children who have experienced the horrors of severe childhood

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maltreatment. As a result, some individuals develop distinct parts that each carry varying aspects of the memory of the traumas so that the individual can go forward in their life and attend school, work, make friends, and participate in life without having to live with the memory of the traumatic events. We purposefully do not discuss the diagnostic criteria for dissociative identity disorder (DID) but highly recommend Brown (2011) for more diagnostic and therapeutic information about DID. While we realize and acknowledge the importance of accurate diagnosis and treatment planning, we have not found it clinically helpful to name dissociation as a “disorder.” We view dissociation as a “biological reaction” with ramifications to every aspect of human existence. We concur with Dell (2009) when he states that spontaneous, survival-related dissociation is part of a normal, evolution-selected, species-specific response; this dissociation is automatic and reflexive and is one part of a brief, time-limited, normal biological reaction that subsides as soon as the danger is over. However, for many people, the dissociative process lingers and can steal away present-moment awareness. When helping people with dissociative parts, it is critical to enhance their understanding of the dynamics of their internal world and how to collaborate with the competing needs and demands of their parts including understanding the underlying sensory experiences of each part. The parts that carry the memory of the traumas often experience flashbacks or frightening body memories. Some parts may be outside conscious awareness of other parts. A client may report losing time and/or feeling very young at times. They may report sensations of numbness or feeling nothing. Even sensing what may be a neutral or pleasant sensation may quickly transform into a sensation connected to fear and terror and then disconnection. As one client shared, “My world is a landmine of triggers.” Helping the client understand dissociation and how this biological reaction actually helped them in their childhood survive their abuse is helpful in reducing shame and increase understanding. Boon, Steele and van der Hart (2011) describe in general terms different categories they have identified in their work with people with parts. We have adapted their work to include additional categories. They describe: 1. Young parts who are younger than the chronological age of the person’s actual age. They are stuck in a developmental stage when they experienced a traumatic event. Young parts can include infants who do not yet have language. Young parts can include developmental stages of young children who cannot yet read or write and those stuck in the adolescent developmental stage.

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2. Helper parts are those that care for other parts of the system. Helper parts can help soothe a part who is younger, for example, to help regulate the system. 3. Parts who Irritate Others hold anger and other parts may find their behaviors and actions unacceptable. They exist to protect; however, their methods may be abhorrent to other parts of the system leading to inner chaos at times. 4. Ashamed parts carry the shame of the actions of other parts and this shame can be paralyzing. We have added: 5. Survival Response parts. Not only does this include being stuck in fight response, it also includes parts that flee and freeze when a threat is perceived from the outside or from another part. As a result of the existential nature of the abuse these individuals may have experienced, they may be always ready to fight or flee on one end of the spectrum or go into a state of immobility—the freeze state—on the other end. All three of these states are biological responses of the nervous system. 6. Parts who want to die. Many systems either have a specific part or a number of parts who regularly have thoughts of suicide. It is important when working with a person with parts to ask to speak to that part and conduct a suicide risk assessment and create a safety plan. The TRM practitioner can also call on other parts who can help a part with suicidal thoughts not harm themselves and inquire how the whole system may be able to help and create a safety plan for the part thinking about self-harm. 7. Sage parts carry wisdom about life and may have an overall knowledge about the motivation behind the behaviors of their parts. One client who was in her 30s described her sage part as being a gray-haired 60-yearold who regularly gave advice filled with compassion. These basic categories can help the client begin to understand the dynamics of their system. Many clients can describe their system in dynamic ways and others may not have known about their parts until coming to therapy. Inquiring about what the client may call the parts of their system can help develop a therapeutic alliance. In addition, the TRM practitioner can request to talk to a part that is not the part who is “out” in the session to help to get greater clarity about challenges the client is facing. Similar to family systems work, doing a genogram of the system and their relationships with one another can help the client gain greater understanding and assist the TRM practitioner in treatment planning.

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Nijenhuis et al. (2004) distinguish between narrative and traumatic memories: Narrative memories are verbal, time-condensed, social and reconstructive in nature, whereas traumatic memories are often experienced as if the once overwhelming event were happening here and now. These experiences consist of visual images, sensations, and motor actions, which engross the entire perceptual field.

These traumatic memories are timeless and fixed. In TRM, we call these memory capsules. Thus, interventions that help individuals learn to track sensations connected to their traumatic memories can help change the sensory experience in the present time, thereby creating a new memory capsule with different sensations that are no longer fixed. Since the aftermath of disorganized attachment is a whole mind-body experience, biologically-based models like the TRM offer interventions for individuals who experience dissociation. The client can learn to shift awareness from the traumatic memory to present-moment awareness, thereby dampening the intensity of traumatic flashback. Each part can learn how to regulate their nervous system. When the client has skills based on present-moment awareness, they can use the skills when not in session and learn that they have an internal locus of control. Parts can move out of the traumatic memory and learn new skills of self-regulation. TRM skills can be transformational for individuals who live with dissociative parts. The following are steps the TRM practitioner can take when working with a client with parts:

Step 1: Creating Safety Creating a therapeutic alliance with a person who has a fragmented sense of self can be challenging. One part may experience greater safety within the therapeutic relationship. Another part within the same person may be highly suspicious of anyone who demonstrates kindness or concern. The perceived kindness can be coupled with fear as the client’s biographical history may have included a primary caretaker who at times gave nurturance and also physically or emotionally abused or neglected them. The TRM practitioner may feel that a positive connection has been made with the client, and then the client may cancel and terminate further treatment. As one part senses connection, another part is fearful of the intrusion. This is an opportunity to engage with the client with understanding and compassion and explore which part is discontinuing therapy. The therapist can acknowledge

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the client’s need for more distance and support their need to seek safety. This approach can be a portal to greater understanding and a stronger therapeutic alliance. The TRM practitioner modifies the TRM wellness skills depending on the developmental age of the part presenting. Providing stuffed animals, materials for drawing and sand play, and toys is essential in engaging younger parts to help create a greater sense of safety through play and to begin to sense pleasant and neutral sensations in present-moment awareness. See Chapter 11 for ideas about working with children to create safety. As many parts can exist within one person, each part can improve their own sense of greater safety by developing resources. As one part becomes aware of sensations of safety in the present moment, the whole system can begin to be helped.

Mary presented with a highly volatile relationship with her husband. As therapy progressed and a therapeutic alliance developed, the TRM practitioner and Mary became more and more aware of Mary’s lapses in time and the existence of parts. Mary had some co-consciousness with some of her parts and described a younger part that would direct Mary to toy stores to buy Barbie dolls. Mary came to one session dressed differently: she wore shorts, her hair was in pigtails, and she was carrying a Barbie backpack. This was her first presentation as Trudy. Trudy stated in a high-pitched voice that she had been waiting to meet the TRM practitioner and wanted to show her the Barbie dolls. The TRM practitioner greeted Trudy and stated how happy she was to meet her and that she wanted to see her dolls. Trudy shared her Barbie dolls and as she did, her muscles relaxed, she breathed deeply, and she often smiled. The TRM practitioner in a gentle way suggested that Trudy pay attention to her body when she felt good talking about her Barbie dolls. Trudy appeared more and more relaxed and the TRM practitioner reminded Trudy that she could remember her dolls at times she felt scared or worried. Trudy closed her eyes and took a deep breath and smiled. Trudy suddenly shuddered and then Mary appeared, somewhat disoriented, not remembering the session. However, her body remembered, and she stated she felt an unfamiliar sense of calm. When the TRM practitioner explained dissociation from a biological perspective, Mary began profoundly changing, as more parts made themselves known and expressed a desire to learn the wellness skills so they too could be aware of sensations of well-being.

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The wellness skills can be introduced to each part of the client, as the TRM practitioner keeps in mind that each part exists to protect and create a greater sense of safety. As each part learns the basic skills and how to become aware of distressing sensations and then to shift awareness to sensations that are neutral and/or pleasant, the person can begin to feel that they are more in charge of their physical and mental health and not at the mercy of the endless reminders that knock them out of their Resilient Zone and into another part without warning. Each dissociative part, stuck in the trauma story, can learn that there is another way of being, a present moment, that can be accessed with greater awareness by using one of the wellness skills. The skill of Grounding can be especially helpful as some clients will reveal they never feel like their feet are on the ground and often have the feeling of floating. Concurrently, as the client works with each part, the concept of collaboration between parts is introduced. The TRM practitioner explains to the client their ability to learn to collaborate with their parts and the importance of understanding the protective and survival strategies utilized by each part. As the client expands awareness, each part can learn new ways to regulate the nervous system and old, fixated reactions can fall away and be replaced with healthier responses to the invariable reminders that have plagued the client’s life. Increasing communication and collaboration among parts is a fundamental goal of treatment. As the parts increase their individual ability to access the Resilient Zone, conflicts between parts can be resolved. Parts can learn greater appreciation for the positive qualities of other parts. As each part senses pleasant and/or neutral sensations connected to this increased understanding, an additional benefit is an expanded, an embodied sense of feeling safer. Clients learn that a positive side effect of collaboration is that one part can help another part who is bumped out of their Resilient Zone. Deanne Edwards LMFT, a therapist who works with clients experiencing dissociation, calls this new learning “mixturing.” “Mixturing” is the ability to bring two or more parts together to help a part that is knocked out of their Resilient Zone. As a child, the only time Tim got a break from the almost constant verbal abuse was when he would have an asthma attack. When that happened, his father and mother would take him to the hospital. Over time, it was discovered that one of his parts, Tommy, had asthma but another part, Jerry, did not. So, when Tommy could not breathe well and began to feel panicky, Tim started asking Jerry for help. When

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the “mixturing” occurred, Tommy’s breathing normalized. When Tim learned that his parts could collaborate, this helped him physically and mentally. He began experimenting with asking for help from other parts when one part was distressed. Ultimately, Tim was able to have what he called a “well-oiled machine” in which each part was working together to make a healthier, more integrated whole.

Step 1 can take an extended period of time. It is essential for the client to have an embodied sense of feeling safer for as many of the parts as possible before doing trauma reprocessing. Some individuals will not be able to work with Tracking their nervous systems. For some people, paying attention to sensations can be too much and lead to sensations of distress. A primary tenet of working with clients who have been traumatized is also being respectful of some clients’ desire not to engage in this kind of therapeutic intervention. In those cases, building the therapeutic relationship with more traditional talk therapies is the best way to begin to build a greater degree of safety between the TRM practitioner and the client.

Step 2: Family Integration (Steps 1 and 2 can be accomplished concurrently.) Part of creating a greater degree of safety is helping the client’s extended family or friendship networks who were not involved in the abuse understand dissociation and parts if they exist. For example, friends and family members can also learn the wellness skills and help the client with Help Now! strategies if they get bumped out of the Resilient Zone and if they are having trouble getting back on their own. When we help family members understand the biology of traumatic experience and that dissociation is part of the elegant design of protection when life experience was too much for their family member, judgment can drop away, and a new compassion and understanding can emerge. In addition, family members often feel helpless when parts experience a traumatic flashback, and their family member then is bumped into their High or Low Zones. Family members can use the wellness skills as self-help to regulate their own nervous systems and as concrete tools to bring their loved one out of the traumatic flashback to the present moment. If the client has parts, the family may not have been aware of the parts; however, they know about the attitude and affect that can change in a

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flash. Family members are relieved to learn about the biology of trauma and most importantly, they learn that their loved one has new options to address the fluctuations in mood and behavior. Susan was often in conflict with her teenage daughter, Terry. Terry complained that her mother was unpredictable—one day being supportive and kind, and the next being authoritarian and rigid. Susan’s husband, Ken, also was frustrated by Susan’s chameleon nature. After working with Susan and helping her understand the biology of dissociation, the TRM practitioner decided to invite Susan’s husband and then her daughter into session to help educate them about dissociation and to teach them the wellness skills that were very helpful to Susan’s increased sense of internal safety. Terry learned in family therapy that her mother would give her different instructions depending on which part was “out” and learned that her mother’s growing ability to collaborate with her parts could help resolve their conflicts. Terry and Susan learned that Susan’s changeability was often fueled by fear that something bad would happen to Terry. Susan and Terry often fought about simple activities of living. Terry became very interested in learning about her mother’s parts and enjoyed conversations with different parts. As Terry engaged her in conversations and Ken supported and nurtured her different parts, Susan’s sense of safety expanded. She was able to sense more periods of calm and was able to ease up on Terry. Terry also felt that she could understand the shifts in her mother and the two of them worked together to negotiate their differences. Ken also began to be less judgmental as he understood the different parts. Susan worked diligently on her wellness skills and began to learn how to self-regulate and to “mixture” with other parts to help her come back to her Resilient Zone. Some clients may be reluctant to include their family in the therapeutic process. The TRM practitioner may have to develop a greater therapeutic alliance with the client before they are willing to think about discussing their tendency to dissociate with others. Many individuals with parts are undercover and have built a lifetime of disguise. Thus, for some people, it can feel too exposing and unsafe to disclose. It is also valuable to talk about boundaries and safety with the client in terms of who within their social network they should share this information with. Although family members’ education and understanding can have great benefits to the client

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and family system, there may be some family situations that are not safe and bringing the family in would be contraindicated. Even if the communication between family members is strained, the family can be educated about dissociation and how parts develop as a result of the client’s traumatic childhood history. Family members as well as the client can learn better coping strategies. The National Association of the Mentally Ill (NAMI) offers a family-to-­family program that is an adjunct to family therapy, helping families understand concrete ways to help themselves and their family member who is suffering.

Step 3: Reprocessing Trauma Learning to work with the freeze response is critical since it is a hallmark of disorganized attachment. As you introduce the concepts of the TRM, some clients will express fear at even the suggestion of beginning to sense neutral or pleasant sensations. In such cases, their bodies may have been the portal to an array of distressing sensations. If the client is amenable, the practitioner can introduce a container of items with different textures to bring up sensation in a safer way. Even different textures of the couch and pillows can be used for this purpose. Inviting the client to describe sensations outside of the body can be a beginning. For example, is the rock hard, smooth, rough? As the person begins to describe textures, you can gently inquire if they have an awareness of sensations inside the body. It can take time for clients to begin to sense the body. After introducing sensation in this way, the TRM practitioner may be able to slowly transition to both the development and intensification of resources that can ultimately be brought to sensation. Once the TRM practitioner assesses that the client’s parts are learning to track sensations and can experience Resourcing and Grounding in the present moment, the TRM practitioner can start working with the sensations connected to the client’s traumatic experiences. Since survival responses are often blocked in these individuals, working on completing the survival responses is a major focus of intervention. Each part must be worked with in developmentally age-appropriate ways. Thus, strategies that help children need to be brought into the therapy session with adults. For example, having a client develop age-appropriate resources for each part, and using art exercises to reinforce and deepen the resources can begin to build a “tool kit” of resources to be drawn upon before and during any processing of painful material.

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Justine had experienced sexual and physical abuse throughout her childhood, which was spent growing up in a cult. As a result, she developed many parts, some of whom were children, some adults, some men, and some women. Her clothing reflected which part awakened for the day first, as each part preferred different styles. Each holiday tended to set off flashbacks for Justine because of ritual abuses in her past during these times. As one particular holiday approached, Justine reported that “the children” were all very frightened and were causing her to feel confused and unable to cope. Having already educated Justine about dissociative process and the wellness skills, the therapist combined Resourcing with art. Justine took a large piece of paper and folded it several times, creating squares on the page. In each square, Justine created a developmentally appropriate resource for each of her child parts. She was then invited gently by the therapist to sense into each resource and notice what happened inside; if desired, she was also invited to touch each resource image while sensing into it. This process was repeated for each part. Justine reported that each child part experienced reduced anxiety and increased calm as a result. She then took the art home to remind the children of their resources until the frightening holiday passed, and she shared that this was the first holiday during which she didn’t need to stay inside with all the doors locked and blinds drawn. The resources developed during that session were also employed in future sessions for further trauma reprocessing. Building competency in the six wellness skills will help the client when not in session. Creating internal and external resources and finding neutral places within the body accesses and widens the Resilient Zone. As the person is able to track their nervous system (including identifying High Zone and Low Zone states), they develop an increased sense of mastery and trust, thus increasing a sense of safety. The person can also learn to track sensations to alert them that they are beginning to dissociate. When they learn to intercede on this “hijacking” of the nervous system, they can learn to stay in the present moment by using the wellness skills of the TRM/CRM. In addition, as their sensory capacity expands, clients learn that the boundaries between the walls of the parts do not need to be so separate. The walls can be permeable. One client described her parts as being in a large apartment building with screen doors between apartments instead of solid steel doors. As she learned to sense each part, complete survival responses, and regulate disturbing sensations, the parts were able to see through the screens and visit one another’s apartments. This was her form of “mixturing.”

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The client may require help in separating the need to be on alert and hypervigilant with being able to be calmer in order to enter their Resilient Zone. Many clients spend a lifetime expecting danger in every situation or, conversely, not reacting when danger exists. Their reactions to traumatic reminders may make no sense to them because there is no factual or autobiographical memory, only implicit memory. Brown (2011) reported that common somatoform symptoms in individuals with parts can include abdominal pain, pelvic pain, joint pain, face and head pain, a lump in the throat, back pain, non-epileptic seizures, and pseudo-asthma. Each part may hold different somatic symptoms. We contend that these symptoms are often connected to implicit memory releasing a “memory capsule” within the body that is experienced somatically, set off by either internal or external reminders. The memory capsule holds all the sensory ingredients of the traumatic memory (Scaer, 2007). Psychoeducation about implicit memory and trauma can be very helpful. Gently helping the client sense even neutral sensations can be a beginning portal to be able to experience pleasant sensations. When working with reprocessing traumatic experiences, clients will often report an array of somatic symptoms. When we bring a client’s awareness to parts of the body that are less symptomatic or neutral, the somatic symptoms will often dissipate within a few moments. Paying close attention to gestures connected to self-soothing can also help the client alleviate the symptoms. The TRM practitioner can also shift the client’s awareness to a resource, Grounding, or one of the Help Now! strategies if the activation within the nervous system becomes too distressing. TRM practitioners can also use the skills of Titration and Pendulation to ease somatic symptoms and can guide the client in using one or a combination of TRM skills. There is new hope and awareness that somatic symptoms can dissipate and/or be managed. Parts exist to protect a person, help them survive, and regulate distress. Helping each part with new sensory skills helps the whole system. When parts learn to complete a survival response and begin to sense this new embodied experience, the nervous system is reset. As the TRM practitioner works to help the client restore the survival responses, other parts may appear who are not presently known to the TRM practitioner or to the client. Some parts may appear for the first time and they may have an angry affect directed towards the TRM practitioner for “messing” with the system (as one part of one of our clients suggested). Such parts will block further reprocessing until this conflict can be addressed. When this occurs, the TRM practitioner can thank the part for coming to therapy and suggest that the part share as little or as much as they would like to about their part. The TRM practitioner can demonstrate gratitude to the part for their years of vigilance. This stance

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can be disarming, as the part usually achieves distance between their part and others by an angry stance. This may happen over a number of sessions, but this stance can help the part learn more adaptive ways of being part of the system. The TRM practitioner may have to return to Step 1 strategies to help create a greater sense of safety for the new part before proceeding with trauma reprocessing. As the client comes out of a freeze response, they may have an impulse to complete a fight or flight response. When a client is completing a survival response, their understanding of collaboration among parts is critical. A part can learn that as they are able to collaborate, older or stronger parts can help younger parts and together they can organize their nervous system to have the strength and energy to complete a survival response. See Chapter 4 for an expanded explanation of completing survival responses.

Jim was a survivor of ritualistic sexual abuse. He came to therapy because of challenges in his marriage. He loved his wife very much but at times disconnected from her and raged at her, demanding a divorce. The TRM practitioner suggested a joint session. When Jim’s wife Carrie arrived, she shared that he was erratic, at times being peaceful and loving, at other times acting childlike and dependent, and at other times being full of rage. Carrie was exasperated. As Carrie began to talk about her husband’s rage, Jim began to shake uncontrollably, almost falling off his chair. The TRM practitioner used Grounding to bring Jim back into his body. At that moment, different parts of Jim cascaded out and he rapidly switched to different parts, to his wife’s surprise. As Jim’s nervous system calmed with Grounding, he began talking in an English accent, sharing with his wife and the TRM practitioner that he had been waiting to talk to someone for years. The Englishman was the first part to make himself known to his wife and to the therapist. Over the course of many months, 16 different parts appeared. Carrie came to therapy intermittently to learn about and be introduced to new parts. Each part loved Carrie, but some were frustrated by her interactions with them. Carrie realized that she had been aware of the parts without knowing what they were. With the TRM practitioner’s guidance, Carrie began making friends with each part, realizing that each of Jim’s parts had helped him survive a horrendous childhood. Carrie had sincere compassion for each part of Jim as they became known to her. Jim’s outbursts lessened as Carrie’s compassion grew. Jim was also able to

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learn about his parts and as he collaborated with each of them, he was able to experience more internal calm. Each part was introduced to the wellness skills in age-appropriate ways. Most parts loved the wellness skills and liked listening to the iChill app. Carrie was able to learn what set off each part and that each part had different needs. All TRM skills were used over the course of therapy. Jim had male and female parts and there were times when the male parts helped the female parts reprocess sexual trauma. The male parts “mixed” with the female parts to provide an embodied strength to help Jim complete the survival response. A recurring somatic symptom shared by most of the parts was an experience of being strangled, accompanied by sharp pain in the throat. The TRM practitioner helped Jim titrate the sensation in the throat with each part. Over a period of many months, he completed a survival response of pushing away the aggressor. This chronic pain symptom disappeared altogether. Jim is now able to collaborate with his parts, which he describes as the Knights of the Round Table who have regular discussions about moving forward in positive ways as a collaborative whole, at the same time acknowledging the individual parts. He stated that the parts do not want to go away: “They want to survive to help me survive but now they work in synchrony, not in disharmony.”

Step 4: Collaboration and Wellness Clients who have experienced disorganized attachment can wonder if there is hope for a different life. We have worked biologically with clients for years and have seen hope where there had been only despair. We have had the honor of witnessing a new collaboration of parts that have become a symphony, working as a well-practiced orchestra. There is beauty in witnessing a client’s heightened ability to be creative, generative, and socially engaged with an expanded friendship network. We have seen individuals with parts who lived in dysregulated states begin to experience sensations of joy, happiness, and peace. We have borne witness to individuals learning to stop the dissociative process by Tracking their sensations and bringing themselves back to the present moment. A person with this expanded ability to stay present in the moment has more choices to live dynamically with the ups and downs of life and has a greater aptitude for managing life stresses. It has been a sacred honor to be a guide accompanying clients to heal from a horrendous childhood and provide support in ways the many parts never imagined were possible.

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With an expanded knowledge of the various attachment styles and the utilization of TRM/CRM skills, people can experience greater wholeness and feel like they are in the “driver’s seat” of their lives. They are able to deepen their Resilient Zones by regularly employing wellness skills in between sessions, and they experience getting bumped out less often. Over time, the TRM practitioner’s role changes from holding frequent sessions to providing occasional tune-ups to address the windstorms of life that can happen to any one of us—with or without parts. In closing this chapter, we felt it imperative to include some considerations on working with attachment styles in light of both the Covid-19 pandemic, which caused heightened awareness of the importance of community, and the state of our world in the wake of George Floyd’s murder, and conversations about racism in the US and beyond. We are certainly aware that the field of psychology is dominated by Western white male perspectives, and attachment theory is no different. Mainstream attachment research is predicated on the idea of psychological autonomy with an emphasis on the mother/infant bond. While this is adaptive mainly for the Western middle-class (comprising less than 5% of the world’s population), it does not take into consideration the cultural values of non-Western environments (Keller, 2012). Much more can be said on the need for more research and increased awareness of how attachment, connection, and safety is experienced by other cultures. Both TRM and CRM do take the individual and community into cultural consideration by using essential skills of Tracking and invitational language to allow the client to lead. We don’t assume to know a person’s life experience, but rather allow and encourage the story of the body to gently emerge. The TRM practitioner can thus honor a person’s race, culture, heritage, and perception of their early attachment. As therapist and anti-racist educator Resmaa Menakem (2017) writes in My Grandmother’s Hands: Healing does not occur in a vacuum. We also need to begin mending our collective body. This mending takes place in connections with other bodies —in groups, neighborhoods, and communities…healing can ripple outward from one body to another, and from groups of bodies into our systems and structures. This communal healing can help us steadily build respect, recognition, community, and, eventually, culture.

This beautifully stated sentiment underscores the ways that looking at our attachments through a somatic lens can impact healing and deepen both our individual and collective Resilient Zones.

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References Ainsworth, M. D. S., Blehar, M., Waters, E., & Walls, S. (1978). Patterns of attachment. Hillsdale, NJ: Erlbaum. Beebe, B., Jaffe, J., Markese, S., Buck, K., Chen, H., Cohen, P., … Feldstein, S. (2010). The origins of 12-month attachment: A microanalysis of 4-month mother-infant interaction. Attachment & Human Development, 12(1–2), 3–141. Blizard, R. (2003). Disorganized attachment, development of dissociated self states, and relational approach to treatment. Journal of Trauma and Dissociation, 4(3), 27–50. Boon, S., Steele, K., & van der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for patients and therapists. New York: W. W. Norton & Co. Bowlby, J. (1973). Attachment and loss, Vol. 2: Separation, anxiety and anger. London: Hogarth Press. Brown, L. S. (2011). Guidelines for treating dissociative identity disorder in adults: Third revision: A tour de force for the dissociation field. Journal of Trauma and Dissociation, 12(2), 115–187. doi:10.1080/15299732.2011.537247. Chitty, J. (2013). Dancing with Yin and Yang: Ancient wisdom, modern psychotherapy and Randolph Stone’s polarity therapy. Boulder, CO: Polarity Press. Dana, D. (2018). The Polyvagal theory in therapy: Engaging the rhythm of regulation. New York: W. W. Norton & Company. Dell, P. F. (2009). Understanding dissociation. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond (pp. 709–825). New York: Routledge. Keller, H. (2012). Attachment and culture. Journal of Cross-Cultural Psychology, 44(2), 175–194. Kolacz, J., Dale Lourdes, P., Nix Evan, J., Roath Olivia, K., Lewis Gregory, F., Porges Stephen, W. (2020). Adversity history predicts self-reported autonomic reactivity and mental health in us residents during the COVID-19 pandemic, Frontiers in Psychiatry, 11. https://www.frontiersin.org/article/10.3389/fpsyt.2020.577728 Liotti, G. (2006). A model of dissociation based on attachment theory and research. Journal of Trauma and Dissociation, 7(4), 55–73. Menakem, R. (2017). My grandmother’s hands: Racialized trauma and the pathway to mending our hearts and bodies. Las Vegas, NV: Central Recovery Press. Nijenhuis, E. R. S., van der Hart, O., & Steele, K. (2004, January). Trauma-related structural dissociation of the personality. Trauma Information Pages. http://www. trauma-pages.com/a/nijenhuis-2004.php

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Payne, P., Levine, P. A., & Crane-Godreau, M. A. (2015). Somatic experiencing: Using interoception and proprioception as core elements of trauma therapy. Frontiers in Psychology, 6, 93. http:// doi.org/10.3389/ fpsyg. 2015.00093 Poole-Heller, D. (2019). The power of attachment – how to create deep and lasting intimate relationships. Boulder, CO: Sounds True. Porges, S. W. (1995). Orienting in a defensive world: Mammalian modifications of our evolutionary heritage: A polyvagal theory. Psychophysiology, 32(4), 301–318. Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, self-regulation. New York: W. W. Norton & Company. Porges, S. W. (2020). The Covid-19 pandemic is a paradoxical challenge to our nervous system: A polyvagal perspective. Clinical Neuropsychiatry, 17 (2), 135–138. http:// doi.org/10.36131/CN20200220. PMID: 34908984; PMCID: PMC8629069. Porges, S. W. (2021). Polyvagal safety: Attachment, communication, self-regulation. New York: W.W. Norton & Company. Roisman, G. I., Padrón, E., Sroufe, L. A., & Egeland, B. (2002). Earned-secure attachment status in retrospect and prospect. Child Development, 73(4), 1204–1219. Scaer, R. (2007). The body bears the burden: Trauma, dissociation, and disease (2nd ed.). Binghamton: Haworth Medical Press. Schore, A. (2009). Attachment trauma and the developing right brain: Origins of pathological dissociation. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond. New York: Routledge. van der Hart, O., Nijenhuis, E. R. S., & Steele, K. (2006). The haunted self: Structural dissociation and the treatment of chronic traumatization. New York: W. W. Norton & Company.

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Veterans, Active-Duty Service Members, and Their Loved Ones Elaine Miller-Karas and Jan Click This chapter will focus on: 1. The issues facing veterans and service members 2. The integration of the Trauma Resiliency Model (TRM) and the Community Resiliency Model (CRM) with veterans and service members

Overview of the Issues There are thousands of veterans and active-duty service members suffering from mental health challenges originating from their military service in the United States. Census reports in the United States estimate that there are roughly 18 million veterans and 2.1 million active-duty and reserve service members (U.S. Census, 2020). The cost of war to our world community affects every aspect of society. We have worked internationally with communities experiencing conflict in 2022 and with others who live in the wake of conflicts that have devastated their communities. The toll on mental health is burdensome for all of society, causing individual, familial, and community suffering. This chapter focuses on helping veterans and service members from our experience of being in the United States. We want to express that the interventions can be used for veterans and active-duty service members from our worldwide community. Worldwide those who serve their countries during war are exposed to many potentially traumatizing experiences. Wartime deployments can result in severe injuries and violent death, sometimes occurring suddenly and not always on intended targets and resulting in the death of civilians, including children. Those who serve in the military are at risk of experiencing other traumas such as interpersonal violence, racism, gender-based assaults, DOI: 10.4324/9781003140887-17

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bullying, and physical and sexual abuse. Many societal issues affect those who serve in the military, including service by those who identify as part of the LGBTQ community. Although policies have changed in the United States, there continue to be widespread challenges for LGBTQ individuals serving in the military. The leading causes of homelessness among veterans are post-traumatic stress disorder (PTSD), social isolation, unemployment, and substance abuse. Veterans account for 13% of homeless adults in the United States (HUD, 2022). Substance abuse disorders (SUDS), including alcohol use, continue to be a problem among veterans and military members. SUDs are associated with significant adverse medical, psychiatric, interpersonal, and occupational outcomes. From 2001 to 2009, the percentage of veterans in the Veteran Health Administration system receiving an opioid prescription increased from 17% to 24% (Teeters et al., 2017). Similarly, veterans’ overall opioid overdose rates increased to 21% in 2016 from 14% in 2010 (Lewei et al., 2019). Blimes (2021) states that young men and women in the Iraq and Afghanistan conflicts have served longer tours of duty, been exposed to more raw combat, and suffered higher rates of disability than during any previous U.S. war. It is estimated that 36% of the post-9/11 cohort of veterans have a PTSD diagnosis. While combat and deployments are linked to increased risks for mental health conditions, general military service without combat or deployment can also lead to difficulties. Kessler et al. (2014) found that 85% of those who self-identified as having had a mental health condition reported that the problem began prior to joining the Army. Purcell et al. (2021) described significant pandemic impacts on veteran well-being, especially loneliness and sorrow stemming from isolation and disruptions to ordinary routines. She reports that the emotional impacts of COVID-19 sometimes deterred engagement in both routine and wellness care. Veterans already struggling with chronic mental and physical health conditions and those who experienced transitions or losses during the pandemic described the most severe impacts on their well-being. The Institute of Medicine (2014) reported spouses and partners of service members and veterans who have PTSD may experience PTSD symptoms themselves and can experience relationship distress in response to the service member’s or veteran’s PTSD symptoms. Military caregivers experience worse health, greater strains in family relationships, and more workplace problems than non-caregivers. Further, military caregivers are at higher risk for depression. The caregivers may be very young and may also be caring for children, which can amplify the strain on the caregivers.

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The U.S. mental health system, charged with serving active-duty service members, veterans, and their families, has difficulty meeting their needs. Nelson et al. (2021) reported that patients with serious mental illnesses were more likely to receive delayed initial appointments in three of five clinical settings (post-traumatic stress disorder, substance use disorders, and psychosocial rehabilitation clinics) and had significantly longer average wait times for an initial appointment when referred to the PTSD clinic for an initial appointment. Nelson’s findings suggest that the majority of the Veteran Health Administration patients with serious mental health conditions with more complex needs, particularly those with trauma-related care needs, may be more likely to experience treatment initiation delays. In addition to traditional professional mental health counseling, interventions must be created worldwide outside the usual delivery system of mental health services. A safety net can be created to respond to this public health emergency in which individuals and communities are educated about the neurobiology of trauma and resiliency through peer support networks using the Community Resiliency Model. Many veterans and active-duty service members are not “psychologically oriented.” However, they may be amenable to learning simple wellness skills that teach them about the biology of stress and trauma. The paradigm shift from “pathology or mental weakness to biology” can greatly boost a person’s self-esteem. Learning CRM skills can reduce traumatic stress symptoms and contribute to greater well-being (Grabbe et al., 2020). The wellness skills of CRM are helpful for the active-duty service member and veterans and their family members because the entire family system can learn to speak a common language and use the wellness skills for co-regulation. Once the veteran or service member can learn to regulate their nervous system, they may be ready to reprocess the traumatic experience. However, we have also discovered that once individuals learn to bring their awareness to the present moment and intercept the multisensory reminders of their traumatic war experiences, they more fully engage in the activities of daily living. The need to reprocess an event does not become as necessary to some.

Clinical Application of TRM and CRM Chapters 3 and 4 detail the skills of TRM and CRM. The following sections highlight psychoeducation, the skills, and their application to specific common themes faced by individuals due to military service.

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Importance of Psychoeducation and Biology Versus Mental Weakness For those who have served in the military, being able to persevere and get through any situation is an essential ingredient to being a successful service member, as are completing one’s mission and helping one’s buddies survive. The idea of asking for help or entering into therapy may mean that they are weak and that something is wrong with them. Biologically based models like TRM and CRM, focusing on skill-building, are much more acceptable to many service members and veterans than traditional therapy where the focus may be on pathology. The practitioner explains that their nervous system is dysregulated based on many months of being on high alert during deployment. When it is understood that it is not about being “screwed up or crazy,” there is a significant shift in their perception of the situation. We explain that even though their nervous system is not in balance, they can learn the wellness skills to help the nervous system begin to reset and experience more extended periods in their Resilient Zone. This concept is critical when teaching these wellness skills in a group setting.

A veteran was driving to Disneyland when he spotted something on the side of the road. He immediately turned his minivan away from what was garbage on the roadside, almost causing an accident. The sight of trash on the roadside sparked a memory of when his convoy was blown up by an improvised explosive device (IED) where he had almost been killed. After learning the wellness skills and how to track his nervous system, he was able to identify the beginning sensations of fear, immediately resource and ground while driving, and shift his nervous system to present-moment awareness. The simple practice of the skills over time was transformative. The veteran felt empowered that he could reclaim his body and mind and not be tormented by the daily reminders that had accompanied him while driving in Los Angeles. Indeed, he was learning to pay attention biologically and distinguish between sensations and distress and well-being. His nervous system could tell the difference now between the match and the forest fire!

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The Tasks of Daily Living Education about the High, Low, and Resilient Zones is critical. As veterans learn the wellness skills, they Track the differences in the sensations between the zones. Over and over as we teach this concept to veterans, they describe the shift they experience as they walk through their activities of daily living and are better able to manage difficult situations as they learn the skills. A veteran described going into a building supply store to purchase some items and when he got to the checkout line, he asked the clerk for his veteran’s discount. She replied he could only get the discount on Veterans Day. This veteran replied that the discount was supposed to be every day. As the clerk insisted that he was not eligible for a discount, the veteran tracked his nervous system. He realized that he was getting angry and moving out of his Resilient Zone. He put his hand on the counter to ground himself and then thought about his daughter, who is an essential resource for him. The veteran sensed he was calming down, returning to his Resilient Zone. He calmly asked to speak with the manager. He ended up getting the discount for himself that day. He eventually had an opportunity to speak with the corporate office of this company and advocate for other veterans to receive the discount every day. In the past, he would have become so angry that he would have left the store without purchasing his items or been escorted out of the store by security. This experience had significant meaning and he said it was as if he got his life back.

Restricted Range of Affect Individuals who have been in combat and have seen the horrors of war may develop different perceptions of life and death than those in the civilian world. In order to survive combat, many experience emotional numbing. They may seem to be callous and indifferent to the pain of others. Many veterans have a restricted range of affect. This stance can adversely affect their interpersonal relationships. The upside of emotional numbing is that a person does not feel the pain and the downside is that they do not feel the joy. Learning how to read the nervous system through Tracking coupled with a resource can help the individual begin to sense pleasant and neutral sensations that can lead the nervous system out of being shut down.

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After a Marine returned from Iraq, his wife had a miscarriage with twins. She understandably was very emotional and devastated. The veteran reported that he did not feel anything. His wife accused him of not loving her or the twins. The concept of emotional numbing was explained as a biological survival response to help him get through the rigors of war. Gradually, as the man began to use the wellness skills of Tracking, Resourcing, and Grounding, he was able to experience his emotions more fully. As his Resilient Zone began to widen, he was able to experience greater closeness with his wife and children.

Discipline and Order and Traumatic Coupling Discipline and order are essential components in military and combat operations. They can save lives in combat; however, the civilian versus military mindset can create challenges for service members or veterans attempting to reintegrate into civilian life. For example, many individuals return to school after discharge from the military. They have been shot at, watched buddies die, and lived in 130-degree heat. One veteran who enrolled in school became frustrated with the civilians in his classes who complained about insignificant issues. He had a low tolerance for “whiners” and the lack of respect he saw some students exhibit. It was helpful for the veteran to realize that his classmates’ behavior was distressing because in a war zone, the lack of discipline could result in someone dying. He knew this cognitively. However, simply telling himself to stop reacting that way did not change the reactivity of his nervous system. The veteran responded to those transgressions as if they were a life-and-death situation. Further, the veteran would sit in the back of the classroom, against the wall, scanning the room for signs of trouble. The TRM practitioner taught the veteran the wellness skills to help him self-regulate when faced with distressing situations. As his nervous system settled, he was able to have insight into his reaction to his fellow students and how it was connected to his war experience.

Destruction of the Soul Tick (2005) writes about the impact that war can have on the soul. He states that becoming an effective warrior may mean violating one’s moral code and

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deconstructing one’s soul to survive. One Vietnam veteran, a captain in the Marine Corps, described the gut-wrenching experience of violating his own moral code on multiple occasions to save his men. He said, “To help keep my men alive and do my duty as their leader meant violating my moral code.” Among the most challenging work he did in his healing process was coming to terms with that internal conflict. The person he thought that he was had to be put aside for him to be a good leader and help keep his men alive. Moral injury is understood to be the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code. Potentially morally injurious events include a person’s own or other people’s acts of omission or commission, or betrayal by a trusted person in a high-stakes situation. (Williamson et al., 2021). First discussed in military settings, moral injury is a specific type of psychological injury that reflects an enduring impact on an individual’s self-image and world view. Experiences of moral injury can knock a person out of their Resilient Zone. Learning Tracking can help identify the sensations connected to thoughts and feelings about moral injury. Working to unwrap the experience through TRM can help reconstruct the present moment experience and provide new meanings that can relieve the suffering around moral injury issues.

Aggressor–Prey–Witness: Understanding the Perfect Storm of the Nervous System The “aggressor, prey, and witness” paradigm helps individuals understand the biology of their nervous system when in their different roles as a result of military service. Some individuals who experienced trauma due to their service may feel like there is danger everywhere. Simultaneously, the person can experience biological reactions connected to being the aggressor, the prey, or the witness. The biological responses happen automatically, without conscious thought. An aggressor is a person’s role if they are actively engaged in finding and fighting a threat. Prey is a person’s role when they feel they are under attack. The role of a witness is when a person sees, hears, and smells all parts of the aftermath of being in combat. These roles may equate with survival in a combat zone. If a person is in all three roles simultaneously, it can create the perfect storm within the human nervous system that heightens reactivity and can lead to their being always bumped out of the Resilient Zone. There is no magic “reset” button for when the service member returns home and

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is faced with the tasks of daily living. Helping the veteran, service member, and their family understand this paradigm can reduce the shame and self-blame experienced when integrating back into family life. In addition, the wellness skills of both models teach the person to become aware of the sensations connected to the High and Low Zones and most importantly, to the Resilient Zone. As they can differentiate between sensations associated with each zone, they then choose to use one of the wellness skills to return to their Zone of Well-Being.

Traumatic Grief and Loss and Shock Trauma Traumatic grief differs from normal grief and loss. It violates our understanding of what is right and just in our value system and worldview. If a soldier talks with a buddy one minute about what video they will play after they get back from patrol, and the next minute they are hit by an IED and the buddy is killed, this is shock trauma. For the service member to complete the mission, they need to put grief aside, as war leaves little space for grieving. There needs to be a degree of security from enemy attacks for the grief process to begin. Survivors may go over and over the incident, often thinking that there must have been something they could have done to save their buddy. They may experience rage toward the enemy and want revenge, and they may believe that if they let go of the grief, they will not be honoring the buddy who was killed. Conversational Resourcing helps the veteran to think differently about the loss. An Iraq veteran was stuck grieving for his buddy who was killed during a second deployment. The thought consumed him, “If I had been there, I could have helped him survive.” The TRM practitioner used Conversational Resourcing and asked, “If it was you that died, how would you want your buddy to honor you? Would you want him to be stuck in the grief of your death? How would you want him to live his life?” The veteran said, “I would want him to live life to its fullest; that is how I would want him to honor me.” The TRM practitioner asked what he noticed as he expressed those words aloud. He took a deeper breath and his body relaxed. The new meaning provided relief to his mind and body.

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When we work with traumatic grief and loss, the following additional Conversational Resourcing Questions can be helpful: • “What is your favorite memory of your buddy?” • “What was the best part of having your buddy for a friend?” • “If he would have known that you would survive him, what would he have said to you?” Often the answers evoke sensations connected to gratitude for knowing the person and sadness from their death. The TRM practitioner acknowledges the sadness and invites the client to draw attention to the sensations of gratitude. As the person experiences the sensations connected to good memories and the sad ones, the lens widens. They often express that they can hold both memories, the positive and the sad ones, without being overwhelmed by the grief.

Moral Dilemmas: Living with Guilt and Shame Shame and guilt can be challenging for veterans and service members trying to integrate into civilian life. Many individuals who decide to enlist in the military do so out of duty and service to their country. One of the horrors of war is the killing of non-combatants. It is not always possible to determine who is the enemy. Veterans have described having children run toward them and having to make a split-second decision whether to shoot or not. The child could have been booby-trapped. If the service member did not shoot, they could endanger their entire unit. Harming and killing children are among the most harrowing experiences to live with as they are against one’s values. When the client is able to express their shame and guilt and work biologically, they can unwrap new meanings. The concept of atonement has emerged spontaneously when working with those who have killed. The following is an illustration of atonement shared by a psychologist treating combat veterans. In the heat of combat, a veteran was responsible for the death of a small girl. She appeared to be the same age as his daughter. The face of the girl haunted him. He shared that every time he looked at his daughter, he saw the child he had killed. The psychologist talked to him about the Knights of the Round Table and how when they came back from battle in the Crusades, they would sometimes be consumed with guilt. The priest required them to perform an act of service to atone for what they had done. Acts of atonement are powerful, and the veteran took his advice to heart. He decided in honor of the child he had killed, he would guard the playground in an inner-city neighborhood in his

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town to protect children from being harassed by gangbangers. So, every Saturday, he stood guard at that playground to protect the children (Silver & Rogers, 2002).

Violations of the Social Contract A social contract is a voluntary agreement among individuals. According to any of the various theories of Hobbes, Locke, or Rousseau, organized society is brought into being and invested with the right to secure mutual protection and welfare or regulate the relations among its members. Service members are trained for combat and various military operations. They know that they may be shot at or might shoot at others when they go into a combat zone. They prepare for that eventuality and see it as part of a deployment. The violations of the social contract are troubling because of betrayal by those who are supposed to protect. A veteran described an incident where they were expecting to be overrun by the enemy. He was given just ten rounds of ammunition. He expressed anger at not getting the equipment that he needed and that if overrun, he and many other service members would have died unnecessarily. Strong feelings concerning violations of the social contract can be amplified when a warrior has experienced childhood trauma and was betrayed by primary caregivers. Before reprocessing a traumatic war incident, the TRM practitioner educates and teaches all six wellness skills. Then, the practitioner starts with “Trauma plus one” (T + 1). Trauma plus one refers to going to the end of the story first—the survival story, which is often imbued with the energy of life and relief. If there was a moral injury as described above, the practitioner could ask, “Can you tell me about the moment you knew you were going to survive the event though you did not have all the ammunition you needed?” The TRM practitioner invites the person to notice the sensations of survival. Often there is great relief in mind and body when the survival of self and others is recounted. The person is asked if there are any additional thoughts about the moral injury. Frequently, the person can come to terms with the memory, and meaning emerges organically. “I realized I did the best I could do and although I didn’t have all I needed, it’s over and I and others survived.”

Anger, Rage, and Fear of Killing The most common reactions service members experience after returning from deployment are anger and rage. In TRM terminology, this is being stuck in the High Zone. Aggression and high arousal levels can be advantageous

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and necessary in a war zone. When troops go through military training before deployment, they are taught to tap into their anger. This anger can help them overcome obstacles, override the fear response, and potentially increase their chances of survival. As one veteran shared, “If you think, you die.” Unfortunately, this anger can become the default response. What helped them survive in the combat zone can become a significant liability when trying to readjust after deployment or to civilian life. If the person is stuck in the High Zone, they may take action that they would not take if they were in their Resilient Zone and could evaluate the consequences of their actions. It is not uncommon for active-duty service members and veterans to fear that they could kill or significantly harm a civilian when integrating into civilian life. One service member reported waking up in the middle of the night from a nightmare ready to pounce on his wife. Others say that even minor irritations can spark an overly aggressive, hostile response. Another veteran shared that the very impulse that would have made him an excellent warrior could now land him in jail. When using the TRM model with persons experiencing rage and anger, it is essential that before trauma reprocessing, the wellness skills have been shared so the person can sense being in their Resilient Zone. Many are fearful of how intense the rage can be and want to avoid it. They may be afraid of hurting the practitioner. They may believe that they will lose control if they let it out. They may have lost control in the past, which may be why they have come to therapy. It is essential to work very slowly to help the person gain confidence that they can now be in charge of their reactions by Tracking their nervous system and using the other skills. The TRM practitioner can help the client begin processing the traumatic events by using Titration, Pendulation, and Completion of Survival Responses. One veteran, after experiencing Titration, imagined a plate in the center of his core. He would only put the amount of anger on that plate that he felt he could manage to keep the activation level at a manageable level. Anger can come up for a variety of reasons. It can mask underlying feelings of helplessness, sadness, guilt, and grief. Those feelings could be a liability in a war zone when one needs to complete a mission. However, the emotional numbing essential in combat can interfere with intimacy and connections with loved ones. Practitioners need to explain how the nervous system works and the adaptive response of emotional numbing during combat.

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George had been in prison and was trying to turn his life around. When learning the wellness skills, he noticed that when he practiced the skills he did not get as upset by some of the small things that would trigger his irritability and, in some instances, his rage. George wanted to share a trauma story that had haunted him since 2003, when he and his battle buddies were trapped and surrounded. Some of his buddies died in the incident. As he started to talk about the event, his legs began to move and sweat. He was asked to track what his body wanted to do. He stopped, looked at his practitioner, and said, “I have to stop because I want to kill you.” The practitioner knew that George’s biggest fear was that he would be triggered into killing a civilian. The practitioner stated, “George, you can stop and notice what it is like inside to stop.” George looked surprised, tracked his body, and began to tremble and feel a lot of heat (release sensations). The practitioner brought his attention to the releases. George took a deep breath and began to cry softly. He then repeated, “I did stop, and I can stop.” As new meaning emerged in the present moment, George was invited to repeat the words and to sense his body. George stated, “This is the first time since 2003 that I have felt safe in my skin.”

Complex Trauma When service members and veterans have complex trauma and have experienced childhood or developmental trauma, it can take longer for them to learn how to track their nervous systems and begin to find neutral or pleasant sensations inside. A female veteran asked when learning about the concept of the Resilient Zone, “What if you have never been in your Resilient Zone?” She had experienced childhood sexual abuse and military sexual assault and sexual harassment. Initially, the Help Now! strategies helped her the most. She needed to make several attempts at finding a resource that didn’t overwhelm her with distressing sensations. Over time, she began to notice neutral sensations inside and started to experience being in her Resilient Zone. When clients cannot find positive sensations, they are encouraged to focus instead on neutral sensations. With time, individuals can track and notice neutral sensations and the depth of the Resilient Zone widens. When someone’s nervous system has been dysregulated their entire life, it can take longer for them to begin to experience neutral or pleasant sensations. They may experience a paradoxical reaction to calming down because of

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traumatic coupling with an experience of their body being calm and being in danger. This was the case for a woman who had been sexually harassed by a senior officer. She had also been sexually assaulted at night as a child, so initially, she would go into her High Zone when she started to calm down. The psychoeducation on the biology of traumatic experience was essential in explaining to her what was happening in her nervous system. Over time, she began untangling those experiences and feeling calmer on the inside when working with the wellness skills and the TRM for trauma reprocessing.

Stuck in the High and Low Zones Individuals stuck in the High Zone may take actions they would never take when in their Resilient Zones. A helpful metaphor is that it’s easier to stop the train before it leaves the station than to go 100 miles an hour and already be 50 miles down the track. The goal is to learn to track the nervous system and intercede with one of the wellness skills, so the nervous system does not leave the station. Some individuals are stuck in the Low Zone and still others bounce back and forth. It can be like walking through molasses for those stuck in the Low Zone. Everything takes a tremendous amount of energy. Just as the Help Now! strategies can be helpful if stuck in the High Zone, these tools can also be beneficial for those stuck in the Low Zone. When a veteran or service member is stuck in the Low Zone, the practitioner can ask them to get up and walk around, inviting them to sense the movement of their arms and legs and their feet making contact with the ground. The therapist can also ask the client to push against a wall or door. Anything that helps them move major muscle groups and joints can help them get back into their Resilient Zone.

Working with the Freeze Response The freeze response can be a common experience for veterans and service members, particularly those who have experienced Military Sexual Trauma. If a veteran or service member experienced a freeze response during combat, they might be flooded with shame. The military trains service members to override their fear during combat. Even with training, a service member may freeze during combat. If they froze, it may result in another service member’s injury or even death. Many individuals who have experienced a freeze response in combat may have also survived childhood trauma. Children who

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experience trauma often go into a freeze response. Thus, extreme fear may set off a freeze response because of childhood trauma. As discussed in previous chapters, working with the freeze response can be challenging. A female veteran was assaulted while she was sleeping. She saw herself as someone who was very strong and had effectively handled many difficult situations in her military career and in her life. She was very distressed about having this freeze response and saw it as a sign of weakness. The concept of the freeze was explained to her. She was sound asleep when the assault occurred, so she did not have time to take any defensive action. After providing psychoeducation about the freeze response and being assured that the veteran had the TRM/CRM wellness skills well anchored in her body, the practitioner began to work with the client on this memory of the assault. The session began with questions about the moment of survival: “When did you know you would get through this? Who helped you survive?” Once her survival story was anchored in sensation, the veteran was invited to begin to tell her story. As the client started to tell the story, she reported feeling like she was trapped and could not move. She noticed sensations of cold and an eerie calm. She was invited to see if there was a place inside where she could move just a little bit. As she focused on where she could move just a little, she noticed her body was heating up and there was more and more movement. Resiliency pauses were inserted frequently, giving her more time, pendulating and titrating the memory. As the practitioner and client slowly worked, the client continued to notice release sensations such as tingling and heat. The practitioner drew the client’s attention to the movement in her feet and invited her to sense whatever motion her feet wanted to make. She said she wanted to run to safety. The client had a problem with that because, as she said, “Soldiers don’t run.” The practitioner explained that it did not mean she would run in real life; she was just working on letting go of the stuck energy in her body. She began clutching her hands, and the practitioner asked what her hands wanted to do. She replied, “I just wanted to punch that guy.” She invited the client to let her hands make whatever motion they wanted. As she moved, punching in the air, she continued to experience release sensations. New meaning began to emerge, and she said, “This wasn’t my fault. This guy was an aggressor and a coward for attacking me in my sleep.” She was then asked to become aware of her sensations as she said the words. She breathed

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deeply and said, “I think I can begin to put this behind me now.” This new meaning was then anchored in sensation. She continued to report sensations of release. She took a deep breath and stated, “I survived!” and declared she could feel her strength to her core.

Ending a Session When ending a session, practitioners should be aware that there may be more that needs to be processed. The wellness skills are brought in at the end of every session. The iChill app was developed at the direct request of a group of women veterans at the Veterans’ Administration. who, when learning the wellness skills, wanted something that could help them in between sessions. The practitioner can suggest exploring the iChill app outside of the session.

Conclusion As women who have never served and had family members who served in World Wars I and II, we have not always known all the nuances of military service. Service members and veterans have educated us. We have sometimes been tested to see whether or not we could hold the experiences of war and killing. We have had the honor of helping those who have given so much to many. We have learned that the gentle approaches of TRM can guide the nervous system back into regulation. Most importantly, we have seen where individuals can learn to shift out of sensations of distress when reminded of a traumatic experience and gently shift to sensations connected to well-being and resilience. A service member, Jennifer, had been deployed twice to Iraq. She had been harassed during her first deployment. This harassment triggered childhood memories of assault. After her second deployment, she became suicidal. All her attempts to deal with her distress were not enough. She wrote a suicide note and had a suicide plan. She decided to try a therapist who had experience working with service members. She learned the CRM wellness skills and neuroscience behind her symptoms. She discovered she was not aware of her Resilient Zone. She realized she had her darkest moments when she was in her High

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and Low Zones. She slowly became aware that she could access her Resilient Zone as she practiced the skills. Gradually, the suicidal thoughts lessened and then stopped. She understood her reactions as being biological rather than human weakness. Jennifer is no longer suicidal. She feels whole again and she has become a CRM skills teacher dedicated to serving active-duty service members and veterans.

References Blimes, L. (2021). The Long Term Costs of US Veterans of the Afghanistan and Iraq Wars, 20 Years Cost of War Research Series, Watson Institute International and Public Affairs, Brown University. Grabbe, L., Higgins, M., Baird, M., Craven, P., & Fratello, S. (2020). The Community Resiliency Model® to promote nurse well-being. Nursing Outlook, 68(3), 324–336. doi: 10.1016/j.outlook.2019.11.002. Epub 2019 Dec 30. PMID: 31894015. Institute of Medicine (2014). Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder; Board on the Health of Select Populations; Institute of Medicine. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington (DC): National Academies Press (US); 2014 Jun 17. PMID: 25077185. Kessler, R. C., Heeringa, S. G., Stein, M. B., et al. (2014). Thirty-day prevalence of DSM-IV mental disorders among non deployed soldiers in the U.S. army. JAMA Psychiatry, 71, 504–513. doi:10.1001/jamapsychiatry.2014.28 Lewei, A. L., Peltzman, T., McCarthy, J. F., et al. (2019). Changing trends in opioid overdose deaths and prescription opioid receipt among veterans. American Journal of Preventive Medicine, 57(1), 106–110. Nelson, S. M., Mach, J. J., Hein, T. C., Abraham, K. M., Jedele, J. M., & Bowersox, N. W. (2021). Access to timely mental health care treatment initiation among Veterans Health Administration patients with and without serious mental illness. Psychological Services. Advance online publication. https://doi. org/10.1037/ser0000534 Purcell, N., Sells, J., McGrath, S. et al. (2021), “Then COVID happened...”: Veterans’ health, wellbeing, and engagement in whole health care during the COVID-19 pandemic. Global Advances in Health and Medicine, 10, 1–15, DOI: 10.1177/21649561211053828. Silver, S. M., & Rogers, S. (2002). Light in the heart of darkness: EMDR and the treatment of war and terrorism survivors. New York: W. W. Norton & Company.

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Teeters, J. B., Lancaster, C. L., Brown, D. G., & Back, S. E. (2017). Substance use disorders in military veterans: prevalence and treatment challenges. Substance Abuse and Rehabilitation. 8, 69–77. doi:10.2147/SAR.S116720 Tick, E. (2005). War and the soul: Healing our nation’s veterans from post-traumatic stress disorder. Wheaton, IL: Quest Books. US Census (2020). https://www.census.gov/newsroom/press-releases/2020/­veteransreport.html US Department of Housing and Urban Development. https://www.hud.gov/press/ press_releases_media_advisories/hud_no_22_022 Williamson, V., Murphy, D., Phelps, A., Forbes, D., & Greenberg, N. (2021). Moral injury: The effect on mental health and implications for treatment. Lancet, ­Psychiatry, 8(6), 453–455.

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Addiction, Dependence, and Substance Use Disorder Elaine Miller-Karas and Jessica Karas Waterson This chapter is not meant to be a complete discussion of addiction but rather will highlight basic terms and some components of the neurobiology of addiction that are important to consider in how TRM and CRM may be helpful in the treatment and management of addictions. This chapter will: 1. Describe how TRM and CRM can be used to help individuals dealing with substance use, misuse, and addiction 2. Describe the problems faced within society as a result of substance use, misuse, and addiction 3. Describe how the pandemic is affecting individuals and families dealing with substance use, misuse, and addiction 4. Describe how TRM/CRM wellness skills can be integrated into a Motivational Interview and to Stages of Change Theory 5. Describe one innovative prevention program called Life Care Specialists

Defining Terms Addiction. A person who is addicted struggles to meet the obligations of their family, social network, and employment. American Society of Addiction Medicine (2022) defines addiction as a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Dependence is a physical reliance on a drug, characterized by symptoms of tolerance and withdrawal. As a result, an individual needs to ingest higher dosages to feel the drug’s effects. If this person stops use abruptly, they will

DOI: 10.4324/9781003140887-18

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also experience acute withdrawal symptoms, as their body craves more of the drug. Like addiction, dependence happens with chronic drug use. Substance use disorder (SUD) described by Koob and Volkow (2010), also known as drug use disorder, is the persistent use of drugs (including alcohol) despite substantial harm and adverse consequences. Substance use disorders are characterized by an array of mental, physical, and behavioral symptoms that may cause problems related to loss of control, strain to one’s interpersonal life, hazardous use, tolerance, and withdrawal. Substance use disorder became the scientific term for these conditions in 2013.

Introduction The Trauma Resiliency Model (TRM) and the Community Resiliency Model (CRM) have skills that can be easily integrated into addiction treatment programs, community-based prevention projects, and private psychotherapy practices. Conventional approaches for treatment of addiction often include cognitive-based psychological interventions and wellness programs like mindfulness, dialectical behavioral therapy (DBT), self-management and recovery training like SMART Recovery, and 12step programs like Alcoholics Anonymous and Narcotics Anonymous. Sharing CRM/TRM key concepts and wellness skills offers a biological approach that can help those with problematic behaviors and substance use disorders in their recovery journey. Education about the multisensory cues and developing awareness of the environmental factors that can spark substance use can be integrated into conventional approaches to treatment. The powerful impact of CRM even after a small dosage of the key concepts and wellness skills was demonstrated by the outcomes of a CRM workshop given to a group of women in a drug treatment center by Dr. Linda Grabbe and her colleagues. Grabbe et al. (2021) provided a single five-hour CRM workshop to an urban drug treatment center for economically challenged women in the Southeastern United States. Using a pre-post mixed methods design, they collected data from 20 women on well-being, physical symptoms, anger, depression, anxiety, and spirituality. The post-test revealed that participant somatic complaints, anger, and anxiety symptoms had declined significantly, with a moderate-to-large effect size; well-being increased significantly, with a small effect size. Furthermore, participants found the skills and concepts of CRM helpful and shared them with others, demonstrating how the skills can be used for peer-to-peer support, a common feature

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of conventional treatment like Alcoholics Anonymous. The authors concluded that CRM is a feasible, inexpensive, and acceptable training that may be valuable for persons with addictions.

The Problem Adverse childhood experiences (See Chapter 2) have been linked to dependence and addiction to alcohol, gambling, video games, shopping, and sex. Dysregulation in neurobiology such as the dopamine reward system has been found in problematic engagement with gambling, video games, and shopping, and both behavioral and substance addictions share similar executive functioning challenges as demonstrated by deficits in decision-making and difficulties in delaying rewards (U.S. Surgeon General, 2016). The number of family and community members who suffer as a result of deaths connected to substances is incomprehensible. Saad (2019) reported on a Gallup survey that almost half of American families have dealt with substance misuse in their families. Only slight differences were recorded by the survey regarding race or sex. Forty-six percent of U.S. adults reported having dealt with substance misuse in their families. Eighteen percent said those were related just to alcohol, while 10% said their problems were related just to drugs. Another 18% said they had dealt with both. Daglis (2021) reported that COVID-19 is related to many addictions that increased during the pandemic. Most of them include internet addiction, gaming, gambling, various drugs, alcohol, and pornography. Avena et al. (2021) reported that pandemic-related stress, anxiety, and isolation, in addition to disrupted treatment and recovery programs, can increase the likelihood of substance misuse, addiction, and relapse. The death toll from substance misuse, opioid use disorder, and substance use disorder within the United States is staggering. Excessive alcohol use is responsible for more than 95,000 deaths in the United States each year, or 261 deaths per day. These deaths shorten the lives of those who die by an average of almost 29 years, for a total of 2.8 million years of potential life lost. Provisional data from CDC’s National Center for Health Statistics indicate that there were an estimated 100,306 drug overdose deaths in the United States during the 12-month period ending in April 2021, an increase of 28.5% from the 78,056 deaths during the same period the year before. The new data documents that estimated overdose deaths from opioids increased to 75,673 in the 12-month period ending in April 2021, up from 56,064 the year before (CDC, 2021a, 2021b).

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Biological Factors Post-traumatic stress disorder (PTSD) and SUD frequently co-occur. Estimates of lifetime PTSD amongst SUD patients range from 26% to 52%, with estimates of current PTSD between 15% and 42%. Among individuals diagnosed with PTSD, estimates of comorbid substance abuse range from 19% to 35% and comorbid alcohol abuse from 36% to 52% (Roberts et al., 2015). There is strong evidence of a causal relationship between post-­traumatic stress disorder and addiction (Chilcoat et al., 1998). The relationship between PTSD and SUD is easy to understand as some people who suffer from symptoms of PTSD have survived incidents where they themselves have sustained serious physical injuries which are often treated with prescription opioids by medical professionals. Treating both PTSD and SUD concurrently can help the client have additional tools to respond to the physiological and emotional arousal that can occur in both conditions. Sympathetic nervous system hyperarousal is a primary symptom of PTSD. It occurs when a person’s body suddenly kicks into high alert, as a result of multisensory reminders of the traumatic experience. Even though real danger may not be present, the body acts as if it is, causing lasting stress after a traumatic event. (See Chapter 5’s description of the HPA-Axis.) In addition, the biological aspects of substance use, and misuse can cause reactions of anxiety and stress also resulting in sympathetic hyperarousal. When in sympathetic hyperarousal, a person can be thrust into satisfying cravings in order to induce a parasympathetic response. Many individuals who suffer physical and emotional pain seek out substances and engage in behaviors in order to decrease pain and increase feelings associated with sensing calmer states. In TRM/CRM language, if a person is so bumped out of the Resilient Zone into the High and/or Low Zones for too long, life can become intolerable, and people will look for all sorts of escape routes including substances and behaviors that initially provide relief that eventually can lead to misuse and addiction. Parsons and Hurd (2015) explain neuroadaptation as a process where the body compensates for a chemical’s presence in the body in order to function normally. For people who use drugs or alcohol, this neuroadaptation can lead to tolerance and misuse over time. The neuroadaptations impact brain functioning and are responsible for the transition from controlled, occasional substance use to chronic misuse. The neuroadaptations are the physiologic changes that occur in order to maintain homeostasis.

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The U.S. Surgeon General’s Report (2016) described the three regions of the brain that are the primary networks involved in the development of substance use disorders—the basal ganglia, the extended amygdala, and the prefrontal cortex. The basal ganglia control the rewarding, or pleasurable, effects of substance use and are also responsible for the formation of habitual substance use. The extended amygdala is involved in stress and the feelings of anxiety and irritability that often accompany substance withdrawal. The prefrontal cortex discussed in detail in Chapter 5 is involved in executive functioning which includes the ability to organize thoughts and activities in clear and focused ways, including exerting control over whether or not to use substances (Parsons & Hurd, 2015). The basal ganglia are a group of structures located deep within the brain that play an important role in coordinating body movements and in learning routine behaviors and forming habits. Repeated activation of the “habit circuitry” contributes to the compulsive substance seeking and use associated with addiction. The “habit circuitry” explains the intense craving for the substance and the compulsion that occurs when persons dealing with addiction are exposed to cues in the environment connected to their substance misuse. External and internal cues can result in a desire to use. External cues could include a song, a smell, a place, or a person. Internal cues could include rapid heart rate, accelerated breathing, stomach discomfort, and muscle tension. The skills of CRM/TRM help identify the external and internal multisensory cues. When a person learns to identify the unpleasant sensations connected to the multisensory cues, they can intentionally bring awareness to pleasant or neutral sensations. The person can implement one of the CRM/TRM wellness skills resulting in nervous system regulation that could quell the compulsion to use. With enough practice, new pathways can be developed along with new habits to diminish the intensity of cues or to remove them altogether. The following case example illustrates the power of the CRM/TRM wellness skills. While working in a residential treatment program for chronic pain and addiction, it was common to treat people who were in states of hypoarousal and hyperarousal. One example is a woman we will call Gigi, in her early thirties, who presented with an addiction to alcohol and cocaine. She agreed to come to treatment because her addictions were interfering with her job and interpersonal relationships. She had a high ACEs score and had been in and out of therapy since she was 14 years

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old. She was impulsive and would vacillate between the High and Low Zones. She often would engage in high-risk sexual encounters and was chronically late to work from staying up all night partying. She would drink alcohol to come down from the cocaine. She lacked healthy coping skills to manage her feelings and behaviors. Psychoeducation about the zones and basic three skills of Tracking, Resourcing, and Grounding were taught to her in the first three sessions. She found the skill of Tracking to be life-changing; she never felt in control of her emotions and behaviors and often had regret about things she would do while using. When she connected with the sensations in her body that were pleasant, unpleasant, and neutral, she was then able to have a greater awareness into reading the physical sensations in her body. Through the skill of Tracking, she reported feeling empowered that she had a choice of what to pay attention to. There was a whole other world of sensation in her body that she now had a skill to help her understand. She was able to identify specific sensations that would occur in her body right before she would go into a High Zone or Low Zone state. When she learned this, she was able to bring in other wellness skills to help her stay in her Resilient Zone or bring her back if she was stuck in the High or Low Zone for too long.

The extended amygdala plays an important role in addiction because of its association with emotions and stress. The extended amygdala and its sub-­ regions, located beneath the basal ganglia, help regulate the brain’s reactions to stress—including the survival networks of “fight or flight” and emotions of anxiety and irritability (Parsons & Hurd, 2015). When the extended amygdala is activated due to a perceived threat (whether internal or external), the resulting experience may be a felt sense of anxiety and irritability. Addiction behaviors are often attempts to reduce the felt sense of stress responses, including activation leading to the fight or flight responses. TRM’s reprocessing skills especially target survival responses like “fight and flight” that may have been thwarted as a result of traumatic experiences. Integrating the wellness skills of TRM/CRM due to its easy accessibility and usability into treatment programs can give clients additional support as they enter the recovery process. Learning to distinguish between sensations of distress and sensations of well-being helps individuals learn how to stabilize their

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nervous systems without using substances or behaviors that have led to their lives becoming unmanageable like in the case study of Gigi. In addition, the wellness skills of TRM/CRM have also been shown to reduce anxiety and depression at a statistically significant level (Grabbe et al., 2020). The extended amygdala is also important in memory formation. When the brain forms memories associated with our well-being or our distress, it processes the multifaceted elements of a memory including the sensations and emotions that occurred during memory formation. “Cue anticipation” refers to the environmental cues that can set off a craving. Cravings can not only lead to use and misuse but also to relapse. These cues are often called relapse triggers or cues. They not only involve thoughts and emotions but also sensations. CRM/TRM’s focus on tracking the sensations connected to thoughts and feelings can help to identify the sensory cues connected to a person’s relapse triggers that may otherwise go undetected. Relapse triggers are not only cued by thoughts and emotions but also by sensations. This expanded sensory information gives the person a new awareness. This awareness provides a choice of what to pay attention to—the sensations connected to the impulse or sensations that are pleasant or neutral connected to cultivating well-being by practicing the TRM/CRM skills. We theorize that the repeated practice can create new neuronal connections and could reduce the intensity of the relapse trigger. The amygdala’s role in emotional memory is responsible for the cues derailing a person’s efforts to cut down or stop substance use. The brain forms an association between pleasant memories of drug use or addictive activities. The more a person repeats the cycle of use, the more it strengthens the emotional memory circuits associated with these cues. Negative emotional memories play an important role in withdrawal. As withdrawal begins, the symptoms set off an unpleasant multisensory memory. Thus, in the earlier stages of addiction, the pleasurable experience of the drug motivates a repetitive use. In the later stages, there is a sense of relief when the withdrawal symptoms abate. The relief from withdrawal symptoms can continue to motivate the repetition of the cycle of misuse. The motivation to get relief from the overactive brain stress systems which produce negative emotions leads to drug- and alcohol-seeking behaviors. Neuroadaptations within the extended amygdala contribute to increased stress reactivity and negative emotional states in addiction (Parsons & Hurd, 2015). So, if overactive brain stress systems lead to alcohol- and drug seeking behaviors, clients can learn adaptive responses to stress which are embedded in the TRM/CRM skills. Learning the CRM/TRM wellness skills could contribute to their toolbox to assist with relapse prevention.

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The prefrontal cortex is part of the complex network of the brain and is responsible for complex cognitive processes described as “executive function”—the ability to organize thoughts and activities, prioritize tasks, manage time, make decisions, and regulate one’s actions, emotions, and impulses. Mahan and Ressler (2012) report that diminished prefrontal cortex control over the extended amygdala is particularly prominent in humans with PTSD. Interoceptive awareness (i.e., Skill #1: Tracking) and learning to read the sensations connected to a relapse may help the individual learn to reduce stress and the urge to use. In addition, the wellness skill #6, Shift and Stay, of CRM/TRM reminds the person how to shift to other sensations that support well-being that we theorize can—with practice—override the sensations connected to a relapse. Richard, a 51-year-old widow, lost his wife to cancer. He started binge drinking and suffering from panic attacks while at his home. He first came to therapy looking for skills to cope with loss, increased alcohol use, and panic attacks. Over the first three sessions, all six wellness skills were introduced. At the onset of treatment, we started with psychoeducation about the nervous system and the Resilient, High, and Low Zones. Richard explored how he was using alcohol to help decrease his anxiety symptoms. We uncovered environmental triggers that would cause a cascade of unpleasant physical sensations in his body. Emotionally, he was able to identify that being in the house that he lived in with his now deceased wife was hard for him, but he didn’t fully connect how that affected him on a sensory level until he learned the skill of Tracking. It was uncovered that his panic attacks happened only while he was in his house. He realized his wife’s belongings were cues that opened up multisensory reminders that were unpleasant and caused the panic attacks which then contributed to drinking too much in his attempts to feel better. Over time he was able to track what was happening in his body while being at home. He then used the skill of Shift and Stay to identify the unpleasant sensations and shift to somewhere in his body that felt better and stay there. He did this by going to a part of his house that he considered calming. He used the skill of Resourcing and was able to identify a spot in his house that was connected to a pleasant memory. Whenever he felt the unpleasant sensations building in his body, he was able to go to this spot in his house to help override the sensations of distress. Over time he was able to drink less, decrease his panic attacks, and feel less depressed.

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The CRM/TRM Innovation: Integration into Motivational Interviewing and Stages of Change Motivational Interviewing (MI) and TRM/CRM have nonjudgmental approaches. This nonjudgmental approach helps clients resolve the ambivalence that had prevented them from realizing personal goals. MI’s overall goal is to enhance the client’s readiness to change. MI described by Miller and Rollnick (2002) does not operate from a deficiency model that seeks to instill knowledge, insight, skills, correct thinking, or even motivation. Rather, the objective is to evoke the client’s own motivation, with confidence in the human desire and capacity to grow in nourishing directions. Instead of implying that “I have what you need,” MI communicates, “You have what you need.” Motivational interviewing emphasizes empathic understanding and acceptance as catalysts for change. TRM practitioners and CRM guides have a similar strength-based perspective. TRM/CRM help clients focus on sensations of well-being which helps them return to their Resilient Zone. In their Resilient Zone, the client can better resolve the ambivalence that has prevented change. In the Resilient Zone, a person has more adaptive cognitions with enhanced ability to create solutions to their life’s challenges. Motivational Interviewing strategies were first developed for working with individuals who had challenges with addictions. Miller et al. (2002) emphasized that knowledge does not necessarily correlate to behavior change. MI involves exploring the client’s own arguments around change and is differentiated into two phases: the first is focused on increasing motivation for change, and the second on consolidating commitment. When there are challenges, the client’s experience can be explored with empathy and compassion using the MI interventions and integrating the TRM/CRM skills. MI and the TRM/CRM both: • • • •

Help the client recognize and solve their own problems Guide rather than direct Collaborate and take a non-confrontational, conversational approach Guide the client to explore solutions to the challenges they are encountering with reducing or cutting back on problematic addictive behaviors

When the client learns to read their own Nervous System to identify sensations that can aid their capacity for self-regulation, this contributes to their sense of well-being. Reading the nervous system helps manage distress and more accurately identifies sensations connected to the motivation to change. In addition, Conversational Resourcing can be easily integrated into the MI intervention.

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MI’s effectiveness as an intervention has been researched across various populations. Miller and Rollnick (2002) described that MI interventions can be effective based upon the following: 1. Helping professionals who practiced MI elicited increased levels of change talk and decreased levels of resistance from helping professionals, relative to more overtly directive or confrontational counseling styles. 2. The extent to which clients verbalize arguments against change (resistance) during MI will be inversely related to the degree of subsequent behavior change. 3. The extent to which clients verbalize change talk (arguments for change) during MI will be directly related to the degree of subsequent behavior change. Bohnhert et al. (2016) found that “Brief intervention based on Motivational Interviewing is effective in reducing prescription drug intake in non-­treatment-seeking clients, specifically with individuals demonstrating dependence on or problematic use of prescription drugs in a hospital setting.” As the body of evidence supporting MI has grown, it has often been examined as an intervention in combination with other evidence-based treatments. Carroll et al. (2001) found: First, that Motivational Interviewing techniques can be taught to and used by “real world” clinicians. Second, Motivational Interviewing techniques, provided in one session, are powerful and practical in the short term, in this case doubling the return rate of this patient population.

CRM can be easily integrated into the MI approach and CRM’s accessibility is an alignment with MI as a short-term intervention.

Creating a supportive helping environment using MI concepts The TRM practitioner/CRM guide uses the concepts of MI specifically in four domains: 1. Expression of empathy: The TRM practitioner/CRM guide does this by seeing, considering, feeling, and sharing the client’s experience. The TRM practitioner’s attitude is directed towards a better understanding of the client’s behavior. This will enable the client to be more willing to accept change, engage in a gentle, open discussion of lifestyle issues, and

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correct disbeliefs. Sometimes, when helping professionals have seen the havoc caused by someone grappling with an addiction, they might feel less empathy for the client. Using the wellness skills to stay within their own Resilient Zone can increase the helper’s compassion towards the client and cultivate what is known as the “MI spirit.” 2. Client Self-Efficiency: The client’s responsibility is to choose and carry out action, whereas the CRM guide/TRM practitioner’s focus is helping the client stay motivated and supporting their sense of self-efficiency by helping the client use the wellness skills to build on their strengths. 3. Clarifying Inconsistencies: Using MI, the TRM practitioner/CRM guide clarifies any inconsistencies the client might be experiencing by expanding the client’s perspective to understand the difference between the client’s current behavior and change. Using MI methods, exploring the client’s potential consequences of their current behavior can illuminate the course that client would like to take. There are some instances when the course is not clear; if the client is gently asked to be curious about the sensations connected to their thoughts and feelings, the course can become clearer and embodied. 4. Working with Resistance: Using MI, the TRM practitioner/CRM guide does not confront the client’s resistance, but instead learns to “roll with it.” As a result, the client’s resistance will usually decrease. This avoids confrontation and arguments, while inviting the client to shift and clarify their perception. The TRM practitioner/CRM guide can also invite the client to examine a new perspective, but without imposing it, and invite the client to notice the sensations connected to the new perspective. Most importantly, the TRM practitioner/CRM guide values the client as their own resource for finding solutions to their problem.

Motivational Interviewing and the CRM/TRM Integration TRM practitioners/CRM guides can integrate sensory-focused questions when conducting a Motivational Interview. Inquiring about the quality of the sensation can assist clients in beginning to learn about the sensations connected to their thoughts and feelings about changing behaviors. The sensations connected to what they like about drinking may not be pleasant if, for example, their drinking is getting them into trouble at work and at home even though there are many things they may like about drinking. If the sensation is unpleasant, the TRM practitioner/CRM guide can inquire if there is a place inside the body that is pleasant or neutral and if they can

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shift their awareness to those sensations (i.e., Shift and Stay). As they shift their awareness, the client is invited to track the sensations. If the client notices a shift in sensations, the client can be asked if there are any thoughts and/or feelings coming up with regard to their motivation to change their drinking behavior in the present moment. Often, more adaptive thoughts emerge spontaneously about the motivation to change. The TRM practitioner/CRM guide continues to invite the client to notice sensations that are pleasant or neutral connected to the thought or feeling. Paying attention to the sensations connected to beliefs about behavior change that are embodied empowers the client to think about taking action if in the contemplation stage (see “Stages of Change Theory”). The following scripts are examples of approaches that can be taken to determine a client’s motivation to change along with questions about their sensory experience connected to their thoughts and feelings. When asking the Tracking question, “Is the sensation pleasant, unpleasant, or neutral?” invite the client to continue to track places in the body that are pleasant or neutral. If the client reports the sensation is unpleasant, invite the client’s curiosity to explore sensations that are less unpleasant no matter how small of a sensation. We will use drinking for our example.

Benefits of Continuing the Behavior • Can you share the benefits of continuing to drink alcohol? • What do you like about drinking alcohol? • As you tell me what you like about drinking, what are you aware of happening on the inside? • Is the sensation pleasant, unpleasant, or neutral?

Concerns If the Behavior Does Not Change • What are your concerns or what are you afraid of if you continue to drink? • As you tell me about your concern, what happens on the inside? • Is the sensation pleasant, unpleasant, or neutral?

Concerns If Change Takes Place • If you were to stop drinking, what would you be concerned about? • As you share those concerns, what are you aware of on the inside? • Is the sensation pleasant, unpleasant, or neutral?

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Benefits in Trying to Improve the Behavior • How would it benefit your life if you did stop drinking? • As you share how it would benefit you, what are you aware of on the inside? • Is the sensation pleasant, unpleasant, or neutral?

Scaling Question: Determine Motivation • On a scale from 1 to 10, with “1” representing no motivation at all to stop drinking and “10” representing the most motivation you have ever had, how would you rate your motivation today? • What do you notice inside as you share with me your motivation to change? • Is the sensation pleasant, unpleasant, or neutral?

When Motivation Is Low • What would have to happen in your life to move your motivation from a “3” to let’s say a “6”? • As your motivation increases, what happens on the inside? • Is the sensation pleasant, unpleasant, or neutral?

Exception Question • Has there been a time in the past when you were able to cut down or stop drinking? • If so, what were you doing then that you are not doing now? • As you remember what you were doing then, what happens on the inside now? • Is the sensation pleasant, unpleasant, or neutral?

Miracle Question: For Stuck or Discouraged Clients • Let’s say a miracle happened in the middle of the night and all the problems you have had with stopping drinking are gone, how would you know the miracle had happened? • What specifically would you be doing differently to make the miracle happen? • Are you willing to start doing any part of this now? • As you think about the parts you are willing to do now, what happens on the inside? • Is the sensation pleasant, unpleasant, or neutral?

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By shaping questions in a nonjudgmental way and adding the Tracking questions, the TRM practitioner/CRM guide can help the client add the sensory information to their cognitions about changing their behavior or not. Another way of asking about the miracle question, which can also be a way of developing a future template of a resource, is through the medium of expressive arts. In TRM/CRM, we can invite the client to create two drawings–one representing where they are in the present moment with their current problem and the other representing what their life would look like if the miracle had occurred and the problem was solved. • Begin with inviting the client to explain the drawing representing the miracle having taken place and the problem is resolved. • As the client explains and looks at the drawing, inquire what the client is noticing inside the body. ○ Are the sensations pleasant, unpleasant, or neutral? • If pleasant or neutral sensations are reported, invite the client to continue to notice those sensations. • If unpleasant sensations are reported, invite the client to shift awareness to more pleasant aspects of the drawing. • Choice Point: You can stay with the pleasant sensations connected to the Miracle drawing or invite the client to share the drawing connected to where they are in the present moment. • If they decide to describe the second drawing, ask them what sensations they are noticing. If they report unpleasant sensations, draw them back to the pleasant sensations of the first drawing or ask them if there is anything they would like to add to the drawing that is about the present moment. Using the expressive arts can be another portal of knowledge and possibly discovering what else may be true about their current situation. This is another vehicle that could increase hope and motivation for the client to begin to take the steps needed to change.

Stages of Change Theory In the CRM guide’s/TRM practitioner’s efforts to support client change, it is essential to integrate the Transtheoretical Theory of Change by Prochaska

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and DiClemente (1992). The stages of change theory can be easily interwoven into interventions with clients. By identifying the client’s position in the change process, the TRM practitioner/CRM guide can customize the method of intervention and focus efforts on moving towards the next stage of change integrating CRM/TRM skills. The stages are identified as: Precontemplation, Contemplation, Preparation, Action, Maintenance, and Relapse. The following will summarize the Transtheoretical Theory of Change incorporating TRM/CRM concepts: The initial precontemplation stage is when the client is not thinking about change and is unaware of any problem related to their behavior, is unconcerned about their behavior, and ignores anyone’s belief that they are doing something harmful. The TRM practitioner/CRM guide does not assume that the client is ready to change, but instead discusses the client’s feelings and experiences, and provides the necessary health education in small, understandable increments in accordance with the methods learned in MI. The key concepts of the CRM and TRM like the Zones can be shared in the educational process. The second stage is the contemplation stage in which the client is considering whether or not to change since there are reasons to continue the challenging behavior and reasons to stop. The client is constantly debating in an internal struggle whether or not to change the behavior. The role of the CRM guide/TRM practitioner is to help the client explore the pros and cons of change, to identify the client’s personal motivations for wanting to make a change, and to have the client identify their own motivation in order to encourage short-term achievable goals. As the client explores the pros and cons, the practitioner/guide explores the sensations connected to weighing in on the different reasons to change or to not change. The third stage is the determination/preparation stage in which the client decides how they are going to change and whether they may be ready to change their behavior or at least get ready to make the change. The role of the TRM practitioner/CRM guide is to be supportive; to reinforce all positive progress to help the client build self-confidence; to help the client monitor the barriers encountered in the gains and losses; and to consider that it may take time to move to the next stage (action); and then to encourage the exploration of sensations connected to the preparation stage. The fourth stage is the action stage in which the client will begin taking the essential steps to change the targeted behavior. The client will need help identifying practical steps, recognizing high-risk situations, and learning new coping strategies that can be incorporated in their activities of daily living.

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The role of the TRM practitioner/CRM guide is to provide encouragement and to discuss ways the client can continue to make progress including how to integrate the wellness skills into the activities of daily living including orientation to the iChill app. If the client has successfully entered the action stage, this will lead into the fifth stage which is the maintenance stage, where clients will seek to sustain and tolerate long-term changes beyond six months. The TRM practitioner continues to encourage and support as well as offer community resources to provide further help and support. Encouraging the embodiment of the change by inviting the client to notice the sensations connected to the action stage can help anchor the changes being made within the nervous system. In the event of the client relapsing (sixth stage), there is a reinitiation plan for the client. Depending on the behavior of focus, people can make several attempts to quit a behavior before being successful, and this is typical of the change process. The process of change is rarely the same in subsequent attempts or with different behaviors. The role of the TRM practitioner/CRM guide is to remind the client that a relapse can be temporary and can be viewed as a learning opportunity rather than a failure. Someone who has relapsed is not a failure; instead, relapse is part of the change process and should be normalized. Further, an exploration of what were the thoughts and feelings that were part of what sparked the relapse along with the identification of the sensory cues will help the client understand more about factors leading to the relapse. The client can also be asked to notice the sensations that arise as they recount the thoughts and feelings and/or identify the sensory cues. They can then use the TRM/CRM skills to manage any distress that arises to see if the distress can be uncoupled from the thoughts, feelings, and/or cues hopefully resulting in reducing the chance of these thoughts, feelings, and cues setting off a relapse in the future. Amanda, a 20-year-old college student entered therapy after a sexual assault on campus. After the assault on campus, the client started abusing Xanax and engaging in self-harming behavior. Amanda would scratch her left side of her lower stomach intensely to a point of breaking the skin. She came to treatment wanting to learn coping skills so she could stop scratching herself and had hopes of cutting Xanax out of her life completely. Amanda would scratch two to three times a week and was running out of her prescription sooner than was advised from her psychiatrist.

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Amanda was taught the six wellness skills of TRM. Within the first month of individual psychotherapy, she was able to cut back on her self-harming behaviors and reduce her use of Xanax. She went from scratching twice to thrice a week to only scratching once in two weeks. She was reluctant at first to completely go off the Xanax. However, as a result of coordination with the prescribing psychiatrist, we worked together so she could slowly wean off the Xanax. She was able to reframe her thinking and instead of looking at the one time she scratched in two weeks as a negative thing, she saw her progress. We explored cues that happened that led up to the relapse in self harm. She was able to start to identify unpleasant sensations that were happening in her body right before she scratched. We also explored meanings and feelings around the relapse. Within six months, she was able to wean off her Xanax and at this writing has not self-harmed.

Ambivalence It is important to note that the second and third stages (contemplation and preparation stages) are phases of ambivalence, where MI is an operational counseling method that augments motivation through ambivalence resolution. The three critical components of ambivalence motivation are: 1. Checking the client’s perception of the importance of change (willingness to change) 2. Checking the client’s level of confidence in relation to change (ability to change) 3. Checking the client’s urgency to change (readiness to change). Accordingly, the readiness phase is influenced by a mixture of two factors: how important is the change to the client and how confident is the client about making the change. The ambivalence phase is an innate struggle, where conflicting attitudes or feelings coexist in an individual and they are interlocked simultaneously with either wanting to change or not wanting to change. The signs of a client’s readiness to change can include indicators they are less resistant, or they have fewer questions about the problem. Ambivalence is viewed as positive because it opens the door to examination of other options. Sensory awareness of the thoughts and feelings connected to ambivalence can help unlock the more adaptive path for the client.

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Understand Ambivalence Understand that there are benefits in changing the behavior and benefits in maintaining the behavior. The client may have fears and concerns about changing behavior. The TRM practitioner/CRM guide must discover the nature of the fears and concerns. Integrating sensory awareness by tracking the sensations connected to changing and not changing the target behavior can be another portal of information that can bring more awareness to the client.

Conclusion As a society, we must explore innovation and work with our community stakeholders to expand what is offered to youth and adults to reduce or eliminate the factors that lead to addictions. In addition, offering supportive, humane approaches like MI coupled with interoceptive awareness can help individuals make their own decisions on whether or not to change their use of substances and behaviors. Trauma-informed education underscoring the biological underpinnings of addiction is imperative. Skill development that includes strategies that reduce nervous system activation and are integrated into daily living to provide an array of wellness skills based upon neuroscience could proliferate throughout society. One innovation that is a shining example of what is possible comes from Cammie Wolf Rice who created the Christopher Wolf Crusade (CWC) in the memory of her son who died from an opioid overdose. Christopher passed after a 14-year battle with substance misuse and dependence. As with so many others, his battle with opioid dependence began with a prescription. Christopher was diagnosed with Ulcerative Colitis in middle school. This diagnosis led to countless surgeries and thousands of prescription opioids. When Christopher passed, Cammie Wolf Rice, his mother, turned her suffering and pain into action with the insight she had to work to prevent this from happening to one other person and family. In 2018, Cammie founded the CWC with a mission to end substance misuse before it begins. After all of the time that Cammie spent in the hospital with Christopher, she recognized a huge need for intervention. No one educated Christopher or his family about the risks of his pain medication until it was too late. Cammie Wolf Rice has created a new level of care called Life Care Specialists in hospitals. Life Care Specialists (LCSs) are trained to understand drug dependence and state-of-the-art approaches like MI and the Stages of Change Theory. All LCSs have been trained to be CRM Teachers or CRM Guides.

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After surgery, orthopedic trauma patients are in immense pain. The only solution provided in the current standard of care is an opioid, an addictive drug. With a Life Care Specialist, trauma patients are provided with educational resources and alternative pain management skills. These skills include the CRM, Guided Imagery, Progressive Relaxation, and other ­evidence-based wellness skills and nervous system regulation techniques. LCSs work one-on-one with patients to develop personalized pain management plans and are trained to evaluate personal risk factors for substance misuse and to give referrals. As of this writing, the first group of LCSs has completed a two-year pilot study at Grady Memorial Hospital in Atlanta, Georgia, and is finishing a randomized control trial to gather evidence about the effectiveness of LCSs. Early results suggest a 25% reduction in opioid medication use after intervention by the LCS. In addition, the preliminary data is showing a reduction is Emergency Room readmission for pain management. This study is being conducted under the supervision of the Emory University Institutional Review Board (IRB) and Mara L. Schenker, MD. This study is registered on clinicaltrials.gov. To learn more about CWC, go to www.cwc.ngo. CWC is also implementing LCS program across the state of Georgia in rural hospitals with high opioid prescribing. At each of these rural centers, LCSs will teach the skills of CRM to patients as part of their patient toolkit and to providers in the health system. The skills have been shown to have a significant impact on those on the front line. This training will provide necessary Continued Medical Education credits to healthcare workers. This model of patient and provider education has already been implemented at Grady Memorial Hospital. The LCS’s role is scalable, sustainable, and affordable. You walk into the room of a patient who has suffered a traumatic injury and is trying to cope with their pain. You walk out of the room with the patient reporting that their anxiety has decreased, their pain is more manageable, and they know that their pain medication is addictive. Bailey, LCS since 2019

References American Society of Addiction Medicine. https://www.asam.org/quality-care/­ definition-of-addiction (accessed 2/19/22). Avena, Nicole M., Simkus, Julia, Lewandowski, Anne, Gold, Mark S., & Potenza, Marc N. (2021). Substance use disorders and behavioral addictions during the

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COVID-19 pandemic and COVID-19-related restrictions. Frontiers in Psychiatry, 12, 21. https://www.frontiersin.org/article/10.3389/fpsyt.2021.653674 Bohnert, Amy, Bonar, Erin, Cunningham, Rebecca, Greenwald, Mark, Thomas, Laura, Stephen Chermack, Stephen, Blow, Frederic, Walton, Maureen (2016) A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among emergency department patients at risk for prescription opioid overdose, Drug and Alcohol Dependence, Volume 163, Pages 40–47. Carroll, K. M. et al. (2001). Motivational interviewing to enhance treatment initiation in substance abusers: An effectiveness study. The American Journal on Addictions, 10(4), 335–9. doi:10.1080/aja.10.4.335.339. Centers for Disease Control. (2021a). https://www.cdc.gov/alcohol/features/­ excessive-alcohol-deaths.html Centers for Disease Control. (2021b). https://www.cdc.gov/nchs/pressroom/nchs_ press_releases/2021/20211117.htm Chilcoat, H. D., & Breslau, N. (1998). Posttraumatic stress disorder and drug disorders: Testing causal pathways. Archive of General Psychology, 55, 913–917 Daglis, T. (2021). The increase in addiction during COVID-19. Encyclopedia. 1(4),1257–1266. https://doi.org/10.3390/encyclopedia1040095 Grabbe, L., Higgins, M., Baird, M., Craven, P., & Fratello, S. (2020). The Community Resiliency Model® to promote nurse well-being. Nursing Outlook, 68(3), 324–336. doi: 10.1016/j.outlook.2019.11.002. Epub 2019 Dec 30. PMID: 31894015. Grabbe, L., Higgins, M., Jordan, D. et al. (2021). The Community Resiliency Model®: A pilot of an interoception intervention to increase the emotional self-regulation of women in addiction treatment. International Journal of Mental Health Addiction 19, 793–808. https://doi.org/10.1007/s11469-019-00189-9 Koob, G. F., & Volkow, N. D. (2010). Neurocircuitry of addiction. Neuropsychopharmacology, 35(1), 217–238. Mahan, A. L., & Ressler, K. J. (2012). Fear conditioning, synaptic plasticity and the amygdala: Implications for posttraumatic stress disorder. Trends in Neurosciences 35(1), 24–35. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. (2nd ed.). New York: The Guilford Press. Parsons, L. H., & Hurd, Y. L. (2015). Endocannabinoid signaling in reward and addiction. Nature Reviews Neuroscience 16(10), 579–594. Prochaska, J. O., & DiClemente, C. C. (1992). The transtheoretical approach. In J.C. Norcross & M.R. Goldfried (Eds.), Handbook of psychotherapy integration. New York: Basic Books.

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Roberts, N., Roberts, E., Jones, N., Bisson, J. (2015), Psychological Interventions for Post-Traumatic Stress Disorder and Co-Morbid Substance Use Disorder: A Systematic Review and Meta-Analysis, Clinical Psychology Review 38 (25–38), https://doi.org/10.1016/j.cpr.2015.02.007 Saad, L. (2019). Substance abuse hits home for half of Americans. Gallup. https:// news.gallup.com/poll/267416/substance-abuse-hits-home-close-half-americans. aspx (accessed 2/13/21) U.S. Surgeon General. (2016). Facing addiction in America: The surgeon general’s report on alcohol, drugs, and health. Washington, DC: HHS.

Part V

Research

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Research on the Community Resiliency Model (CRM): Need, Theoretical Basis, Status, Tools, and Next Steps Linda Grabbe, Susanne Montgomery, Kimberly Freeman, and Beverly J. Buckles This chapter will: 1. Describe the early uses of the Community Resiliency Model (CRM) and the Trauma Resiliency Model (TRM) 2. Describe a Systematic Approach to Designing CRM Research to Expand its Evidence Base 3. Describe the measures used to research CRM 4. Describe the published research on CRM The past few decades have brought about the realization that exposure to natural or man-made trauma is much more prevalent throughout the world than had been previously thought (Straussner & Calnan, 2014). With this recognition came an acknowledgment that one of the most neglected, albeit needed, interventions in global health was the provision of appropriate, timely, trauma-focused mental health services. More than at any time in the past, the United Nations (UN), its development partners, and the entire international community of humanitarian NGOs now see trauma-informed mental health services as an integral part of international development needs (UN, 2021) Consequently, the need to incorporate trauma-informed approaches in all international interventions, and the need for realistic and appropriate methods to bring such services to high-risk or at-risk settings is greater than ever before. As a reflection of this change, all UN- and USAID-funded

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development projects must now not only provide evidence of trauma-­ informed mental health services, but also demonstrate the inclusion of effective, sustainable programs that can be assessed for positive community impact (WHO, 2010). In light of the great need and in consideration of the ever-present stigma associated with behavioral health interventions, WHO (i.e., WHO small countries initiatives) and Healthy People 2020 are promoting resiliency-informed interventions, as a way of reaching communities that are traditionally not open to interventions labeled “mental health.”

CRM and TRM: Early Uses and Outcomes While early adoption of CRM research occurred mainly in the U.S., the origins of the Trauma and Community Resiliency Models (TRM and CRM) lie in a series of international natural emergencies in the early 2000s. Although Mental Health First Aid was the primary tool used per WHO guidance in post-disaster settings, some mental health providers who lent their assistance in the tsunami in Southeast Asia were schooled in Somatic Experiencing, a sensory psychotherapy for trauma developed by Peter Levine (Levine, 1997). Because of the urgency of the disaster conditions, these workers (one of whom was Elaine Miller-Karas) could only offer brief ­somatic-based interventions to trauma victims, usually in a single encounter. Elaine Miller-Karas and Laurie Leitch led disaster responses through the Trauma Resource Institute, using the Trauma Resiliency Model after earthquakes in Haiti and China. The U.S. Research published subsequently demonstrated lower than expected rates of post-traumatic stress disorder (PTSD) symptoms (Leitch, 2007; Leitch et al., 2009; Parker et al., 2008). From this series of events, and based on scholarly and mounting anecdotal evidence, TRM emerged as an accessible psychotherapeutic training for mental health providers, and CRM emerged as a stand-alone, preventative self-care intervention, essentially a kind of population-level mental healthcare because once learned, the learner may serve as teacher to others in their network as a “CRM guide.” Elaine Miller-Karas and colleague Laurie Leitch taught TRM’s self-­ regulation skills to 350 Sichuan earthquake front-line workers in a “train the trainer” approach (Miller-Karas & Leitch, 2009). The vast majority of these workers subsequently used the skills to protect their own well-­ being and also taught the emotion regulation skills to trauma survivors they

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were working with; this was a demonstration of the multiplicative effect of CRM’s simple skillset. Although then called TRM, this was the staging ground for CRM, and constituted the first evidence for CRM as a preventative, stand-alone, self-care intervention, which could be shared easily with clients. At the Trauma Resource Institute, Miller-Karas went on to develop TRM and CRM with the intention of making the models as accessible as possible to reach therapists and broad swaths of populations (Miller-Karas, 2015). CRM’s instructional “iChill” app helped to further facilitate the understanding and transfer of the CRM concepts and skills to a lay audience leading to and supporting a broader dissemination of the model. ­Miller-Karas envisions reaching a social change tipping point of CRM practice within a given community of enough individuals (25%) (Centola et al., 2018), such that CRM’s destigmatizing perspective on mental health and simple self-regulation skills might become part of a culture. CRM is unique because it is adaptable to any culture and may be taught relatively quickly. In addition, learners can immediately practice the skills, teach them to others, and the techniques may be helpful in moments of stress or crisis. It is critical, however, that in addition to this lay acceptance, the research literature on CRM results in published measurable outcomes to support this enthusiasm. In this context, many practitioners, evaluators, and researchers have since attempted to not only apply CRM, but increasingly design studies to evaluate effectiveness. For instance, CRM has been applied as a powerful crisis intervention model in diverse settings that were (a) domestic (e.g., Flint, Michigan Water Crisis; Orlando, Florida Pulse Nightclub Shooting; Las Vegas, Nevada Shooting at Route 91 Harvest Music Festival; Paradise, California Wildfire; Hurricane Florence) and (b) international (e.g., Ukrainian invasion, Côte D’Ivoire civil war, Philippines Typhoon Yolanda), some of which are currently in progress toward publication. Similarly, CRM interventions have been used in countries recovering from the severe stress of war and genocide (e.g., Rwanda, Ukraine and Northern Ireland), and with refugees in Germany, indicating the healing potential of CRM. Domestically, CRM was applied as a tool to promote mental wellness among health care providers and in community-based settings to promote diversity and inclusion of groups, e.g., LGBTQ, veterans, minorities, and marginalized groups. The outcome evaluations of several of these have been published. These findings are encouraging and provide the needed foundation for conducting more systematic and rigorous research in hopes of meeting the standards for an evidence-based treatment.

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A Systematic Approach to Designing CRM Research to Expand its Evidence Base The concept of Evidence Based Research (EBR) originally came from the field of medicine (Howick et al., 2011) and refers to the integration of the best research evidence (not opinion) with clinical expertise and clinical outcomes as a means to achieve the best practices for patient care. Even in the field of behavioral health, external programmatic funding for interventions and treatments increasingly requires an evidenced-based or at least an evidence-informed base for the project. This involves following the research processes depicted in the Evidence-Based Pyramid (EBP) to document the effectiveness of a new intervention. The pyramid describes progress toward consensus on the effectiveness of a new intervention. The quality of evidence increases as the pyramid narrows, beginning with expert observations and opinions of respected authorities at the base, followed by peer-reviewed published articles using observational studies (case reports, case controlled studies), non-experimental cohort studies, quasi-­ experimental and randomized controlled studies, and finally, consensus-building systematic reviews that summarize multiple studies with replication of findings in different settings and populations, documented in meta analyses (Walden University, 2022). The higher the level on the pyramid, the more rigorous the research and the closer an intervention comes to gaining evidenced-based status. CRM is moving along this spectrum and has at least reached evidence-­informed status with some experimental and even randomized controlled studies; these have allowed for new federal funding sources for CRM. An additional perspective to this EBP approach focuses on levels of r­ealworld applications of health interventions. The five-tiered Health Impact Pyramid (HIP) was conceptualized by former Center for Disease Control Director Thomas Frieden to classify different types of public health interventions, according to their impact on health in a society (Figure 15.1) (Frieden, 2010). The HIP may serve as a framework for evaluating and researching TRM and CRM, as well as other mental health interventions. Interventions at the bottom of the pyramid have the greatest public health impact; interventions at the top of the pyramid are individual encounters which require much more time, money, and effort; while top-level interventions may have strong individual effect, by nature, they cannot impact broader segments of populations. The maximum possible sustained public health benefit is obtained when interventions take place at all of the five levels (Frieden, 2010). CRM and TRM may fit at multiple levels of the pyramid. In Figure 15.2, we briefly describe possible uses and context of CRM and TRM with respect to the Health Impact Pyramid.

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Figure 15.1  Frieden’s Health Impact Pyramid Source: Thomas L. Frieden, The Health Impact Pyramid, American Journal of Public Health, April 2010, reprinted with permission from the American Journal of Public Health.

Figure 15.2  The CRM and TRM in the Context of the Health Impact Pyramid

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Published Research on CRM As CRM/TRM interventions were being delivered nationally and abroad, resulting in groups or populations that reported improved lives and functioning, the models increasingly gained the attention of respected practitioners who supported the building excitement about CRM’s relevance and effectiveness (Level one of the EBP). At the same time, the number of CRM teachers certified through the Trauma Resource Institute multiplied and CRM teachers who were university-based and trained in research methods began the research that is now in the process of leading to CRM’s acceptance among evidence-based resiliency practices. Given the theoretical relevance of TRM/CRM and the need to develop the research base for CRM status as EBP, an initial group of researchers has been conducting studies on CRM—some observational, some within subject, some longitudinal and others either quasi-experimental or experimental. This group is ever expanding, with new researchers joining the Trauma Resource Institute’s research and measurement committee, as well as graduate students and human service professionals to expand research on new CRM applications across the nation and abroad.

CRM Research in the U.S. Before more formal research occurred, Miller-Karas recognized the applicability of CRM to chronically traumatized populations in the U.S. and abroad, and she and her colleagues taught the CRM skills in post-disaster environments in Haiti (Citron et al., 2013) and to members of marginalized groups in the U.S. (Citron & Miller-Karas, 2013), with highly positive program evaluation results; all demonstrated beneficial mental health effects after participants learned the simple CRM stabilization skills to manage stress. Building on this work, several research groups set out to rigorously research CRM in a variety of target populations, using a variety of doses and research designs. Research that has been published, submitted, or in-progress in U.S.-based research publications that demonstrate the broad and expanding reach and findings of CRM. Thus far, a total of 11 papers have been published/accepted (N=7) or are in the process (N=4) of being published. They include a mix of theoretical papers arguing for the research basis or applications for CRM (Grabbe & Miller-Karas, 2018; Grabbe et al., 2022 in review; and Duva et al., 2022, accepted for publication), observational, single group, pre/

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post-test longitudinal studies with various follow-up lengths ranging from one-to-two hour interventions in-person lectures (Barolle et al., in progress; Leitch et al., 2009), one-hour virtual trainings (Duva et al., 2021 in progress); three-to-five hour interventions (Grabbe et al., 2021; and Grabbe et al., 2021; Reddy et al., 2022), traditional week-long trainings (Freeman et al., 2021; Baek et al., 2022); and interventions blending CRM into another intervention, also referred to CRM+ (Joachim-Celestin et al., 2022). Other papers report on quasi-experimental studies (Leitch et al., 2009), and experimental randomized clinical trials (Grabbe et al., 2020b Duva et al., 2021). Populations served include • social service workers after an earthquake, • a mix of health care workers and nurses prior to or during the COVID-19 epidemic (Grabbe et al., 2019; Grabbe et al., 2021; Barrolle et al., in progress; Duva et al., in progress), • a mix of minoritized, underserved community members experiencing trauma (Freeman et al., 2021), • veterans (Baek et al., in progress), • Spanish-speaking Latinas in a lifestyle intervention (Joachim-Celestin et al., 2022), • underserved women in drug treatment (Grabbe et al., 2021), and • African Americans with memory impairment (Reddy et al., 2022). Table 15.1 outlining the research done in the U.S. Significant outcomes findings is in the Appendix. (P=.05 or better) initially focused on CRM implementation, such as training relevance, use, and satisfaction with CRM (Leitch et al., 2009) found that the CRM skills were well received by participants, who applied them personally for self-care and in their work (Leitch et al., 2009). Subsequent research added increasing numbers of standardized scales (all had acceptable-to-high internal validities for the populations studied) to the outcome studies, in addition to implementation measures, which remained strong across all subsequent studies. In CRM’s first randomized controlled trial (RCT) (Grabbe et al., 2020), in studies of persons with addiction (Grabbe et al., 2020), and frontline workers (Grabbe et al., 2021); in a second CRM RCT of a single-hour, virtual CRM training, results demonstrated improvements in well-being, stress symptoms, and perception of interprofessional teamwork during the COVID-19 pandemic (Duva, 2021). In all studies outcomes were strong (P=