‘Help Them See There is Hope’: Insights from the Guru of TST – Part 1

by Michele Rosenberg

Every journey into new territory goes better with a guide. On our quest to become trauma-informed, CFSA is fortunate to have the help of Dr. Glenn Saxe, one of the prime developers of Trauma Systems Therapy (TST). Recently, he talked to me about his work.

Michele: How did you come to develop TST?

SaxeDr. Saxe: While working at Boston Medical Center, an inner city hospital, my team was providing what I thought was the best of outpatient care. But there came a point when we grew concerned about the number of youth we saw who were facing ongoing stressors and traumas. The term “Post-Traumatic Stress Disorder” didn’t make sense when for too many children, the trauma was in the present.

We set out to find a way to address the current needs of these youth. Between 2000 and 2003, we began to write our manual and to develop the processes, instruments, and tools that would eventually become TST. We began to collect pilot data in Boston, and in 2004, we did the first formal dissemination and data collection in a county-led child welfare/mental health collaboration in upstate New York. In 2005, we published our first outcome study based on data from 110 families. In November 2006, Guilford Press published our treatment manual, and we launched TST at the annual meeting of the International Society for Traumatic Stress Studies in Los Angeles. In December 2006, the TST development team moved to Children’s Hospital at the Harvard Medical School, and since 2010 has been based at the Child Study Center at the NYU Langone School of Medicine, where I’m chair of the Department of Child and Adolescent Psychiatry.

TST has grown and developed over this time and is currently being implemented in public and private mental health and child welfare settings in 14 states and the District of Columbia. We’ve recently revised and updated the model, with a new TST manual coming out from Guilford in 2015.

Michele: What makes TST different from other approaches?

Dr.Saxe: TST is distinct in several respects.

  • TST focuses not solely on a traumatized child but rather on the “trauma system.” It focuses on helping the youth learn to better regulate his emotions and behavior while at the same time creating a stable social environment around him that is filled with signals of care.
  • To effectively address the needs of the trauma system, TST requires a multi-disciplinary treatment team. Every team member has a distinct role.
  • TST uses Ready Set Go, a specific strategy for getting and keeping youth and families in treatment. We identify a goal or priority that’s meaningful to the youth and family. Then we build a plan around helping them see how working with the team will support them in achieving their goal.
  • TST is based on three phases of treatment, each with its own corresponding intervention strategy.
  • TST is an organizational as well as a clinical model. This means we don’t train individuals to be TST clinicians. Rather, we help organizations embed TST in a meaningful and sustainable way into their day-to-day functioning.

I made a decision early on not to claim intellectual property rights for TST. For a model such as ours to be successfully integrated into an organization, one size can’t fit all. We encourage agencies implementing TST to first learn the model and then work with us to make adaptations that best suit the needs of their population and setting. The TST Innovation Community is a group of agencies around the country doing just that. Through this collaborative process, we now have adaptations of TST for populations such as refugee youth and traumatized adolescents with substance abuse issues and for settings including foster care, residential treatment, and school-based programs.

Michele: Does TST work with kids of all ages?

Dr. Saxe: We originally collected data on youth ages 6 to 19. Currently, we’re piloting use of TST with children as young as 3 in a therapeutic nursery, with promising preliminary experiences. Another site in our Innovation Community is piloting use of the model with adults.

Michele: In your research, can the brain really be healed?

Dr. Saxe: Although there’s clear evidence that traumatic events can affect the structure and function of the brain, there’s also evidence that this doesn’t have to be permanent. The concept of neuroplasticity shows that the brain is reactive to environmental factors. A child raised in a nurturing, positively stimulating environment will develop in a neuro-typical fashion, whereas a child who is neglected or maltreated early on will show less-than-ideal brain development. But traumatized people can respond to treatment. Many of us believe this is related to healing of the brain systems responsible for traumatic stress—what we call the Survival Circuit. More research is needed, but there’s reason to hope.

Michele: So much happens in the birth-to-five-year period of development. For older youth, is there a point of no return?

Dr. Saxe: The impact of trauma on the brain doesn’t have to condemn children to a life of dysfunction. Older youth can respond to intervention, particularly help with building emotional regulation skills and creating a stable, nurturing environment in which they feel wanted and cared for. This helps to combat the very common, although often unconscious, belief among many traumatized youth that they don’t deserve support and won’t have a positive future.

We often see that they lose hope, and people start to view their negative behaviors as representing who they are rather than as a predictable pattern of response to environmental cues. This is why it’s so important to promote interventions that help youth and those working with them to see there’s hope. By promoting treatments such as TST, the youth themselves—as well as parents, foster parents, teachers, caseworkers, and others—can all start to see the role they can play in “fixing a broken system.” That way, older youth can certainly be helped to turn things around.

Coming Next: A TST case study to illustrate the usefulness of Dr. Saxe’s approach

Dr. Glenn N. Saxe, MD, is chair of the Department of Child and Adolescent Psychiatry and operates the Child Study Center at the Langone School of Medicine at New York University. He is a co-developer of the Trauma Systems Therapy approach and co-author of the defining manual Collaborative Treatment of Traumatized Children and Teens (Guilford Press, 2007). He is a consultant to the DC Child and Family Services Agency in our work to become a trauma-informed public child welfare system.