How Does TST Work? Insights from the Guru of TST – Part 2

by Michele Rosenberg

In my last post, Dr. Glenn Saxe, one of the prime developers of Trauma Systems Therapy (TST), shared the good news that abuse and neglect don’t need to scar children for life. While more research is needed, there’s hope that brains can heal, including those of older youth. But how does that work? Dr. Saxe gives us a glimpse through a typical case study of a child who received TST while in foster care.

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Dr. Saxe’s Typical Case Study:
An Instance of Neglect, a Team Approach

Neighbors discovered Rodney*, 10, unsupervised for long periods without adequate Saxefood and not attending school. Due to this neglect, child welfare removed him from his mother who was struggling with substance use. Rodney is now placed in a foster home through an agency implementing TST. The TST team for Rodney consists of the foster care agency caseworker, that caseworker’s supervisor, the clinician Rodney is seeing at a local mental health clinic, the psychiatrist at the foster care agency, Rodney, and his foster mother Mrs. W. His bio mother, who is in in-patient substance use treatment, participates when she can. The caseworker also keeps in close contact with the teacher and social worker at Rodney’s school.

Worrisome Behavior

Mrs. W. has been fostering children for years, and the agency considers her to be one of their strongest foster parents. She reports Rodney does well most of the time and is generally quiet, respectful, and follows her rules and limits. But she is upset and concerned that Rodney periodically becomes aggressive and trashes his room. At these times, he destroys property, and upsets the other foster children in the home. She is surprised by these episodes because he is not usually aggressive and at these times, appears frightened and looks past her, unable to respond.

Not: “Why is This Child So Bad?”
Rather: “What Has This Child Been Through?”

The team agrees that the caseworker will meet with Mrs. W. to provide psycho-education about trauma, to explain Rodney’s history of neglect and abandonment, and to help her understand his behavior in the context of his life experience. She begins to realize that his behavior is not disrespectful or oppositional but is emotional and behavioral dysregulation in reaction to traumatic reminders. Mrs. W. receives this information well and wants to help Rodney. The team agrees the best way to go about this is to gain a better understanding of patterns involved with his episodes of dysregulation.

Assessment

Mrs. W. reports that she does not notice a pattern, that it seems Rodney’s behavior appears out of the blue. The caseworker explains the concept of the moment-by-moment assessment and works with Mrs. W. to look for patterns. They consider the last two times Rodney acted that way and realize both incidents occurred on the same day he had a visit with his birth mother. He came home from the visit, went right to his room, was quiet for about an hour, and then began yelling and breaking things in his room. The team’s initial hypothesis is that something happening during the visits is upsetting him. The team speculates that Rodney’s mother is saying something upsetting, such as blaming him for the authorities being involved in their lives.

It turns out that these visits are supervised, but the team is not getting information about them. The team then reaches out to the person assigned to supervise the visits, and enlists that person as a member of Rodney’s TST team. According to this person, the visits are actually going quite well. Rodney and his birth mother seem genuinely happy to be together. Mother is loving and tells Rodney she is doing everything she can to get him back. She is complying with her substance use treatment (which the team confirms) and is in her own therapy as well. She is accepting services from the Department of Social Services and working to get adequate housing in place.

Identifying the Trigger and Priority Problem

The team then reconsiders their previous hypothesis and concludes that what is triggering Rodney is actually that the visits are going well. The hope of reuniting with his mother while also feeling safe and supported in the foster home is confusing and overwhelming to him. The team now begins to think that what is triggering for Rodney is actually the transition from visits with his birth mom back into the foster home. With this new hypothesis, the team develops the following TST Priority Problem:

When Rodney experiences signals of loss, such as positive visits with his birth mom followed by transitioning back into the foster home, he feels sad, confused, and angry, which occasionally leads to aggression and property destruction. This can be understood in the context of his history of neglect and inconsistent caregiving.

Addressing the Environment

With this new understanding, the team determines that Rodney is behaviorally dysregulated and that his environment, although safe and nurturing, is distressed due to these difficult transitions for him. This means that Rodney, at this point, is in the Safety Focused Phase of Treatment in the TST model. The team thus sets out to address the Priority Problem by creating a plan that will anticipate these moments of difficult transition for Rodney and proactively address them. The team agrees that rather than allow Rodney to enter the foster home after a visit and immediately isolate in his room, he requires attention from Mrs. W. to ease this transition. The team strategizes ways to introduce “signals of care” into the environment and decides that Mrs. W. will meet Rodney outside her home when he returns from a visit. She will ease the transition by taking a walk with him, going to the park, or spending time at home playing a game with him. Mrs. W. is not sure how this will go because Rodney usually seems uncomfortable and quiet when they are alone together but agrees to try.

No More Meltdowns

Mrs. W. reports back to the team that after the next visit, she met Rodney at the door as planned and spent time alone with him. After being initially quiet, Rodney appeared sad and spoke about missing his mom and feeling confused about having positive feelings for both his mom and Mrs. W. After Rodney talked, he and Mrs. W. played a game, and Rodney remained calm and safe for the rest of the night. This was the first time he did not have an incident following a visit with his mom. This pattern repeated after the next several visits.

Eventually, the team arranges a meeting with Rodney, his birth mother, and Mrs. W., which is very helpful in allowing Rodney to feel both women are working together to help him. He no longer has meltdowns in the foster home.

Dr. Glenn N. Saxe, MD, is the 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.

* Name changed to protect privacy. Photo is an illustration only and does not depict actual children in care.