TRAUMA

TREATMENT
IN ACTION
Over 85 Activities to Move Clients Toward
Healing, Growth and Improved Functioning

Varleisha D. Gibbs PhD, OTD, OTR/L

& Nikki Harley, MSOD
Copyright © 2021 Varleisha Gibbs and Nikki Harley

Published by
PESI Publishing
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Eau Claire, WI 54703

Cover: Amy Rubenzer

Editing: Jenessa Jackson, PhD
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ISBN: 9781683733966
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 About the Authors

Varleisha D. Gibbs, PHD, OTD, OTR/L

As an occupational therapist, Varleisha has a passion for designing
strategies to support individuals in their journey to live their most
independent and fulfilled lives. In addition to being a licensed occupational
therapist, she is an author, speaker, and expert in the areas of the
neurological connections for self-regulation, sensory processing, trauma
responsive care, and health and wellness. She is the author of Self-
Regulation & Mindfulness and Raising Kids with Sensory Processing
Disorders.

Varleisha’s experience extends beyond her professional training, as her

personal journey consists of various traumatic events that have shaped who
she is today, including growing up in high-crime and low-income
environment, contending with the absence of her biological father,
navigating the death of various family members, and facing her own
complex medical diagnoses. With her family’s support, Varleisha flourished
and found solace and relief from her physical and emotional pain through
the arts. She played the piano, sang in choirs, studied theater, and eventually
became a professional dancer. These experiences led Varleisha to develop a
love for social service, philanthropic initiatives, and healing through the
arts.

Learning to overcome these obstacles and heal holistically has helped

Varleisha thrive in her multi-faceted professional career. She holds four
degrees in psychology, occupational therapy, and health sciences and
leadership, with a focus on health disparities in the autism community.
After spending nearly a decade in community practice helping children and
families with special needs, she eventually landed in academia and chaired
the first occupational therapy program in the state of Delaware.

Varleisha subsequently became the first Black American woman to serve as

the Scientific Programs Officer at the American Occupational Therapy
Foundation. While still in leadership as a vice president at her national
association, Varleisha continues to lecture internationally and has authored
four books, one of which is a bestseller. She has dedicated her time to
teaching professionals, parents, teachers, and others the importance of using
rhythm and movement to promote health and well-being. Her desire is to
help shift others toward growth and healing despite traumatic experiences,
diagnoses, or suboptimal living conditions.

Nikki Harley, MSOD, MT (ASCP), is an award-winning organizational

development practitioner, speaker, and consultant. With over a decade of
practice in the areas of organizational culture, climate, and human
performance development, her focus includes building organizational
diversity, equity, and inclusion (DEI) capacity, conflict resolution, climate
assessment, onboarding, training compliance, leadership development,
organizational change management, and performance and well-being
coaching. In the capacity of master alternative dispute mediator and trainer,
Nikki has facilitated the examination and resolution of organizational
conflict, successfully investigating and mediating hundreds of workplace
disputes. She credits traveling globally as a part of the Department of
Defense’s coveted Executive Leadership Development Program as a career
capstone experience.

Organizational development and well-being work is Nikki’s calling and

deep passion. She has had the honor of witnessing the positive impacts of
organizational climates and cultures that are connected and aligned with
their values, purpose, and passions. Her work examining the impacts of
organizational trauma and toxic and hostile workplaces led to a desire to co-
create organizational development solutions focused on both organizational
and individual holistic well-being. A principal consultant and wellness
coach at Imprint Wellness, Nikki has partnered with a wide range of clients,
from Fortune 500 companies to governmental agencies and nonprofits, in
co-creating, optimizing, and sustaining harmonious and safe organizational
climates and cultures. Nikki’s approach to organizational development
fosters whole-person alignment, where individual goal achievement is
assessed through a mind-body-spirit lens rooted in heart-centered
mindfulness. Nikki believes that art is a powerful catalyst for
transformation. As a creator and artist, she uses art and creative expression
to foster healing and well-being in both herself and her clients. Her vision
and passion is cultivating sanctuary within, from the inside out.

Nikki earned a Bachelor of Science in Medical Technology from the

University of Delaware and a Master of Science in Organizational
Development and Knowledge Management from George Mason University.
She is an avid transcendental meditation and vinyasa yoga practitioner.
Nikki lives and works from her home base in Wilmington, DE. She spends
her free time creating, going to the beach, hiking, gardening, and biking.
Trauma Treatment in ACTION is her first book.
 Table of Contents
Acknowledgments

Introduction

Part One — ACT

Chapter 1: Acknowledge and Be Aware of Trauma

Chapter 2: Create Growth

Chapter 3: Teach Neuroeducation

Part Two — ION

Chapter 4: Intergenerational Factors

Chapter 5: Organizations and Systems Re-Traumatization

Chapter 6: Now Is the Time for ACTION

Bibliography
 Acknowledgments
Thank you to my husband and children, who are my rocks. You are always
willing to allow space for me to feed into others seeking my guidance.
Thank you to Nikki Harley for your willingness to support this work. As I
placed my thoughts into the various chapters, my beloved grandmother,
Thelma Freeman, passed away, further connecting me to this content. I
dedicate this book to her and to all of my loved ones who have passed away
since my last publication, including my grandfather, Allen Freeman, and
mother, Vanest Freeman. They all provided me with love and guidance and
taught me how to live even in the face of trauma and adversity. I must also
acknowledge those who left this earth during the coronavirus pandemic that
occurred in the midst of completing this book. Lastly, I thank my inner
child, who continues to push my creativity and who reminds me of my
dream to become a doctor to help people heal. While my path did not lead
me to become a medical doctor, this career is truly an honor.

—Varleisha D. Gibbs

As a first-time author, I am inspired by the guidance of my grandmother,

Rachel Harley, who tirelessly encouraged her grandchildren to make their
mark on the world, and my mother, Cornelia Strickland Harley, whose
unwavering love remains my inspiration. I would like to thank Dr. Varleisha
Gibbs for the opportunity to explore my passion for all things
organizational development and Angela Warren, MS, for her steadfast
friendship and expertise. I am especially grateful for the advice and counsel
provided by C. Shaw, MEd, whose guidance, support, and passion for living
purposefully are unmatched. Lastly, none of this would be possible without
those on whose shoulders I stand; I am my ancestors’ wildest dream.

—Nikki Harley
 INTRODUCTION

It is an unfortunate yet true fact: We will all experience trauma during our
lifetime. Although some may debate this statement, let us provide you with
some examples. We may experience vicarious trauma as a result of
frequently watching or hearing of natural disasters or mass murders on the
news. Likewise, we may experience trauma as a result of growing up in
neglectful and impoverished living conditions in which we do not have all
of our needs met, or we may be exposed to it via the community violence
that characterizes the inner-city neighborhood in which we live. This type
of repeated and prolonged exposure to trauma is known as complex trauma,
which is associated with a range of more long-lasting ramifications.
However, trauma can even happen as a result of an isolated incident, such
as an accident or injury to ourselves or someone we know. When we
experience trauma, it affects how our brain functions and how we interact
with others and society as a whole. It alters how we view ourselves, our
environment, and our surroundings (Guarino et al., 2009). We become more
vigilant and anxious, and we may struggle to function on an emotional and
physical level.

As unsettling as it may be, we cannot ignore the impact of trauma. We must

acknowledge and accept trauma in order to allow for healing and improved
functioning. Toward this end, this book is a call to action to encourage
movement toward healing and growth. In particular, the activities and tools
presented here support an ACTION-from-Trauma approach (Figure 1):
• Acknowledge and be Aware of trauma
• Create growth from trauma
 • Teach neuroeducation and steps toward growth
• Intergenerational factors
• Organizations and systems re-traumatization
• Now is the time to take ACTION to create growth from trauma

Figure 1. ACTION-from-Trauma Approach

We also present trauma as a dynamic and multifaceted condition through

the Five Dimensions of Trauma Model, which is an integral aspect of
teaching and providing neuroeducation on the multilayered nature of trauma
(Figure 2). These five dimensions of trauma include:
• Structural Trauma: Exposure to trauma or frequent stress can
result in changes at the brain level that impact neurological
functioning.
• Physical Trauma: Trauma can hide in the body and manifest
within one’s sensorimotor system, leading some people to exhibit
 sensory issues with regard to touch, movement, food, and more.
• Complex Trauma: Frequent exposure to traumatic events or the
experience of living in conditions of chaos can lead to behavioral
dysfunction. This includes trauma experienced during the
developmental stages of childhood; contextual factors, such as
neglect by a caregiver; and environmental factors, such as
impoverished or violent living conditions.
• Intergenerational Trauma: Trauma is passed down across
generations through the role of epigenetics and vicarious trauma.
• Social and Cultural Trauma: Organizations and systems can
affect trauma through the impact of racism, classicism,
organizational trauma, implicit bias, and re-traumatization.

ACTION-FROM-TRAUMA APPROACH
THE FIVE DIMENSIONS OF TRAUMA MODEL
The condition of trauma is dynamic.
An individual, population, or community can be exposed to various
forms of trauma. Ultimately, the exposure and experience impacts
neurological functioning.
Hence, the model proposes that structural trauma (i.e., changes on the
neurological level) occurs as a result of the other forms of trauma.
When there is more exposure to the various forms of trauma, the
severity of structural trauma increases.
Each form of trauma has secondary conditions as revealed in the
model. Acknowledgment of the complexity provides a platform for
addressing the needs of the individual, population, or community.
 Figure 2. The Five Dimensions of Trauma Model

As these five dimensions illustrate, trauma has the ability to change the way
we think and act, accumulates over time, transmits across generations if left
unaddressed, and is further impacted by society and the organizations upon
which we depend. By establishing dimensions or categories of trauma, we
can gain clarity regarding the underlying factors of behavior and areas of
dysfunction.

“NOT JUST FOR MENTAL HEALTH PROFESSIONALS”

This book is intended not only for mental health practitioners but for any
allied health professionals who desire more tools to assist their clients with
healing, including occupational therapists, rehab specialists, physical
therapists, social workers, and counselors. Because trauma is so pervasive,
the clients you serve may very well present with a history of trauma that
can impact your provision of care and negatively affect their treatment
outcomes. They may struggle to follow through with treatment
recommendations, have poor session attendance, exhibit aggressive
behavior, and lack trust in you as the therapy professional.

In order to be of support and provide effective therapeutic services, allied

health professionals need to acknowledge the signs and symptoms of
trauma. You must be able to identify and analyze the trauma that exists in
your clients, even if your practice is not focused on mental health. You must
understand trauma as a dynamic condition that presents in various forms.
You must also recognize any trauma within yourself and the potential re-
traumatization that you can unknowingly impose on those you serve.

WHY WE WROTE THIS BOOK

Dr. Varleisha Gibbs

As an occupational therapy student, entering into a full-time clinical

experience was more than intriguing. It was my first summer of fieldwork,
and I planned to learn everything it took to become a stellar clinician. In my
mind, that meant helping heal those for whom I had the honor to provide
treatment and care. I knew I wanted to work with children, yet I also had a
desire to work with various age ranges. Regardless, there was a common
denominator when it came to those I wished to serve: sensorimotor and
neurological conditions. That summer, the curriculum required a mental
health affiliation. I was able to enter into a fieldwork position at a mental
health hospital for all age ranges, which included a pediatric department
with a sensory gym. The patients had various diagnoses requiring sensory-
based intervention. This was an area of practice in which I desired more
hands-on experience, and my enthusiasm could not be contained.

My first day began with an intake of a young teenage female. She entered
with a quiet and passive demeanor. While she spoke, my supervisor shared
her chart for my review. I practically gasped out loud as I read about
physical, emotional, and sexual abuse. As the young lady smiled and shared
her story, I could not understand how she survived such horrible ordeals.
Soon it became clear. As she began to discuss some of the events I read in
the chart, I witnessed how disconnected she was from these experiences.
Her narrative seemed to speak of someone else and not that of her own. She
even laughed at some of the abuse as if it were normal. I did not know it
then, but that was her sense of “normal.” Those recurring acts were normal
to her. With repeated abuse, neglect, and loss, she had learned to accept her
trauma and, at the same time, had become an observer to it as opposed to
the one who experienced it. I soon realized that her experiences had led to
severe psychosis and hallucinations. Her ability to disconnect from the
trauma had led her to disconnect from reality itself. Whether it was
happiness, anger, or fear, there was little variation in her emotions.

Not long after, I completed an intake for a 3-year-old female who was wise
beyond her years. Her story rang familiar. Her ability to move between
laughing with the staff and attempting to cause physical harm was eerily
similar to the adolescent female. I began to notice similarities with the
various children in both the inpatient and outpatient units. Many of them
were part of the foster care system. Most had experienced various traumatic
events even before their birth, as their parents had struggled with addiction
or been the victims of abuse during pregnancy. Other children lived with
grandparents who attempted to keep them within the family despite an
absent parent. The grandparents presented with that same disconnected
demeanor.

In my undergraduate and graduate degree programs, I learned about mental

health and psychosocial treatment models. However, nothing could have
prepared me for the patient population at that fieldwork placement.
Throughout the three months I spent at the site, I found myself crying in my
car during lunch almost every day. What I witnessed was simply
unexpected. Little did I know, it was in fact my own traumatic experience.

It is my desire to use my personal experiences and stories, not only of that

summer I just described but of the various children and families I worked
with over the years, to help other practitioners. It has been almost 20 years
of encountering the unexpected impact that trauma has on the success of
our treatment interventions. From working in schools in low-income areas
of New York City to working with wealthy parents in affluent New Jersey
towns who have discovered their child has a terminal illness, I have seen a
lot. I decided to compile my clinical and research expertise to help other
occupational therapists and rehab professionals. To expand upon this lens,
Nikki Harley provides another perspective as an organizational
development and conflict resolution expert.

Nikki Harley, MSOD

Having worked in the field of organizational development for over a

decade, I approach holistic organizational transformation from a dialogic
perspective, with a special interest in organizational culture and climate. I
see value in examining the interface of human behavior and systems—
specifically, the connection between organizational trauma and healing.
This passion and interest were born out of witnessing the very real and
serious impacts organizational trauma and dysfunction have on
environments and individuals. Most of us have witnessed organizations
with high turnover or challenges retaining talent. We have heard of spaces
that are toxic or unpleasant to work in. We know of places rife with
unresolved conflict or ineffective leadership. After assessing, investigating,
and mediating hundreds of toxic and hostile workplaces, I have witnessed
firsthand the influence imbalanced environments have on the minds, bodies,
and spirits of individuals. My own experience with occupational burnout
was a catalyst for personal reflection and transformation. My practice and
personal experiences further demonstrated the importance of individual
well-being within our organizational systems, leading me to acknowledge
that growth and movement toward healing happens not solely at the
individual level but at the organizational and system levels. Creating and
sustaining safe, adaptable, and aware organizations is a critical strategic
business imperative and is necessary for moving toward ACTION. These
realizations, made urgent by the current impacts of social and cultural
trauma, inform the whole-person-centric solutions created in Trauma
Treatment in ACTION.

HOW WE DEFINE TRAUMA

Throughout this book, we do not define trauma solely based on diagnostic
criteria because certain forms of trauma are not part of the fifth edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5®;
APA, 2013) or other clinical diagnostic manuals. Instead, we move past
diagnosis by mapping out the signs and symptoms of common presentations
we have encountered. There are various levels of stress and trauma that can
impact a person’s life. Not every individual will meet the threshold for
clinical diagnosis, yet their actions and behaviors deserve our attention.

Trauma comes in many different forms, though all forms of trauma share
some commonality. For the intent of this workbook, we define trauma as
the impact that adverse experiences have on a person’s mental,
psychological, physical, financial, and overall well-being. Adverse
experiences can include abuse, neglect, loss, physical assault, sexual
assault, accidents, natural disasters, poverty, homelessness, imprisonment,
and other potentially traumatic experiences. These adverse experiences can
occur repeatedly throughout a person’s life or be isolated to a specific event,
and they also extend to the impact on the unborn child. In this respect, most
individuals have experienced at least one adverse event in their lifetime
(Felitti et al., 1998).

The detrimental effects of trauma are well-illustrated through the notable

Adverse Childhood Experiences (ACE) Study, which helped to redefine
trauma by connecting it to childhood experiences and not limiting it to the
posttraumatic stress experienced by veterans of war (Felitti et al., 1998). In
fact, the ACE Study found that trauma has a negative impact not only on
mental well-being but on physical well-being as well. Specifically,
individuals who reported at least two traumatic events in childhood were
two to four times more likely to have a variety of negative health outcomes
later in life, including chronic diseases and a reduced life expectancy.

These findings highlight the notion that trauma does not simply lead to
social and emotional difficulties. It can also result in physical dysfunctions
and behavioral challenges that, unbeknownst to you, have led clients to seek
your services. They may exhibit heightened pain responses, hyperactivity,
and aggression that are the result of adverse childhood experiences and past
traumatic events. By reading this book, we seek to provide you with a
primer in identifying the physical signs of trauma, unwrapping hidden
trauma, and acknowledging the unconscious beliefs that influence the
severity of trauma.

HOW THIS WORKBOOK CAN HELP

The word trauma can overshadow the individual. Hence, this book
encourages providers to take a strengths-based approach in conjunction
with acknowledging what happened to the person. There is also an
emphasis on creating growth versus simply healing. Healing is vital but
sometimes seems too far-fetched, produces additional stress, and may imply
brokenness. Therefore, not only will this workbook unveil a trajectory of
healing activities—such as screening procedures, body awareness mapping,
grounding activities, breathwork, sensorimotor work, and early intervention
strategies—but more importantly, it will discuss the use of autonomic
rhythms, respect and empathy, gratitude statements, and tools to create
growth. It provides igniting, life-changing principles that are easy for
anyone to apply.

The book is separated into two parts: The first part is ACT. To act is to do
or take action. The acronym ACT stands for: Acknowledge and be Aware
of trauma, Create growth from trauma, and Teach neuroeducation and steps
toward growth. The second part is ION. Just as ions are created by
interaction, trauma does not happen in isolation for the individual. The
acronym ION stands for: Intergenerational factors, Organizations and
systems re-traumatization, and Now is the time to take ACTION to create
growth from trauma.

To capture the complexity of trauma, this workbook covers the entire

lifespan and addresses all age ranges. In each chapter, we address how
individuals may present with and experience trauma across the lifespan,
ranging from childhood and adolescence to adulthood and older adulthood.
We also include hands-on activities for clients, caregivers, and pediatric
populations in particular. Throughout each chapter, we provide background
information, screening tools, activities, case studies, and reflective
practices. We also provide recommended age ranges for specific activities
and screening tools. We strongly recommend that you read the supporting
information before utilizing the tools and activities. You can also feel free to
make copies of worksheets and activities for clients.

Whether trauma is a primary or secondary treatment condition, gaining

knowledge and becoming familiar with trauma-informed intervention
strategies is a must for any allied health professional. But more so, taking
action is a much-needed next step. We must focus on areas of opportunity
and begin to create growth for those living with trauma. It is our hope that
this book guides you in helping your clients to heal and move toward a
better quality of life… and for you to be able to do so as well!
PART ONE
ACT
 CHAPTER 1
ACKNOWLEDGE AND
BE AWARE OF TRAUMA

The first step in our ACTION-from-Trauma approach is to Acknowledge

and be Aware. This step includes acknowledging how trauma presents,
understanding the various risk factors for trauma, maintaining an awareness
of the various categories and types of trauma, and learning the foundation
of trauma-informed care. It also involves understanding the normal stress
response so you can recognize the difference between function and
dysfunction in response to acute stress. Finally, it involves examining your
own readiness to care for those with trauma and learning how to use
ACTION language that is trauma-informed.

In this chapter, we aim to justify the need to expand upon the current
practices and employ ACTION steps toward healing through the following
sections:
☐ A Call to ACTION
☐ Screening for Traumatic Experiences
☐ Complex Trauma Across the Lifespan
☐ SAMHSA’s Trauma-Informed Care Approach
☐ Normal Stress Response
☐ Detecting Acute Stress
☐ Detecting Level of Self-Regulation
 ☐ Readiness to Provide Trauma Care
☐ From Trauma-Informed to ACTION Language
☐ Next Steps: Moving to the C in ACTION to Create Growth
☐ Case Scenario

A CALL TO ACTION
Before we start on our journey, we want to recognize the multitude of
professions and variety of settings in which you may practice, as well as the
many tiers of care that you may provide. As an allied health professional,
you may work with at-risk individuals and families who present with
challenging behaviors that impact your provision of care. You may also
provide intensive trauma-specific care, such as exposure therapy, cognitive
behavioral therapy, or other forms of psychotherapy. In making a call to
action, it is not our intent to replace any intensive trauma-specific services
you may already be providing. Rather, our ACTION-from-Trauma
approach is intended to accompany those services and expand upon current
trauma-informed practices so you can best support outcomes for your
clients. Remember, trauma is complex and requires the support of an
interdisciplinary team.

Although the ACE Study raised much-needed awareness regarding trauma,

an unfortunate result of these efforts is that we have begun to define the
individual by their trauma (Ginwright, 2018). By applying the label of a
“trauma victim,” we have impeded upon our lens to see the whole person. It
has caused us to focus on people’s deficits versus their innate capacity for
resiliency (Leitch, 2017).

There is also a lack of specific guidance and recommendations when it

comes to taking action in applying the now popularized model of trauma-
informed care (Ginwright, 2018; Yatchmenoff, Sundborg, & Davis, 2017).
It is time to shift the paradigm of trauma. Through our work, we want to
reinvigorate the importance of looking at the person first as opposed to
labeling the client by their pain. We want to shift the focus of our attention
to well-being and growth versus the treatment of pathology. In doing so, we
take a strengths-based approach and redirect our attention by looking at
each person’s strengths and detecting available opportunities for growth.

In addition, we need to revisit our trauma lens and expand it to include an

individual’s family, community, culture, organizations, systems, and
societal experiences (Becker-Blease, 2017). That is because the experience
of trauma is tethered to the community, policy, health care, child welfare
services, the criminal justice system, and much more. It is for this reason
that our ACTION-from-Trauma approach ventures into the Five
Dimensions of Trauma Model to encapsulate the multitude of factors that
can catapult us to the next level of care. We must address collective
encounters of trauma and hold accountable those who impact an
individual’s experience of trauma.

SCREENING FOR TRAUMATIC EXPERIENCES

Individuals with trauma frequently utilize health and behavioral services.
Therefore, the likelihood that you will encounter a client with trauma is
high. In fact, certain communities and settings may have a universal spread
of trauma among their members. Regardless of your practice setting or
discipline, consider screening and assessing for trauma during the intake
process and throughout your period of care. This is especially important
when a client is overusing health care services, exhibiting difficulties with
non-compliance, or presenting with overt signs of trauma, such as
avoidance, detachment, or elopement. Being able to detect trauma early can
facilitate successful treatment outcomes and promote growth toward
healing. Therefore, be aware of the following trauma risk factors, and use
the following checklist to identify those clients at risk for trauma.

Trauma Risk Factors Checklist

☐ Minority status. Those from underrepresented racial and ethnic

groups are more likely to experience trauma.
☐ Acute stress. Exposure to ongoing stressful events and crises may
diminish the ability to cope in the presence of trauma.
☐ Childhood adversity. Living in an impoverished or violent
community, being exposed to domestic violence or parental
neglect, experiencing a lack of cohesion within the family system,
or growing up in a household characterized by parental physical
or mental illness, parental stress, or parental substance abuse can
all result in a child experiencing trauma.
☐ Physiological characteristics. Certain biomarkers, such as low
heart rate variability and low cortisol levels, have been found to
negatively correlate with the ability to cope in the presence of
trauma.
☐ Chronic or life-threatening health conditions (experienced by
the client or a loved one). Being diagnosed with a serious illness,
such as cancer, or with a progressive neurological condition (e.g.,
amyotrophic lateral sclerosis or ALS) are stressful life crises that
are also traumatic.
☐ Low socioeconomic status. Poverty is associated with chronic
stress, exposure to violent and unhealthy environments, and lack
of access to health care. It impacts the ability of parents to
properly care for their children and can curtail growth and
development.
☐ Lack of education. As a social determinant of health, education
has a direct correlation with health outcomes, socioeconomic
status, and life expectancy. These factors align with the trauma
risk factors mentioned above.
☐ Genetics and family trauma. Some people are predisposed to
trauma and have difficulty coping with secondary trauma due to
intergenerational trauma, in which the effects of trauma are
passed down across generations through epigenetic changes to
DNA.
☐ History of trauma. Having prior exposure to trauma may
increase the likelihood of future exposure to trauma, possibly due
 to the accumulation of stress and the resurfacing of symptoms
from traumatic events.
☐ Domestic violence. Physical and emotional harm results in stress,
anxiety, and fear, and it threatens one’s safety. The chronic and
persistent threat of domestic violence has long-term effects for the
victim and for those witnessing the abuse.

While many of us can experience stressful situations, trauma can result in

the development of posttraumatic stress disorder (PTSD) when it impacts
someone for at least a month or more. The clinical symptoms of PTSD span
across four main categories of symptoms (APA, 2013):

☐ Intrusive thoughts and repeated memories, dreams, or

flashbacks of the traumatic event. These symptoms present
challenges to various areas of life, such as sleep hygiene, social
interaction, and the ability to care for oneself and others.
☐ Avoidance of reminders of the trauma. This may involve
avoiding people, places, activities, or certain interactions that lead
to unwanted memories or physical sensations that are reminiscent
of the trauma.
☐ Negative thoughts and feelings. Symptoms can include negative
self-appraisal, loss of interest in things previously enjoyed, shame,
blame, loss of memory related to the trauma, or social isolation.
☐ Hyperarousal. Exposure to trauma leads to lack of concentration,
challenges in modulating arousal levels, hypervigilance,
impulsivity, aggression, and difficulty sleeping.

In the presence of PTSD, exposure to trauma can lead to biophysiological

reactions that not only present themselves in the moment but also persist
across an extended time frame. The fight-or-flight system remains in a state
of constant activation, resulting in hyperarousal, anxiety, and avoidance.
Individuals become stuck in the trauma, leading to problems with everyday
activities, social interactions, and the ability to navigate life. Their
perception of the world becomes framed by the trauma. Their focus
becomes survival and protection, which limits their ability to see beyond
the symptoms. This trauma lens limits people’s vantage point by narrowing
their view of the surrounding peripheral world, in turn making their world
smaller. People are no longer able to see the full picture of events in their
lives and instead have a more centralized view of the world, which poses a
threat to their well-being (Figure 3).

Figure 3. The Trauma Lens of Protection

There are various categories of traumatic experiences, including trauma that

is expected versus unexpected, as well as trauma that is directly
experienced versus indirectly experienced. To expand our view of the
trauma landscape, we must review the complexity of trauma further by
considering the many dimensions of trauma (i.e., structural, physical,
complex, intergenerational, social and cultural) that can fall within each of
these categories. Utilizing the Five Dimensions of Trauma Model as a
guide, we outline some specific factors to consider before you initiate a
screening and assessment process. We also highlight the potential impact of
traumatic experiences based on different categories of trauma and age
ranges (Table 1).
Categorization of Examples of Impact
 Traumatic Early Childhood and Adolescence Adulthood and Older
Experiences* School Age Adulthood
Expected (e.g., passing
An expected trauma In adolescence, the Expected trauma may
of a loved one who wasmay lead to significant passing of a loved one greatly impact anyone
ill) complex trauma. For who was ill may lead to regardless of their age.
example, a child who is changes in personality, For example, a person
living in foster care and challenges at school, with type 1 diabetes
who is returned to their and difficulty engaging mellitus may be aware
biological family as or socializing with of a prognosis requiring
planned may respond others. a lower-limb
with maladaptive amputation. Such an
behaviors, such as event can change how
challenges with they socialize, challenge
learning, sleeping, their ability to work, and
toileting, and engaging impact their roles, such
with others. as caring for others.
Unexpected (e.g., The unexpected passing An unexpected move Unexpected traumatic
sudden departure of a or departure of a loved from an individual’s events may greatly
family member) one due to incarceration childhood community affect well-being. For
can lead to maladaptive secondary to parental example, the sudden
behaviors, such as divorce can lead to loss of employment can
detachment, aggression, maladaptive behaviors, lead to anxiety,
and challenges in such as detachment, depression, substance
academics. elopement, aggression, use, aggression, and a
and challenges in poor outlook on life.
academics.
Isolated (single Depending on the An isolated traumatic An isolated traumatic
incident, such as a developmental stage, an event, such as a sexual event, such as a home
sexual assault) isolated traumatic event, assault, can lead to invasion for an older
such as a car accident, changes in personality adult living alone, can
can lead to changes in or behavior requiring lead to changes in
personality or behavior intervention. Physical personality or behavior
requiring intervention. trauma may result, requiring intervention.
Physical trauma may such as hypersensitivity, Physical trauma may
result, such as even if temporary. result, such as
hypersensitivity, even if hypersensitivity, even if
the effects are temporary.
temporary.
Pervasive (ongoing, Pervasive trauma can This may be a form of Adults may experience
such as repeated have significant complex trauma that complex trauma in the
physical abuse or implications on has significant form of ongoing
homelessness) development. For implications on an domestic violence,
example, a child living adolescent’s outlook on which can cause
in poverty or life. For example, structural trauma and
experiencing ongoing ongoing abuse or sex interfere with their
abuse may have trafficking may result in ability to establish
structural trauma as a structural trauma and future goals.
result, leading them to lead to challenges with
develop complex establishing future
trauma. goals.
Intentional (e.g., Intentional trauma, such Adolescents who Spousal abuse or
neglect from a parent, as neglect from a parent, experience bullying by caregiver abuse of an
physical or sexual may lead to social- their peers may exhibit older adult may lead to
assault) emotional issues, such social-emotional issues, social-emotional issues
as lack of trust in and such as a lack of trust that manifest as acute
detachment from others. and risk-taking anxiety, distorted
Structural trauma may behaviors. Structural expectations, and
lead to physical and trauma may lead to detachment from others.
complex trauma. physical and complex Structural trauma may
trauma. lead to physical and
complex trauma.
Unintentional (e.g., Certain unintentional Adolescents who Systematic and
natural disaster or traumatic events experience unintentional organizational culture
pandemic) represent a form of forms of traumatic and policies can result
social or cultural events, such as in retraumatization. This
trauma, such as pandemics or natural may be revealed through
pandemics or natural disasters, can experience changes in personality
disasters, which can be acute stress in response and behaviors. Adults
very frightening to to the event. The effects may also experience
children due to a sense of this type of social or feelings of insecurity,
of loss of security. cultural trauma may guilt, and shame in
Feelings of helplessness be revealed through response to this social
and uncertainty can changes in personality or cultural trauma.
cause acute anxiety and and behaviors, such as
stress, which can lead to detachment, avoidance,
PTSD if unaddressed. and aggression.
Children may display
aggression, have
problems sleeping, and
exhibit difficulty
concentrating.
Directly experienced Directly experiencing In adolescence, the There are several
(e.g., poverty due to abuse, neglect, or other
direct experience of implications of directly
loss of employment) traumatic events has trauma, such as living in experiencing trauma,
very strong implications
unsafe environments, including challenges in
for child development.experiencing abuse and performing activities of
It can impact typical neglect, or being daily living, practicing
brain development, exposed to a traumatic self-care, properly
affect emotion event, can negatively caring for others, and
regulation, and lead to
impact development and engaging in social
dysfunction in sensorythe establishment of interaction.
processing. future goals. The
adolescent may isolate
themselves, be
aggressive, and have
difficulty with
academics.
Indirectly experienced Intergenerational Intergenerational Intergenerational
(e.g., shared trauma can impact trauma can impact an trauma can impact
experienced of a children based on their adolescent based on one’s experiences and
parent or observing caregiver’s interactions how their caregiver interactions with the
the impact of with them. For example, interacts with them. For world. For example,
injustices, such as a parent who example, a parent may adults may reveal
unjustified killings) experienced sexual reveal strict and certain fears grounded
abuse by a family aggressive behaviors in stories or norms set
member may reveal toward the child by their family, which
aggressive and secondary to their are based on historical
overprotective behaviors personal struggles with events. Family members
toward their child in an systemic racism and a can pass on a lack of
attempt to prevent them history of violent attacks trust, shame, and
from experiencing the on family members. anxiety to their
same abuse. These These behaviors are offspring.
behaviors are based on based on the caregiver’s
the caregiver’s personal personal experiences
experiences and views. and views.

Table 1. Categories of Trauma and Their Impact

*There is the possibility of structural or physical trauma in all categories.

COMPLEX TRAUMA ACROSS THE LIFESPAN

In the United States alone, it is documented that more than 700,000 children
experience abuse or neglect, though more than 3 million are suspected to
have experienced abuse based on investigations by child protection
agencies and services rendered (National Children’s Alliance, 2019). In
addition, four out of five times, the abusers in these situations are typically
family members. This type of trauma during childhood can have
detrimental effects on an individual’s neurodevelopment and psychosocial
well-being across the lifespan. It can result in what is known as complex
trauma, which is a term used to describe “exposure to multiple traumatic
events, often of an invasive, interpersonal nature, and the wide-ranging,
long-term impact of this exposure” (National Child Traumatic Stress
Network, 2017). In this book, we define complex trauma as the continued,
long-term exposure to traumatic events that impacts a person at various
biopsychosocial levels. These traumatic events can include continued
violence, poverty, hunger, illness, and abuse that becomes intolerable. Such
events are prevalent in minority populations, specifically those of low
socioeconomic status.
 The Substance Abuse and Mental Health Service Administration
(SAMHSA) provides the following examples of complex childhood
trauma (2014b):
☐ Psychological, physical, or sexual abuse
☐ Community or school violence
☐ Witnessing or experiencing domestic violence
☐ Commercial sexual exploitation (including sex trafficking)
☐ Refugee or war experiences in the military
☐ Family-related stressors (e.g., deployment, parental loss or
injury)
☐ Neglect
☐ Life-threatening illness

We can expand upon these examples to also include:

☐ Maternal exposure to physical, mental, or emotional abuse
☐ Maternal malnourishment
☐ Racism and oppression
☐ Poverty
☐ Homelessness
☐ Being incarcerated as a minor
☐ Incarceration of a parent
☐ Living in the foster care system
☐ Intergenerational transmission of trauma (see chapter 4)

For such pervasive experiences of trauma, Dr. Judith Herman has suggested
a diagnosis of complex PTSD given that the long-term implications of
complex trauma are not captured in the traditional diagnosis of PTSD
(Herman, 1997). According to Herman, those with complex trauma may
require a different approach to care than those with the clinical diagnosis of
PTSD. They may experience impulsive and aggressive behaviors and
exhibit non-compliance or reduced participation in therapy, leading to poor
treatment outcomes. They may also have other pathological conditions,
exhibit challenges with personal relationships, and seek support through
multiple visits to medical professionals. In addition, those with complex
trauma may exhibit emotion dysregulation, musculoskeletal problems,
challenges with sensory perception, poor self-care, and cognitive deficits
(Gorman & Hatkevich, 2016). As result, they may struggle to perform basic
and instrumental activities of daily living.

Practitioners delivering therapeutic services need to be aware of these

behavioral, emotional, cognitive, interpersonal, and somatization difficulties
accompanying complex trauma. For example, physical distance, emotional
withdrawal, freeze, and aggressive behaviors can be mistaken for other
diagnoses, such as attention-deficit/hyperactivity disorder (ADHD) or
oppositional defiant disorder, or for non-compliance (Smith, 2010).
Maintaining an awareness of these different manifestations of complex
trauma can prevent against misdiagnosis and ill-informed treatment plans.
This further supports our platform for the ACTION-from-Trauma approach.

Trauma, and particularly complex trauma, is a concern for early childhood

development, as it can disrupt neural development associated with the
ability to modulate stress and emotions. As a result, children may
experience separation anxiety, poor eating habits, and nightmares. Those
who are of school age may experience anxiety, fear, guilt, shame, learning
difficulties, and poor concentration, while adolescents may present with
secondary conditions, such as eating disorders, depression, substance use
disorders, depression, loneliness, and risk-taking behaviors (SAMHSA,
2014b).

In addition, young children have not developed coping mechanisms to

properly address life stressors, and they rely primarily on their parents and
caregivers as a source of regulation. However, many children presenting
with complex trauma may have caregivers who themselves have significant
exposure to trauma, and they may struggle to manage stress, self-regulate,
and interact with others. Indeed, individuals who were exposed to trauma in
their earlier life stages frequently experience symptoms of depression and
PTSD as adults (Dunn, Nishimi, Powers, & Bradley, 2017). It is for this
reason that our ACTION-from-Trauma approach is for the lifespan. Trauma
can start early in life and continue onward. Therefore, some of the age-
specific approaches we present in this book are not for pediatric clients but
for their caregivers.

To address complex childhood trauma, the focus should be on restoring

the child’s sense of safety, increasing attachment, enhancing
appropriate affect, and improving cognitive, behavioral, and social
functioning (Harley, Williams, Zamora, & Lakatos, 2014). To do so, we
must take a biopsychosocial approach when it comes to awareness. First,
society and medical professionals alike must acknowledge the neurological
and physiological impacts of trauma. We must then consider the influence
of the individual’s culture, community, and family makeup. In addition, we
must gain better awareness of symptomatology in terms of how trauma can
manifest. Perhaps most importantly, though, we must attend to the child-
caregiver connection. The bonds that children develop with their caregivers,
including those involved in their education, are some of the most impactful.
Caregivers play a huge role in detecting dysfunction that can impact a
child’s well-being. Therefore, successful treatment approaches for trauma
require a two-person focused intervention that addresses the caregiver and
child alike (Gibbs, 2017a). The onus is not only on the child but on all
adults involved. When all these factors work together, it enhances the
initiation of ACTION from trauma (Figure 4).
 Figure 4. Biopsychosocial Approach to Awareness

SAMHSA’S TRAUMA-INFORMED CARE APPROACH

While we emphasize moving to more action-oriented approaches, it is

crucial to provide information on trauma-informed care. The trauma-
informed care approach serves as a starting point to apply the concepts we
introduce in this workbook. Therefore, ensure you have a general
understanding of trauma-informed approaches and principles before
initiating any of the activities in this workbook.

The concept of trauma-informed care, which was first developed by

SAMHSA, acknowledges that nothing is wrong with someone exposed to
trauma. It shifts the focus from “What is wrong with you?” to “What
happened to you?” We expand upon this definition of trauma-informed care
to also consider the question “What do you need to grow from here?”

SAMHSA’s trauma-informed approach starts with the three E’s of trauma as

a means of identifying and defining trauma: events, the experience of these
events, and effect. At the most basic level, events represent what actually
occurred. As stated in the DSM-5, the individual must be exposed to a
traumatic event. This is a requirement of the diagnostic process, yet it leads
to various debates about what events should be included. The individual’s
experience of these events goes deeper in acknowledging how the person
interpreted the event. What did they feel? What meaning did the event have
to them personally? As with most parts of life, we all have varying
interpretations of lived experiences, and what we may label as “traumatic,”
another may not. Finally, the effects highlight the adverse impact of the
trauma, including its short- and long-term effects on behavioral,
psychosocial, and physical health (SAMHSA, 2014a).

Detecting trauma with the three E’s is an initial step to the trauma-informed
approach. Once trauma has been detected, there are four approaches and six
principles that guide the subsequent care and intervention process. The four
approaches involve realizing the widespread impact of the trauma and
potential roads to recovery; recognizing the signs and symptoms of trauma;
responding by integrating knowledge about trauma into policies,
procedures, and practices; and resisting re-traumatization by identifying
possible triggers and toxic environments for all involved. In addition, the
following six key principles drive the process (SAMHSA, 2014a):

1. Safety. Ensuring physical and psychological safety at every level

of the organization (e.g., client and staff)
2. Trustworthiness and transparency. Being open and transparent
regarding decision making and goal development
3. Peer support. Sharing lived experiences from others with a
similar trauma history
4. Collaboration and mutuality. Sharing power and decision
making
5. Empowerment, voice, and choice. Supporting self-advocacy
6. Cultural, historical, and gender issues. Removing stereotypes
regarding culture, race, ethnicity, sexual orientation, religion,
gender identity, etc.

While recovery may be challenging, it is possible. Our workbook primarily

focuses on trauma-informed care approaches versus specific treatment
models. However, resilience and recovery depend on support from the
various angles, levels, and systems of care. You are part of that hierarchy.
In addition, we want to remove the strain of the word healing when it
comes to recovery from trauma. Healing may lead to thoughts of
brokenness or something being “wrong” with the individual. Instead, we
approach care through the creation of growth.

How does that growth occur? As a result of trauma, the brain may develop
neural connections that are grounded in persistent fear, stress, and anxiety.
Luckily, we produce new cells and neurons each day, and the brain has the
capacity to rewire itself and form new neural connections through a process
known as neuroplasticity. Trauma-informed approaches, as well as current
clinical practices, may support the brain’s ability to heal itself, but we must
go beyond current approaches and act with strategies focused on growth.
We need to repackage our message to illustrate the possibility of growth on
a structural level to enhance well-being in life.

NORMAL STRESS RESPONSE

The neurological changes that occur following trauma align with a variety
of bodily changes that also occur in response to stress. To illustrate, we start
with an examination of the universal stress response, which reflects a
typical reaction to stress. It was once believed that unaddressed universal
stress responses resulted in trauma. We now know that not everyone who is
exposed to stress will experience trauma. It is the absence of recovery from
the universal stress response that may lead to dysfunction. This universal
stress response is governed by our body’s autonomic nervous system, which
is an internal alarm system we have in response to stress, threats, and the
unexpected. While our body’s alarm signals are mostly short-lived, they can
persist in strength and frequency in response to stressful or traumatic
events, which has long-term implications. But what defines a “normal
stress” response versus acute stress or posttraumatic stress? Let us review to
begin our Acknowledgment and Awareness of trauma.

Imagine that you have a trip planned. You have been excited for this
vacation and can barely sleep. You finally close your eyes and drift off.
Before you know it, it’s morning. As you rise, you notice that your alarm
did not go off, and you are now an hour behind your scheduled departure
time. You race to pack your luggage and gather other items for your trip.
After quickly calling for transportation to the airport, you grab your keys
and quickly head outside.

Once you are in the car, you realize that you have neglected to grab your
passport. You tell the driver to please wait as you run inside to obtain your
necessary identification. This has now cost you valuable time! You then tell
the driver that you are short on time. Of course, there is traffic on the
highway, and it is taking you even longer to get to the airport. You finally
arrive, but the line for security seems to be out the door. After you make it
through, you run toward your gate, where the airport staff inform you that
they have been calling your name and were about to close the doors.
However, you made it just in time! You locate your seat on the flight and
finally get to rest a bit after your ordeal. Unfortunately, it is hard for you to
relax, and you still feel the racing of your heart and the labored breathing
from your lungs. It seems as if it takes the entire flight to your destination
for your body to calm.

While this example may seem dramatic, most people would not view it as
traumatic. It reflects a common and universal stress response, which is
known as the fight-or-flight response (Figure 5).
 Figure 5. The Fight-or-Flight Response*

In response to stressful or threatening situations, the brain sends out a signal

that there is a problem, which activates the body’s sympathetic nervous
system, resulting in a release of stress hormones to the body that prepare the
individual to fight back against the stressor (fight) or run away from it
(flight). However, stressors do not solely involve negative events, as even
positive events and experiences can cause stress. This is known as eustress.
Distress is a term that refers to negative stress, which impacts our
physiology in a more negative manner, whereas eustress refers to positive
forms of stress (Table 2). These stressors can be internal, external, or a
combination of both.
 Examples of Distress Examples of Eustress
Financial stressors Work needed to complete a desired degree
Work-life imbalance Marriage/wedding planning
Illness or death Giving birth
Divorce Caring for a loved one
Abuse/neglect Creating, such as working on a desired project
Add your personal examples (consider both Add your personal examples (consider both
internal and external factors): internal and external factors):

Table 2. Examples of Distress and Eustress

The body’s stress reaction was first identified by Hans Selye (1974), whose
work on the stress response resulted in his identifying a three-phase
response to stress called general adaptation syndrome (Tan & Yip, 2018).
The phases consist of an alarm phase, a resistance phase, and an exhaustion
phase. The alarm phase occurs when the brain perceives a threat or
problem, resulting in the activation of the body’s fight-or-flight system. Our
blood flow increases, our heart rate accelerates, and our lungs dilate to
increase oxygen throughout the body in the brain. Some people may
experience feeling a bit out of control, while others may experience
increased mental acuity as they prepare for fight or flight.

After the initial shock of the stressor wears off, we then enter the resistance
phase, in which the body continues to mobilize the resources needed to
adapt and cope with the stressor. Assuming the stressor finally abates, then
the body’s parasympathetic nervous system activates as a means of
returning the body to baseline and regaining a sense of homeostasis.
However, even after the events that triggered the stress have ended, the
reaction throughout the body persists. The stress hormones may linger for
several hours before returning to baseline.

If the stress is chronic, though, then the resistance phase can lead to
exhaustion if recovery and relief do not occur. Because the body’s resources
are finite, they eventually become depleted, which potentiates the
development of trauma. The following are signs and symptoms of the
exhaustion phase that signal a trauma response, which providers need to be
Aware of:
☐ Depression
☐ Frequent crying
☐ Feeling sick
☐ Numbness
☐ Flashbacks or vivid memories of the stressor
☐ Nightmares
☐ Negative thoughts, such as:
o Shame
o Guilt
☐ Avoidance of people, places, or things that remind them of the
stressor
☐ Hypervigilance
☐ Hyperactivity
☐ Anxiety
☐ Detachment
☐ Aggression
☐ Confusion and difficulty remembering details of trauma
☐ Chronic physical pain and poor circulation
☐ Repetitive body movements
☐ Weight gain
☐ Illness and secondary health conditions

Trauma is unique to each individual and may present in additional ways not
listed here. In addition, we have all experienced at least a few of these signs
and symptoms, so how do you know if the universal stress response is
headed toward exhaustion and a trauma response? It starts with analyzing
your own reactions to stress. What does it feel like to you? Do you have
coping mechanisms that allow you to recover from stress? Review the
following ACTION Personal Reflection: ABCs of the Universal Stress
Response worksheet to help guide you in a personal reflection. Feel free to
use additional paper if you need to expand on your thoughts. You can use
this worksheet with your clients as well.
 PROVIDER WORKSHEET
ACTION PERSONAL REFLECTION: ABCs
OF THE UNIVERSAL STRESS RESPONSE

The following activity will assist you in connecting to the universal

stress response. Reflect on an experience that caused you to feel
concerned, anxious, uncomfortable, nervous, or fearful. Write the
details of what occurred before you began to feel stressed, what you
felt at the moment, and how you recovered following the experience.

1. Antecedent (Alarm Phase): What was the stressor? Consider

aspects of who, what, when, where, why, and how.

2. Behavior (Resistance Phase): How did you feel or react to the

stress? Consider what you heard, felt, saw, smelled, and thought, as
well as your initial reaction.

3. Consequence (Recovery Phase): What occurred after your

reaction? Consider how long it took you to recover, whether your
reaction was helpful or appropriate, and what actions you performed
to feel better after the experience.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

DETECTING ACUTE STRESS

The primary difference between a clinical diagnosis of PTSD and acute
stress disorder (ASD) involves the onset and duration of the symptoms.
While both disorders interfere with functioning, the symptoms of ASD are
briefer in duration and do not exceed a one-month time frame. Most
individuals will have an immediate recovery from ASD, but if the
symptoms continue to persist after one month, then the diagnosis is revised
to PTSD. Although some of the examples we share in this workbook may
not meet the criteria for a clinical diagnosis of ASD or PTSD, both
disorders deserve attention given their association with reduced health and
well-being. Indeed, clients who have experienced acute stress may still
require support and intervention to enhance their quality of life even if they
do not meet diagnostic criteria. Therefore, practitioners should identify
additional methods to detect dysfunction. The following checklist can
initiate the screening process for acute stress that may perpetuate into more
chronic stress:
☐ While formal assessment tools are needed to develop targeted
intervention approaches for trauma, practitioners should first
complete an informal screening process to determine whether
clients require further assessment or referral. Be sure to adhere to
the four approaches of trauma-informed care when conducting this
screening: realize, recognize, respond, and resist re-traumatization.
☐ Our initial focus in the ACTION-from-Trauma approach is the
detection of trauma. Given that acute stress can precipitate trauma,
this is a place to start the screening process. Such a landing point
allows you to attempt to curate an understanding of the client’s
experience without being too invasive, which addresses the first
principle of trauma-informed care: safety. Continually prioritize
safety and seek out immediate support for your client, or yourself,
in the presence of potential harm or danger.
☐ Remember that the person is not their trauma. Seeing the person
first is key! In addition to their history of trauma, they may bring
strength, resilience, support systems, and coping mechanisms that
work. Do not assume you have to “fix” the person while creating
growth toward healing.
 ☐ Both ASD and PTSD can interfere with attendance and treatment
adherence, and it may result in early termination of services. Start
out by trying to build rapport, and be willing to share some of your
life to connect. Prioritize learning about the person first before you
delve into their trauma.
☐ Other diagnoses, such as depression or anxiety, may reveal similar
symptoms. It is important to use proper screening tools and
determine the required professionals who can best support your
client.

The following is an informal acute stress screening tool for practitioners to

consider when determining next steps with clients, as well as a scoring
guide to help practitioners interpret a client’s scores.
 PROVIDER WORKSHEET
ACTION ACUTE STRESS SCREENING
TOOL

Check all that apply to your client/caregiver following your session.

Analyze your results to consider next steps based on clinical
reasoning and tools within this workbook.

NAME:_________________________

DOB: __________________________

DATE: _________________________
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 PROVIDER HANDOUT
ACTION ACUTE STRESS SCREENING
TOOL ANALYSIS

Practitioners can use the following scoring guidelines to interpret a

client’s scores on the ACTION Acute Stress Screening Tool. Based on
your interpretation, consider the next steps to take as provided within
each zone.
 Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

DETECTING LEVEL OF SELF-REGULATION

Maslow’s hierarchy of needs views motivation as a factor in growth and

development (Maslow, 1943). In the presence of trauma, motivation
becomes more in alignment with protection and self-preservation. When
people are deprived of their basic needs due to lack of resources, abuse, or
injustices, deficiency and dysfunction are the outcomes. Fear, anxiety, and
stress emerge, which pose a challenge to self-regulation. The pyramid
structure implies a hierarchy for growth, expanding upon the idea that
people are not in a fixed state but are constantly developing.

In her book Self-Regulation and Mindfulness, coauthor Gibbs (2017b)

developed a seven-level self-regulation and mindfulness hierarchy based on
Maslow’s hierarchy of needs (Figure 6). It presents a structure for
caregivers and professionals to gain insight on individuals healing from
trauma with regard to their self-regulation abilities (i.e., ability to adapt and
adjust their arousal levels to meet the demands of the environmental and
required activities; involves sensory processing, emotion regulation, and
executive function). The hierarchy also provides guidance regarding their
mindfulness skills (i.e., ability to be present, engaged, and self-aware).
Starting from the bottom up, the first tier of the pyramid represents the
foundation of safety and preservation. As individuals ascend to the top of
the pyramid, they develop reciprocal mindfulness.
 Figure 6. Seven-Level Self-Regulation and Mindfulness Hierarchy (Gibbs, 2017b)

When interacting with an individual living with the aftermath of trauma,

you should have an idea of their general level of functioning as it relates to
their self-regulation and mindfulness abilities. Reviewing the hierarchy may
assist you in developing goals for the client and acknowledging gains they
have made. When complex trauma ensues, you must realize that
chronological age may not equate to the client’s ability to self-regulate and
to be aware of their behavior. In fact, some adults may present at the
foundational and mid-levels of the hierarchy due to their history of trauma.

The following two checklists provide a method to determine the client’s

level on the hierarchy. The first checklist is intended for adults, whereas the
second checklist is intended for caregivers to complete in relation to their
child’s level on the hierarchy. Review the purpose of the checklist and your
intent for using the data. After completion, be sure to revisit each response
with the client. This dialogue will allow you to clarify the items and make
any necessary adjustments.
 CLIENT WORKSHEET
SEVEN-LEVEL SELF-REGULATION AND
MINDFULNESS CHECKLIST

Review each statement within the following checklist. Check all of

the boxes that best apply to you.
I. Reciprocal Mindfulness:
☐ I have great relationships with others and get along with most people.
☐ I often help others in need and give them my advice.
☐ I recognize what people think of my behavior by reading their body language. I try to
better understand their feelings by asking questions.
II. Self-Actualized Mindfulness:
☐ I know when I am anxious or feeling out of control (e.g., racing heart rate, sweaty
palms, tight muscles) and have the ability to calm my body (e.g., slowing down my
breathing).
☐ I often share my feelings and seek out the feelings of others to improve my behavior.
☐ I enjoy connecting with new people and can change my actions to better engage with
them.
III. Aesthetic Mindfulness:
☐ Although I sometimes feel out of control, I am aware of my actions and my effect on
others.
☐ I am aware of my emotions and challenges and try to make improvements.
☐ Even when upset, I am able to respect others in my surroundings and their property.
IV. Cognitive Mindfulness:
☐ I am easily upset by others but try my best to keep my emotions under control.
☐ I often feel anxious and/or out of control (e.g., racing heart rate, sweaty palms, tight
muscles), and it takes a long time to calm my body.
☐ I often attempt to engage with others. However, I have difficulty making friends and
being in long-term relationships.
V. Self-Esteem:
☐ I try my best and want to engage with others, but I frequently upset them, and my
emotions are often out of control.
☐ Even though I try, I am unable to calm myself after becoming upset.
☐ I have difficulty finishing what I start, keeping a job, and getting along with others.
VI. Belonging and Social Acceptance:
 ☐ I occasionally spend time with others, but I lack trust in most people.
☐ I occasionally try new things, but it usually does not go well.
☐ I am often anxious, fearful, worried, and/or out of control around others.
VII. Safety and Self-Preservation:
☐ I do not try new things (e.g., food, change in routine, meeting new people) and am
fearful of the unknown.
☐ I am aggressive at times and/or run away from things I do not like.
☐ I am often sick and/or tired.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT WORKSHEET
SEVEN-LEVEL SELF-REGULATION AND
MINDFULNESS CAREGIVER CHECKLIST

Review each statement within the following checklist. Check all of

the boxes that best apply to your child or the child you are caring for.
My child (or child I am caring for):
I. Reciprocal Mindfulness:
☐ Knows when they are in need or when others are in need (e.g., tells a teacher when
their peer is upset).
☐ Frequently helps others having a challenging time (e.g., helps a friend needing a push
on the swing or tries to help a friend calm down).
☐ Recognizes what people think of their behavior by looking at body language. They
try to better understand others’ feelings by asking questions (e.g., asking if a friend is
angry with them).
II. Self-Actualized Mindfulness:
☐ Has awareness of what their body needs to finish tasks and engage with others (e.g.,
stating they need a break or expressing how they feel).
☐ Often shares their feelings and seeks out the feelings of others to improve their
behavior.
☐ Always tries their best to follow directions and to improve interactions with peers.
III. Aesthetic Mindfulness:
☐ Sometimes has outbursts but is aware of their actions and their effect on others.
☐ Is aware of their emotions and challenges and tries to make improvements.
☐ Even when upset, will respect others in their surroundings and the property of others.
IV. Cognitive Mindfulness:
☐ Gets easily upset but tries their best to keep their emotions in control.
☐ Often seems anxious or upset, and it takes a long time for them to calm their body.
☐ Often tries to engage with others but has difficulty making friends.
V. Self-Esteem:
☐ Is frequently upset by others, and their emotions are often out of control.
☐ Attempts to calm themself when upset, but it does not work.
☐ Has difficulty finishing projects, keeping friends, and/or staying at the same school.
VI. Belonging and Social Acceptance:
 ☐ Occasionally spends time with others, but they appear to lack trust in most people.
☐ Occasionally will try new things, but it usually does not go well.
☐ Often seems anxious, fearful, worried, and/or out of control around others.
VII. Safety and Self-Preservation:
☐ Does not try new things (e.g., food, change in routine, meeting new people).
☐ Is aggressive at times and/or runs away from undesirable experiences.
☐ Is often sick and/or tired.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Review the checklist upon the client’s completion. To identify the client’s
level, determine the section containing the most check marks. If there is
more than one section with the same amount of check marks, select the
lowest level on the hierarchy (e.g., if the reciprocal mindfulness and self-
actualized mindfulness levels both have three checkmarks, the client falls at
level II, self-actualized mindfulness). However, if a client has check marks
within the higher levels, this indicates areas of potential and strengths to
acknowledge. To better illustrate this process, we provide an example and
analysis here. For guidance in applying the client’s level into treatment
planning, we also provide a chart connecting the seven-level self-regulation
and mindfulness hierarchy to areas of consideration for intervention
activities. Lastly, we present a treatment planning tool to synthesize the
information gained from the checklist and other methods of assessment.
 SAMPLE ANALYSIS OF RESPONSES

I. Reciprocal Mindfulness:
☑ I have great relationships with others and get along with most people.
☐ I often help others in need and give them my advice.
☐ I recognize what people think of my behavior by reading their body language. I try to
better understand their feelings by asking questions.
II. Self-Actualized Mindfulness:
☑ I know when I am anxious or feeling out of control (e.g., racing heart rate, sweaty
palms, tight muscles) and have the ability to calm my body (e.g., slowing down my
breathing).
☑ I often share my feelings and seek out the feelings of others to improve my behavior.
☐ I enjoy connecting with new people and can change my actions to better engage with
them.
III. Aesthetic Mindfulness:
☑ Although I sometimes feel out of control, I am aware of my actions and my effect on
others.
☑ I am aware of my emotions and challenges and try to make improvements.
☑ Even when upset, I am able to respect others in my surroundings and their property.
IV. Cognitive Mindfulness:
☐ I am easily upset by others and try my best to keep my emotions in control.
☐ I often feel anxious and/or out of control (e.g., racing heart rate, sweaty palms, tight
muscles), and it takes a long time to calm my body.
☑ I often attempt to engage with others. However, I have difficulty making friends and
being in long-term relationships.
V. Self-Esteem:
☐ I try my best and want to engage with others, but I frequently upset them, and my
emotions are often out of control.
☐ Even though I try, I am unable to calm myself after becoming upset.
☑ I have difficulty finishing what I start, keeping a job, and getting along with others.
VI. Belonging and Social Acceptance:
☐ I occasionally spend time with others, but I lack trust in most people.
☑ I occasionally try new things, but it usually does not go well.
☐ I am often anxious, fearful, worried, and/or out of control around others.
VII. Safety and Self-Preservation:
☑ I do not try new things (e.g., food, change in routine, meeting new people) and am
fearful of the unknown.
 ☐ I am aggressive at times and/or run away from things I do not like.
☐ I am often sick and/or tired.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Although there are check marks at every level in this sample checklist, the
person falls more into level III on the hierarchy, while progressing into level
II. This gives the clinician the opportunity to acknowledge behavior below
aesthetic mindfulness that the client can address while strengthening those
at their identified level and above.

At each level of the hierarchy, there is a neurological connection that

impacts functioning. Behavior provides an observable representation of
what is occurring neurologically, and what we witness at the behavioral
level represents a manifestation of the underlying neural dysfunction
resulting from trauma. Secondary to trauma, it is vital to acknowledge the
overpowering effect of lower-level, more primitive areas of the brain that
are responsible for safety and self-preservation. By taking a bottom-up
approach, we attempt to connect survival behaviors to the functions related
to the brainstem, followed by emotion regulation to the limbic system,
followed by higher-level executive functioning within the cortices of the
brain.

An individual’s ability to successfully engage and function with others and

within the environment requires the various parts of the brain to work
together. To this end, overactivity of lower-level structures may impair
access to higher-order brain structures involved in self-regulation and
mindfulness. This does not equate to a lack of intellect. It implies
challenges in self-regulation and the presence of a trauma lens of
protection. Therefore, when selecting activities and treatment interventions,
it is crucial that you detect where individuals land in their ability to self-
regulate and be self-aware. The following table assists in such analysis for
all age groups.
Level Neural Functioning Considerations for Interactions and
 Interventions
Levels VI–VII: Brainstem Level Functioning: Activities should be body-focused and
Foundational Level Reactive versus responsive engagement less top-down. At this level, the person
with others and their environment primarily utilizes neurological
structures for arousal and safety
Body Signals and Actions: preservation. Decrease environmental
o Protective flexion positions stimulation (including overuse of
o Arms and legs close to the body verbal directives), and consider using
o Eloping behaviors gestures or simple verbal cues to
o Hiding (e.g., wearing a hooded communicate. Provide sensory-rich
jacket with head covered or activities, ensuring safe boundaries and
sunglasses indoors) exits due to eloping behaviors, and
o Preferring specific clothing, food, develop safe, comfortable spaces.
and rigid routine
Provider/Caregiver/Educator
o Unsafe risk-taking behavior
Considerations: At this level, it is
o Aggression
difficult for the person to listen and
o Repetitive and stereotypical follow directions, especially when
movements other things are occurring in the
environment. Try to decrease noise and
clutter in the environment, avoid
speaking too loudly, and don’t offer too
many activities. They may need your
help to provide or identify sensory
input to calm and engage. This may
include input to the skin, deep pressure
to the muscles, controlled movement,
aromatherapy, rhythmic music, and
activities. Be careful to set expectations
and use open communication for
scheduling and changes in plans.
Level V: Limbic System Level Functioning: Caregivers and providers should
Mid-Level Challenges regulating emotions during continue strategies from the
social interaction; Difficulty with foundational level while also exploring
learning and memory; Increased strategies to improve self-awareness
detection and awareness of sensory and recognize reactions to sensory
stimuli but exhibits challenges with stimuli. Incorporate visual cues and
integrating multiple sensory stimuli for sensorimotor activities to enhance body
self-regulation; Challenges with awareness.
executive functioning in the frontal
areas of the brain Provider/Caregiver/Educator
Considerations: At this level, the
Body Signals and Actions: person attempts to follow directions
o May present with sensory-seeking and engage with others, though it may
or avoidance behaviors be challenging at times. The use of
o Has an awareness of personal needs visual aids, such as schedules and
signs, may make it easier for them to
 o Exhibits challenges with social follow directions. Set up the
engagement environment so it is organized, and
o Responds well to routine have needed tools and resources readily
o May have poor eye contact available. Develop ways to schedule in
o Quickly changes emotions when sensory and controlled movement
presented with a trigger breaks.
Levels I–IV: M Cortical Level Functioning: Increased Caregivers and providers should
Higher Level responsiveness to others and the continue strategies from the mid-level
environment via activation of the while also increasing top-down
frontal lobes (i.e., areas of the brain activities that incorporate self-
involved in executive functioning); regulation, sensory processing, emotion
Ability to adapt their level of arousal regulation, and executive functioning.
based on the environment due to Selfmonitoring can assist in enhancing
integration throughout the nervous abilities to participate in daily
system activities.

Body Signals and Actions: Provider/Caregiver/Educator

o Has an awareness of personal needs Considerations: At this level, the
o Responds well to routine person knows what to do and how to
o Occasionally responds to emotional adjust arousal as needed, though they
triggers may need reminders and prompts to
o Self-advocates personal needs help maintain awareness of arousal and
continue making the best choices. Work
on selfmonitoring of growth and
positive interactions.

Table 3. Seven-Level Self-Regulation and Mindfulness Hierarchy Across the Lifespan

After completing the seven-level self-regulation and mindfulness checklist

and reviewing the chart presented in Table 3, use the following plan to
assist you in selecting areas to address when developing long-term
treatment goals. Refer to the sample goals at the end of this worksheet for
assistance.
 PROVIDER WORKSHEET
SEVEN-LEVEL SELF-REGULATION
AND MINDFULNESS HIERARCHY
TREATMENT PLAN

Client’s Name: _________________________

Date: _______________________________

Date of Birth: __________________________

Re-assessment Date: ________________

I. Clinical history and background information:

II. Self-regulation and mindfulness seven-level hierarchy level:

III. Assessment tools utilized (if applicable to your practice):

IV. Scores and results (if applicable to your practice—attach any

additional information):

V. Long-term treatment goals based on assessment outcomes:

Sample Long-Term Treatment Goals

Client will:
 • Use verbal cues to request a break when overwhelmed 80 percent
of the time (within six months)
• Refrain from physically harming themself or others 100 percent of
the time (within one year)
• Utilize a visual schedule to stay on task throughout the day 75
percent of the time (within six months)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

READINESS TO PROVIDE TRAUMA CARE

This workbook provides strategies intended to guide the practice of allied

health professionals in gaining techniques that support their scope of
practice and that enhance their ability to address the needs of their clients
and clients’ families. Before introducing these concepts into your care
approaches, though, it is necessary to assess your own readiness to provide
trauma care. To do so, you can use the following Practitioner Readiness for
Trauma Care Checklist (Cook, Newman, & The New Haven Trauma
Competency Group, 2014). Revisit this checklist while reviewing, and after
completing, this book.

Practitioner Readiness for Trauma Care Checklist

As a provider, I am able to:

☐ Tailor trauma assessments and interventions in a way that
considers diversity in socioeconomic, organizational, community,
population, and intersecting cultural identities
☐ Employ a biopsychosocial approach to care that considers the
complex interactions of cognitive, biological, psychological, and
social factors
☐ Understand the impact of traumatic experiences across the
lifespan and between family members (e.g., pediatric providers
have knowledge of the impact of trauma on the adult caregiver)
☐ Acknowledge short-term and long-term effects of trauma (e.g.,
comorbidities, housing-related issues) and person-environment
interactions related to trauma (e.g., running away from home and
being assaulted)
☐ Perform shared decision making with clients and focus on
strength, resilience, and areas for growth
☐ Provide a sense of autonomy, safety, and security with an
awareness of how trauma impacts an individual’s and
organization’s sense of trust
☐ Understand trauma reactions and their implications for
assessment and treatment (e.g., able to alter plans in the presence
of avoidance behaviors or triggers)
☐ Acknowledge how society, organizations, and systems can result
in the possibility of re-traumatization
☐ Effectively tolerate trauma-related content and the intense sharing
of traumatic experiences
☐ Engage in self-care and self-reflection to protect against burnout
and compassion fatigue
☐ Maintain self-awareness of my own personal experiences that can
impact trauma treatment
☐ Utilize evidence-based interventions and strategies
☐ Work collaboratively with other disciplines and within my scope
of practice to optimize care and enhance positive outcomes
☐ Communicate and translate assessment findings into tailored
treatment approaches
☐ Acknowledge what stage the client is in as it relates to their
trauma so I can pivot care and provide appropriate interventions
FROM TRAUMA-INFORMED TO ACTION LANGUAGE

Those who have experienced trauma experience it with each context of their
lives. Therefore, it is crucial that practitioners have an awareness of how
words can trigger and further complicate the patient relationship. Even if
we don’t intend to do so, our words and actions can reinforce clients’ fear-
based reactions, defensive responses, and avoidance behavior. However,
there are direct methods we can intentionally use to avoid re-traumatization.
In particular, Leitch (2017) suggests a resilience model that includes
strength-based and protective questioning. This strategy empowers the
individual and presents a respectful and empathic dialogue that decreases
the opportunity for re-traumatization. Expanding on this approach, our
ACTION-from-Trauma approach promotes the use of respect and empathy
language, as well as gratitude and growth statements.

Respect and empathy language involves gaining permission from the client
to discuss or address certain topics, which provides them with a sense of
validation and acknowledges their lived experiences. Gratitude and growth
statements involve making the individual feel appreciated and part of the
process. These two styles of communicating provide positive reinforcement
and strengthen the client-practitioner relationship, which leads to growth.
Table 4 provides examples of each type of language, though you should
always adjust this language to meet the intellectual and developmental
needs of the client and/or caregiver.
Respect and Empathy Language Gratitude and Growth Statements Children
O “What do you need?” O “Thank you!”
O “Do you need a break?” O “I like your hard work!”
O “How can I help?” O “Wow! Look at how you grew today by
O “All done? Or do you need more?” finishing your work!”
O “I want to help you.” O “You have grown so much!”
O “What you experienced is not okay. What
support do you need?”
Adolescents, Adults, and Older Adults
O “That is really challenging, and I see you are O “That was brave of you.”
upset. Can I suggest some strategies to assist O “Your sharing shows your strength.”
with your anxiety?” O “Look at all you have done since and despite
O “Would it be okay for us to discuss how that of…”
made you feel?”
O “While it may not have been the best choice, O “That is tough to talk about. I appreciate your
your response matches how you felt.” openness and trust.”
O “How can I help you grow from here?”
O “Did that make you feel uncomfortable? That
was not my intent.”
O “I see that may not have been the best way to
phrase that. What I meant was…”

Table 4. ACTION Language

Try to sandwich respect and empathy language with gratitude and growth
statements so you can build trust and connect to the natural flow of our
nervous system (Leitch, 2017). Here is an example of a parent-teacher
conference to discuss a preschool child having tantrums and physical
aggression:
“I am glad you came in today. I know it takes time away from your work. I respect the
dedication you have for your son. I want to discuss what happened in class yesterday. Would
it be okay if I start? I appreciate your allowing me to share. Now I want to focus on how we
can work with him to grow from here. What are your thoughts?”

This dialogue invites the parent to be part of the decision-making process as

opposed to making them feel isolated or that their child is being punished.
In addition, keep the following key considerations in mind when speaking
with clients or their caregivers:
☐ Speak clearly and concisely, avoiding jargon.
☐ Do not make judgments or assumptions.
☐ Avoid labeling and re-traumatizing the individual by seeking too
many details. The focus should be on emphasizing growth and
identifying opportunities to develop action steps.
☐ While it is important to make appropriate referrals for clients who
require additional support and direct trauma services, do not
discount shared experiences. (Be sure to address any legalities
regarding mandated reporting in your state.)

NEXT STEPS: MOVING TO THE C IN ACTION TO

CREATE GROWTH*
Although this chapter is focused on Acknowledging and being Aware of
trauma, there are several considerations that providers must take into
account when screening for and assessing trauma prior to proceeding to the
next step of Creating growth. At this step, you must address the second
principle of a trauma-informed approach: trustworthiness and transparency.
That is, you need to be open and transparent when it comes to decision
making and goal development. This workbook is intended to support your
practices, building upon your training and knowledge. Be sure to use your
clinical reasoning and judgment moving forward. Note that there may be
legal implications requiring mandated reporting of certain information
based on your state. Figure 7 provides an algorithm to assist you in
determining how to precede.

Figure 7. Algorithm to Assist Providers in Determining Next Steps following the Trauma Screening

If you determine that the client requires additional screening or a formal

assessment, provide education and reasoning for the screening and
assessment. First, ensure protection by providing a safe space. If possible,
discuss areas of strength and a desire to expand upon such factors. For
example, perhaps the client or caregiver has consistently attended sessions
or meetings. You can highlight their commitment and willingness to
continue working together. If it is a new referral, the intake process should
begin with a focus on available resources, desires, and goals. This must
precede discussions on trauma. For children in particular, you can build
rapport by asking them to draw a picture of their world, including their
family, things they enjoy, where they live, and so on. Use the images to
identify areas of concern, and then discuss how you want to help those
areas. For adolescent and adults, you can start by inquiring the following:
☐ How would you describe yourself?
☐ Who is in your life (e.g., friends, family members, social
supports)?
☐ What are the areas that present as challenging?
☐ What do you want to improve?
☐ How can I help you grow?

After establishing a relationship, you can then share your desire to build
upon the areas discussed. In order to enhance well-being and growth toward
their goals (for themselves or their child), you need to learn more about
their experiences and determine specific areas to target. You can use the
following script as a guide, though please be sure to utilize language and
communication skills that best support the client:
“We all experience events that challenge us and make it hard to do the things we want and
have to do. Some examples of challenges are _______________ [list as appropriate, such as
loss of work, illness, loss of a loved one to death or departure, poverty, etc.]. For some, the
challenges we face continue to build upon each other over time, or one big event can replay
for us. I want to know if there are any barriers for you [or your child] that we can address
and remove to create growth. We will focus on your strengths and some available resources
to address them. While we must first identify challenges, these will not be our focus. Your
goals and desires will be our focus.”

Next, invite the client to the table when it comes to exploring their trauma
history. Ignoring the signs of trauma in your clients can actually be a
catalyst to ignite such behaviors. However, the client has a right to not
participate in a formal screening or assessment. If they desire to proceed,
only attempt to collect necessary information that relates to your treatment
practice and impending goal development. Try to acknowledge statements
or actions that may be triggers for the client and acknowledge their reaction.
Take a sensitive approach in proceeding, and anticipate that your actions
can re-traumatize the client. Be sure to gain permission to initiate a formal
evaluation and assessment, sharing each step of the process before
beginning. Invite the client or caregiver to verbalize their perception of the
process to ensure that they are not misinterpreting your communication.

Before beginning with the assessment, make sure that you provide a safe
context and a comfortable environment. Ensure there is proper space to
allow distancing if you are in a face-to-face environment, and assist the
client in selecting a preferred seating position. Modulate your tone of voice
to provide a supportive and comforting tone. Always be aware of cultural,
literacy, or linguistic barriers that you need to address before proceeding.

In addition, form an emergency plan to address red flags and possible

triggering of emotions during the assessment. For example, have necessary
contact information on hand so you can report abuse to welfare services,
have a variety of calming techniques readily available to address anxiety
and stress, and make sure you have non-violent self-protection training in
the event of aggressive outbursts. Remember to provide support and praise
where appropriate, and check in periodically to ensure that the client or
caregiver understands the process (e.g., “I want to make sure that I’m clear
and that I don’t move through things too quickly. In your own words, what
did you hear me say?”).

When conducting an assessment, it is necessary to use valid and reliable

standardized assessment tools. As an allied health professional, consider
your scope of practice, licensure, and clinical skills, given that not all allied
health professionals can administer such tools. In that case, it is necessary
to make an appropriate referral to a licensed professional. Valid and reliable
assessment tools provide a formalized structure to the evaluation process.
They also highlight areas of need across various contexts and areas of life.
Based on our ACTION-from-Trauma approach, the assessment should
reveal strengths to utilize in treatment. Before administering any
assessment, review the guidelines for each tool and the time required to
administer. Here are some available tools to consider:

☐ Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)

☐ PTSD Symptom Scale Interview for DSM-5 (PSS-I-5)
☐ Structured Clinical Interview for DSM-5 (SCID-5)
☐ Strengths and Difficulties Questionnaire (SDQ)
☐ VIA Character Strengths Survey
☐ Mini-Mental State Examination (MMSE) or Folstein test
☐ Child and Adolescent Needs and Strengths (CANS)
☐ Family Needs & Strengths (FANS) Assessment
☐ Childhood Trauma Questionnaire (CTQ)
☐ Pediatric Emotional Distress Scale (PEDS)

Although conducting a complete interview and history taking is necessary

to gain an understanding of your client, you should avoid requesting
specific details that can be overwhelming and traumatic to revisit. Be sure
to not place labels on their behaviors, as doing so can indirectly place a
negative connotation on what they share. If possible, it is best to utilize a
self-report tool so clients can write down their experiences. The following
are some options available through the Centers for Disease Control and
Prevention, though be sure to address your client’s preferred language and
health literacy level:
☐ Adverse Childhood Experiences (ACE) Questionnaire:
https://www.cdc.gov/violenceprevention/acestudy/pdf/BRFSS_Ad
verse_Module.pdf
☐ Family History and Health Appraisal Questionnaires (see “Study
Questionnaires” tab):
https://www.cdc.gov/violenceprevention/childabuseandneglect/ace
study/about.html
Depending on your practice setting, this assessment can be part of your
intake process with all clients and families. The following pages contain a
modified version of the Adverse Child Experiences (ACE) Questionnaire,
as well as the Pediatric Adverse Experiences Questionnaire, which you can
give to clients.
 CLIENT WORKSHEET
THE ADVERSE CHILD EXPERIENCES
(ACE) QUESTIONNAIRE*

I’d like to ask you some questions about events that happened during
your childhood. This information will allow us to better understand
problems that may occur early in life and may help others in the
future. This is a sensitive topic, and some people may feel
uncomfortable with these questions. Please keep in mind that you can
skip any questions you do not want to answer. All questions refer to
the time period before you were 18 years of age.

While you were growing up, during your first 18 years of life:
1. Did you live with anyone who was depressed, mentally ill, or
suicidal?
______ Yes ______ No
2. Did you live with anyone who was a problem drinker or
alcoholic?
______ Yes ______ No
3. Did you live with anyone who used illegal street drugs or
who abused prescription medications?
______ Yes ______ No
4. Did you live with anyone who served time or was sentenced
to serve time in a prison, jail, or other correctional facility?
______ Yes ______ No
5. Were your parents separated or divorced?
 ______ Yes ______ No
6. Did your parents or other adults in your home often or very
often slap, hit, kick, punch, or beat each other?
______ Yes ______ No
7. Did a parent or other adults in your home often or very often
hit, beat, kick, or physically hurt you in any way? Ever hit
you so hard that you had marks or were injured? (Do not
include spanking.)
______ Yes ______ No
8. Did a parent or adult in your home often or very often swear
at you, insult you, or put you down?
______ Yes ______ No
9. Did an adult or person at least five years older than you ever
touch you sexually?
______ Yes ______ No
10. Did an adult or person at least five years older than you ever
try to make you touch their body sexually?
______ Yes ______ No
11. Did an adult or person at least five years older than you ever
force you to have sex?
______ Yes ______ No

Now add up your “yes” answers. This is your ACE score.

___________
* Adapted from
https://www.cdc.gov/violenceprevention/acestudy/pdf/BRFSS_Adverse_Module.pdf
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT WORKSHEET
PEDIATRIC ADVERSE EXPERIENCES
QUESTIONNAIRE

I’d like to ask you some questions about your child. Some of these
questions are sensitive. You do not have to answer if you are
uncomfortable. This information will assist in gaining clarity of your
child’s needs and can provide areas to address when we develop a
treatment plan.

Has your child experienced any of the following?

1. Problems with sleep, such as difficulty falling asleep,
difficulty staying asleep, restlessness, nightmares, or
bedwetting?
______ Yes ______ No
2. Changes in behavior, such aggression, increased attachment,
detachment, or increased sadness?
______ Yes ______ No
3. Challenges with eating, such as loss of appetite, eating
quickly, overeating, or other significant changes in eating
habits?
______ Yes ______ No
4. Verbalized feelings of hopelessness or feeling unsafe?
______ Yes ______ No
5. Gut issues, such as constipation, bowel movement accidents,
or soiled underwear (encopresis)?
 ______ Yes ______ No
6. Urinary accidents (enuresis)?
______ Yes ______ No
7. Major changes in the homelife (e.g., death of family
members, parent leaving the home, changes in the family
structure)?
______ Yes ______ No
8. Any events that may cause sadness, fear, or increased stress?
______ Yes ______ No

In what areas would you say you and your child need assistance?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Once you complete the assessment and additional screening tools, address
what has happened to the client since the trauma. The perception of trauma
is extremely unique. Some may recover from a traumatic experience
without professional intervention, while others may require support and
treatment along their healing process. Highlight where the client has
showed signs of strength after the trauma, such as being brave or resilient to
even share the experience.

In addition, explain how you plan to utilize the information you have
gleaned, including your plans (with permission) to share any findings with
other professionals involved in the client’s care, such as the health care or
education team. When appropriate, use visuals to share feedback, such as
drawings, graphs, and scores. Relate the client’s lived experiences with your
results. Some clients may not be aware how the traumatic events they
reported are connected to their behaviors, and they may be unclear of the
services required to address these behaviors so they can best reach their
treatment goals. Highlight a few key points and areas to initially address,
and provide brief education on common themes and trauma symptoms.

It is also crucial that you follow up on any assessments by checking in with

the client and/or caregiver to ensure they are not overwhelmed before
departing. Ensure that they are alert and oriented by doing an environmental
check-in. For example, ask them to identify objects in the environment, or
ask if the temperature in the room is comfortable. If you witness any signs
of discomfort, acknowledge it to the client, and consider using
somatosensory approaches, such as deep pressure, breathing exercises, or
stretches (see chapters 2 and 3). Before they leave, share your intent for the
remainder of your day, and ask them what plans they have for the rest of the
day. If they do not appear prepared to depart, invite them to stay longer to
address any emotions that remain.

Know that trauma screening and assessment is ongoing and, in general,

should be revisited throughout the treatment process. The timing and
emotional state of the client can greatly impact the results, which can lead
you to miss or misinterpret shared information. Some clients may also
withhold information until they gain a feeling of trust for the practitioner.

Finally, take a client-centered approach when it comes to treatment

planning, goal setting, and intervention objectives by ensuring that you
collaborate with the client or caregiver. Invite your client to assist in
developing a plan of care. They must be fully involved in this process to
avoid re-traumatization and enhance trustworthiness and transparency. Be
open and answer their questions with basic terminology. Check in to assure
their understanding of your interpretation and to gain assurance of your
accuracy. Additionally, acknowledge the presence of comorbid conditions
or diagnoses that need to be addressed. Be sure to take an interprofessional
approach to meet the client’s needs that reach outside of your scope of
practice.

CASE SCENARIO*
Review the following case study. Then use the worksheet to apply
some of the ACTION approaches discussed in this chapter.

Name: Stephanie
Setting: School-based
Age: 11

I first met Stephanie when she was in the sixth grade. I was working as
a school social worker at her middle school. She was 11 at the time
and was living in an urban, low socioeconomic status environment
with her mother and two brothers. The whereabouts of her father were
unknown.

Prior to transitioning to middle school, Stephanie had attended three

different elementary schools between the second and fifth grades, all
of which were spread throughout the state. Her kindergarten and first-
grade school experiences were unknown because our district was not
able to secure those school records.

During her sixth-grade year, Stephanie was not known as a

“highflyer,” meaning that she was not a student who consumed a vast
amount of our school’s resources. The school administration and team
members only issued Stephanie a total of seven office discipline
referrals throughout that entire school year. Referrals ranged mostly
from classroom disruption to defiance of school authority. She was
absent only four days, tardy a total of nine days, and her final grades
were in the A–B range. Relatively speaking, she was not a student of
concern within our building. In fact, I do not have record of or even
recall providing Stephanie with any intervention support that school
year.

Stephanie’s seventh-grade year was starkly different from her sixth-

grade year. She went from requiring little to no support to needing
various intervention supports. I recall her teachers describing her as
irritable, loud, argumentative, disruptive, defiant, and both physically
and verbally aggressive. She received out-of-school suspension a total
of 13 days and was suspended in school for a total of 4 days.
Stephanie also received 48 office discipline referrals for major
offenses, 20 referrals for minor offenses, and was sent to our school’s
time-out room 43 times. She was absent a total of 37 days, tardy a
total of 49 days, and failed four classes.

The school decided to refer Stephanie to our problem-solving team,

and the Communities in Schools (CIS) site director and I were tasked
with implementing intervention supports. Fortunately, throughout her
sixth- and seventh-grade school years, our school psychologist
engaged our staff in a professional development series educating us on
the negative impact that adverse childhood experiences can have on
brain development. We learned that negative experiences can actually
stunt a child’s cognitive and social-emotional development as a result
of constantly living in a fight-or-flight state.

Based on this knowledge, we began to view Stephanie’s behavior

changes through a different lens, and instead of thinking, “What’s
wrong with her?” we shifted our thoughts to “What happened to her?”
We also realized that in order for us to implement effective supports,
we had to first gain a better understanding of the experiences that
seemed to cause the changes in her behavior. Gathering details was a
challenge—Stephanie’s attendance was inconsistent, and attempts to
connect with her mother were unsuccessful due to nonworking
telephone numbers and failed home visits—but we were able to gather
that Stephanie and her family had lost their housing and had been
forced to live between family members’ homes and a shelter.

The intervention supports we decided to put in place were focused on

strengthening Stephanie’s resiliency by establishing positive
relationships with school staff and by providing her with structure,
consistency, and skill-building opportunities. We intensified a well-
known and evidence-based intervention called Check-In/Check-Out
(CICO). Stephanie connected with either the CIS director or me three
times a day: morning, midday, and afternoon.
During the morning check-in, we assessed both her mental and
physical preparedness for school while helping her set behavioral
goals and identify strategies she could use to help her achieve those
goals. We then checked in with her midday to see how her day was
going, and during the afternoon check-out, we helped her reflect on
her day. We cheered successes and problem solved around any
difficulties she experienced in an effort to decrease the likelihood of
their reoccurring. Stephanie’s teachers were also expected to provide
her with regular constructive feedback as a means of developing a
relationship and skill building with her.

We discovered that the fidelity of the intervention’s implementation

greatly depended on the staff member’s mindset and the lens through
which they viewed Stephanie’s behavior. Staff members who still
tended to think, “What’s wrong with her?” were less likely to correct
Stephanie’s behavior using a problem-solving approach that would
preserve the integrity of the relationship they were trying to build with
her. Instead, their use of punitive corrective measures either sustained
or escalated her challenging behavior. On the contrary, staff members
who shifted their mindset and began to approach Stephanie in a way
that conveyed “I’m here and care about you” were less likely to
experience negative interactions with her, and they were more likely to
successfully deescalate her during times of challenging behavior.

___________
* Case study by Adriane L. Simpson, MSW
 PROVIDER WORKSHEET
CASE ANALYSIS

In this chapter, we have reviewed the background information on the

various dimensions and types of trauma. After reading through
Stephanie’s case, see if you are able to connect her trauma to her
functioning. Use the following worksheet to analyze the case.

Task #1: What were the red flags that Stephanie had experienced a
trauma? What would have been your next steps after she began to
have challenges at school? List your thoughts here.

Task #2: What level of the seven-level self-regulation and

mindfulness hierarchy would you expect Stephanie to be on? What
were some of Stephanie’s strengths, resources, or opportunities?

Task #3: How could you utilize ACTION language with Stephanie?
Provide some example statements.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

____________
* Adapted from https://www.polar.com/blog/recovery-from-exercise/
* Portions of this section are based off of the Substance Abuse and Mental Health Services
Administration. (2014b). Trauma-informed care in behavioral health services. Treatment
Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD:
Substance Abuse and Mental Health Services Administration.
 CHAPTER 2
CREATE GROWTH

The second step in our ACTION-from-Trauma approach is to Create

growth. To do so, we present tools to monitor growth at the individual level
rather basing a client’s growth on external comparisons (e.g., other children
within the school setting). Although we offer a variety of activities in this
chapter, they are not intended for everyone. Some activities could actually
be a trigger. Breathwork, for example, is an activity that you must present
carefully given that many individuals with a trauma history hold tension in
their bodies that poses a challenge to deep breathing. Forced breathing can
even trigger a fight-or-flight reaction. Therefore, it is critical that you
engage in an exploration of each client’s history prior to enacting these
recommendations.

In this chapter, we aim to justify the need to expand upon the current
practices to employ action steps toward healing through the following
sections:

☐ Creating a Growth Contract and Needs Plan

☐ Grounding Activities and Practitioner Check-Ins
☐ The Sensory Connection
☐ Contextual Sensory Investigation
☐ ACTION Creating Growth Tools
☐ Case Scenario
CREATING A GROWTH CONTRACT AND NEEDS PLAN
When addressing trauma, information gathering is important, but there is
the need to go beyond information (Leitch, 2017). We also need to better
understand and gain knowledge of what to do for clients. While healing is
the ultimate goal, it should not be the focus. We have found that such
language is a trigger for clients because it insinuates brokenness. If clients
invite a discussion on healing, that is fine. However, growth is more
achievable, and you can help clients obtain it in the small steps they take
each day.

In order to create growth, you must start by decreasing stress and anxiety,
forming a professional relationship, and learning more about areas for
growth. Determine what the individual needs rather than assuming. And
always ask permission to perform activities, particularly those that include
touch.

The onus is not solely on the client. Remember, as the practitioner, you play
a major role. The following worksheets can serve as a starting point to
support you in assessing a client’s needs and developing a plan to Create
growth. The first worksheet helps you to perform a client needs assessment,
while the next two worksheets allow you to create a plan that can best
support the client in expressing their needs in a way that supports autonomy
and safety.
 PROVIDER WORKSHEET
ACTION NEEDS ASSESSMENT

Age Range: All

Objective: To acknowledge trauma and identify areas of need and

resources to support treatment planning

Directions: The first step toward growth is not instant healing. It is

acknowledging where the person and family are in the given moment.
Are they able to acknowledge their trauma? Do they look through a
trauma lens, impeding their ability to acknowledge areas of strength
and resilience? Are there necessary supports and resources you can
assist in obtaining? Upon re-assessment, return to this worksheet to
determine growth.

Client Name: _______________________

Date: ______________________________

Date of Birth: _______________________

Re-assessment Date: _________________

Acknowledgment of Acknowledgment of the Interdisciplinary team Who
strength, resilience, support, trauma List all types and is needed to move toward
and available resources categories of trauma, as well balance?
as what support is needed
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 PROVIDER WORKSHEET
ACTION CREATING GROWTH:
WHAT I NEED PLAN

Age Range: Children

Objective: To develop a method to communicate needs that supports

the client’s progress toward growth

Directions: Following a screening or assessment, it is crucial to have

a plan to provide safety, set boundaries, and develop autonomy. Use
this checklist to identify sensorimotor activities, mindfulness
practices, or other methods that best support the child’s arousal and
that facilitate their participation in required tasks, treatment sessions,
and engagement with others. Work with caregivers, and the child as
appropriate, to develop these activities. Highlight a way to
communicate needs through specified statements or nonverbal
options. (Gestures are especially useful for young children.) This
should be a starting point for continued strategizing to expand
methods of communication.
Desired Action Key Words, Phrases, or Strategies
End a task ☐ Say “Stop please”
☐ Use pictures with a stop sign
☐ Signal with gestures
Share needs ☐ Say “I need...” or “I want...”
☐ Say “Give me”
☐ Use pictures of desired items to select
☐ Signal with gestures
Express feelings ☐ Use “I feel” statements
☐ Use pictures of emotions
☐ Signal with gestures
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 PROVIDER WORKSHEET
ACTION CREATING GROWTH:
WHAT I NEED PLAN

Age Range: Adolescents and adults

Objective: To develop a method to communicate needs and promote

a feeling of safety that supports the client’s progress toward growth

Directions: Following a screening or assessment, it is crucial to have

a plan to provide safety, set boundaries, and develop autonomy. To do
so, you can establish a safety contract that highlights ways clients can
communicate their needs through specified statements or nonverbal
options. This is a contract that clients can sign with you as the
provider, as well as with their educator, caregiver, or any other key
individuals. The following is a sample template you can adjust based
on policies, regulation, and the specific needs of the client.

Provider/Educator: I agree to try my best to listen to your

needs. When you say _________________ (e.g., “I need a break;
a walk; to stop”), we will take a moment to stop. We will work
together to help you grow. To help you relax and feel safe, I will
_________________ (e.g., list preferred and available activities,
such as “assist you in meditation” or “perform a yoga or
movement break”).

Client: I agree to try my best to share what I need. When I say

(or do) these things, it means I am upset, overwhelmed, or need
to stop: ________________ (e.g., “I need a break; a walk” or I
gesture to stop). To help me relax and feel safe, I need
 _____________ (e.g., list preferred and available activities, such
as “to meditate” or “to take a yoga or movement break”). I will
let you know when I am in need.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

GROUNDING ACTIVITIES AND PRACTITIONER CHECK-

INS

Grounding activities are a great place to start with any care for trauma
because they facilitate present-moment awareness. Clients who have a
history of trauma frequently experience dissociative symptoms, such as
flashbacks and intrusive memories, that cause them to reexperience the
trauma as if it were still occurring in real time. By using grounding
techniques, clients can reorient themselves to the here and now, which can
decrease dissociative symptoms as they become more aware of the moment
and acknowledge being safe.

One simple grounding technique involves asking clients to make self-

awareness affirmations, in which they simply state information about
themselves based on orientation to time and space (e.g., “I am [name]” and
“I am at [location]”). You can use similar techniques with children by
asking them self-awareness questions, such as “What is your name?” and
“How old are you?” and “What is this [point to familiar object from the
environment]?” In the following sections, we will explore several other
types of grounding techniques, including mindfulness activities, sensory
awareness exercises, and breathwork, and we will present activities and
tools you can use with clients in each of these categories.

Grounding Activities: Mindfulness

Mindfulness is the quality of fully immersing yourself in and being aware
of the present moment. It involves purposefully focusing all of your
attention to whatever it is you are doing at the moment. Clients do not need
to schedule extra time to practice mindfulness but can incorporate it into
their everyday activities. For example, they can take a mindful walk with
bare feet and connect to the sensations they feel on the ground, or they can
practice mindful eating at their next meal by eating slowly and describing
the characteristics of the food, such as the color, texture, smell, and taste.
Clients can also set aside time for formal mindfulness practices by engaging
in meditation. These practices can be guided or independent. You can also
use the following activities with clients to promote mindful awareness.
 IN-SESSION ACTIVITY
MINDFUL FINGER COUNTDOWN

Age Range: Children

Objective: To reorient to the present moment with touch and mindful

counting

Directions: Have the child hold up their hand with their fingers
separated. As you demonstrate the movements, ask them to imitate
you. Take your thumb and second finger, and touch the pads together.
With each breath, you will have the child touch the pads of the
remaining fingers as described in the script below.

Provider Script: State out loud “four.” Take a deep, purposeful

breath and have the child do the same. Move to your next finger,
touching the pads of your thumb and third finger. State out loud
“three.” Again, take a deep, purposeful breath and have the child do
the same. Continue with the remaining fingers, breathing in between
and having the child imitate. Count down to one, repeating the
process if needed.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
MINDFUL FINGER COUNTDOWN

Age Range: Adolescents and adults

Objective: To reorient to the present moment with touch and mindful

counting

Directions: Use the following script while demonstrating the activity

to the client.

Provider Script: Hold up your hand in front of your face. What do

you see? Notice the creases on your fingers. Increase your focus, and
look at the front and back of your hand. Now, with your fingers
separated, identify five things in your environment. What do you see?
After you identify five things, flex your thumb into your palm. You
should now have four fingers raised. Next, name four things you feel,
such as the temperature in the room, your clothing, the floor, or the
chair you’re sitting in. Flex your pointer finger into your palm. Now
you have three fingers extended. Next, name three things you hear in
your environment. After, flex your middle finger into your palm,
leaving two fingers extended. Name two things you smell in your
environment. After, flex your ring finger into your palm, leaving one
finger extended. Finally, name one thing you would like to taste that
makes you feel happy.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
A-G-E BREATHING*

Age Range: All

Objective: To practice narrowing and expanding the focus of mindful

awareness

Directions: Use the following script with your client.

Provider Script: Envision the following figure is an hourglass. Just

like an hourglass expands at the top, narrows in the middle, and
expands again at the bottom, you will follow three steps to widen the
focus of your attention, narrow it, and then widen it again. Start by
bringing your attention to the present moment. Broaden the focus of
your attention to acknowledge anything you are experiencing in this
moment, including any thoughts, sensations, or feelings (awareness).
Next, narrow the focus of your attention by bringing your awareness
to your breathing. Focus on the inhale and exhale of each breath
(gathering). Finally, expand the focus of your attention once more and
become aware of your whole body, recognizing the sensations
throughout your body, face, and head (expanding).
____________
*Adapted from Mindfulness-Based Cognitive Therapy for Depression: A New Approach to
Preventing Relapse (Segal, Williams, & Teasdale, 2001)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT ACTIVITY
MINDFUL EATING

Age Range: All

Objective: To become present and practice mindfulness through

touch and taste

Directions: Choose a preferred snack. Before eating, use your senses

to explore the food. Take your time to scan the food and smell it,
using your hands to feel its texture and temperature. Place a small
portion of the snack in your mouth, and allow it to sit on your tongue
for a bit. Slowly begin to move it around your mouth and begin to
chew it slowly. Once you are finished, answer the questions below.

Note: For smaller children, an adult must be present to assist with the
activity and to ensure the food is safe and appropriate for the child to
consume. Place it in front of them to first explore with their hands.

1. What color is it?

2. What does it smell like?

3. What does it feel like in your hands?

4. What does it feel like to chew it?

5. How does it taste?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
GUIDED MEDITATION

Age Range: Adolescents and adults

Objective: To bring the attention to the body and become aware of

the present moment

Directions: Find a comfortable space for the client to sit, and have
them place their body into a comfortable position. Ask them to close
their eyes and envision the following scene as you read the script
aloud to them. (Give them permission to keep their eyes open if they
desire.)

Provider Script: You are walking through a wooded area. You can
feel the leaves crumble under your feet and the branches snap with
every step you take. It is a hot summer day, and you feel the heat from
the sun. A welcome cool breeze blows against your face. You look
around and see the birds flying above and hear them chirping to one
another. As you slowly make your way through the woods, the light
begins to get brighter as you move to where the trees are spaced
farther apart.

You come upon an open space. It is a beautiful field with soft grass.
You decide to take your shoes off to feel the blades beneath your feet.
In the air, you smell the flowers that provide this scenic landscape. As
you continue to walk, you hear people laughing and playing in the
distance. As you get closer, you see a body of water. It is a lake. You
decide to place your feet in the water. It is cool and clear. You can see
all the way to the bottom. You decide to sit in the water, allowing it to
cool your body. You place your arms behind you and look up to the
sky. You feel a sense of relaxation and renewal as you take a deep
breath through your nose. Then you slowly exhale through your
mouth. You do this a few times, taking three deep breaths. Now,
wiggle your toes and your fingers, and begin to move your feet,
hands, arms, and legs. Slowly open your eyes and return.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT ACTIVITY
OPPOSITE HAND USE

Age Range: All

Objective: To bring your focus to the present moment through

movement

Directions: Choose a familiar task, such as writing, brushing your

teeth, combing your hair, or pouring a simple glass of water, and
perform the selected task with your nonpreferred hand. If you are
right-handed, use your left hand. If you are left-handed, use your right
hand. When you are finished, answer the following questions.

1. How did you perform the activity compared to when you use your
preferred hand?

2. Was it more challenging to complete the task? In what ways?

3. Where was your focus during the task?

4. What emotions did you experience (e.g., frustration)?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Grounding Activities: Brain Rhythm and Body Awareness

The brain loves rhythm and repetition (Gibbs, 2017b). In fact, several
bodily functions rely on or produce rhythm, such as our heartbeat, circadian
rhythms, and breath rate, as well as the sucking reflex. Because rhythm and
repetition have an inherently soothing quality, those with trauma may
present with repetitive behaviors and actions, such as hand-flapping or body
rocking, in an attempt to self-regulate. When they perform such
sensorimotor actions, a synchronous rhythm occurs that decreases external
stimuli and provides a self-regulatory function. However, clients may not
always implement the most efficient or appropriate methods. For example,
some children may perform self-stimulatory behaviors that are harmful in
nature, such as head-banging, whereas adults may seek out risky behaviors
and addictions, such as heavy alcohol use and compulsive sexual behavior.

As practitioners, we can provide specific methods to enhance preferred

responses in the brain that utilize rhythmic activity. For example, it can be
helpful to use a metronome with clients during specific tasks, such as
writing, reading, or deep breathing. Metronomes are readily available via
smartphone apps or online videos, or you can purchase an actual device. In
addition, you can help clients reground themselves through rhythm by
offering activities that involve a level of repetition, such as mandala
drawing, rhythmic breathing, and marching, dancing, or drumming
exercises. The following section offers several of these activities that you
can introduce to clients.
 CLIENT ACTIVITY
MANDALA DRAWING AND COLORING

Age Range: All

Objective: To enhance focus, attention, and mindful awareness of the

senses involving vision and movement

Directions: Obtain a sheet of paper and pencil. Place a dot on the

paper to indicate your starting point and, using a compass, make
various size circles on the paper in a preferred pattern. This could
involve overlapping the circles and choosing different starting points
for each. You can also make circles by tracing a circular-shaped object
or attempt to draw freehand. Be creative. Use a ruler to add different
shapes around and through your circles, such as triangles or hexagons,
similar to the example here. Follow by coloring the mandala as
desired. For younger children, you can use a pre-printed design for
them to color or paint. You can also enlarge the design and use it as a
pattern to fill with various colors of modeling clay or dough.
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
RHYTHMIC BREATHING

Age Range: All

Objective: To enhance focus, attention, and body awareness through

breathing

Directions: You can choose to perform the following activity with a

metronome sound, with music (e.g., slow drumming sounds), or with
chimes. The client may be seated or lying on their back. Use the script
that follows.

Provider Script:
1. Become aware of your breath.
2. Slowly inhale through your nose.
3. Gently exhale through your mouth.
4. Allow your breath to flow naturally.
5. Begin to notice the rhythm of your breath.
6. Notice the rhythm of the sound around you.
7. Continue breathing, allowing your breath to join the rhythm
of the sound being played.
8. If desired, you can count to yourself to highlight the rhythm.
For example, inhale 2-3-4, exhale 2-3-4. (Note to provider:
This is especially useful with younger children.)
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
MARCHING TO THE DRUM

Age Range: All

Objective: To enhance focus, attention, and body awareness through

movement and sound

Directions: You can choose to play music over the speakers (e.g.,
drumming music), or play a small drum you can hold, such as a
bongo. If a drum is not available, you can use a large coffee can with
a plastic lid or other available items (e.g., the bottom of a small tin
paper waste bin). Allow the client to sit or stand, and read the script
that follows.

Provider Script:
1. Play a slow beat on the drum. (Note to provider: If selecting
music to play over speakers, press start.)
2. Begin to march in place to the rhythm.
3. Focus on the following:
• Feel the sensations on the bottoms of your feet as they hit
the floor.
• Sense the pressure pushing through the joints of your
ankles and legs.
• Listen to the sound of the music.
4. Once complete, take a gentle breath through your nose, and
blow the air out of your mouth.
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
BODY MAPPING POETRY

Age Range: Adolescents and adults

Objective: To release internal stressors and express how trauma

manifests internally

Directions: In this activity, the client will create a poem by

developing a personal awareness of their body’s function and needs.
This activity is intended to be personal and allow for self-reflection,
so although you can offer support and guidance, you should follow
the lead of your client. If the client desires, they may invite you to
view their poem at the end of the exercise, but it is their choice
whether or not they want to share. To start, provide them with a sheet
of paper and a writing utensil. You can offer to transcribe for them if
they desire.

Provider Script:

Step 1: Focus on your body. Do you notice any pain, discomfort, or

tightness? To simplify the activity, you can also select one region of
your body toward which to draw your attention. Here are some
suggested regions you might want to focus on:

• Feet and ankles

• Legs and knees
• Pelvis and middle section (belly region)
• Back and chest (heart)
• Arms, wrists, and hands
 • Shoulders and neck
• Face, top of the head, and back of the head

Once you have selected a part of your body that you’d like to focus
on, complete the following statement to describe what you feel in that
part of your body:

In my _______________________, I feel ______________________.

Please write your responses on the piece of paper provided. If you are
comfortable with continuing, select another region of your body and
repeat this step until you are ready to move on.

Step 2: Next, think about what images come to mind as you think
about these feelings in your body. List as many pictures that come to
mind. This could be a random image or a word that dashes into your
mind. Please write your responses on the piece of paper provided.

Step 3: Now ask yourself what it is that you desire to feel in your
body. How will you know that you are experiencing this feeling?
Where will you feel it in your body? For example, perhaps you desire
to feel at peace, and you will know that you are feeling peace when
your back is relaxed, your feet are no longer tense, and your heart
beats in a controlled rhythmic pattern. Think about these desired
feelings, and list as many pictures that come to mind. This could be a
random image or a word that dashes into your mind. Please write your
responses on the piece of paper provided.

Step 4: Finally, create a poem that reflects the awareness you have
gained from your body. To do so, review the words you wrote down.
Use them to begin writing your poem in the space provided here. Use
your creativity to move beyond this suggested outline, and do not
place pressure on yourself to write a perfect poem. It does not have to
rhyme, and you do not have to use everything you wrote during the
first three steps. The purpose is to provide an outlet for what your
body is experiencing and to conceptualize it into words. At the end of
 the poem, develop a positive affirmation by filling in the blank to the
statement “I am _______________.”

(Note to provider: You can provide the following template for the
client to write down their poem.)

I am ________________________________________

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Grounding Activities: Breathwork

When the sympathetic nervous system is activated, we experience changes
in our body that prepare our body to respond to the threat at hand. Our
pupils dilate, our muscles tense, our heart races, and our breathing quickens.
Individuals with a trauma history often remain in this heightened nervous
system state even after the threat has long passed, and when they feel
triggered, they may take quick and short breaths. This quickened breathing
only serves to further exacerbate their autonomic reactions, and they may
find themselves experiencing panic attacks or exhibiting defensive reflexes
as a result. By engaging in deep breathing activities, clients can activate
their parasympathetic nervous system to counteract this activation and
return their body to a state of homeostasis.

Breathing is an unconscious process that is directly controlled by an area in

the brainstem called the medullary respiratory center, which is responsible
for arousal and unconscious bodily functions (Figure 8). External factors,
such as stress and exercise, modify the medullary respiratory center’s
output. However, we can also exhibit conscious control of our breathing by
recruiting higher-order brain structures. The breathing exercises that we
offer in this section will allow your client to gain practice in finding more
regulated breathing that facilitates a calm and alert nervous system.
 Figure 8. Medullary Respiratory Center

When introducing breathwork to clients, there are a few important aspects

to keep in mind. First and foremost, be aware that individuals with a trauma
history may be triggered by the breathing exercises presented here and may
experience increased anxiety as a result. Present breathwork slowly by
checking in to assess the client’s experience and see how they are reacting.
This may not be a place to start for everyone. In addition, clients with
trauma often hold tension in their muscles that may make it difficult to
engage in deep breathing. Therefore, consider practicing gentle stretching
and mindfulness activities prior to beginning breathwork, as this may help
better prepare clients.

Choose a comfortable position and location to perform the breathwork. The

supine position is usually optimal, as it allows for movement of the
diaphragm. However, some clients may find sitting or lying prone on their
stomach more comfortable than supine on their back. Allow the client to
choose what works best for them to develop a sense of trust and autonomy.
As clients begin the exercises, they should focus on diaphragmatic
breathing by pushing out their abdominal area on the inhale and flattening it
during the exhale. They should also breathe in through the nose and out
through the mouth, as this assists in filtering air and controlling carbon
dioxide intake. If necessary, you can use counting cues or an external aid to
help clients focus on their breaths. Breathwork should be rhythmic when
possible.
 IN-SESSION ACTIVITY
DIAPHRAGMATIC BREATHING

Age Range: All

Objective: To decrease sympathetic nervous system activation,

decrease stress hormones, and allow for calm and focused attention

Directions: Invite clients to lie on their back, or invite them to choose

a position of comfort. Explain that you will be practicing
diaphragmatic breathing, and instruct them to place one hand on their
belly area and another on their heart. Ask them to take a deep breath
through their nose while feeling their belly rise and fill with air. On
the exhale, they should allow the air to gently leave their mouth,
allowing the belly area to flatten. To help clients follow this rhythmic
breathing pattern, you can use reminder cues, such as “smell the roses,
blow out the candles.” When introducing this activity to children, you
can attempt these same instructions, depending on their
developmental level. Otherwise, use a visual aid, such as a toy or
stuffed animal, to assist in the exercise. For example, have the child
lie on their back, place the item on their belly, and allow the item to
rise with the in-breath and gently fall with the out-breath.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
ALTERNATE DIAPHRAGMATIC
BREATHING

Age Range: All

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Directions: Have clients sit on a therapy or physio ball, with their feet
placed firmly on the ground. Ask them to gently roll their hips
forward so their back is resting on the ball. Then instruct clients to
stretch their arms above their head while taking a deep breath in
through the nose. As they return to a seated position, ask them to
exhale slowly out of their mouth. When doing this activity with young
children, safely position the child on the ball either by having them
squat in front of it or by placing them on top of it supine. Gently roll
them back and forth, and encourage them to do sit-ups to produce
exhalation.

Note: Those with back or spinal conditions should avoid this activity.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
HILLS AND VALLEYS

Age Range: All

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Directions: Use the following script while demonstrating the activity

to the client.

Provider Script: Place your finger on the star to begin tracing the
path. At the star, take a deep inhale through your nose, and hold it for
three to five seconds. Follow along the path by tracing your finger up
the hill, while exhaling out of your mouth. Once you reach the bottom
of the hill, inhale again as you trace your finger forward through the
valley. Continue following the path until you reach the next hill, and
exhale as you climb. (Note to provider: Repeat as needed.)
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
BENDS AND TURNS

Age Range: All

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Directions: Use the following script while demonstrating the activity

to the client.

Provider Script: Place your finger on the star to begin tracing the
path. At the star, take a deep inhale through the nose, and hold it for
three to five seconds. As you exhale, follow along the path, blowing
slowly out of your mouth. At the stop sign, take a deep inhale in your
nose again and relax. (Note to provider: Repeat as needed. You can
print these images to use as needed in various environments,
including while on the go!)
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
LABYRINTH BREATHING

Age Range: All

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Directions: Use the following script while demonstrating the activity

to the client.

Provider Script: In this activity, you will use your finger to trace the
path of a labyrinth while coordinating with your breath. Place your
finger on the starting star to begin. At the starting star, take a deep
inhale through your nose while tracing your finger toward the stop
sign. Once you reach the stop sign, exhale slowly out of your mouth
until you reach the next star on the path. At the star, take another deep
inhale until you reach the following stop sign. Continue this pattern of
inhaling at the stars and exhaling at the stop signs until you reach the
last stop sign on the path. (Note to provider: Repeat as needed. Two
labyrinth templates are provided for you on the next pages. You can
print these cards to use as needed in various environments, including
while on the go!)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 LABYRINTH BREATHING TEMPLATE

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 LABYRINTH BREATHING TEMPLATE

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
LETTER BREATHING

Age Range: All

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Directions: Use the following script while demonstrating the activity

to the client.

Provider Script: Use your finger to trace the letters of the alphabet,
following the sequence provided by the numbered arrows and in the
direction of the arrows. You may select the letters of your name,
specific words (such as relax), or the entire alphabet. Each letter has
numbers on it. Each number is an indication to start, stop, and relax
your breath.

As you go through the letters, that is the pattern you will use: start,
stop, and relax. For example, the letter A has three numbers followed
by arrows. Starting at number one, inhale through your nose while
tracing your finger down the first line of the letter. Once you reach the
end of the line, lift your finger and place it on top of the letter, next to
the number two. At the number two, exhale out of your mouth while
tracing down the line. Once you reach the end of the line, lift your
finger to place it on the number three and relax.

Continue on to the next letter with a deep inhale, following the

breathing pattern outlined here. (Note to provider: You can use the
following template or cut out individual letters to use as desired.)
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 LETTER BREATHING TEMPLATE

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
TRUMPET BREATHING

Age Range: All

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Directions: Use the following script while demonstrating the activity

to the client.

Provider Script: Inhale through your nose, and then place the tip of
your thumb in your mouth, similar to the image provided here. After
inhaling, fill your cheeks with air, not allowing any of your breath to
escape. Count between three to five seconds, exhale through the
mouth, and repeat. After you complete this activity a few times,
discuss how it felt before, during, and after the activity. Remind
yourself to use this trumpet technique if you feel upset or have a lot of
energy to let out. A great way to start your day is by practicing this in
the morning.
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
TUNNEL RACE

Age Range: Children

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Items Needed:
• Cotton balls
• 2–5 cardboard paper towel or toilet paper rolls
• Tape
• Straws
• Scissors

Directions: You can choose to complete the following activity with

the client or in preparation for your session. Use cardboard rolls to
create a tunnel by adhering them together with tape into a desired
shape. If you want, you can use scissors to cut angles for corners. If
you’re having the client work with another person or race against a
peer, make two structures. When you’re done creating your tunnel,
place it on a flat surface.

Provider Script: Use the straw to blow the cotton ball through the
tunnel until it gets to the end. Whoever gets to the end first wins! Or
try to beat your personal best time! (Note to provider: If needed, you
can tape together multiple straws to allow air to reach deep within the
tunnel.)
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
BOX RACE

Age Range: Children

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Items Needed:
• Cotton balls
• Small cardboard box (e.g., shoebox)
• 5–10 straws
• Scissors
• Glue or tape

Directions: You can choose to complete the following activity with

the client or in preparation for your session. Take the straws and cut
them into various sizes. Use glue or tape to adhere them to the inside
of the box into whatever pattern you desire.

Provider Script: Choose a starting point where you can place a

cotton ball, and use a straw to blow the cotton ball along the path to
the other side of the box. See how long it takes to get to the end. You
can take this home to practice after our session. If you want, we can
make two boxes so you can race someone!

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
WALL RUN

Age Range: Children

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Items Needed:
• Cotton balls
• 2–5 cardboard paper towel or toilet paper rolls
• Straws
• Painter’s tape
• Scissors

Directions: You can choose to perform the following activity with the
client or in preparation for your session. Take the cardboard rolls and
cut them in half lengthwise. Then use painter’s tape to adhere the rolls
to the wall, placing them in staggering tiers.

Provider Script: Take a cotton ball and place it on the top tier, and
then use a straw to blow it from the top level until it reaches the end.
Try to beat your personal best time by prolonging your exhale! Let me
show you how!

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT ACTIVITY
FIRE-BREATHING DRAGON

Age Range: Children

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Items Needed:
• Plastic or paper cup, construction paper, or cardboard toilet paper
roll
• Tissue paper or party streamers
• Glue or tape
• Scissors
• Craft pom-poms (optional)
• Googly eyes (optional)

Directions: (Adult to assist as needed) To start, you will need a tube

to make the body of the dragon. This can be a plastic or paper cup
with the bottom cut off, construction paper rolled together with tape
or glue, or a cardboard toilet paper roll. Select whatever color paper
you desire. You can use paint for additional fun. Next, cut tissue paper
into strips, or select a few pieces of party streamers, and adhere them
inside one end of the tube. Decorate the top of the tube with eyes by
adhering pom-poms with optional googly eyes. Place your mouth on
the end of tube without tissue paper or streamers, take a long deep
breath, and blow!
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT ACTIVITY
HOMEMADE KAZOO*

Age Range: Children

Objective: To decrease the sympathetic nervous system response,

increase focus and attention, and enhance parasympathetic nervous
system activity

Items Needed:
• Pen or pencil
• Cardboard paper towel or toilet paper roll
• Wax paper
• Rubber band
• Scissors

Directions: (Adult to assist as needed) Use a pen or pencil to poke

holes in a straight line along the top end of the cardboard tube. Cut
out a small square of wax paper just big enough to cover one end of
the tube, and use the rubber band to secure the wax paper in place. To
play the kazoo, put your mouth on the open end of the tube, and blow
into it while making a humming sound. Try to see if you can change
the sound of the notes that the kazoo makes by covering different
holes with your fingers.
 ____________
* Adapted from Self-Regulation and Mindfulness (Gibbs, 2017b)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Practitioner Check-Ins and Daily Schedules

Practitioner check-ins and daily schedules can also support the use of
grounding activities. Within your session, or throughout the day depending
on the setting in which you work, be intentional about checking in with
your client. For example, if you work in a school setting, establish a routine
wherein various team members consult with the child to bring attention to
the child’s personal needs. For example, team members might check in to
see if the child needs a break or if it’s okay to proceed, or they can check in
to see if the child needs to talk about feelings based on any nonverbal
signals they may have witnessed.
When scheduling check-ins, look for opportunities in the client’s current
schedule. In order for this to be a successful practice, you should
intentionally identify times within an established routine. Table 5 provides
some examples of daily schedules for different age ranges, which involve
various check-in points throughout the day. The ACTION Creating Growth
tools presented at the end of this chapter can also assist with checking in.
Time of Day Early Intervention Daycare/School Adult/Older Adult
Schedule Schedule Schedule
Morning Caregiver takes a quiet Caregiver checks in to Take a quiet moment,
moment before gauge the child’s needs. either sitting on the
engaging with the child. Child performs floor or in comfortable
Caregiver provides the stretching, massage, and position, to perform
infant with a massage. breathwork with the grounding activities.
Caregiver checks in caregiver. Quiet moment Perform self-massage.
with support teams, to start the school day, Check in with support
such as a friend, family such as covering eyes teams, such as a friend,
member, or early and being still. family member, or
intervention counselor.
provider/case manager
(at least once per week).
Lunch Take the opportunity to Have a mindful snack Take a moment to
engage during mealtime. (before or after lunch if perform mindful eating
Notice the child’s not within the same at the start of a meal.
reaction to the food room). Teacher or staff
presented. Acknowledge member to check in and
and describe their see what the child needs
reaction (e.g., “Was that to move toward goals.
yummy?”).
Afternoon Take a mindful walk Take a mindful walk, Take a mindful walk or
together and perform perform stretching or perform body scanning,
sensorimotor activities, yoga, and practice stretching, and
such as yoga, swinging, breathwork activities breathwork.
and tactile play (e.g., before returning to work
sandbox activities). or scheduled activities.
Evening Check in and debrief Debrief from the day Debrief from the day
from the day with and check in with a with support teams,
support teams, such as a caregiver-initiated such as a friend, family
friend, family member, discussion. Perform member, or counselor.
or counselor. Perform breathwork, Share area of growth
aromatherapy for aromatherapy for toward personal goals.
calming and a caregiver- calming, a caregiver- Perform breathwork,
provided massage provided massage, and aromatherapy for
before bed. stretching before bed. calming, and stretching
before bed.

Table 5. Sample Check-In Schedules Across Age Groups

In addition, you can use the following worksheet to track the use of
grounding exercises throughout the day. It is particularly helpful for
teachers or parents to use with children and adolescents so they can record
their reactions to the activities and share them with their provider. Be sure
to review the directions to ensure the caregiver has a solid understanding of
the intent of the worksheet.
 CLIENT WORKSHEET
ACTION DAILY GROUNDING PRACTICES

Age Range: Children and adolescents

Objective: To organize the use of grounding exercises throughout the

day and document reactions to the exercises

Directions: Use the following chart to record the child’s use of

grounding practices throughout the day. You can choose to replace the
exercise listed with other grounding practices. It is important to record
the child’s reaction to the exercise to ensure the selected activity does
not trigger distressing symptoms, such as anxiety. The observation
notes can also highlight continued areas of need (e.g., a need to
increase the frequency of daily check-ins).
AM PM Observation Notes
Take the Following
(Identify (Identify
Breaks Each Day
Time/Period) Time/Period)
Breathwork
Take breaks every 3–5
minutes to blow out
the energy (can use
feathers, tissues,
pinwheels, etc.).
Brain Freeze
Use a bell, chime, or
gentle drumbeat to
indicate that it is time
to freeze;
Turn down lights and
have the children stop
their activity and get
into a comfortable
position with their
eyes closed for 1–3
minutes.
 Check-Ins
Perform check-ins
throughout the day or
session by performing
grounding activities
for 3–5 minutes.
Stretch and Exercise
Take 3–5 minutes to
stretch the upper and
lower body muscles.
Perform progressive
relaxation or yoga
poses (or other
physical activities).
Exercises of Choice:

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

THE SENSORY CONNECTION

Now let us delve deeper into the connection between our emotions and the
physical reactions in our body. According to the James-Lange theory of
emotions, our emotions arise in response to physiological changes we
experience in our body (Borg et al., 2013). For example, if you are walking
alone at night and hear footsteps quickly approaching behind you, your
heart may start to race, and you may begin to tremble. The James-Lange
theory maintains that it is the physical sensation of your heart pounding and
your body trembling that makes you realize you are afraid. The manner in
which we interpret our physiological arousal determines our emotional
experience. That is, emotions occur in response to internal body sensations.

Sensory stimuli can occur in various forms, such as visual (sight), olfactory
(smell), auditory (sound), gustatory (taste), tactile (touch), proprioceptive
(body awareness in space), vestibular (sense of balance and coordinated eye
movement), interoceptive (internal sensations), nociceptive (perception of
pain), thermal reception (detection of temperature), or pruritic (itch). When
experiencing any emotion, such as fear, the unconscious brain processes the
sensations through the various sensory systems. Therefore, to best
understand the emotional responses of someone dealing with acute or
chronic stress, or exposure to significant trauma, you must first understand
the physical presentation of trauma.

When individuals have experienced acute stress or trauma, the memories

associated with the traumatic or stressful event are often encoded as sensory
memories, which reflect the physical sensations that the individual
experienced at the time of the traumatic event. It is for this reason that
certain textures, sounds, or other sensory stimuli can elicit an intense
emotional memory of the trauma. For example, a woman who was sexually
assaulted by a man wearing a strong cologne may now have an unconscious
aversion to the smell of men’s cologne. The smell may immediately elicit a
sensory memory of the trauma and mentally transport her back to the time
of the assault.

These sensory memories are often experienced as intense fragments rather

than fully developed memories. In these situations, the amygdala responds
unconsciously via our senses. That is because the sensory areas of our brain
are connected to our limbic system, which is the region of the brain
involved in the experience of fear. In this respect, the sensory brain
provides a gateway from the unconscious brain to the conscious neocortex.
Therefore, it is not uncommon for individuals who have been exposed to
trauma to experience sensory dysfunction, including hypersensitivity,
atypical processing, increased pain, dermatological irritation,
hypoventilation, frequent yawning, dry mouth, dry eyes, and increased
perspiration (Gutpa, Jarosz, & Gupta, 2017; Mueller-Pfeiffer et. al, 2013;
Wallwork et al. 2017; Yochman & Pat-Horenczyk, 2019).

In extreme cases, the sensory dysfunction that accompanies trauma can lead
to the development of a comorbid sensory processing disorder (SPD).
Specific subtypes of SPD include sensory modulation disorder, sensory
discrimination disorder, and sensory-based motor disorder (Miller,
Anzalone, Lane, Cermak, & Osten, 2007). Although SPD is not recognized
in the latest edition of the DSM, practitioners continue to recognize the
impact of sensory processing dysfunction, as individuals with SPD present
with dysfunction in a variety of areas, including sensory modulation,
discrimination, and sensorimotor activity. In particular, they may:

• Display challenges in responding to incoming sensory stimuli and

adapting to the demands of the sensory stimulation presented
• Exhibit inappropriate emotional responses, inappropriate social
behaviors, and an inability to functionally attend to a task
• Present with challenges in sensory modulation, which may lead to
the appearance of defensiveness or under-arousal or to the seeking
of sensory stimulation
• Overreact to sensory input secondary to taking in sensory
information too quickly or for an extended time frame
• Exhibit hyperactive or inattentive symptoms
• Have difficulty with sensory discrimination (i.e., interpreting the
“where” and “what” in regard to sensory stimuli)
• Avoid certain activities and prefer routine and predictable activities
• Need motivation and encouragement to attend to activities,
especially gross motor play
• Crave sensory input
• Exhibit uncoordinated motor patterns, poor body mechanics, and
“clumsy” motor skills (Gibbs, 2017b)

For individuals with PTSD, this sensory dysfunction appears to have a

unique pathology that is absent from other disorders involving
hypersensitivity to threat, such as generalized anxiety disorder (Clancy,
Ding, Bernat, Schmidt, & Li, 2017). These findings support a need to
include sensory-based interventions to assist in sensory processing and
integration for those with PTSD. In addition, being able to recognize the
comorbidity between PTSD and SPD is crucial given that misinterpretation
of symptomology can result in misdiagnosis. For example, someone
displaying hyperarousal or craving behaviors may receive an inaccurate
diagnosis of ADHD, and this misdiagnosis can then lead to unsuccessful
treatment approaches.

To ensure accurate diagnosis, you should prioritize the use of standardized

assessment tools in any evaluation process. The following tools can assist
you in initiating a screening of sensory dysfunction in your client while
using an ACTION-from-Trauma approach. These tools can provide
guidance for proceeding with a more formal assessment process. Of note,
these tools should not be used in isolation of the evaluation process. They
should serve as a guide to make connections between a client’s sensory
systems and symptoms associated with trauma, and they should be used in
conjunction with other standardized tools.
 PROVIDER WORKSHEET
ACTION SENSORY BODY SCAN

Client Name: _________________________________

Date of Birth: ________________________________

Date: ________________________________________

Check all that apply (as reported or observed)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 ADMINISTRATION INSTRUCTIONS
ACTION SELF-REGULATION
SELF-ASSESSMENT

Age Range: Adolescents and adults

Objective: To help identify the client’s typical threshold tolerance and

arousal levels, as well as stimuli supporting or impeding their function

Items Needed:
• A pencil and paper (optional)
• List of provided questions

Directions: Ask the client to fill out the Self-Regulation Self-

Assessment, and use their answers to select appropriate target
activities. Follow up with the client by discussing how certain
environments and sensory stimuli can help us get through our day or
make it challenging. Explore how the client can use that knowledge.
Lastly, use the information to select daily activities to support their
preferences.

Scoring: Only questions 1 through 3 receive a score. Give 5 points

for each item the client endorses, with the exception of the last item
(“None of the above apply”), which receives a score of 1. Please note
that this is not a standardized tool. It is intended to provide you with
some insight into the client’s ability to self-regulate. It will also assist
in how you interact with them and set goals. Use the following
guidelines to interpret your client’s scores:
 • 16–85 (High): The client may have significant challenges
with self-regulation. Review the remaining questions to gain
better insight and discuss with the client. Goals should
emphasize areas of concern as defined by the client, as well
as areas related to sensory processing and emotion
regulation.
• 4–15 (Moderate): The client may have moderate areas to
address regarding self-regulation. Review the remaining
questions to gain better insight and discuss with the client.
Goals should address areas of concern as defined by the
client, as well as areas related to sensory processing and
emotion regulation. The clinician can consider incorporation
of cognitive-based goals.
• 3 (Low): While the client may not express any areas of
concern, be sure to review the remaining questions to gain
better insight and discuss with the client. Goal development
should address areas of concern as defined by the client.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT WORKSHEET
ACTION SELF-REGULATION
SELF-ASSESSMENT*

This activity can assist you in determining where your energy is

focused, what causes you stress, and how you adapt your arousal and
react to such experiences. To follow, we will make goals to address
any areas of concern. Complete each of the following statements, and
select the answer(s) that applies to your personal experiences.
1. I would best describe myself as: (circle all that apply)
a. Enjoying a lot of activity (e.g., movement, running, jumping)
b. Avoiding physical activity
c. A thrill-seeker (e.g., enjoy climbing)
d. Disliking loud or irritating sounds (sometimes this may be
other people talking)
e. Disliking certain lighting, such as the lights at school
f. Preferring to wear only one type of clothing (e.g.,
sweatpants)
g. None of the above apply
2. I would describe my daily eating as: (circle all that apply)
a. Sometimes I have difficulty knowing when I am hungry until
the last minute.
b. I am always hungry and/or thirsty.
c. I only like certain foods and am somewhat picky.
d. None of the above apply
3. In social environments, like work or school, I: (circle all that
apply)
a. Often have to use the bathroom and have to rush to get there
in time
b. Do not like using the bathroom (Explain:
________________________)
c. Often feel my heart racing
d. Often feel myself getting anxious and will breathe quickly or
heavily
e. Prefer to be alone
f. Do not like a lot of movement and prefer to stay in one spot
g. Have challenges working with others or in a group
h. Often get into debates or arguments with others
i. None of the above apply
4. I am a daydreamer (e.g., drifting off in class).

______ Yes _______No

5. What bothers me the most while around others is:

6. What bothers me the most while in public is:

7. What makes me feel better when I am upset, sad, or irritated is:

____________
*Adapted from Self-Regulation and Mindfulness (Gibbs, 2017b)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
INFORMAL SENSORY STRESS
INVENTORY:
HOW FULL ARE YOUR CUPS?*

Age Range: Adolescents and adults

Objective: To help identify the client’s sensory preferences and

stimuli supporting or impeding their function

Directions: Obtain the necessary items listed here, and then use the
provider script and provider instructions that follow to complete the
activity.

Items Needed:
• 7–10 disposable cups
• Marker
• Water
• Food coloring (optional)
• 1 gallon-size pitcher (or alternative container)

Provider Script: Sometimes we must address the feelings and

emotions hiding in our emotional brain to make sense of our
reactions. Assume that this pitcher of water symbolizes you. We often
have to spread ourselves to assist others, tolerate social environments,
and simply navigate our day. Symbolically, we start with a full pitcher
that depletes throughout the day. Yet we cannot allow ourselves to be
completely depleted. There still needs to be something left for us.
This activity will help you determine where your energy is focused
and how much energy you use on a daily basis. Following the activity,
we will make goals to address the areas that cause you stress and
hyperarousal.

Provider Instructions for the Client: To start the activity, be sure

you have a tabletop or flat surface available. Use a marker to draw
three lines on each cup and write the words okay, a lot, or too much
under each line.

Next, ask the client to use the words okay, a lot, or too much to fill in
the blank for each statement. You can also select your own questions
and modify them as needed. Once the client answers each item, fill up
a cup to the corresponding line for each response. Some cups may
remain empty if the client does not identify that as an area of concern.

Thinking about your workplace (or school or home):

1. Describe the noise level: __________________

2. Describe the lighting: __________________
3. Describe the seating or chairs: __________________
4. Describe the smells: __________________
5. Describe your interaction time with others:
__________________
6. What do you like about the setting? __________________
7. What do you dislike about the setting? __________________

Discuss the results to identify ACTION goals that can address each
area of concern. Are there any empty cups? Be sure to discuss those
as well. Now that the client experienced the exercise, request for them
to label additional cups. What other questions (daily experiences) do
they think should have been included? Where would they fill those
cups to?
At the end of the session, how much water remains in the pitcher? Are
their cups too full, and is the pitcher too empty? How much energy do
they expend throughout the day on sensory and social stressors? Can
they make a connection with the underlying trauma and the triggers
they experience in the environment? What are the signs that they may
be triggered or reaching their threshold (tolerance level)? What
objects or events in their environment can better support them?

__________
*Adapted from Self-Regulation and Mindfulness (Gibbs, 2017b)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 PROVIDER WORKSHEET
ACTION SENSORY-SEEKING OR
SENSORY-AVOIDING SCREENING

Age Range: All

Objective: To help identify the client’s typical sensory preferences of

seeking or avoiding behaviors to identify activities to support their
needs

Directions: Use the checklist below to identify sensory preferences in

the areas of vestibular, proprioception, tactile, gustatory, auditory,
visual, olfactory, and thermoreception. You can interview the client or
caregiver, or complete the checklist based off of observation across
sessions.

Client Name: _____________________________

Date of Birth: ________________

Date: _________________
Notes (e.g., no Sensory-Seeking Sensory-Avoiding
specific preference) Preferences Preferences
Movement, Touch, Intense physical Slow, calm, or
and Pressure activity, climbing, predictable
rough activities, deep movements; grounded
pressure, various activities; gentle
textures pressure; specific
textures
Food Intense, spicy, or sour Mild or bland flavors,
flavors; crunchy soft textures
textures
Music Intense, upbeat, or Predictable, calm, or
 unpredictable sounds soothing sounds
Sight Visual stimulation, Dim light and calming
such as video games visual stimulation
or fast-paced movies
Smell Intense, strong smellsMild smells that do
or unusual smells not result in noxious
reactions
Temperature Cold, intense, and Warm, comforting
alerting temperatures temperatures

Based on these findings, what activities would you recommend to

support the client’s needs?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

CONTEXTUAL SENSORY INVESTIGATION

The human body receives multiple forms of sensory stimulation throughout

the day. We must integrate these sensations in order to make sense of and
use them. That is how we function and connect to the world. Therefore,
along with identifying potential cues that can trigger an emotional response,
assessment and intervention also require that you analyze the various
contexts in the environment that can trigger or support the client. A
contextual approach to examining the storage of traumatic memory must be
as dynamic as the human nervous system itself. The environment must not
solely be comfortable, but it must also support emotional safety. When
possible, the therapeutic environment should consist of items that provide a
home-like feel. It should be clean and devoid of clutter, and you should
limit the use of smells and aromas, or use them conservatively. To support
emotional safety, you also need to ensure the areas surrounding the
therapeutic environment, such as parking lots, are well-lit.

Use the following Contextual Sensory Investigation Tool to consider the

changes you can make (if feasible) to the various settings that the client
frequents—including the home, school, private practice office, foster care
and respite care settings, inpatient settings, and work environments—to
promote safety and contextual sensory integration.
 PROVIDER HANDOUT
ACTION CONTEXTUAL SENSORY
INVESTIGATION

Scan the environment, starting with the floor and then moving to the
perimeter, ceiling, and finally the space within the room. What does
the client prefer? What do they need to perform at their optimal level?
It may not be what you desire. They might require noise to focus and
attend, or they might need visual stimulation or movement to have a
prolonged conversation. What changes can you make in accordance
with these preferences? Consider the following from their perspective
by asking guiding questions or observing their reactions.
 Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Although the previous handout can help you organize certain settings in a
way that promotes contextual integration and emotional safety, this can be
more difficult to accomplish when clients are living in unsafe and
impoverished neighborhoods. It is certainly easy to assess the environment
within a structured setting, such as a school, but some individuals
unfortunately live in areas that are unsafe and lack resources to
appropriately support health and well-being. The social determinants of
living in such impoverished environments are clear, with trauma certainly
topping the list of potential risks. The lived experiences are ongoing and
persistent for individuals living in these environments. With that in mind,
what can professionals do to support the impact of trauma as it continues?
How does one find safety in the midst of a storm? The following are some
suggested strategies you can apply and recommend:

☐ Do not make assumptions. Determine the client’s or caregiver’s

perspective of their living environment. Trauma is a subjective
experience.
☐ Children in unsafe neighborhoods are an at-risk group who most
likely have indications of trauma. Therefore, make efforts to
educate everyone who plays a role in the child’s life, including
parents, teachers, administrators, medical providers, extended
family, and so on. Work with these individuals to address verbal
and nonverbal strategies they can use to avoid triggers and support
growth.
☐ Employ ongoing self-regulation strategies to prevent acute stress
from turning into long-term trauma.
☐ Keep in mind that re-traumatization may occur when individuals
receive disciplinary actions that remove them from secure settings
(e.g., school or work). In addition, the use of physical restraints or
other parental disciplinary actions (e.g., yelling, physical
 discipline, removal of activities supporting arousal) can result in
re-traumatization for children.
☐ Address the home and school environments to identify safe spaces.
For adults, it could be a room or large closet where they can feel
protected and calm. Take care that the space the client selects is
indeed safe and well-ventilated. For children, use large bins or
boxes to create sensory bins filled with rice, beans, or balls. You
can also offer a large beanbag chair that they can safely sit on, or
you can cover a table with a large sheet of fabric to make a tent
under which children can sit.

ACTION CREATING GROWTH TOOLS

There must be provisions to establish a safe and protective context and

environment. Practitioners must work with clients and caregivers to set
boundaries and expectations. Those with trauma should have a way to
communicate their needs, to be able to cease activities that trigger them and
cause them discomfort, and to feel in control to support resilience. The
following are tools for creating growth. They target the clients and the
caregivers of young children and older adults. Remember that clients,
including very young and older populations, require that you work with
their families or support systems. While clients are the focus, these tools
may also be implemented with those providing care for your client.
 PROVIDER WORKSHEET
ACTION GROWTH PLAN

Age Range: All

Objective: To develop an ACTION plan toward creating growth

Directions: Work with the client or caregiver to highlight areas of

strength, support systems, opportunities, and needs. Interview the
client using the questions from each of the sections below. Include
ACTION goals that you can implement on the ACTION Growth
Chart that follows.
What personal skills and abilities do you (or Who can assist (e.g., family, interdisciplinary
the person you are caring for) have? team members, educators)?

What external supports do you (or the person Actions to support growth in this area:
you are caring for) have?

Actions to grow this area:

What do you (or the person you are caring Who can assist (e.g., family, interdisciplinary
for) desire when it comes to self-care (e.g., team members, educators)?
sleep, diet, emotion regulation, socialization,
school, employment, spirituality)? Actions to support growth in this area:

Actions to grow this area:

ACTION step notes:

Date to be initiated: _____________________

Date to revisit: ___________________

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT WORKSHEET
ACTION GROWTH CHART

Age Range: Children

Objective: To highlight gains and progress toward growth

Directions: Based on the child’s Growth Plan, list their ACTION

goals on this sheet or on another document. Reflect on the progress
the child has made toward these goals in a given time frame, such as
during one class or therapy session, daily, or monthly. Write in the
action the child performed that moved them toward their goal in each
gardening box, moving from left to right. Adults can complete this
worksheet on behalf of the child, but the child should be involved as
much as possible. For younger children, you also need to consider
caregiver goals. Use this chart to check in whenever you see
opportunities for growth throughout the day. This activity is not meant
to focus on any negative events or failures. Highlight even small
gains!

ACTION goals for growth:

1. ____________________________________________________
____
2. ____________________________________________________
____
3. ____________________________________________________
____
4. ____________________________________________________
____
5. ____________________________________________________
____

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT WORKSHEET
ACTION GROWTH CHART

Age Range: Adolescents and adults

Objective: To highlight gains and progress toward personal growth

Directions: Based on your Growth Plan, list your ACTION goals on

this sheet or on another document. Reflect on the progress you have
made toward these goals in a given time frame, such as daily,
monthly, or bi-monthly. In each box, write in the action you
performed that moved you toward your goal (moving from the bottom
up), or simply place the ACTION goal number in the box. This
activity is not meant to focus on any negative events or failures.
Highlight even small gains!

ACTION goals for growth:

1. ____________________________________________________
____
2. ____________________________________________________
____
3. ____________________________________________________
____
4. ____________________________________________________
____
5. ____________________________________________________
____
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT WORKSHEET
ACTION “I NEED” DAILY TOOL

Age Range: Children

Objective: To develop a method to communicate needs to support the

child’s progress toward growth

Directions: When children are working toward goals, you can use this
tool to keep track of what tasks need to be done, what the child needs
to support their growth, and what reward they can receive once the
task is complete. In the “I need” box, place images of actual items that
are known to support the child (e.g., a self-regulation and mindfulness
break, food or water, sensory stimulation). In the “To do” box, place
images of daily tasks the child needs to complete, such as eating,
doing schoolwork, or sleeping. Lastly, in the “I want” box, place an
image of an activity or item the child will earn once they complete
each required task.
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT WORKSHEET
QUALITY OF LIFE ANALYSIS TOOL

Age Range: Adolescents and adults

Objective: To track daily or weekly areas to identify needs for

balance for improved quality of life

Items Needed: Colored pencils, crayons, or different-colored ink

pens

Directions: Developing weekly goals can assist you in improving

your quality of life and increasing satisfaction toward life goals. This
worksheet allows you to record your small gains as you work toward
long-term goals. To start, develop long-term goals—one month, six
months, or one year from now—in each of the areas listed in the
following wheel. Write down your goals on the list provided. Then
choose a color that symbolizes success and growth, and color in each
section of the wheel to indicate if you believe you’ve achieved
success or growth toward the goals you listed for each of those areas.
Consider coloring in 50 percent for goals that are in progress. At the
end of each day or week, try your best to take 10 minutes to reflect on
your participation in the areas identified within the wheel. You can
adjust those areas if desired.
Weekly Goals:

Work:
______________________________________________________

Leisure:
_____________________________________________________

Rest and sleep:

_______________________________________________

Physical, emotional, and mental health:

____________________________

Self-care:
____________________________________________________

Caring for others:

______________________________________________
Social participation:
____________________________________________

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

CASE SCENARIO*
Review the following case study. After, we will demonstrate how we
applied some of the ACTION approaches discussed in this chapter.

Name: Clare
Setting: Community-based
Age: 55

When Clare was born, her mother, Mary, had a challenging delivery.
They questioned if Clare had cerebral palsy when she failed to meet
her developmental milestones. Clare was 3 years old when she began
to walk. She also displayed repeated behaviors, such as rocking and
biting her lip and fingers. Her speech was loud, and she had challenges
with receptive language. Once she began school, she had challenges
both academically and socially. She presented with significant
defensive reactions and aggression due to verbal attacks from her
peers and continued discipline from her teachers. Some of the negative
peer interactions resulted from her hyperactivity, which made them
uncomfortable. However, she also faced racism, being one of the few
students of color at her school. Mary found herself having to go to the
school frequently throughout the week on Clare’s behalf.

Luckily, Clare was able to get through her schooling and obtained a
job after high school, though she had difficulty maintaining work and
was often unemployed. In addition, she had challenges maintaining
relationships—as her personality went from happy and cheerful to
defensive and argumentative in a narrow window of time—and she
had several romantic partners before finding her husband. While she
loved being around her family and friends, she had a history of getting
into physical altercations with her loved ones. She would also leave
when confronted about her behaviors. Nonetheless, Mary and her
other family members were very supportive of Clare.

Clare also reported having frequent back and joint pain, which
impeded her ability to function on the job. As a result, she often
visited the doctor for pain management intervention. Eventually, she
had surgery on both her shoulders and wrists and was told it was due
to repetitive stress on her joints. Despite everything, Clare became a
mother to a son named Sam. Like Clare, Sam had difficulty at school
and with his peers. The school frequently called Clare to attend
meetings in which Mary accompanied her as the grandmother. Both
Clare and Mary would sit for hours, appearing numb, listening to the
team proposing plans for Sam, often suggesting disciplinary action,
including removal from his current school. This even resulted in Sam
being sent to an inpatient psychiatric program for children. Sam would
later share stories about being placed in a quiet room and hating the
inpatient program. The cycle seemed to continue.

After speaking with Clare and Mary, I learned more about their family
history. Mary lived with a chronic illness and was frequently
hospitalized while Clare was growing up. As a child, Clare found it
challenging not knowing if her mother would survive and return home
or not. For Mary, dealing with the burden of her illness, experiencing
violent racism in her town, being a mother to Clare, and then caring
for her grandkids as another parental figure started to weigh on her.
She presented with “battle fatigue.” Their reactions were that of going
through the motions and just getting through each day.

The following pages contain a completed ACTION Growth Plan and

Growth Chart for Clare, who we focused on for this analysis. As you
review Clare’s plan, take into account that Clare is attending
occupational therapy and physical therapy services following one of
her shoulder surgeries. She has consistently attended sessions but does
display moments of frustration and aggression. Her symptoms of pain
continue in other joint areas.

__________
* Case study by Varleisha Gibbs, PhD, OTD, OTR/L
 CASE SCENARIO: CLARE
ACTION GROWTH PLAN

Age Range: All

Objective: To develop an ACTION plan toward creating growth

Directions: Work with the client or caregiver to highlight areas of

strength, support systems, opportunities, and needs. Include ACTION
goals that you can implement on the ACTION Growth Chart that
follows.
What personal skills and abilities do you (or Who can assist (e.g., family,
the person you are caring for) have? interdisciplinary team members, educators)?
Enjoys socialization, self-advocates (i.e., Son’s school social worker, Clare’s family and
voices her opinion when unhappy), respects friends
health care providers Actions to support growth in this area:
What external supports do you (or the person We must identify a case manager with
you are caring for) have? employment services to also assist with other
Strong family support, close community, available resources. With Clare’s permission,
social services/school-based team for Sam follow up with the referring medical provider
Actions to grow this area: to discuss plan of care and possible
Address communication skills to increase correlation of joint pain to stress, body
socialization with family, friends, and social mechanics, and fatigue.
services/school team. Develop a
Communications Needs Plan. Use language
from the Communication Plan at least once
daily.
What do you (or the person you are caring Who can assist (e.g., family,
for) desire when it comes to self-care (e.g., interdisciplinary team members, educators)?
sleep, diet, emotion regulation, socializing, Mary and other family members can assist
school, employment, spirituality)? and may benefit from some of the activities.
Clare desires decreased pain! She enjoys Physical therapy and counseling services are
attending services at her church. But recommended to address areas of concern as
sometimes she is too tired to attend due to not expressed by Clare.
sleeping secondary to her pain. Actions to support growth in this area:
Actions to grow this area: Complete sensory inventory and screening to
Use body mapping to investigate areas of determine sensory needs, and explore
tension. Utilize breathwork to decrease stress sensory-based activities in sessions to follow.
and anxiety. Address sleeping positioning to Provide Clare referrals based off of her
avoid muscle tension. insurance coverage. Check in with her via
telephone a few days after to see if she
requires support to initiate the appointments.

ACTION step notes: Neuroeducation is an important next step for

Clare. The occupational therapist (OT) will check in with Clare at
least one time a week via phone between sessions and will follow up
with case management. We will complete sensory screenings and
inventories, including a contextual sensory investigation.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CASE SCENARIO: CLARE
ACTION GROWTH CHART

Age Range: Adolescents and adults

Objective: To highlight gains and progress toward personal growth

Directions: Based on your Growth Plan, list ACTION goals on this

sheet or on a supplementary document. Reflect on the progress you
have made toward these goals in a given time frame, such as daily,
monthly, or bi-monthly. In each box, write in the action you
performed that moved you toward your goal (moving from the bottom
up), or simply place the ACTION goal number in the box. This
activity is not meant to focus on any negative occurrences or
perceived failures. Highlight even small gains!

ACTION goals for growth:

1. Use Communication Plan at least 1x daily (“I need” statements,
“I feel” statements, and self-expression when upset).
2. Utilize breathwork and body mapping 1-2xs daily.
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CHAPTER 3
TEACH NEUROEDUCATION

Cells make up our bodies. Our nervous system in particular consists of

billions of cells called neurons. The neurons form neural pathways that
connect the body to the brain and to other structures of the central nervous
system. The neurons that fire together wire together, meaning that neurons
that communicate frequently with one another develop stronger
interconnections (Hebb, 1949). This process reflects the basic premise of
neuroplasticity in that neurons can change and adapt themselves in response
to our experiences. This process, however, occurs in a very organized
manner that requires activation of a presynaptic neuron to then stimulate a
postsynaptic neuron. The firing is not necessarily simultaneous but more
sequential, and it results from the repeated stimulation of a presynaptic
neuron on a postsynaptic neuron (Hebb, 1949).

Accordingly, our experiences shape our neurological makeup, and this

process occurs despite how we define or perceive our experiences.
Certainly, it would be great for our brains and nervous systems if we could
grow and be shaped based only on the occurrences that support us and
allow us to be most productive. Unfortunately, experiences that interfere
with our quality of life can also shape who we are neurologically. When it
comes to stress and trauma, experiences involving acute stress can
transition into posttraumatic stress when the neurons associated with that
experience grow or exhibit metabolic changes, resulting in structural
alterations to the pathways between them.
In this chapter, we aim to review the neurophysiological changes resulting
from exposure to stress and trauma and present strategies for
neuroeducation through the following sections:

☐ Stress and Physical Health

☐ Anxiety versus Fear
☐ Memory
☐ Perceptual and Recognition Memory
☐ Fear Conditioning
☐ Bio Signs
☐ The Brain-Gut Connection to Trauma
☐ Trauma and Secondary Conditions
☐ Case Scenario

STRESS AND PHYSICAL HEALTH

If our emotions provide the bedrock for trauma, then we must examine
them first. How do our experiences help shape the pathways connected to
these emotions? And when there are alterations in such pathways, what
structural changes occur in our brain? Let us start by examining our
emotional brain center, known as the limbic system. The limbic system
controls basic functions, such as our emotional reactions and affective
experiences (like fear and pleasure), and is implicated in the formation of
memories. To this end, it is vital for our emotional processes. The structures
of the limbic system include the amygdala, hippocampus, hypothalamus,
thalamus, mammillary bodies, cingulate gyrus, olfactory system,
parahippocampal gyrus, orbital frontal cortex, nucleus accumbens, and
fornix. It should be noted that the specific structures constituting the limbic
system continue to be controversial, as experts are not in complete
agreement.
The structures that form the limbic system are often considered more
primitive parts of the brain that serve as a “watchdog” in ensuring our
protection and survival. When things do not go as expected, the limbic
system sends out an alert to our body that activates our autonomic nervous
system. This alert is automatic and instantly activates our fight-or-flight
response. For this reason, some people identify the limbic system as our
“survival” brain. In contrast, our more “rational” brain consists of structures
that make up the neocortex, which are newer in terms of our evolutionary
development. The neocortex is more involved in logic and control, and it
provides a foundation for our imagination and conscious thoughts. While
the rational brain is crucial to our daily functioning, it requires time to
process our experiences and is slow in comparison to the automatic inner
workings of the limbic system.

So how does the limbic system work to serve as our “watchdog”? It does so
by detecting threats and unexpected events. In the presence of such events,
a neurochemical reaction occurs that results in the release of stress
hormones into the body. The release of these stress hormones, in turn, leads
to elevations in blood sugar levels and the storage of fat in areas of the body
such as the abdomen. Epinephrine and norepinephrine trigger an adrenaline
rush characterized by a burst of energy. This quick, yet systematic, reaction
initiates when the amygdala acknowledges that there is a “threat” present.
The amygdala communicates with the hypothalamus, resulting in the
release of corticotropin-releasing hormone (CRH), which then initiates the
release of adrenocorticotropic hormone (ATCH) by the pituitary gland.
Ultimately, this process causes the adrenal glands, located at the top of the
kidneys, to produce cortisol. The hypothalamic-pituitary-adrenal (HPA)
axis assists in the eventual return to baseline. The specific chemicals and
hormones released during the fight-or-flight response are as follows:

☐ Catecholamines (epinephrine, norepinephrine): Released by the

adrenal glands, triggering the fight-or-flight reaction
☐ Corticosteroids (glucocorticoids, cortisol): Involved in the stress
response and are also involved in controlling our energy,
metabolism, inflammation, and immunity responses
 ☐ Oxytocin: Assists in a return to baseline by reducing cortisol
levels and blood pressure (enhancing feelings of pleasure), which
promotes the healing and recovery process but can inhibit the
consolidation of memories
☐ Opioids: Dampen the effects of stressful or traumatic events by
decreasing the pain response but can also compromise the
consolidation of memories

Given the physical effects of stress on the body, there are several long-term
implications of a prolonged or chronic stress response. First, given that
stress results in elevations in cortisol (which is the hormone involved in
maintaining and regulating metabolism), chronic stress and anxiety can
interfere with metabolic functioning. Additionally, because the fight-or-
flight process heightens one’s senses—for example, sharpening one’s
visual, auditory, and tactile sensory systems—extended exposure to
heightened levels of epinephrine may lead to hypersensitivity to sensory
stimuli. Furthermore, norepinephrine causes narrowing of the blood vessels,
in turn increasing blood pressure, which can affect physical health over
time. These physical effects are further complicated by the fact that stress
suppresses the immune system as a means of preserving energy, and it
increases the body’s inflammatory response (Pelt, 2011). For certain racial
groups whose history is riddled with traumatic events, such as Black
Americans, the physical effects of trauma are especially significant to
consider.

The following is a list of secondary conditions that may occur following

repeated and prolonged trauma that impacts a person’s physical and mental
health and well-being:

☐ Cardiac disease
☐ Hypertension
☐ Stroke
☐ Type 2 diabetes
☐ Ulcers
 ☐ Obesity
☐ Chronic fatigue syndrome
☐ Chronic pain
☐ Alcoholism and other forms of addiction
☐ Poor self-care
☐ Comorbid psychiatric conditions, such as depression and anxiety
disorders

ANXIETY VERSUS FEAR

Those suffering from traumatic experiences often have high levels of fear
and anxiety, and although these two emotional experiences are related, they
are distinct. Fear is an emotional response that occurs in reaction to tangible
events, objects, or experiences in our lives that pose some threat or danger.
In contrast, anxiety arises in anticipation of some future perceived threat
that is unknown or more diffuse in nature. This is not to say that anxiety is
bad or shameful. In fact, anxiety can serve us by highlighting the things that
are of importance to us. At the same time, it can also prevent us from
accomplishing our desires when it paralyzes us from taking action.

Despite the differences between fear and anxiety, they both involve similar
physiological changes associated with the stress response. Even the
imagined dangers associated with anxiety become tangible through
physiological changes in the body. After the perceived or real danger has
passed, most people can return to emotional baseline. However, when there
are challenges in recovery, this can lead to ASD and possibly even PTSD.
To further explore the neurochemical reactions of trauma, we must start
with the HPA axis.

During stress, the release of CRH triggers the pituitary gland to release
stress hormones, which consequently activates the adrenal gland to release
cortisol and then works in a feedback loop. In order to move out of acute
stress, individuals must return to a state of homeostasis, which is achieved
when cortisol exhibits a negative feedback effect on the pituitary gland,
inhibiting further release of stress hormones. Although this occurs in
normal conditions, it is more difficult for individuals with a history of
trauma and chronic stress. In fact, cortisol levels are often ironically lower
in those with PTSD (Yehuda et al., 2016), which may make them more
susceptible to the long-term effects of trauma. Given that cortisol is a
marker of stress, it may seem counterintuitive that PTSD would be
associated with lower baseline levels of cortisol. However, the lower levels
of this hormone may actually explain why these individuals struggle to find
recovery. They do not have high enough levels of cortisol to contain the
feedback loop triggered by the HPA axis, resulting in continued activation
of the stress response.

When individuals are in this constant stress loop, they are unable to
properly store, encode, and retrieve traumatic memories. It becomes
unprocessed emotional chaos. In fact, the temporal lobe—which houses the
amygdala and hippocampus, both of which are responsible for the
formation of emotional memories—decreases in volume in response to
trauma. When trauma and stress are prolonged, research reveals that these
structural changes even extend to include decreased total brain volume as
well (Hedges & Woon, 2010; Krugers, Lucassen, Karst, & Joëls, 2010;
Schoenfeld, McCausland, Morris, Padmanaban, & Cameron, 2017;
Shonkoff et al., 2012). Not surprisingly, these changes in neurological
makeup and structural alterations can interfere with learning and academic
performance.

In order to provide clients and caregivers, including educators, with

education regarding the development of trauma and the neurochemistry of
the stress response, you can review the following handout. This handout
contains key points and facts that you can develop into a script or use as an
informational factsheet to share. We also provide a subsequent handout for
children that presents this information in a more simplified manner.
 CLIENT HANDOUT (ADULTS)
LEARNING ABOUT TRAUMA

☐ There are many life challenges that can result in traumatic

experiences. Trauma is not your fault!
o For example, there is evidence that trauma can be passed
between generations. What your parents and
grandparents experienced could affect you now.
o Sometimes, society and cultural differences can lead to
trauma too. For example, witnessing racial attacks and
violent riots are traumatic experiences for some
individuals. Even within an organization or work
environment, we can have traumatic experiences, such
as workplace bullying.
☐ The more trauma someone is exposed to, the more likely they are
to have complex trauma.
☐ When you experience traumatic and stressful events, it can cause
physical dysfunction. These physical effects are real and not
imagined! Some examples of the physical effects of trauma
include:
o Difficultly sleeping
o Gut issues, such as diarrhea and constipation
o Heart conditions and high blood pressure
o Lung problems, such as respiratory infections
o Neurological problems, such as numbness or pain
o Issues with the kidneys and urinary system
 o Skin issues, such as rashes
o Strokes
o Type 2 diabetes and high blood sugar
o Ulcers
o Weight gain and obesity
o Chronic fatigue syndrome
o Chronic pain
o Alcoholism
o Poor self-care
☐ Trauma can affect your memory and your ability to regulate your
emotions. You may find it difficult to control your anger or calm
down after getting upset.
☐ Even though trauma is associated with many challenges, you
came before the trauma. That means you have areas of strength
that you can draw on to enhance beyond the trauma!

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT HANDOUT (CHILDREN)
LEARNING ABOUT YOUR BRAIN

There is a part of our brain that is really smart and playful, kind of
like a small dog.

Sometimes, things happen that make that part of our brain angry, mad,
sad, or afraid. It has trouble listening, playing, or learning. We do not
feel like ourselves. That little dog starts to get really loud and active.
 That part of your brain tries to get happy and will run around, bark, or
jump—whatever it takes to get happy! It loves feeling good!

Like having a small dog as a pet, you have control. Not only can you
train that part of your brain to feel good, but you can feel good too!
You have a leash and other training tools we will share.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

MEMORY

When the body senses a threat and goes into survival mode, the brain
structures involved in this process now switch modes and focus on
protecting the individual. For example, the hippocampus virtually changes
roles—from a storer of memory to a protector—as it seeks to determine
similarities in prior experiences. It analyzes the sensory stimuli to determine
if the present event aligns with stored emotions that once posed a threat. In
doing so, it identifies whether there is a need to respond in a similar fashion
to how it did with previous stressful or threatening experiences.

Similarly, when there is a perceived threat, the amygdala bypasses the

cortical circuits involved in higher-order functioning, allowing it to react
without awareness through a direct pathway triggered by stress, fear, or a
novel event. As a result, there is frontal lobe degradation and shutdown in
the presence of severe stress and fear, and cognitive flexibility is impaired.
Once the amygdala receives the signal of possible impending danger, it
communicates with the hippocampus, which typically works to encode
memory into experiences in context and sequence. When the hippocampus
cannot pull from past memories or recognize the present experience,
memories are not stored long term.

In addition, the flood of stress hormones released into the body further
prevent memories from being consolidated. In particular, excessive amounts
of cortisol interfere with the storage of long-term memory while enhancing
short-term emotional memories that involve more sensory details associated
with the event rather than specific details. It is for this reason that trauma is
often associated with fragmented sensory memories of the event as opposed
to explicit memories that are verbal in nature. The painful and fearful
aspects remain easily accessible as the brain attempts to make sense of the
trauma. As the body releases opioids and oxytocin in an attempt to comfort
and return the body to baseline, individuals are not afforded the opportunity
to make sense of the traumatic details. Instead, they continue to revisit the
event through flashbacks and nightmares. Meanwhile, crucial details remain
blocked and hidden as the brain works to protect the person from further
harm (Maren, 2014). Individuals may struggle to recall the details of the
event or even feel pain.

When the brain cannot properly file these memories, they become “stuck”
in the brain’s limbic system. In turn, these memories remain active and can
be easily triggered by external stimuli that we interpret through our senses.
When these memories become triggered, the prefrontal cortex—which
plays a major role in executive functioning and our ability to respond
appropriately to our environment—starts to shut down and is unable to
process what is happening fast enough. As the body is exposed to prolonged
levels of stress hormones, the hippocampus decreases in volume and the
amygdala increases in volume (Krugers et al., 2010) (Figure 9). The brain,
body, and sensory systems become overwhelmed in the presence of
prolonged stress.
 Figure 9. Changes in Amygdala and Hippocampal Volume as a Result of Increased and Chronic
Exposure to High Levels of Cortisol

PERCEPTUAL AND RECOGNITION MEMORY

Trauma memories are not your typical memories. It is for this reason that
we store trauma in a complicated sensorial way. Engrams, which are units
of cognition within the brain, provide us with a more quantifiable view of
memory storage. In particular, Ryan and colleagues (2015) postulate that
engram cells are located throughout the cortex as opposed to existing
simply within one area. More complex experiences require engrams in
various locations to store these multifaceted sensorial occurrences. While
there are specific areas of the brain correlated to very explicit forms of
memory, most memories are stored in complex biophysical and biochemical
means throughout the brain. Traumatic memories in particular are stored
within various engrams in the sensory brain structures.
 Figure 10. The Sensory Aspects of the Brain Are Involved in the Storage of Perceptual and
Recognition Memories

The parietal, occipital, temporal, and insular lobes allow for the processing
of sensations and present a connection to our body schema. These structures
communicate with the unconscious brain to try to make sense of the
incoming information. Fear conditioning has a strong connection with these
cortical areas, which results in recognition memories and perceptual
memories. Recognition memory is a form of declarative memory that
involves the ability to match stored memories with similarities in
experiences so we can recognize people, objects, and events as familiar.
Recognition memory differs from recall in that it lacks the detailed
information of recall memory, and it may not require hippocampal
involvement (Bowles et al., 2010). Perceptual memory also lacks the detail
of recall and semantic memory, and it involves long-term memory of visual
and auditory information, such as memory of particular voices and facial
features.
While the specific memory processes involved in traumatic experiences are
controversial, this knowledge leads us to consider that recognition and
perceptual memories supersede episodic and semantic memories. Given that
trauma can also result in hyperactivity in the lateral and posterior parts of
the brain, trauma can impact working memory as well, which is required for
day-to-day tasks. With decreased activation of the anterior portions of the
brain, individuals with a trauma history can be easily triggered by sensory
stimuli and contextual factors—all the while lacking explicit details of
traumatic events.

In the next section, we present a handout to help clients understand the role
of memory in the trauma response and fear conditioning, followed by
various tools and activities that are intended to improve memory and help
clients navigate challenges they may be experiencing in completing daily
tasks. We also provide visualization techniques and methods to structure the
day.
 CLIENT HANDOUT (ADULTS)
THE NEUROCHEMISTRY OF TRAUMA

☐ The parts of our brain that are in charge of memory, speaking,

listening, and learning are the same parts of our brain that control
our response to fear and stress. We call it the emotional brain.
☐ When we are afraid or stressed, our emotional brain triggers a
release of chemicals in our body that prepares us to respond to the
threat.
o When the emotional brain responds to a perceived threat
in this manner, it goes into protective mode. In this
protective mode, the emotional brain is overly focused
on our survival and does not do a good job when it
comes to encoding specific details of the event into our
memory.
☐ While we may remember a traumatic event right after it happens,
the stress of the event can cause us to forget specific details over
time.
o Instead, we remember trauma through our senses—
through specific sounds, sights, smells, textures, or
places that remind us of the trauma.
o When there is some sort of sensory input in our
environment that reminds us of the trauma—like a
certain sound or smell—our body reacts to the
experience as if the trauma was still occurring.
o These body reactions drive our emotional responses, like
fear.
☐ But we can learn how to slow down and notice our sensory body
responses, and in doing so, we can learn to respond to triggers
instead of reacting to them.
☐ Although trauma can cause the brain to not develop as it should,
our brains change and grow with each experience. That means we
can make new experiences to allow growth.
☐ Then we come up with ways to make our bodies feel better, and
our minds will start to grow!

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION WORKSHEET
ACTIVITIES OF DAILY LIVING:
MEMORY ACTIVITIES

Age Range: All

Objective: To improve working memory, assist in planning to prepare

for necessary tasks, and decrease daily stress

Directions: Identify an activity of importance that may be causing the

client challenges. For example, perhaps they are struggling to arrive to
work on time or to maintain appointments, which is leading to
additional dysfunction and stress. Discuss the needed steps to
complete that particular activity, and write down each step in
sequential order. As a follow-up activity, write the steps out of order
and have your client place them in the correct sequence. Here is a
sample memory activity for getting to their therapy appointments on
time, followed by blank spaces for you to use with your client.

Sample Activity: Getting to Therapy Appointments on Time

☐ Locate house and/or car keys
☐ Dress yourself (and others you care for, such as children or
older parents)
☐ Prepare food and eat (and feed others if applicable)
☐ Awaken at least one hour before departure time
☐ Comb hair
☐ Brush teeth
 ☐ Ensure you have proper transportation, including enough
gasoline for the car
☐ Identify how much time is required for travel, taking into
account traffic or wait time for public transportation
☐ Communicate with necessary parties—such as your partner,
childcare providers, and home health aides—regarding your
departure time
☐ Plan to leave the home at least 15 minutes earlier than
required to reach your destination

Ask your client to use the space here to write out the steps they
need to take to complete an activity.

☐ Step 1:
_______________________________________________

☐ Step 2:
_______________________________________________

☐ Step 3:
_______________________________________________

☐ Step 4:
_______________________________________________

☐ Step 5:
_______________________________________________

☐ Step 6:
_______________________________________________

☐ Step 7:
_______________________________________________
☐ Step 8:
_______________________________________________

☐ Step 9:
_______________________________________________

☐ Step 10:
______________________________________________

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
MEMORY STRATEGIES

Age Range: All

Objective: To improve overall memory, assist in participation in daily

activities, and decrease daily stress

Directions: The following 10 activities can assist with enhancing

memory. We provide specific examples for each activity, which you
can expand upon and tailor to your client’s specific intervention
needs, or you can suggest self-directed activities for your client.
1. Memory Cards
2. Chunking (Categorization)
3. Rehearsal/Role-Play
4. Visualization
5. Mnemonics
6. Mindful Activities
7. Structure Everyday Routines
8. Association
9. Contextual Organization
10. Think Out Loud

Memory Cards

Place a row (or more) of playing cards on the table. Allow the client
to study the cards for a few minutes, and then take the cards away.
Wait a few minutes, and ask the client to replicate the card order from
memory.

You can modify this activity with young children by asking the child
to place two to three simple images in order of what comes next. For
example, you can provide three images that demonstrate the steps
involved in blowing bubbles and ask the client to order them
sequentially. You can also play a memory game by hiding objects in
the environment and asking the child to recall their location.

Chunking

In this activity, clients will enhance their ability for short-term recall
by “chunking” related pieces of information together. Ask clients to
study the shopping list in the left-hand column and to come up with
four categories that describe the items listed. Then ask them to make
another “chunked” list of the items within each appropriate category,
as shown in the right-hand column here. Instruct clients to study the
chunked list for three to five minutes. Remove the list, and ask them
to recite the shopping list from memory as best they can.
List Chunked List
Hamburger rolls Bakery
Cereal Hamburger rolls
Ice cream Loaf of bread
Potato chips
Apples Frozen Food
Grapes Ice cream
Rice
Potatoes Produce
Soup Apples
Loaf of bread Grapes
Potatoes

Prepared Food
Cereal
Potato chips
Rice
Soup

Rehearsal/Role-Play
Identify a daily activity that is an obstacle for your client, such as
cooking dinner for the family or helping the children with their
homework. For children, this activity could involve coming home
from school and completing their required routine (e.g., homework,
chores) before bedtime. Discuss the various steps needed to complete
each task, and write them down as you both verbalize your thoughts.
You can use the Activities of Daily Living worksheet to help you
organize the activity into steps. Make sure to assist the client in
identifying any missed steps. Once you are finished, review the steps
and allow the client to determine if anything appears inaccurate or
needs revisions. Next, invite the client to participate in a role-play
activity where you pretend to act out each step of the activity. Prompt
the client if they appear to miss a step. Be sure to take notes so you
can reflect on areas of success and address any missed steps that you
need to continue to work on.

Visualization

Similar to the Rehearsal/Role-Play activity, identify a daily activity

that causes difficulty for your client. Have them write down the steps
required for the task. Then ask the client to close their eyes if they are
comfortable doing so, or they can simply sit quietly. Next, have the
client visualize themselves performing each step that the activity
requires. Ask them to verbalize each step. As they share the steps,
take a moment to ask what they are feeling. At the end, inquire
whether they were successful at fully completing the task. Lastly, ask
them to reflect on their visualized performance and to identify any
areas in which they think they require improvement.

Mnemonics

This activity provides a method for storing, encoding, and recalling

information, experiences, or tasks (such as to-do lists). Make a list of
concepts or tasks that the client needs to complete, like the example
provided here. Take the first letter of each task to make a mnemonic,
such as WARS:
 Wash laundry
Answer emails
Request extension on paper
Study for exam

Mindful Activities

Mindfulness practices have been shown to increase the volume and

density of the hippocampus, which is the area of the brain associated
with memory. Therefore, one way to improve overall memory is to
ask clients to incorporate mindfulness into their daily routine by
having them focus their full attention on the task at hand. To start, ask
clients to focus on monotasking (as opposed to multitasking) by
selecting one activity to perform at a time. The activity should be
slow and, if possible, rhythmic. The following are some examples of
mindful activities that clients can try:

☐ Walk slowly with bare feet on a grassy lawn or sand, while

focusing their attention on their surroundings and breathing
☐ Cook a meal and focus solely on the preparation
☐ Allot time to speak with someone, such as a friend, child, or
parent, and listen to them without any distraction
☐ Eat a meal while chewing slowly, focusing on the taste,
smell, and texture of each bite
☐ Breathe slowly while sitting or lying down in a relaxed
position, and focus on their breath
☐ Sit and mindfully pet their pet
☐ Practice grounding activities (see chapter 2)

Structure Everyday Routines

One way to help clients remember the tasks they need to complete is
to have them create a structured schedule of their daily routines and to
set reminders for each task. Doing so can increase focus and attention,
and it can also decrease stress. Compensatory strategies, such as
writing down appointments and setting reminders, can alleviate
anxiety related to disorganization and problems with running late or
missing appointments.

Here are some examples of strategies:

☐ Use a journal to write down daily tasks that need to be

completed, starting in the morning when stress hormones are
low.
☐ Place sticky notes on the bathroom mirror with tasks to
complete, remove them as the day goes on or at the end of
the day, and replace the sticky notes for the next day.
☐ Use a visual schedule that contains pictures to depict the
tasks within your routine.
☐ Utilize a smart phone or email system to set reminders and
alerts.

Association

Associative memory is the ability to learn and remember the

relationship between unrelated concepts or items, such as the name of
a person we just met. To assist with memory storage and recall, clients
can connect new information with already established information.
For example, they can sing the components of new information to the
rhythm of a song they know well. They can also perform associative
memory tasks to recall the names of people, places, or objects. The
following is a simple example to illustrate the use of a face-name
associative memory task:
You want to remember the name of someone you just met. To do so, you associate
their name with one of their features or with something they wore. For example, Julie
had on beautiful jewelry. She reminds you of a childhood friend who had the same
name.

Contextual Organization
Clients can decrease stress and improve efficiency by having the
environment set up and organized for each activity they need to
complete. Help the client choose a specified location where they will
perform each task, and then ask them to write down the commonly
used materials they need to complete each task. Then assist them in
identifying ways to keep these materials nearby. For example, if a
parent needs to assist their child with homework, or a child needs to
perform their own homework, they can have all the necessary items
(e.g., pen, paper, highlighter, calculator) in a drawer near their desk or
within specific containers. The containers can be inexpensive, such as
shoeboxes. That way, they can avoid having to search for the items
when they are needed.

Similarly, contextual organization can support successful completion

of morning self-care tasks. For example, clients can identify what
clothing they will wear the night before and place the needed items
for the morning in convenient locations for quick access (e.g.,
hanging on the closet door). They can also utilize a similar method for
other needed items for the morning (e.g., locating their keys and
wallet and placing them on a tray). In the kitchen, they can continue
using such organizational methods. For example, clients can consider
putting items on the counter as visual reminders and plan meals ahead
by meal prepping. In addition, they can place shopping lists, recipes,
and reminders on corkboards or sticky notes on the wall nearby.

Think Out Loud

Research has found that we can improve memory and facilitate

learning when we say words out loud to ourselves compared to saying
them in our head (MacLeod, Gopie, Hourihan, Neary, & Ozubko,
2010). Therefore, the next time clients need to organize their thoughts
and actions, have them consider the following questions, and ask them
to answer each question out loud to determine the most appropriate
course of action:

☐ What do I want to do?

 ☐ Who needs to be involved?
☐ What do I need to successfully complete this task?
☐ When does it need to be completed?
☐ How often does it need to be completed?
☐ Where do I need to be to complete the task?
☐ Why do I need to do this task?
☐ How can I improve at doing this task?
☐ How long will it take?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

FEAR CONDITIONING

When examining how traumatic memories are stored, it is important to

consider the role of classical conditioning. In classical conditioning, a
previously neutral stimulus (conditioned stimulus) is paired with an
unconditioned stimulus that naturally elicits a reflexive (or unconditioned)
response (Pavlov, 1927). For example, in Pavlov’s classic experiment with
dogs, he repeatedly presented a bell (conditioned stimulus) and then
provided the dogs with food (unconditioned stimulus), which naturally
resulted in an increase in salivation (unconditioned response). After several
repeated pairings, the dogs began to salivate in response the bell tone alone
in the absence of any food presentation. This new response to the bell
reflects a conditioned response. While most clinicians are very familiar with
classical conditioning, we often fail to discuss the defense reflex that may
also emerge.

The defense reflex (or defense response) is a protective reflex that occurs in
the presence of an unexpected or threatening stimulus. It is accompanied by
a sudden change in motor and neurophysiology that can trigger a defense
cascade, which is five-step reaction that occurs on a continuum in response
to perceived threats (Kozlowska, Walker, McLean, & Carrive, 2015). The
first step in the cascade involves a state of high arousal, in which the body
mobilizes for action in response to the identified trigger. This is
subsequently followed by the fight-or-flight response as the body activates
the resources necessary to deal with the threat head-on or escape from it. At
the third step, the body may enter a state of freeze, which halts the fight-or-
flight response while still allowing the body to remain on high alert.

If the threat is too overwhelming—and fighting or escaping is not possible

—then the body shuts down and enters into a state of tonic or collapsed
immobility as somewhat of a last resort for self-preservation. In this state,
the person experiences paralysis in movement and speech, and loss of
muscle tone may occur as well, resulting in collapsing and fainting. Once
the threat has passed, individuals may enter into the fifth stage of the
cascade—quiescent immobility—which is an adaptive reaction intended to
allow the body to recover and heal from the trauma. Although quiescence is
initially an adaptative response, it can become maladaptive if it continues to
persist beyond the time needed for healing (Kozlowska et al., 2015). The
end result could be chronic fatigue and pain syndromes.

The defense cascade can become conditioned when an individual’s

autonomic nervous system and sensorimotor responses become part of the
individual’s habitual response pattern (Figure 11). Their brain becomes
wired to respond to sensory stimuli and contextual factors like it did at the
time that the threat occurred (Kozlowska et al., 2015). The fear response
becomes conditioned, and undesired memories regarding the trauma surface
in the presence of similar sensory stimuli (Pavlov, 1927).
 Figure 11. Fear Conditioning and the Defense Cascade

When fear conditioning occurs, individuals can present with physical

trauma even in the absence of a true threat because they perceive the need
to protect themselves. They may have a reduced reflex threshold secondary
to pain and exhibit enhanced nociceptive reflexes (e.g., blinking, enhanced
limb withdrawal reflex). They may also exhibit exaggerated startle
responses, physical aggression, and elopement or escape behaviors.
Children in particular may manifest these behaviors by scratching, biting, or
rolling on the ground while kicking and screaming. They may also run
away from home (Darwin, 1872/2009; Wallwork, Grabherr, O’Connell,
Catley, & Moseley, 2017).

To assist in screening for defense reflexes, utilize the following defense

checklists. The first checklist is intended for children and adolescents under
18 years of age, while the latter is for adults. When conducting these
screenings, please note that the presence of defense reflexes does not
necessarily indicate a correlation to trauma. Other factors may be the cause,
such as other diagnoses, phobias, or recent physical injury or procedures.
 PROVIDER WORKSHEET
ACTION PEDIATRIC DEFENSE
REFLEX CHECKLIST

Client Name: _________________________________

Date of Birth: _________________________________

Date: ________________________________________

Check all boxes that may apply. You should use this as a guide along
with standardized assessment and evaluation procedures. It is not
intended to be used in isolation of standardized instruments to
determine diagnosis or to develop treatment plans.

Part 1:
☐ Complains about pain or discomfort, or displays hypersensitivity
to:
☐ Smell
☐ Visual input (e.g., lights)
☐ Touch
☐ Sound
☐ Taste
☐ Gross motor movement
☐ Using the bathroom
☐ Such complaints or observations occur (circle): Sometimes /
Occasionally / Often
☐ Notes: ________________________________

Part 2:
☐ Presents with sensory-seeking behaviors through the following
forms of input:
☐ Smell
☐ Vision
☐ Touch
☐ Sound
☐ Taste
☐ Gross motor movement
☐ Such behaviors occur (circle): Sometimes / Occasionally / Often
☐ Notes: ____________________________________________

Part 3:
☐ Presents with nociceptive reflexes (eye blinking, trunk flexion,
limb withdrawal reflex):
☐ Physical aggression, such as scratching and biting
☐ Eloping or escaping behaviors (e.g., sitting with head and
hands covered)
☐ Pulling away
☐ Rolling on the ground while kicking and screaming
☐ Heightened startle responses
☐ Hyperarousal
☐ Rage
☐ Such behaviors occur (circle): Sometimes / Occasionally / Often
☐ Notes: _______________________________________________
Summary and Key Findings:

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 PROVIDER WORKSHEET
ACTION ADULT DEFENSE
REFLEX CHECKLIST

Client Name: _________________________________

Date of Birth: _________________________________

Date: ________________________________________

Check all boxes that may apply. You should use this as a guide along
with standardized assessment and evaluation procedures. It is not
intended to be used in isolation of standardized instruments to
determine diagnosis or to develop treatment plans.

Part 1:
☐ Complains about pain, or discomfort, or displays hypersensitivity
to:
☐ Smell
☐ Visual input (e.g., lights)
☐ Touch
☐ Sound
☐ Taste
☐ Gross motor movement
☐ Using the bathroom
☐ Such complaints or observations occur (circle): Sometimes /
Occasionally / Often
☐ Notes: _______________________________________________

Part 2:
☐ Presents with sensory-seeking behaviors through the following
forms of input:
☐ Smell
☐ Vision
☐ Touch
☐ Sound
☐ Taste
☐ Gross motor movement
☐ Such behaviors occur (circle): Sometimes / Occasionally / Often
☐ Notes: _______________________________________________

Part 3:
☐ Presents with nociceptive reflexes (eye blinking, trunk flexion,
limb withdrawal reflex):
☐ Eloping or escaping behaviors (e.g., sitting with head and
hands covered, ending session prematurely)
☐ Aggression
☐ Heightened startle responses
☐ Speaking loudly
☐ Hyperarousal
☐ Rage
☐ Such behaviors occur (circle): Sometimes / Occasionally / Often
☐ Notes: _______________________________________________

Summary and Key Findings:

 Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

BIO SIGNS

Given that trauma is often stored in fragmented sensory memories that are
easily triggered by external stimuli, it is important to teach clients how to
tune into their body signals (or “bio signs”) so they can recognize when
they are becoming triggered. This involves learning to notice changes in
heart rate, respiration, and skin appearance. When clients learn how to
detect these changes in their body, they have the ability to perform self-
regulation techniques to help them respond instead of reacting.

Before working with clients to develop awareness of their body signals, it is

crucial that you acknowledge the client’s tolerance for experiencing touch,
remaining seated, and participating in tabletop activities. The client should
have the tolerance to sit still or lie down for at least 15 to 30 seconds. They
must also tolerate minimal touch for short intervals of time. Also make sure
to identify effective methods of communication and signals that clients can
use if they become uncomfortable.

In addition, obtain a baseline measure of the client’s breathing and heart

rate while they are sitting down. Avoid recording this information
immediately following activities of high arousal. If possible, use a timer and
heart rate device to gather the needed information. There are several
inexpensive sports watches available that measure heart rate and pulse. If
you are using a timer, obtain the pulse rate on the client’s wrist or neck for a
60-second period (or for 30 seconds and multiply by two). To detect their
respiratory rate, count the number of times the client’s chest rises and falls
during the same 60-second time frame. Obtaining a baseline measure of
skin appearance and feel is more qualitative, but it is still an important
biomarker. To do so, ask clients to turn their hands with their palms facing
up. Gently stroke their palm to detect its temperature and moisture. Use
descriptors to categorize its appearance and feel, such as cold, clammy,
warm, hot, or sweaty (Gibbs, 2017b).

Once you have obtained these baseline measures, you should measure the
client’s physiological responses before and after selected activities, such as
breathwork and sensorimotor work. This information may provide you with
additional information regarding their reaction to certain techniques. You
can use the following chart to monitor pre- and post-differences in heart
rate, respiration, and skin temperature. Be sure to guide the client as you
measure these recordings. If you are providing trauma-specific
interventions, you can use this chart to record their physiological responses
before and after discussions regarding their trauma history or when
conducting exposure therapy. In the next section, we also provide several
additional tools and activities clients can use to develop greater body
awareness.
 PROVIDER WORKSHEET
ACTION BIO SIGNS CHART

Client Name: _________________________________

Date of Birth: _________________________________

Directions: Use this chart to detect physiological responses to

stimulation to the body. Monitor pre- and post-differences in the
client’s heart rate, respiration, and skin temperature following an
activity or sensory stimulation.
Date Pre-Breathing Post- Pre-Heart Post-Heart Pre-Skin Post-Skin
Rate (per 60 Breathing Rate (per 60 Rate (per 60 Appearance Appearance
seconds) Rate (per 60 seconds) seconds) and Feel and Feel
seconds)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
ACTION BIO SIGNS SELF-MONITORING

Age Range: Adolescents and adults

Objective: To develop greater body awareness

Directions: Use the following script to teach your client how to self-
monitor bio signs.

Provider Script: Certain emotions can increase your arousal and

cause you to feel overwhelmed or out of control. It is similar to
having the volume on the radio turned all the way up. When the radio
is too loud, you cannot focus on anything else because the sound is
too distracting. In contrast, when you feel tired or sluggish, it is like
having the volume on the radio turned down, perhaps playing some
light, soft, and slow music. If the volume on the radio is too low,
though, you will not be able to hear it. For most of our activities, we
need our volume to be somewhere in the middle.

In this activity, we will practice detecting your body’s volume so you

can gain greater body awareness. Begin by describing the temperature
of your hands. Are they dry, clammy, or sweaty? Next, place one hand
on your heart and the other on your belly. As you breathe in and out,
describe your breathing and heart rate. Would you describe it as fast
(loud), slow (quiet), or in the middle? Now take a deep breath, and see
how your heart rate and breathing rate change. Does your skin
temperature change? What happens to your body responses when you
think about something that makes you angry or frustrated?
After you complete this activity, try to begin using language to
describe your body sensations—such as “It feels too loud” or “I feel
really quiet”—and see if you can get yourself somewhere in the
middle where you desire.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT ACTIVITY
THE SELF-REGULATION AND
MINDFULNESS (SAM) BOX*

Age Range: Children

Objective: To provide a tool for children to acknowledge their

arousal levels—low (quiet), just right (middle), or high (loud)—and
how it supports or impedes daily function

Items Needed:
• A small cardboard box, shoebox, or tissue box (or a pencil case
with a zipper)
• Glue
• Brass brad or pushpin
• Paint (optional)
• Construction paper or cardstock (or any other durable material
that can be cut into an arrow shape and attached to the box)
• “Feelings” images, such as printed pictures of different facial
expressions or emojis
• Markers or crayons

Directions: (Adult to assist as needed)

If using a cardboard box:

1. Take the box and decorate it with construction paper or paint.

2. Draw a circle on the top center of the box to make the “volume
gauge.”
3. Draw an upside-down “Y” in the circle to divide it into three even
sections.
4. Starting at the bottom section and going clockwise, color and
label each section: Quiet, Middle, and Loud. Use different colors
for each section.
5. Cut an arrow out of construction paper or cardstock.
6. Poke a hole in the top center of the box, and use the brad or
pushpin to adhere the arrow to the box.
7. Cut out images that represent different feeling states reflecting
quiet, middle, and loud levels of arousal. You can also use emoji
symbols, draw your own images, or use photos of the child. Place
these images around the dial near the corresponding arousal level
(quiet, middle, or loud).
8. Identify sensory items that can help the child self-regulate when
their arousal is loud or quiet, such as fidgets, a device that plays
music, coloring pages, mandalas, exercise cards, pinwheels, and
bubbles.
9. Use the inside of the SAM box to store these preferred sensory
items. The goal is for children to be in the middle level during
functional activities.

If using a pencil case with a zipper closure:

1. Take a small, round piece of cardstock or other durable material

and poke a hole in the center.
2. Follow previous steps 3 and 4 to make a volume gauge small
enough to fit on a keychain ring.
3. Push a mini metal paper fastener through the center and bend it to
serve as the “arrow.”
4. Take a keychain ring, place it through the gauge on the zipper,
and adhere it to the pencil case attaching the cardstock.
5. Store preferred sensory items inside the pencil case, as indicated
in the previous section.

__________
* Adapted from Self-Regulation and Mindfulness (Gibbs, 2017b)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
BODY SCANNING FOR TRIGGERS AND
REPETITIVE MOVEMENTS

Age Range: All

Objective: To help identify clients’ triggers and physical trauma

presentations

Directions: Trauma sometimes leads to repetitive movements and

sensorimotor dysfunction. Our bodies take over, and we go into
autopilot. In this activity, the practitioner and the client (depending on
developmental level) will scan the body for evidence of these
movements.

Part 1: Practitioner Observation

Ask the client to have a seat. Take note of any repetitive movements
that the client makes, such as eye twitching, squinting, writhing
movements of the hand, mouth movements, rocking, or tapping.
Observe their posture, looking for slouching and flexed positions. Do
they present with self-soothing behaviors?

Part 2: Adolescent and Adult Self-Observation

Provider Script: To start, acknowledge any repetitive movements

you may be making, such as eye twitching, squinting, hand writhing,
mouth movements, rocking, or tapping.

Sit in a calm, relaxed position as you continue analyzing your body.

As you tune into your body, focus on your breathing and heart rate.
Try to take slow, deep breaths. Now widen the focus of your attention
to your whole body, and detect any tension, pain, coldness, numbness,
or warmth. Starting from your feet, work your way to the top of your
head. Suggested body regions to focus on are:
☐ Feet and ankles
☐ Legs and knees
☐ Pelvis and middle section (belly region)
☐ Back and chest (heart)
☐ Arms, wrists, and hands
☐ Shoulders and neck
☐ Face, top of the head, and back of the head

(Note to provider: Document and discuss the findings. Address areas

of concern with stretching, exercise, and sensory-based interventions.)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
MY BODY*

Age Range: Children

Objective: To teach children about their body, sensory system, and

connection to the brain

Items Needed:
• Paper
• Crayons, pencils, or paint
• Provided body template

Directions: Review the song Head, Shoulders, Knees, and Toes. Talk
about the role that each of these parts plays for our bodies. For
example, share how all of our parts are important and strong. Talk
about how we do not use just one part at a time. You can provide
examples, such as needing our eyes to look when listening with our
ears. Next, have the child draw a self-portrait using the image on the
provided printout. This can include their facial features, ears, hair,
preferred clothing and footwear, and any other components they wish
to include.

Once the child is done with their self-portrait, have them share and
explain their picture. See what is missing, and help them fill in those
items. Then talk about our inside parts, such as the heart (feel the
heartbeat), lungs (take slow breaths), and stomach (discuss a full and
empty tummy). Ask them to show you where those parts are by
pointing to the various locations on their portrait.
Optional:
1. Discuss how our inside parts can become loud (fast heartbeat and
quick breathing) or very quiet (slow heartbeat and slow
breathing), causing us to feel energized or tired.
2. Have the child perform loud activities, such as running in place,
followed by quiet activities, such as closing their eyes and sitting
still.
3. Review that sometimes we need to be “in the middle” between
loud and quiet, such as when we are at school or going to public
places.

_____________
* Adapted from Self-Regulation and Mindfulness (Gibbs, 2017b)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
MY BODY TEMPLATE
 Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

THE BRAIN-GUT CONNECTION TO TRAUMA

Just as disorders of trauma are complex, so is the human body. Our systems
do not function in isolation but are interconnected. The vagus nerve in
particular provides a bidirectional connection between the brain and the gut
(Figure 12). It contains both parasympathetic and sympathetic nervous
system fibers that impact gut digestion, inflammation, and nutrient
absorption. Even more, the enteric nervous system allows the digestive
system to have an independent, yet connected, nervous system. We actually
have 100 million neurons in our gut wall. So our guts are somewhat of a
second brain!

Figure 12. The Vagus Nerve Plays a Major Role in the Brain-Gut Connection
In the gut, endocrine cells produce the same molecular serotonin that the
brain makes, which is the neurotransmitter that provides us with a sense of
well-being. In fact, the gut produces approximately 90–95 percent of the
body’s serotonin and 50 percent of its dopamine (Carpenter, 2012).
Therefore, neurotransmitters in the gut can affect mood and behavior. Too
much or too little can have adverse effects on emotional well-being, as well
as physical digestion. Research theorizes that the impact of gut function
directly correlates with other diagnoses, such as anxiety and depression
(Carpenter, 2012).

While neurotransmitters serve a vital role in well-being, gut bacteria (or

microbes) are crucial players as well. There are 100 trillion microbes in the
gut (Carpenter, 2012), and these gut bacteria play a role in the production of
the neurotransmitters that influence several important functions, such as
memory, emotions, and learning. Importantly, infection, illness, or even
hunger and malnutrition can impact the work of these microbes, which in
turn affects brain functioning (Kane, Dinh, & Ward, 2015).

Stress can also have a significant effect on the brain-gut connection. In the
presence of stress, beneficial gut bacteria levels decrease, which results in
increased inflammation and lower production of necessary
neurotransmitters. As it directly relates to trauma, research has revealed a
connection between early life adversity and alterations in gut microbes
(Callaghan et al., 2020), and differences in gut microbes have been found
among individuals with PTSD (Hemmings et al., 2017). As a result, some
research has suggested that the intake of probiotics, as well as other
methods to modulate gut bacteria, may positively impact mood disturbances
and gastrointestinal dysfunction (Yang, Wei, Ju, & Chen, 2019).
Additionally, research has found that early exposure to gut bacteria during
crucial developmental periods in childhood can impact both physical and
neuropsychiatric development (Zhuang et al., 2019).

TRAUMA AND SECONDARY CONDITIONS

When individuals are frequently triggered or exposed to chronic stress, their
body is in a state of prolonged sympathetic nervous system activation,
which can result in increased blood flow to the extremities and tension in
the muscles. As a result, individuals with PTSD may present with physical
trauma in the form of joint and muscle pain (Fishbain, Pulikal, Lewis, &
Gao, 2017). The constant anxiety and fear they experience can lead to
chronic and persistent body tension and pain. Even during rest, some
individuals may find themselves in a protective position, such as a fetal
pose, which results in pain upon awakening. Furthermore, trauma affects
the production of certain hormones in the body, such as prolactin, which is a
protein hormone correlated with pain sensitivity, hypothalamic modulation,
immune modulation, and regulation of mood. In PTSD, prolactin levels
may increase, which results in increased pain sensitivity (Fishbain et al.,
2017; Oliveira et al., 2020).

The experience of significant stress or trauma can also result in sudden

seizures, syncope (i.e., fainting episodes), and vision loss. In her own
experience, Dr. Gibbs has witnessed clients, as well as those in her personal
life, suddenly experience a significant change in their health following
trauma. She has had several clients experience unexplained dizzy spells,
witnessed the sudden onset of seizures, and had a family member suddenly
lose sight. In all of those cases, the individuals recovered. Why did these
physical symptoms occur? According to the defense cascade model, these
individuals experienced a state of collapsed mobility, which then led into
prolonged quiescent immobility and eventually resulted in physical
immobility.

When these secondary trauma reactions occur, clients usually undergo a full
medical process to investigate the root cause of their symptoms. After
ruling out cardiopulmonary and neurological conditions, medical
professionals may suggest a psychological explanation behind their
symptoms. This can make clients feel like doctors are dismissing their lived
experiences. In addition, labeling these symptoms under the umbrella of a
“psychological condition” can result in feelings of shame for clients due to
the stigma often associated with mental disorders.
We must do a better job of connecting the medical and psychological
worlds through biopsychosocial approaches. The defense cascade reveals
the possible source of these physiological conditions. For example,
individuals with a history of trauma often continue to experience
heightened anxiety in response to environmental triggers, resulting in the
same neurochemical reactions that occurred at the time of the trauma. In the
case of seizures, the structures that govern the fight-or-flight response are
located within the same lobe where some seizures originate, which explains
the connection between stress and epilepsy. Lack of sleep and diet may also
contribute to physical stress.

When it comes to vision, stress can result in distorted and blurry vision
because adrenaline puts pressure on the eyes. In addition, the intense
contraction of the eye muscles can result in twitching called lid myokymia.
Over the long term, these physical stressors can deteriorate the nerves
required for vision (Sabel et al., 2018). There is also a connection between
cortisol and vision disorders, such as diabetic retinopathy, glaucoma, optic
neuropathy, and macular degeneration.

That being said, these connections between mental and physical health are
speculative in nature, as the direct connection is unclear. What is clear is the
correlation with trauma and stress. The impact of trauma has emotional,
cognitive, psychological, social, and physiological implications. Therefore,
we must take care to address all these various areas. If you are a provider
who does not perform specific trauma-related care, or if you feel like these
roles should be left for medical doctors or psychiatrists, you must consider
altering your view. Every interaction with the client matters and can be
impactful toward healing.

PHYSICAL AND SENSORY APPROACHES

In this section, we introduce a variety of activities that you can use with
clients to decrease stress and pain within the body. In particular, these
activities aim to address the connection of trauma to physical symptoms and
provide relief to the body.
 CLIENT ACTIVITY
STRETCH AND RELEASE

Age Range: Adolescents and adults

Objective: To decrease stress and pain within the body

Directions: This activity provides a range of different stretches that

you can use to decrease stress and pain within your body. Complete
these stretches when you experience stress and whenever you need to
take a movement break throughout the day. To help address pain and
tension that may occur from sleeping in the fetal position, try to sleep
with a pillow between your legs and arms, and avoid propping up
your head too high. You can also perform these stretches prior to bed.

Note: Be aware of any pain or injuries you may have. Do not perform
any exercises that do not feel safe or that are contraindicated by your
doctor.

Pillow Stretch

Lie on your back. Place a pillow or towel under your lower back and
place your hands overhead while holding the stretch for a couple of
minutes.

Towel Stretch

Take a towel and place it around your neck. Gently pull the towel
forward as you push your head back for a resistive stretch.

Chair Stretch
Position a chair in front of you. Sit on the floor. Lie on your back and
place your feet on the seat of chair. Use a pillow or rolled towel under
your neck. Hold the stretch for a few minutes.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
PROGRESSIVE MUSCLE RELAXATION

Age Range: Children

Objective: To decrease stress and pain within the body

Directions: In this exercise, clients will practice tensing and relaxing

various parts of their body as they work from their head down to their
feet. To start, have the child get into a comfortable position, such as
lying down, and place a soft stuffed toy on their belly. Ask them to
take slow, deep breaths—as if they were going to smell a cupcake
with a candle on top. Then have them “blow out” the candle. Do this a
couple of times. Then use the following script to guide clients through
the exercise, or have them complete the steps on their own.

Note: Use precautions for any injuries. Do not perform if

contraindicated.

Provider Script:
• In this exercise, you will focus on squeezing and relaxing
different muscles throughout your body. You will squeeze each
muscle group for a couple of seconds, and then relax that muscle
group. You will take a deep breath before moving to the next
body part. I will tell you what you need to do at each step.
• We will start by squeezing the muscles of our face and holding
these muscles tightly. Then we will let go, allowing them to relax.
To start, raise your eyebrows like you are surprised. Hold them
there. A bit longer. Now release. Breathe in through your nose,
and slowly blow the air out of your mouth.
• Now squeeze all your face muscles like something smells really
stinky and looks yucky. Squint your eyes closed and wrinkle your
nose. Hold it there. A bit longer. Now release. Breathe in through
your nose, and slowly blow the air out of your mouth.
• Okay, now make a really big smile, keeping your teeth together.
Hold it there. A bit longer. Now release. Breathe in through your
nose, and slowly blow the air out of your mouth.
• Let’s stretch the muscles of your mouth. Open your mouth really
wide. Hold it there. A bit longer. Now release. Breathe in through
your nose, and slowly blow the air out of your mouth.
• Now pucker your lips. Hold them there. A bit longer. Now
release. Breathe in through your nose, and slowly blow the air out
of your mouth.
• We will now move to the muscles in your neck. Look up to the
ceiling. Hold it there. A bit longer. Now release. Breathe in
through your nose, and slowly blow the air out of your mouth.
• Bring your chin to your chest. Hold it there. A bit longer. Now
release. Breathe in through your nose, and slowly blow the air out
of your mouth.
• We will now release the muscles of your shoulders. Bring up your
shoulders as if to say, “I don’t know.” Hold them there. A bit
longer. Now release. Breathe in through your nose, and slowly
blow the air out of your mouth.
• Now for your arms. Make a big muscle and flex your arms. Hold
it there. A bit longer. Now release. Breathe in through your nose,
and slowly blow the air out of your mouth.
• Let’s focus on your hands. Make a fist with each hand. Hold it
there. A bit longer. Now release. Breathe in through your nose,
and slowly blow the air out of your mouth.
• Now put your hands flat and push down on your lap. Hold it there.
A bit longer. Now release. Breathe in through your nose, and
slowly blow the air out of your mouth.
• Next, we are going to focus on your belly muscles. Squeeze in
your belly muscles by pulling in your belly button toward your
spine. Hold it there. A bit longer. Now release. Breathe in through
your nose, and slowly blow the air out of your mouth.
• Let’s move to your legs. Lift your legs slightly off of the floor (or
flex at the hip to raise your leg if you are sitting). Hold them
there. A bit longer. Now release. Breathe in through your nose,
and slowly blow the air out of your mouth.
• Now your feet. Point your toes up toward the ceiling. Hold it
there. A bit longer. Now release. Breathe in through your nose,
and slowly blow the air out of your mouth.
• Next, curl your toes under the soles of your feet. Hold it there. A
bit longer. Now release. Breathe in through your nose, and slowly
blow the air out of your mouth.
• Finally, let’s make all of our muscles tense. Hold it. A bit longer.
Now release. Breathe in through your nose, and slowly blow the
air out of your mouth.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
PROGRESSIVE MUSCLE RELAXATION

Age Range: Adolescents and adults

Objective: To decrease stress and pain within the body

Directions: In this exercise, clients will practice tensing and relaxing

various parts of their body as they work from their head down to their
feet. You can use the following script to guide clients through the
exercise or have them complete the steps on their own.

Note: Use precautions for any injuries. Do not perform if

contraindicated.

Provider Script:
1. Choose a comfortable position, such as lying down.
2. Begin to ground yourself by taking in slow, deep breaths—in
through the nose and out through the mouth.
3. In this exercise, you will focus on tensing and relaxing different
muscle group throughout your body. You will tense each muscle
group for a couple of seconds, then relax that muscle group. We
will incorporate a slow, deep breath before moving to the next
body part. I will guide you through each step.
o We will start by focusing on the muscles of our face. Let’s
begin by raising your eyebrows. Hold them there. A bit
longer. Now release. Breathe in through your nose, and
slowly blow the air out of your mouth.
o Now tightly squint your eyes closed and wrinkle your nose.
Hold it there. A bit longer. Now release. Breathe in through
your nose, and slowly blow the air out of your mouth.
o Let’s continue. Raise your cheeks by smiling and clenching
your teeth. Hold them there. A bit longer. Now release.
Breathe in through your nose, and slowly blow the air out of
your mouth.
o We will now move to the muscles of your mouth. Open your
mouth wide. Hold it there. A bit longer. Now release. Breathe
in through your nose, and slowly blow the air out of your
mouth.
o Now pucker your lips. Hold them there. A bit longer. Now
release. Breathe in through your nose, and slowly blow the
air out of your mouth.
o Moving to the muscles of your neck, tilt your head back,
arching your back while lying on your back. Hold it there. A
bit longer. Now release. Breathe in through your nose, and
slowly blow the air out of your mouth.
o Now tuck your chin toward your chest. Hold it there. A bit
longer. Now release. Breathe in through your nose, and
slowly blow the air out of your mouth.
o Moving to your shoulder muscles, shrug your shoulders
toward your ears. Hold them there. A bit longer. Now release.
Breathe in through your nose, and slowly blow the air out of
your mouth.
o Now for your arms. Flex your biceps by moving your
forearms toward your upper arms. Hold them there. A bit
longer. Now release. Breathe in through your nose, and
slowly blow the air out of your mouth.
o Now make a fist with each hand. Hold it there. A bit longer.
Now release. Breathe in through your nose, and slowly blow
the air out of your mouth.
 o Place your hands flat on the floor or your lap, and gently push
down while applying pressure. Hold it there. A bit longer.
Now release. Breathe in through your nose, and slowly blow
the air out of your mouth.
o Moving to your abdomen muscles, squeeze in your belly
muscles by pulling your belly button toward your spine. Hold
it there. A bit longer. Now release. Breathe in through your
nose, and slowly blow the air out of your mouth.
o Let’s move to your lower body. Lift your legs slightly off of
the floor (or flex at the hip to raise your leg if you are
sitting). Hold them there. A bit longer. Now release. Breathe
in through your nose, and slowly blow the air out of your
mouth.
o Now point your toes up toward the ceiling. Hold them there.
A bit longer. Now release. Breathe in through your nose, and
slowly blow the air out of your mouth.
o Push the heels of your feet against the floor. Hold it there. A
bit longer. Now release. Breathe in through your nose, and
slowly blow the air out of your mouth.
o Next, curl your toes under the soles of your feet. Hold them
there. A bit longer. Now release. Breathe in through your
nose, and slowly blow the air out of your mouth.
o Finally, let’s make all of our muscles tense. Hold it. A bit
longer. Now release. Breathe in through your nose, and
slowly blow the air out of your mouth.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
ILIOPSOAS STRETCHES

Age Range: All

Objective: To decrease stress and anxiety, reduce sympathetic

nervous system activity, and address secondary symptoms of trauma
related to anxiety and stress

Directions: The iliopsoas muscle, which comprises the iliacus and

psoas, has a connection to the diaphragm. The psoas muscle is known
as the “fight-or-flight muscle” because it is triggered when the
sympathetic nervous system activates this defensive response.
However, when someone is in a prolonged fight-or-flight state—due
to significant stress or prolonged anxiety related to trauma—the
iliopsoas muscle can become tight, resulting in flexed posture and
abdominal extension. Stretching this muscle group can greatly calm
the sympathetic nervous system and decrease secondary symptoms of
stress. This activity provides a variety of iliopsoas stretches that
clients can perform to release any tension from this muscle group. Use
the following script while demonstrating these stretches to the client.

Note: Be aware of necessary precautions secondary to any physical

injuries or conditions.

Provider Script:

Lunges
☐ Get into a half-kneeling position with one knee forward and
one knee on the floor.
 ☐ Ensure that the forward knee does not move over the toes.
☐ Gently press your front hip forward to stretch the hip and
pelvic area.
☐ Hold 30–60 seconds and repeat with the opposite leg
forward.

Squat
☐ While standing on a flat surface, separate your feet so they
are slightly greater than hip-width part.
☐ Turn your heels toward each other so your toes are facing
outward at 11 o’clock and 1 o’clock.
☐ Safely bend your knees and squat toward the floor slowly,
keeping your knees in alignment with your toes.
☐ Use a chair or wall to stabilize yourself as needed.
☐ Hold the squat for 30–60 seconds or as tolerated, then return
to a standing position.

Bridges
☐ Lie on the floor or a flat surface with your back in a supine
position.
☐ Place your arms down by your side.
☐ Bend your knees and place your feet firmly on the floor.
☐ Lift your hips up toward the ceiling and hold for 30–60
seconds.

Supine Hip
☐ Lie on the floor or a flat surface with your back in a supine
position.
☐ Stretch your legs out in front of you.
 ☐ Bend one knee, pulling it toward your body with your arms,
and hug it to your chest.
☐ Maintain the other leg firmly on the flat surface.
☐ Hold for 30–60 seconds and repeat on the other leg.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
FACIAL AND EAR MASSAGE

Age Range: All

Objective: To decrease stress and anxiety, reduce sympathetic

nervous system activity, and address secondary symptoms of trauma
related to anxiety and stress

Directions: We know that certain input, such as massage to the face

and acupressure points, can decrease stress and the sympathetic
nervous system response (Lee, Park, & Kim, 2011). In addition, the
external ear has connections to the vagus nerve, which allow access to
the parasympathetic nervous system and can promote rest and
digestion. The following activity provides specific directions for
facial and ear massage. Although this activity is intended for all age
ranges, young children may require imposed input.

Instruct the client to use two to three fingers to massage each of the
areas illustrated here (or choose the specific areas you desire). Have
them gently apply pressure and move their fingers in a circular
fashion for at least five seconds in each location. This massage can be
used daily to prevent stress responses and increase self-regulation.
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
INVERSION EXERCISES

Age Range: All

Objective: To decrease stress and anxiety, reduce sympathetic

nervous system activity, and address secondary symptoms of trauma
related to anxiety and stress

Directions: Placing the body into an inverted position involves

placing one’s head toward the floor. Inversion can help with blood
flow, enhance the immune system, decrease fight-or-flight reactions,
decrease muscle tension, and improve sleep. It activates the vagus
nerve, which increases parasympathetic nervous system activity and
triggers rest and digestion. The following are 10 inversion activities
you can use with clients. Although these activities are intended for all
age ranges, young children may require imposed positioning. Be sure
to avoid activities that may exacerbate any existing injuries or that are
contraindicated due to secondary conditions.
1. Safely rolling on an exercise ball on the belly or back
o Stabilize the ball with your hands (or if working with a small
child, sit on the floor and position the ball between your
legs). Ask the client to lie over the ball, either on their belly
or back. For small children, safely place them on the ball in
the desired position. Provide gentle movement of the ball
back and forth in a rocking motion.
2. Inverted pull-ins on an exercise ball
o Stabilize the ball with your hands (or if working with a small
child, sit on the floor and position the ball between your
legs). Have the client lie over the exercise ball on their belly.
 If needed, provide support by placing your hands around
their core. Be sure to have the client’s permission before
proceeding. Have them walk their hands out away from the
ball to place their body into a forearm plank (i.e., their neck
and trunk should be in alignment in a straight horizontal
position, while their lower legs should remain on the ball).
Have the client bend their knees (so the ball slowly rolls
toward their toes) while they move their hips toward the
ceiling and their head toward the floor. With their body
inverted, hold for a few seconds, then allow the client to
return to the plank position. Select the amount of repetitions
you would like to have the client perform.
3. Downward-facing dog yoga pose
o Ask the client to get down on all fours into the quadruped
position. Then have them tuck their toes under as they lift
their hips toward the ceiling and place their head toward the
floor. Allow them to remain in this position while bearing
weight through their arms. Select the amount of time you
would like for them to maintain the position.
4. Tripod yoga pose
o Ask the client to get into a high-kneel position. Then have
them bend at the hips, placing the top of their head on the
floor. Have them place their palms flat on the floor, with their
fingers facing forward toward their face. Their wrists should
be bent at a 90-degree angle, and their upper arms should be
parallel to the floor. Ask them to straighten their knees,
allowing their hips to move toward the ceiling while they
bear weight through their upper body. With permission from
the client, you can provide stability by placing your hands on
the outside of their hips. Select the amount of time you would
like for them to maintain the position.
5. Legs-up-the-wall pose
o Locate a clear and safe area near a wall. Ask the client to sit
down on the floor facing the wall. Then have them lie on
 their back, raise their legs and feet, and place their legs
gently against the wall. Select the amount of time you would
like for them to maintain the position.
6. Standing forward fold
o Have the client stand in an upright position. Then ask them to
bend at the hips as they bring their chest toward their thighs.
Their head should be pointed toward the floor. They may
place their hands on the floor or on their shins, or they may
grab their ankles. Select the amount of time you would like
for them to maintain the position.
7. Placing items on the floor for retrieval, such as at the desk
o Use a box, storage container, or supply bag to place needed
items under a desk or table in preparation for an activity. For
example, if you are performing arts and crafts, place the
supplies in a bin under the client’s chair. Have them remain
seated while they bend over to retrieve the items. They may
reposition their legs or hold onto the tabletop surface to
stabilize themselves and to avoid loss of balance. Clients can
incorporate this exercise into their daily activities.
8. Wheelbarrow walking
o Have the client get down on all fours into the quadruped
position. Ask them to keep their palms flat on the floor.
Standing behind them, grab one of their legs at a time, and
hold up their lower body while they bear weight through their
arms. Then ask them to walk their hands forward as they
move across the floor with you moving with them as you
hold their legs.
9. Wall handstands
o Locate a clear and safe area near a wall. Place a small pillow
in front of the wall, and ask the client to kneel on the floor
facing the wall. Then have them place their palms flat on the
floor and the top of their head onto the pillow. With
permission, you can assist them in getting into a handstand
 position by guiding their legs toward the ceiling and
eventually against the wall. They should be in an upside-
down position. Select the amount of time you would like for
them to maintain the position.
10. Inversion tables and trapeze swings
o If you work in a clinic with an inversion table (e.g., a physical
therapy or chiropractic facility), you can have the client lie
safely on the table to go into an inverted position. Be sure to
follow safety precautions, and be aware of any
contraindications. If you are in a pediatric sensory integration
clinic and have access to a trapeze swing, explore having the
child sit on top of the swing while you support them. Then
have them lock their legs on the swing by bending their
knees around the bar. While they hold onto the side of the
swing ropes, have them bend backward into an inverted
position with their head toward the floor. Ensure their safety
by providing any necessary support. Select the amount of
time you would like for them to maintain the position while
swinging them in a desired motion.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
SENSORIMOTOR WORK:
SELF-IMPOSED INPUT

Age Range: All

Objective: To decrease stress and anxiety, reduce sympathetic

nervous system activity, and address secondary symptoms of trauma
related to hypersensitivity to sensory stimuli and hyperarousal

Directions: We know that certain input, such as imposed sensory

stimulation, can improve interaction with the environment and
engagement with others. The following provides self-imposed
techniques you can review with clients.

Shiatsu Self-Massage

While sitting down, instruct the client to use their thumbs to provide
pressure to the soles of the feet, moving in a circular manner. Then
have them use their thumbs to provide a pressure massage to each toe
on their feet. Instruct them to apply pressure and to massage the
webbed spaces of their hands. Next, have them apply pressure to their
palms, using their thumb and working down to the wrist area,
continuing with gentle pressure. Then have them use their opposite
hand to pull the other hand backward to stretch the wrist area. Lastly,
invite them to massage their scalp using their fingertips. (Note to
provider: If performing self-massage on the feet, ensure the client is
comfortable with removing their shoes.)

Back and Lower Body Massage

Apply deep pressure input to the muscles of the extremities and back
using a massager, tennis ball, or small bolster. You can also roll an
exercise ball over the body with gentle pressure.

Aromatherapy Lotion Massage

In session, ask permission to use lotion when performing a massage,

or have the client (or caregiver) apply the lotion themselves for a self-
massage.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
SENSORIMOTOR WORK: PARENT-CHILD
MASSAGE

Age Range: All

Objective: To decrease stress and anxiety, reduce sympathetic

nervous system activity, and address secondary symptoms of trauma
related to hypersensitivity to sensory stimuli and hyperarousal

Directions: Stress hormones can increase heart and respiratory rate,

enhance hypervigilance and focus, and suppress immunity and the
digestive system. Overactivation of stress hormones can also decrease
activation in the prefrontal cortex. Thus, it is crucial to find ways to
release these hormones from the body to enhance executive
functioning. Providing deep pressure input to the body is one way to
release stress hormones and relax the body through the release of
calming neurochemicals.

Caregivers can use the following steps to provide a massage to

children of all ages, depending on their individual needs. For
adolescents, consider other activities that allow for self-imposed
input. Demonstrate the following steps while instructing the caregiver
on how to provide a parent-child massage:
1. Starting with the child’s face, use your thumbs to gently massage
the lips and surrounding muscles of the face.
2. Gently massage the child’s scalp using your fingertips.
3. Massage the child’s external ears using slow, circular movements.
4. Next, massage the child’s extremities. Starting with the lower
body, use your whole hand to gently pull the child’s hips toward
their feet. Then pull their shoulder toward their hands when
massing the upper body. Gently roll their arms and legs between
your open palms. Hold the child’s calves and bring their knees
toward their chest, holding for a few seconds.
5. Perform a belly massage using the side of your hand closest to the
pinky finger and moving in a water paddle motion (one hand
follows immediately after the other).
6. Finally, use your hand to gently provide pressure to the belly.
From left to right, spell out the inverted letters I, L, U as indicated
here (McClure, 2017).

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
SENSORIMOTOR WORK:
MULTISENSORY APPROACHES

Age Range: All

Objective: To decrease stress and anxiety, reduce sympathetic

nervous system activity, and address secondary symptoms of trauma
related to hypersensitivity to sensory stimuli and hyperarousal

Directions: Our interaction with the world requires that we integrate

various senses at one time. As part of treatment interventions,
stimulating more than one sensory area at a time can improve our
ability to interact with the environment and engage with others. Long
term, clients may reveal decreased hypervigilance, increased attention
to tasks, and improved self-regulation. Consider using the following
sensory-based techniques with your clients:

☐ Rhythmically swinging with music

☐ Using a metronome during exercise (e.g., jumping jacks,
jumping in place, push-ups).
☐ Visually scanning for objects in a tactile bin while exploring
textures (e.g., placing objects in a bin of dry, uncooked rice)
☐ Bouncing on a ball while reciting the alphabet, states, or
names of sport teams, or while reading letters on a Snellen
chart.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
SENSORIMOTOR WORK:
THERMORECEPTIVE ACTIVITIES

Age Range: All

Objective: To tap into the parasympathetic nervous system via

thermoreceptors and adjust arousal levels to support the demands of
required tasks

Directions: Thermoreceptors, which are located on the skin, allow us

to detect variation in temperatures within our environment. Not only
can the use of ice and heat provide relief from pain, but it can also tap
into the parasympathetic nervous system, allowing for adjustments to
our arousal level. Cold temperatures stimulate the vagus nerve, which
has the strongest innervation to the parasympathetic nervous system.
Moreover, warm temperatures allow for a sense of safety and security.
The manner in which an individual reacts to cold and warm
temperatures depends on their sensory needs. The following
guidelines provide you with some considerations when implementing
thermoreceptive activities with clients:

☐ Hypervigilant and anxious clients: Explore the use of (safe)

warm temperatures, such as a warm heating pad available for
use during work or school, a heated blanket, or a heated
massager. You can perform this prior to the client having to
do work or in preparation for other session activities. Set a
timer to indicate an end time. This can also assist in relaxing
the body before bedtime. Be sure to periodically check the
skin for excessive redness to ensure the temperature is not
 too hot. Check in with the client to ensure they are
comfortable and not experiencing any pain as a result of the
temperature.
☐ Hyperactive and seeking-sensory clients: Explore the use
of cold temperatures, which can involve eating ice chips,
hiding objects within ice cubes and holding the cubes until
melted, freezing finger paint in ice cube trays to use for
artwork, and freezing disposable water bottles for deep
pressure massage. Have the client perform such activities
before having to do work or in preparation for other session
activities. Avoid injury to the skin and teeth by checking that
the client is not experiencing pain or discomfort. Ensure
activities are age appropriate and prioritize safety.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 PROVIDER HANDOUT
AROMATHERAPY GUIDELINES*

Age Range: All

Objective: To tap into the parasympathetic nervous system via the

olfactory system and adjust arousal levels to support the demands of
required tasks

Directions: Aromatherapy, with the use of essential oils, can assist in

addressing arousal and emotions. This handout provides general
guidelines that providers should consider when using aromatherapy
with clients, as well as a list of essential oils (though this is not a
comprehensive list). Aromatherapy practitioners have the expertise to
assist in appropriate guidelines and application.

Note: Be sure to assess for allergies, sensitivities (e.g., nausea),

preferences, and chronic diseases, such as seizure disorders. Ensure
that the treatment area is properly ventilated. Allow a minimum of
five minutes to breathe fresh air between aromatherapy sessions.
Essential Oil Potential Uses
Sweet orange Improves mood, increases alertness, and assists with digestion
Lemon Improves mood and digestive issues
Sandalwood Has a calming effect and increases focus
Bergamot Reduces stress and improves dermatological conditions
Rose Decreases anxiety and enhances mood
Lavender Decreases stress and has a calming effect
Chamomile Improves mood and enhances positive emotions
Peppermint Increases energy levels and improves nausea
Ginger root Improves appetite and boosts immunity
Mandarin Decreases anxiety and improves dermatological conditions
Ylang-ylang Decreases nausea and improves dermatological conditions
Tea tree Boosts immunity and improves dermatological conditions
Jasmine Improves mood

Utilize a device in which you can place the essential oils for diffusion.
Ingestion or skin application is not recommended without proper
training. The following are some devices for diffusion:

o Active diffusion: Actively diffuses the essential oil through

the air with the use of an electrical device
o Passive diffusion: Uses warmth to diffuse essential oils, such
as the use of a ceramic heated stone diffuser
o Carrier diffusion: Involves placing the essential oil within a
container (e.g., a cup), using a cloth on which to place the oil,
or making a satchel in which to carry the oil (e.g., placing dry
rice infused with essential oil into a small chiffon bag)

____________
*Adapted from http://tisserandinstitute.org/wp-content/uploads/2019/02/Clinical-
Aromatherapy-Generic-Policy-2019.pdf

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
VISUAL STRATEGIES

Age Range: All

Objective: To tap into the nervous system via the autonomic nerves
connected to the visual system

Directions: Our visual system connects to the neurological structures

involved in arousal, as the nerves for eye movement originate in the
brainstem and travel to the areas involved in the inhibition and
facilitation of our arousal levels. Vision also has a strong role in our
emotional reactions, as sensory input facilitates the reticular activating
system, thus impacting arousal. By providing clients with visual
stimuli and input to the structures of the visual system, you can alter
their arousal level and improve their ability to respond to stimuli in
the environment. Incorporating continued calming and organizing
input through the visual sensory system can improve arousal,
attention, emotion regulation, and overall functioning over time. Prior
to starting, be sure to ask the client’s permission before introducing
these activities, and recognize any triggers so you can avoid activities
that may result in re-traumatization. Young children may also require
imposed positioning.
☐ Start with gentle eyelid massages. Have the client close their
eyes, and gently use two or three fingers to massage their
eyelids by moving them in a circular pattern three to five
times in one direction, and then repeat in the other direction.
Repeat this three times on both eyes.
☐ Next, perform butterfly breathing. Have the client take their
thumbs and place them gently in each ear, with their palms
 facing forward and their fingers pointing upward. Have them
then wrap their fingers toward the front of their face to cover
the eyes. Have them take a deep breath in the nose, hold it for
five seconds, and then blow out of the mouth.
☐ If they are unable to perform butterfly breathing, consider
simply hiding the eyes. Have them cover the eyes for a
period of time to destress and recharge. This is especially
useful with young children to prevent overstimulation or to
help them calm down when they are becoming overwhelmed.
☐ Next, perform a room-scanning activity, such as an I Spy
game, by identifying objects in the environment. Without
sharing what the object is, state to the client, “I spy
something ______,” and then fill in the blank with
characteristics that describe the object (e.g., saying you spy
something blue to describe a blue ink pen on the desk). Have
them scan the room to locate the object, taking a guess at
what it could be. If they are not correct with their selection,
repeat by sharing another characteristic of the object. In place
of an I Spy game, you can also simply have the client scan
the room, select an object, and describe the object in detail.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT ACTIVITY
EYE YOGA*

Age Range: All

Objective: To tap into the nervous system via the autonomic nerves
connected to the visual system

Directions: Consider including eye yoga as part of your visual-based

activities to enhance focus, increase attention, and regulate arousal.
First review the following instructions, then give it a try.

Place your arms straight out in front of you at nose level.

Then tuck your fingers into your palm and raise your thumbs up (i.e.,
thumbs-up position).

Focus your attention on the thumbs.

Avoiding head movement, use your eyes to follow your thumbs as

they move slowly in the following directions:
(1) up and down,
(2) left to right,
(3) bringing thumbs toward the nose and pushing thumbs away from
the nose, and
(4) in a circular motion. You can repeat each of these movements or
simply do one of each. Incorporate yoga music if desired.
____________
* Adapted from Self-Regulation and Mindfulness (Gibbs, 2017b)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
AUDITORY STRATEGIES

Age Range: All

Objective: To tap into the autonomic nervous system via the nerves
connected to the auditory system

Directions: The use of music before or during a task is one way to

change arousal and decrease stress. When using auditory activities,
consider whether the client’s arousal level is high, low, or in the
middle. For example, if clients are avoidant, hypervigilant, or
overresponsive to sensory input, use music with predictable rhythms,
such as drumming. In contrast, if clients are seeking sensory input,
use upbeat, high-tempo music to meet their needs. Additionally,
attempt to assess the client’s music preference. This involves the
selection of the genre of music. Finally, consider the client’s threshold
for music. That is, consider how much can they tolerate before
desiring to end the activity. The following are examples of auditory
activities to explore:

☐ Listening to music through headphones

☐ Playing games requiring the client to respond to verbal
directions (e.g., playing Simon Says or line dancing to a song
with directions, such as the “Cupid Shuffle”)
☐ Listening to a story read aloud, then answering questions
corresponding to the details
☐ Playing auditory bingo (see next page)
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
AUDITORY BINGO

Age Range: Children

Objective: To tap into the autonomic nervous system via the nerves
connected to the auditory system

Directions: This activity will help clients to focus and attend to

sounds in their environment to enhance their auditory discrimination
skills. Before introducing the activity to clients, take some time to
locate sounds online, such as through social media sites, and record
any sounds that correspond with the images on the bingo card
provided here. Then play these sounds in session with your client, and
have them locate the images that correspond with the sounds on their
bingo card. You can also develop the bingo boards on your own.
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 IN-SESSION ACTIVITY
AUDITORY BINGO

Age Range: Adolescents and adults

Objective: To tap into the autonomic nervous system via the nerves
connected to the auditory system

Directions: Before introducing the activity to clients, take some time

to locate sounds online, such as through social media sites, and record
any sounds that correspond with the words on the bingo card provided
here. Then play the sounds in session with your client, and have them
locate the words that correspond with the sounds on their bingo card.
You can also develop the bingo boards on your own.
Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

CASE SCENARIO*
Review the following case study. Then use the worksheet to analyze
some of the ACTION approaches discussed in this chapter.

Name: Nadine
Setting: Inpatient Psychiatric Hospital
Age: 15

I encountered Nadine at my clinical affiliation at an inpatient

psychiatric facility. During her intake, we reviewed various reports
describing a myriad of physical, emotional, and sexual abuse. The
documents almost led me to tears. Yet my tears had to take a backseat
as I sat as a young student in a room full of psychiatrists, fellows, and
nurses. The team soon invited Nadine in to meet with her and perform
further evaluation. I did not recognize it then, but the entire event was
traumatic for myself and involved a reexperience of trauma for
Nadine.

With each question, the answers became more graphic in nature.

Nadine described the sexual encounters she had experienced with an
adult cousin as if she were writing a novel. She shared his smell and
the sexual sensations she experienced at the time. When asked if she
knew what happened to her was wrong, she shrugged her shoulders
and stated, “I don’t know.” Nadine maintained a smile the entire
interview. It seemed like she put on an act that she had performed on a
multitude of occasions. Along with her smile was the voice of a
younger child. Her voice reminded me of an innocent 5-year-old girl.
It baffled me how she could appear so pure yet speak of such horror.

I began working with Nadine in individual and group sessions, and she
began to look forward to our encounters. As the weeks passed, I
realized the coping mechanisms she had previously revealed had
transformed into psychosis and hallucinations. Nadine expressed that
nighttime was her least favorite part of day. She would experience
night terrors and dreams that I would later discover were flashbacks of
torturous acts imposed by her caregivers during her younger years.
From what I could gather, her abuse ranged from her toddler years to
the present. One of her abusers now resided in prison for his acts
against her.

One day, I arrived to work with Nadine to discover she was placed in
the quiet room. As I approached the padded, locked box in which she
was placed, one of the nurses pulled me aside. Apparently, Nadine had
presented with dangerous behavior and become very physical and
aggressive toward the staff. They feared she would harm herself and
others, so she was placed in the quiet room. Unfortunately, this
became a trend and not an isolated event for Nadine. To further
complicate this situation, I would soon be ending my clinical
affiliation and leaving my role at the facility. When I shared this with
Nadine, she once again expressed the experience of loss. In the voice
of a very young child, she said, “Everyone good always leaves!”
Along with the ache that this statement placed in my heart, I also left
with the fear that Nadine would soon age out of that facility. Where
would she go? And under whose care? I thought about her eventually
becoming homeless and experiencing self-imposed abuse to survive.

___________
* Case study by Varleisha Gibbs, PhD, OTD, OTR/L
 PROVIDER WORKSHEET
CASE ANALYSIS

In this chapter, we have reviewed the neurophysiological changes that

result from exposure to stress and trauma. After reading through
Nadine’s case, see if you are able to connect her trauma to her
functioning. Use the following worksheet to analyze the case.

Task #1: Describe Nadine’s trauma. Use the Five Dimensions of

Trauma Model when developing your description, and consider the
different categories of trauma that describe her experience (expected
versus unexpected, isolated versus pervasive, etc.).

Task #2: What are some precautions you must take into account when
selecting activities? What physical or sensory activities would you
recommend? Why? What challenges would you suspect or anticipate
for Nadine as she eventually enters into the world?

Task #3: What are the next steps? Based on the ACTION-from-
Trauma approach activities presented in this chapter, what would you
recommend?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
PART TWO
ION
 CHAPTER 4
INTERGENERATIONAL
FACTORS

While a diagnosis of PTSD requires that individuals directly experience

trauma, or that they learn of a traumatic event that occurred to a loved one,
it fails to acknowledge a crucial aspect of trauma: that trauma can be
transferred between family members and generations. Known as
intergenerational trauma, this type of trauma affects generations of a
specific group of people and does not require directly experiencing a
traumatic event. The hearing of stories, learned behaviors, and subsequent
rules that emerge all feed into the well-being of generations that follow.
Indeed, there are stories within our history riddled with trauma. Survivors
carry that trauma not only in their minds but in their bodies. The cells in
their body hold onto the trauma and serve as a history book to be shared
with offspring. In this chapter, we aim to review the impact of
intergenerational and vicarious trauma through the following sections:

☐ Introduction
☐ Prevention and Early Intervention
☐ Primitive Reflexes
☐ Understanding the Self: Connection to Intergenerational Trauma
☐ Genogram
☐ Inner Child Work
 ☐ Case Scenario

INTRODUCTION

One of the first studies to highlight the concept of intergenerational trauma

analyzed the grandchildren of Holocaust survivors and found that such
individuals presented with signs of trauma, such as less-than-adequate
coping skills (Rakoff, Sigal, & Epstein, 1966). Since then, hundreds of
studies continue to investigate what was first deemed “survivor syndrome.”
For example, the presence of intergenerational trauma has been found
among descendants of enslaved Africans, Native Americans, refugees, and
victims of genocides. For individuals who are a part of such lineages, the
impact of individualized traumatic events—in addition to the historical
generational experiences of their ancestors—further compounds the
complexity of trauma. Societal and cultural factors, such as oppression and
lack of access to basic necessities, can add to the layer of intergenerational
trauma as well.

Beyond historical and cultural factors, there are underlying neurological

connections that also explain the experience of intergenerational trauma. In
particular, epigenetics provides a deeper explanation for what we see
emerge from our ancestral connections. While many assume that DNA is
fixed, there is an aspect of it that is malleable. Alterations in our genes can
occur as a result of our experiences, particularly those that are impactful.
The process by which such experiences can alter our gene expression is
called methylation. Research has found high rates of methylation among
individuals who survived the Holocaust and their offspring (Kellerman,
2013; Yehuda et al., 2016), demonstrating that exposure to severe stress
leads to changes in gene expression beyond vicarious trauma.

The events of 9/11 further support the existence of intergenerational trauma,

with studies finding that those who were pregnant at the time had children
who exhibited biomarkers associated with increased susceptibility to PTSD,
such as low salivary cortisol levels (Yehuda et al., 2005). Ironically, at the
time of this writing, our society is experiencing a global pandemic caused
by COVID-19. Again, we are faced with an event that will create a
catastrophic and traumatic aftermath. This societal tragedy threatens the
development and resilience of unborn infants and young children being
parented by individuals experiencing this trauma, as the descendants of
trauma are vulnerable to inheriting the emotional, psychological, and
physical adverse effects of trauma. Hence, it is vital we target those at risk
and highlight the impact of their ancestral history. Exploring these familial
connections can provide some solace and potential answers to the personal
difficulties they may be experiencing.

PREVENTION AND EARLY INTERVENTION

For those who are at the beginning stages of life, early intervention services
can curtail the effect of intergenerational trauma that could later emerge and
impact an individual’s quality of life. Therefore, taking an ACTION-from-
Trauma approach also involves providing intervention to newborns, infants,
and toddlers who may be at risk for experiencing future trauma. Let us
explore methods to address the needs of those in early childhood who are
exposed to trauma in utero or during infancy and the toddler years.

During the infant years, over one million neuronal connections are
established every second (Center on the Developing Child, n.d.). The early
years set the stage and tone for what is to follow. While not all trauma is
preventable, we can certainly address the effects of intergenerational trauma
through early intervention services that consider the relationship between
the child and the adults involved in their life. Our neurological reactions are
dependent on our environment and on the individuals with whom we
engage. In her book Self-Regulation and Mindfulness, Dr. Gibbs coined the
term reciprocal regulation to describe the significance of this interaction
between two or more individuals (Figure 13). Neurologically, reciprocal
regulation reflects the process by which our mirror neurons become
activated when we interact with someone else, which then triggers an
autonomic reaction based on that interaction. Not only do we detect and
perceive the feelings and emotions of someone in our presence, but we also
begin to regulate or dysregulate based on that encounter.
Therefore, practitioners need to address the individuals who are involved in
a child’s life to achieve the most optimal outcome in decreasing or
preventing future trauma. Children imitate the adults around them—from
how loudly they speak to the facial expressions they make. They model
how adults exhibit and respond to experiences with frustration, joy,
happiness, or empathy. In order to cease the cycle of trauma, it is thus
necessary to teach caregivers how to regulate themselves so they can
provide a model from which children can learn to self-regulate.

Figure 13. Reciprocal Regulation (Gibbs, 2017b)

Thus, from the start of life, it is critical for caregivers to engage with the
infant as much as possible. Even when children are unable to develop an
initial bond with a primary attachment figure, such as babies who enter into
the foster care system or who go through the adoption process, there are
strategies to enhance the bonding process with their adult caregivers (e.g.,
their foster or adoptive parents). These strategies enhance the caregiver-
child bond and facilitate mental health outcomes for the child and caregiver
alike, whether these strategies are used in the face of traumatic experiences
or as preventative measures (Clark & Kingsley, 2020):

☐ Provide skin-to-skin contact during the first days and months of

life.
 ☐ Perform a caregiver-provided massage, which has been shown to
not only calm the infant but to decrease parental stress and anxiety.
Addressing reciprocal regulation prior to such techniques is vital.
☐ Participate in shared experiences, such as reading to the child.
☐ Ensure consistent play with the child at least once daily.
☐ Feed the child based on their needs rather than doing so at
scheduled mealtimes.

In addition, practitioners should consider providing coaching to caregivers,

teachers, and daycare providers regarding how to interact with children in a
way that facilitates brain development. Here are some strategies to consider:

☐ Recognize and acknowledge the start of an interaction.

☐ Make eye contact during the interaction.
☐ Listen to the child and allow them to lead during play-based
activities.
☐ Share the child’s attention and focus.
☐ Be sure to return the focus by engaging and responding to the
child.
☐ Assist the child with labeling and naming objects in the
environment, as well as those used during the interaction.
☐ Establish an ending to the interaction with words and gestures,
such as signing “all done.”

PRIMITIVE REFLEXES
Early childhood preventative interventions must not only involve parental
interaction. We must also utilize activities focused on the body, as doing so
allows us to address how intergenerational trauma might manifest
physically. In particular, the presence of primitive reflexes, or motoric
actions, in children may provide a red flag for future emotional and
behavioral challenges. Primitive reflexes typically subside in the early
childhood years, but when there is a lack of appropriate integration, these
reflexes persist. This may lead to dysfunction, including poor coordination,
emotion regulation challenges, and difficulty attending to and performing
tasks (Konicarova & Bob, 2013).

Primitive reflexes are most observable during the beginning stages of life
(see Table 6). These reflexes are most necessary for motoric development
and engagement with the environment during the early years. Additionally,
such involuntary reflexes help to transition a newborn through the birthing
canal and assist with feeding. As the baby gains the ability to move and
attend to a caregiver, bonding and attachment occur. Eventually, primitive
reflexes become less observable as they integrate and work with the motoric
system to establish a more coordinated sensorimotor system. Consequently,
they may re-emerge in times of stress and trauma. This is due to their
association with brainstem level functioning.
Primitive Reflex Function
Asymmetrical Tonic Neck Extension of one side of the body and flexion of the other to assist in
(ATNR) Appears 18 weeks in the birthing process and later with reaching, eye-hand coordination,
utero, disappears around 6 and airway passage clearance
months
Symmetrical Tonic Neck Assists in preparation for crawling; when the child is on hands and
(STNR) Appears 4–6 months, knees, a flexed head results in legs extending; when the head is
disappears around 8–12 extended, the opposite occurs, with arms extending and legs flexing
months
Moro Occurs during the first breath of life; continues as a startle reflex in
Appears in utero, disappears response to an unexpected stimulus or threat; the involuntary response
around 6 months is protective, as the infant is unable to distinguish threats; extension of
the body (fall reaction), followed by full flexion (protective position),
occurs spontaneously
Spinal Galant Activates when either side of the spine of an infant is stroked; neck
Appears 20 weeks in utero, extension, hip rotation, and body flexion occur; assists with hip
disappears around 9 months movement and rotation, specifically in utero and during the birthing
process, as well as in the development of crawling
Palmar Assists in sucking, as the hands contract as the baby sucks;
Appears 18 weeks in utero, stimulation of the palms results in flexion or a grasp reflex; activation
disappears around 6 months also leads to the mouth opening and jaw movement
Rooting Assists with feeding; baby will respond to stimulation of the cheek by
Appears at birth, disappears turning toward the stroked side and opening mouth
around 4–6 months
Tonic Labyrinthine Assists baby through the birthing canal
Appears in utero, disappears Forward: As head is flexed, the arms and legs curl toward the body
around 4–6 months Backward: As the head is extended, the body goes into extension
(Backward can sometimes
last into the third year of life)
Landau Head, legs, and spine extend when baby is held in the air horizontally
Appears 3 months, disappears in the prone (belly down) position; assists with muscle tone
around 12 months

Table 6. Primitive Reflexes in Children (Gibbs, 2017b)

Given that the presence of primitive reflex patterns is a strong predictor of

future functioning, the halting of these developmental milestones can
impact successful interaction with the environment (Deiss et al., 2019).
Trauma is one particular risk factor that can lead to developmental delays
among children, with evidence demonstrating a correlation with motor
dysfunction and challenges with self-regulation. This includes poor emotion
regulation, sensory processing, and executive functioning. We further
expand upon the areas of dysfunction in Table 7.
Primitive Reflex Dysfunction
ATNR Poor balance; difficulty with coordinated eye movements needed for
reading and writing; challenges in crossing midline of the body and
separating the upper body and lower body movements
STNR Difficulty crawling on all fours; poor balance; clumsiness; difficulty
with midline activities; poor sitting position (“W” sitting)
Moro Hypervigilant; overactive fight-or-flight reactions; sensitivity to light,
sound, touch; poor emotion regulation; hyperactivity; poor attention
to tasks; frequent illness due to a stressed immune system; fatigue
Spinal Galant Difficulty maintaining a seated position; constant fidgeting; bed-
wetting and bladder accidents; sensitivity to touch and certain textures
(clothing); challenges in following directions and with short-term
memory
Palmar Mouth movement as the child performs cutting, writing, or coloring
activities; chewing on objects, such as pencils; biting people;
difficulty with grasp and speech due to tension in hands and mouth
Rooting Sensitivity in the mouth; challenges with food textures; messy eating;
poor speech articulation
Tonic Labyrinthine Difficulty coordinating body movement and eye movement; motion
sickness; poor balance and posture; poor timing and sequencing
(dyspraxia)
Landau Challenges with motor activities; high muscle tone (hypertonia) and
difficulty learning; toe walking and lack of coordination; possible
difficulty sitting against chair back; absence of the reflex during infant
years indicates hypotonia and possible intellectual disability

Table 7. Dysfunction Resulting from Retained Primitive Reflexes

Depending on the scope of your practice, you should consider including the
activation and evidence of such reflexes in your evaluation and intervention
processes, and reflect on the general need to include gross motor activities
within sessions to address trauma. The following three tables provide
guidelines for such analysis by highlighting some of the various primitive
reflexes, their function, and examples of dysfunction if primitive reflexes
are retained. However, this is not a comprehensive list. Depending on your
clinical reasoning and the scope of your practice, you may need to refer
clients to another professional to support the treatment you perform. Table 8
describes methods to activate the primitive reflexes. These exercises can be
incorporated in a treatment plan to assist in the integration of the reflexes
through exposure.
Primitive Reflex Exercise
ATNR • Place the child in supine on their back. Bring an object (e.g., toy) in
their line of sight, placing it to their side once getting their
attention.
• Encourage them to reach for the object, observing for the presence
of ATNR.
• Alternative option (if age appropriate): Place the child on all fours
in a quadruped position using a bolster if needed.
• Gently turn their head to the side and hold for five seconds.
• Look to see if they can maintain the position or if they fall to the
side opposite of the head being turned, indicating the presence of
ATNR.
STNR • Place the child on all fours in a quadruped position.
• Gently move or have the child move their head up and down and
hold for five seconds in each position.
• Look to see if they sit back on their legs, suggesting the presence of
STNR.
Moro • Safely move the infant by tilting them backward, allowing the head
to move posteriorly.
• Look for extension of the body and extremities followed by flexion
toward midline.
Spinal Galant • Position the infant on their belly in a prone position.
• Gently stroke the left and right sides of their spine.
• Look to see if they move their body toward the stroke.
Palmar • Apply gentle pressure to the infant’s palm by placing your finger
into their hand.
• Look for them to flex their fingers and squeeze your finger. Also
detect movement in their mouth and/or tongue, and attempt to pull
 your finger toward their mouth.
Rooting • Gently stroke the cheeks and above the upper lip of the child
approximately three to five times.
• Look for head movement toward the direction of the stroke and
mouth opening and movement.
Tonic Labyrinthine • Safely hold the infant suspended in a horizontal position in prone.
• Gently tilt their head forward.
• Look for flexion of their trunk and extremities.
Landau • Safely hold the infant in a suspended horizontal prone position.
• Gently tilt their upper body toward the floor.
• Look for extension of the body.

Table 8. Exercises to Activate the Primitive Reflexes*

In addition to the exercises in Table 8, the following list provides you with
simple activities you can consider in assisting with the integration of
primitive reflexes. You can also find additional exercises in Self-Regulation
and Mindfulness (Gibbs, 2017b).
☐ Provide daily tummy time, and avoid placing the baby on their
back for prolonged periods of time while awake.
☐ Promote crawling by placing the baby on their belly while
engaging in play or by propping them up on a bolster, allowing
them to place weight through their extremities.
☐ Incorporate core-strengthening activities, such as placing the baby
on their back and encouraging them to roll over or to sit up to
retrieve a toy.
☐ Provide gentle rocking to encourage movement, such as placing
them in your arms or using a baby swing.
☐ Introduce different food variations as appropriate.

UNDERSTANDING THE SELF: CONNECTION TO

INTERGENERATIONAL TRAUMA
Trauma wounds are not always obvious or blaring. When we hear the word
trauma, we often think about huge, impactful, traumatic events that we call
big “T” traumas. However, there are also smaller events, or those that we
vicariously experience, that can also influence our fears, habits, reactions,
and overall behavior. Known as little “t” traumas, these experiences do not
always come with a clear memory. Nonetheless, when these little “t” events
accumulate over time, they can produce an allostatic load that affects our
personal health and well-being and that of our offspring. In fact, both big
“T” and little “t” traumas are associated with physiological implications
that have the potential to result in unhealthy habits and behaviors.
Unaddressed, they transcend generations and can increase susceptibility to
certain physical diseases and mental health conditions. However,
knowledge can assist us in proactively addressing these factors. For this
reason, we must investigate our clients’ ancestral linage and their
connection to intergenerational trauma.

Because clients unconsciously carry the burdens and baggage of their

family history with them, they can unknowingly experience empathy
overload in response to this intergenerational trauma. Their reactions may
also mimic those of their caregivers and others around them. By identifying
these shared emotions, clients can determine how they manifest. What are
the triggers for these emotions? Where do clients feel and experience these
emotions in their bodies? Once clients acknowledge the historical landscape
of their family, they can liberate themselves from these past events. This
allows them to set boundaries, implement useful coping strategies, and
disconnect from situations that are not their own. To delve into this further,
we will:

• Investigate family dynamics via a genogram

• Determine how familial beliefs and practices inform who clients
become
• Identify how the client’s inner child impacts their ability to address
trauma

GENOGRAM
Similar to a family tree, a genogram is a diagram that uses symbols to draw
connections between family relationships across generations. It can be
useful to determine patterns of behavior and interactions with others.
Symbols are typically used to describe gender, biological (and adoptive)
offspring, and the qualities of familial relationships. Shared information can
also include psychosocial history and medical genetics. A genogram has the
potential to be a complex milieu of familial data. For our purposes, we will
map out a simple genogram using the template that we have provided with
the following worksheet. While this process can certainly allow for a better
understanding of the client’s history, clinicians must take into account the
client’s readiness to review their family history, as doing so can be a lot to
handle and can cause distress. Please use your clinical reasoning. Before
working with a client, consider completing your own genogram as well.
 IN-SESSION ACTIVITY
GENOGRAM: FAMILY HEALING MAP*

Age Range: Adults

Objective: To illustrate family relationships and ancestral information

related to intergenerational trauma

Directions: To start the process, become familiar with the symbols

used in the genogram, which are described below.

Genogram Key:

Characteristics

Health and Mortality

Relationships
Next Steps: Interview the client as you map out the genogram. Use
the template that follows, starting at the bottom. Select the gender
symbol for your client, and connect it to one of the vertical lines for
“children.” Place a double square or circle around the symbol to
indicate them as the client. You can consider placing them in
chronological order in comparison to any siblings (e.g., if they are the
first child, place the client’s symbol below the vertical line furthest to
the left). Write their name or initials below it. Continue to add siblings
if applicable. Moving to the parents, grandparents, and great-
grandparents, write their names or initials next to the corresponding
symbols. Next, update each symbol using the key provided for
characteristics and health and mortality for the various family
members.

The lines on the genogram indicate relationships. Vertical lines

represent relationships with children, while horizonal lines represent
spousal/partner relationships. Update the lines based on the
illustrations in the relationship key provided. For close relationships
between two individuals, draw a parallel line alongside the vertical or
horizontal lines. For unhealthy relationships or divorce, draw a
parallel line, then place a slash through it as indicated. The other
relationship symbols should run parallel to the vertical or horizontal
lines between those two family members. You can choose to add
relationship lines across the genogram as needed (e.g., from a
grandparent to a grandchild).

Have the client review the genogram with the goal of identifying
themes and similarities among the family members. Then ask them
share at least three generational characteristics they would use to
define their family based on stories and/or personal interactions
between family members. They can share values, beliefs, physical
characteristics, cultural traditions, hobbies, unique circumstances
(e.g., career-related factors, immigration history, etc.), and other
personality traits they desire to share. Write down these generational
characteristics and analyze the findings with the client, including how
the client perceives these characteristics in relation to their own
personal traits. How do these generational characteristics impact how
they cope and experience stress and trauma? Use the Genogram
Gratitude and Permission List that follows to assist them in processing
their revelations.

____________
* Adapted from
https://broadcast.lds.org/elearning/FHD/Community/en/Community/Cynthia%20Doxey%20
Green/Tracing_Family_Traits_Using_a_Genogram/Genograms.pdf

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 GENOGRAM TEMPLATE

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.
 CLIENT WORKSHEET
GENOGRAM GRATITUDE AND
PERMISSION LIST

Age Range: Adults

Objective: To assist in processing family relationships and ancestral

information related to intergenerational trauma

Directions: After you complete your family genogram, use the chart
below to list what you are grateful for and what you give yourself
permission to move past with regard to your family trauma. Review
the provided examples to guide you in completing your lists.
Gratitude Permission
After reviewing my family genogram… After reviewing my family genogram…
I am grateful for: I give myself permission to:

(Examples: My spirituality, my culture, (Examples: To change my mind, to leave

my intellect, my love for writing, my unhealthy relationships, to say no, to be great at
passion for dance, my sarcasm, my something, to be assertive, to share my
ability to draw, my ancestors) boundaries, to be different, to ask for help)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

INNER CHILD WORK

As children, we need to rely on others for our survival. Inversely, as adults,

we become increasingly independent and, in turn, may no longer view
trauma as a challenge or obstacle that impedes our growth. We believe we
have the skills and abilities to move past those experiences that once caused
fear and shame. However, addressing the needs, experiences, and beliefs of
the child within can assist in a successful plan of care. To further support
clients in their journey to accept and release any intergenerational trauma
preventing their growth, they must address their inner child.

Children acquire more than their physical characteristics from their parents
and ancestors. The family system also introduces them to rules and morals,
and it provides their first exposure to judgment. When individuals deviate
from these prescribed rules, they tend to develop a sense of blame or shame.
Accordingly, it is important to consider how we (and our clients) form these
concepts in the first place. What your parent believed is connected to their
parent’s belief, which is connected to their parent’s belief, and so forth.
These learned behaviors accompany the neurological and genetic makeup
that are passed through the bloodline. Therefore, how we experience, cope
with, and heal from trauma are all connected to our family.

At the same time, our personal and familial experiences alone do not
explain the connection to who we are and how we reveal our
intergenerational trauma. There is also a connection to the universal
primitive drives and instinctual needs that we have as humans. For example,
newborn babies instinctively know to seek a connection with their caregiver
by crying when they require food, affection, or a diaper change. As
children, we learn to balance these primitive drives with our social, familial,
and cultural norms. We begin to suppress these primitive drives and innate
needs, which ultimately results in the development of our inner child. This
inner child causes us to judge ourselves when it appears we have broken a
rule or moral code. In turn, we hold in our fear, leave behind our child
activities, view our assertiveness as aggression, and conceal our stress.
While we may not realize it, our inner child continues to lead the way and
remains in control during adulthood. Addressing ancestral trauma calls for
us to work with our inner child.

The following activity provides clients an opportunity to connect with their

inner child to grow toward healing. Use this activity to guide your clients in
investigating their core survival needs and desires to better understand their
ability to handle and cope with trauma. Before beginning, explain your
justification for performing the activity and explain how you intend to use
the information. Be sure to incorporate grounding activities during and after
the discussion.
 CLIENT WORKSHEET
BALANCING THE ADULT AND
INNER CHILD

Age Range: Adults

Objective: To connect with underlying innate physiological and

emotional needs to create balance and healing from trauma

Directions: In part 1 of this worksheet, answer the questions listed to

revisit to your childhood. After you have done so, use the chart in part
2 to indicate whether or not you believe your needs are currently
being met by placing an X in the “yes” or “no” column. You may also
place N/A in both columns if the question does not apply to you.
When you are done, total up both columns to identify areas of
strength and areas where you have an opportunity to address the needs
in your life. Then use the last column to write a statement about a
possible connection between your current state and your inner child.
Lastly, in part 3, answer the synthesis questions. Follow with a
grounding activity, such as any of the activities identified in chapter 2.

Part 1:
1. What activities did you love as a child?

2. How did you react if you were unable to do those activities?

3. How were you told you were supposed to act when you could not
do the things you desired?
4. Do you still do any of those desired activities? Why or why not?

5. When you were a child, who were you expected to be or learn to

be (e.g., what type of person, career, etc.)?

6. Did the expectations of your family match who you wanted to be?

7. How did you respond to disagreements or arguments?

8. Did you display behavior that was perceived as aggressive by

others? Provide an example.

9. How did you handle being upset, anxious, scared, or afraid?

10. How were you told to handle those emotions?

11. What did you do to get the attention of your parents, teachers, or
peers?

12. How did they respond to your attempts to get their attention?

13. Did you feel safe, loved, and accepted as a child? By whom?

Part 2:
Yes No Connection to Inner Child
Are my basic needs met?
My financial needs are met.
My biological needs (e.g., food) are met.
My housing needs are met.
Do I feel secure?
I feel safe in the physical environment where I live.
I feel secure in my roles (e.g., as a parent or employee)
I have faith in myself.
Do I belong?
I feel needed by others.
I feel valued by others.
I feel respected.
I have positive interactions with others.
Am I confident?
I am confident in myself (e.g., skills and abilities).
I am confident in those around me.
I see opportunity for growth and healing.
Am I helpful to others?
I contribute to my community/society.
I assist others in moving their goals forward.
I desire to assist others.
Total:

Part 3:
1. What suppressed parts of you do you wish you could let out?

2. What did you do as a child that you wish you could do again?

3. What are you passionate about?

4. Can you turn any of your perceived “negative” or socially

unacceptable qualities into useful attributes? Which of those
qualities could you use to address needs that you identified as not
being met in the previous chart?

5. What parts of your childhood can you now accept, and what can
you release?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

CASE SCENARIO*
Review the following case study. Then attempt to apply some of the
ACTION approaches discussed in this chapter.

Name: Caroline
Setting: Community-Based Practice
Age: 19

I first met Caroline when she was 19 years of age. She was one of five
children raised by a young single mother. Caroline’s mother, Sharon,
had a traumatic childhood with a history of poverty, parental neglect,
and parental addiction. This included growing up with an alcoholic
father who was abusive toward her mother. Sharon received public
assistance to care for Caroline and her other siblings. In the past, they
had experienced various evictions and stayed in homeless shelters in
the interim. They eventually obtained a home through public housing.
Caroline was the eldest child and cared for her siblings when her
mother would work through the evenings, leaving Caroline in charge.
Caroline was 8 years old when she began the role of the other primary
caretaker.

In this caretaking role, Caroline would stay awake to care for her baby
sister until her mother arrived home. When it came time to wake for
school in the morning, both Caroline and Sharon would have difficulty
rising. As a result, the children were frequently late for school or
absent altogether. Eventually, Caroline decided to drop out of school
and work to assist her family financially. Despite her intentions,
Caroline found herself befriending a group of people from her
neighborhood who introduced her to alcohol and illegal narcotics. This
new group of friends gave her a sense of community and security that
she had never experienced before. Caroline began spending significant
amounts of time with her new friends, leaving her siblings home alone
while their mother was at work.

Caroline developed a substance use disorder, which led her down a

path of criminal activity to support her addiction. Secondary to unsafe
behavior, she became pregnant at the age of 17. Unfortunately,
Caroline did not realize she was expecting until she was five months
pregnant, and she continued to utilize narcotics and alcohol throughout
her pregnancy. Once she gave birth, Child Protective Services stepped
in after the medical staff reported her substance use. Caroline was not
able to provide the name of her newborn son’s father, so Child
Protective Services identified a foster family to care for the baby once
he was discharged. The hospital social worker began aligning
resources to identify an outpatient rehabilitation treatment program for
Caroline upon discharge. Although this was not something Caroline
desired, she wanted to work on getting her son back.

The social worker also reached out to the early intervention system,
and a case manager developed a family plan of care, including early
intervention services for the baby. They contacted my agency to begin
an individualized family service plan. The plan involved Caroline
attending therapy sessions at the daycare center her baby attended. I
was one of the therapists who would come onsite, meet her there, and
provide occupational therapy to her infant son. Other team members
provided physical therapy services and additional developmental
interventions as well. The intent was for Caroline to attend at least one
session per week, but this proved to be a challenge as she was often
absent from or extremely late to the sessions. Ultimately, it became
more and more of a task for the entire team. I eventually reached out
to the case manager to suggest a team meeting.

____________
* Case study by Varleisha Gibbs, PhD, OTD, OTR/L
 PROVIDER WORKSHEET
CASE ANALYSIS

In this chapter, we have reviewed background information on

intergenerational trauma. After reading through Caroline’s case, see if
you are able to connect her trauma to her functioning. Use the
following worksheet to analyze the case.

Task #1: Determine the risk factors for intergenerational trauma from
Caroline’s story. List the adverse events you acknowledged here.

Task #2: Using the space provided, practice making a genogram for
Caroline based on the available information.

Task #3: What are the next steps? Based on some of the ACTION-
from-Trauma approach activities in this chapter, what would you
recommend for Caroline and her son?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

____________
* Ensure the age appropriateness of these activities before initiating with a client.
 CHAPTER 5
ORGANIZATIONS AND
SYSTEMS
RE-TRAUMATIZATION

The wide-ranging impacts of social trauma are felt by the collective, with
consequences for those directly connected with the event, as well as indirect
or vicarious repercussions for society at large. Social traumas affect the way
in which we create meaning in the world. As practitioners, we increasingly
operate in spaces at a time when we are both living through the wake of
multiple social traumas and serving individuals who have experienced
multiple dimensions of trauma. This ever-evolving dynamic requires being
aware of the effects of trauma on survivors, as well as being mindful of the
ways in which our lived experiences influence our perspectives and shape
the environments in which we work.

In this chapter, we explore the underpinnings of social traumas and their

effects. We further expound on barriers to care by discussing the impact of
cultural trauma on our ability to provide optimal therapeutic outcomes and
culturally competent interventions. Our ultimate aim is to explore how these
traumas affect our organizational cultures and climates. We discuss the
ways in which social and cultural traumas influence our organizations and
systems, and we examine the potential organizational trauma that ensues in
its aftermath.
Additionally, we review methods used to assess organizations in moving
toward ACTION and discuss ways to create organizational cultures and
climates that are inclusive for all. Finally, we provide reflective practices
and techniques that practitioners can utilize to understand how we present
in spaces, as well as to assist us in remaining resilient and centered in the
midst of widespread turmoil. We anchor our discussion of social and
cultural trauma, including how organizations and systems can result in re-
traumatization, through the following sections:
☐ The Landscape
☐ Social Trauma
☐ Cultural Trauma
☐ Case Scenario
☐ Organizational Trauma
☐ Safe Spaces
☐ Cultural Safety
☐ Conflict Resolution
☐ Organizational Assessment
☐ Trauma-Informed Organizational Governance
☐ Case Scenario
☐ Self-Care Strategies for the Trauma-Informed Practitioner

THE LANDSCAPE
Social traumas are cataclysmic events that break down the basic fabric of
society (Hirschberger, 2018). These include, but are not limited to, wars,
natural disasters, pandemics, and genocides. Social trauma involves a
definable social group, such as one’s family or friends, and it encapsulates
the effects of threats, disaster, deprivation, and violent conflict on a
society’s capacity to adapt to the world, to regulate and nourish themselves,
and to develop. Most of us do not have to reflect back too far to recount a
social trauma or an event that impacted society as a whole.

For many, 2020 was a year that cemented social trauma into our collective
consciousness. At the time of this writing, coverage of the events influenced
by the COVID-19 pandemic are front and center on every newscast,
television station, and social media platform, as well as in the workplace
and at the dinner table. Traumagenic events, such COVID-19, can
precipitate challenges for individuals seeking intervention and recovery
during times of unrest and turmoil. Though the impacts of COVID-19 are
still emerging, traumatic experiences such as these are known to tax coping
resources and challenge personality dynamics (Wilson, 2008).

As a society, we are collectively aware of the very real ramifications of the

COVID-19 pandemic, which included shelter-in-place orders, record
unemployment rates, travel bans, school closings, uncertainty, and loss of
normalcy. With an estimated 24,135,690* reported cases of COVID-19 in
the United States, adding to the 97,116,661 † reported cases globally, and
over 2,081,489 known deaths, our daily lives have dramatically changed as
the world witnesses the unprecedented scale of this pandemic.

The course of this pandemic has shone light on the already vulnerable
communities who struggle to access adequate resources and optimal
interventions even in times of relative normalcy. It has disrupted vital food
supply chains and access to critical health care for fragile communities
worldwide. Each year, an estimated 243 million women ages 15–49 are
subjected to intimate partner violence, with this number increasing under
the conditions created by COVID-19 (United Nations Women, 2020). As
this global crisis continues, resulting in continued disruptions to the health
care system and food supply, maternal and child mortality is expected to
increase dramatically (Roberton et al., 2020).

Moreover, the age of our 24/7 news media cycle can further disrupt,
disorient, and re-traumatize individuals who have experienced social
trauma, adding to an already brewing mix of dynamics. With continuing
coverage of this pandemic, many are overstimulated by a constant barrage
of information regarding the virulence of this virus, with ever-present
updates of its spread throughout the world. As the effects of COVID-19
have begun to touch families in very intimate and personal ways, many
have experienced a bombardment of updates on the health of loved ones,
family members, and—in some cases—strangers who have been infected
with, recovered from, or passed away from the virus.

There are several long-term consequences of the continuing news coverage

of social trauma. In particular, the repeated discussion of traumatic events
and the proliferation of catastrophic images in times of social crisis may
further traumatize already predisposed groups. It can result in the
experience of secondary or vicarious trauma as individuals become
emotionally over-aroused in response to repeated news coverage (Kaplan,
2008). This can disturb treatment progress and interfere with the
intervention success.

For many, COVID-19 has caused lives and practices that were once foreign
—such as social-distancing mandates, wearing personal protective
equipment, and rising social isolation—to become familiar. Although data
regarding the second- and third-order effects of these measures are
emergent, we do know that loneliness and social isolation have serious
impacts on mortality, with similar odds to light smoking and alcohol
consumption (Xia & Li, 2018). As a health care practitioner, you may have
experienced first-hand the impact of these unparalleled events in your
personal life and in the lives of those you serve. As we collectively learn to
adapt our behaviors, expectations, and lifestyles in response to this
pandemic, many of us remain on the front lines interacting with and serving
the public. This underscores the need to understand social trauma and its
impacts on individuals and communities, as well as to tailor interventions
that consider the cultural nuances of those we serve.

SOCIAL TRAUMA

Health care professionals provide vital expertise and intervention in

response to disasters, social crises, and mass traumas. For those of us in
client-facing roles, the upheaval and uncertainty caused by social traumas in
particular can impact the delivery of our services and, ultimately, the
success of our interventions. A large portion of those impacted are children,
adolescents, and their caregivers, which underscores the need for successful
interventions that promote recovery and healing (Joyce, 2020). Like other
forms of structural traumas, those exposed to social trauma may also
express emotion dysregulation, musculoskeletal problems, challenges with
sensory perception and self-regulation, poor self-care skills, and cognitive
deficits (Gorman & Hatkevich, 2016). The current and pervasive proximity
of the COVID-19 pandemic has made understanding social traumas more
critical for those in health care and in public service (Salas, 2020).

Social trauma can occur regardless of race, ethnicity, socioeconomic status,

gender, or culture, although ethnic and racial minorities (particularly young
adults) who come from low socioeconomic backgrounds are at greatest risk
of traumagenic exposure (Benjet et al., 2016). Social traumas
disproportionately affect historically underserved or marginalized
communities, groups, and individuals. While tackling the complexities,
emerging effects, and implications of the COVID-19 virus, we have found
that it has also had a disproportionately devastating impact on historically
disenfranchised communities, particularly Black and Latino communities.

Given that our nation has a historical past of systemically disenfranchising

many communities—especially communities of color—we may not be
ready, willing, or prepared to adequately provide intervention opportunities
for those most affected. Although data for the COVID-19 pandemic is still
emerging, early data shows an overrepresentation of Black people among
hospitalized patients. In addition, while Black people make up about 13
percent of the U.S. population, they account for 27 percent of U.S. COVID-
19 deaths (Kaur, 2020). Many factors contribute to these health disparities,
including differences in living conditions, work circumstances, and
preexisting health conditions experienced by members of ethnic and racial
minorities (CDC, 2020), all of which underscore the need to explore
cultural trauma and its implications on intervention.
CULTURAL TRAUMA

The potential for trauma exists among all major racial and ethnic groups in
our society, yet few studies have analyzed how race and ethnicity are
associated with trauma exposure and/or traumatic stress reactions. The
word trauma implies overwhelming harm, physical injury, emotional stress,
or emotional damage, and these collective experiences are often
exacerbated by the proximity of generational trauma, discrimination, and
historic marginalization (National Network to End Domestic Violence,
n.d.).

Understanding the implications of cultural trauma, as well as its influences

on the communities we serve and the interventions we create, is central to
creating optimal resolutions and outcomes. Cultural trauma involves an
intense loss of connection and identity that is experienced by members of a
group and is permanently imprinted in the group’s collective consciousness
(Alexander et al., 2004). This trauma subsequently shapes the collective
norms, behaviors, and mores of that culture. The trauma need not have been
experienced by all in the social group, but its influence and impact are
commonly accepted by those affected (Eyerman, 2019, p. 23). Examples of
cultural traumas include, but are not limited to, African-American
enslavement and its aftermath, the Holocaust, Native American genocide,
and refugee and immigrant trauma. Though not a comprehensive account,
these examples of cultural trauma provide a foundation for understanding
the wide and complex experiences faced by those whom we serve.

Understanding the cultural and historical experiences and perspectives of

those who seek our services is vital to producing successful treatment
outcomes. It is important to understand that although the traumagenic
experiences may have occurred in the distant past, the legacy of those
traumagenic experiences remains for many in the collective group.
Therefore, providing transformative interventions in communities that have
experienced or are experiencing the effects of cultural traumas requires
culturally competent environments that are safe, empowering, trustworthy,
collaborative, and transparent. These environments should also facilitate
personal reflection, development, and empathy.
Understanding the impacts of social and cultural trauma is critical to
developing an ACTION approach and sustaining culturally competent
treatment interventions. “Amidst the countless panoramas of traumas that
are part of any disaster, the rendering of care must be responsive to the
cultural context of suffering” (Marsella et al., 2008, p. xii). In particular,
practitioners must acknowledge that trauma patterns and behaviors are
repeated in a manner that impacts individuals in successive generations.
Cultural traumas often exist in our family units, which affects our
communities and relationships for subsequent generations. These traumas,
which are a byproduct of our human experience and the experience of those
who have come before us, are real and present. Cultural trauma renders an
individual vulnerable to further trauma and to possible regression
throughout their lifetime. An integral part of implementing effective
treatment interventions and facilitating healing is understanding the impact
that this cultural trauma has on clients. This means showing sensitivity to
the situational and historical dimensions of the trauma, including racial,
religious, socioeconomic, and political aspects.

There are many examples of practitioners facilitating interventions with

good intentions, yet failing to understand the cultural, historical, and
socioeconomic dimensions and context of a disaster or the complexity or
nuance of the ensuing trauma, thereby subjecting clients to re-
traumatization. The response to victims of Hurricane Katrina provides an
example of the gross underestimation of the extent to which historic
socioeconomic conditions, systemic disenfranchisement, and cultural norms
can impact the provision of disaster relief and optimal interventions.

The cultural dimensions of trauma are also currently playing out in the
midst of the COVID-19 pandemic. Many groups have witnessed acts of
xenophobia, scapegoating, and—in some cases—physical assaults against
Chinese Americans. Between January 28, 2020, and February 24, 2020, San
Francisco researchers reported over 1,000 cases of xenophobia against
Chinese American communities (Blanding & Solomon, 2020). These
events, though not isolated, in the context of historic cultural trauma
provide a foundation for the urgent requirement that we provide culturally
appropriate and tailored interventions for those impacted.
In addition, racism and bias have a profound impact on the health status of
children, adolescents, emerging adults, and their families (Trent, Dooley, &
Dougé, 2019). In the case of Americans of African descent—who have
experienced multigenerational trauma as a direct result of colonialism,
enslavement, lynching, Jim Crow laws, mass incarceration, and other acts
of deliberate disfranchisement and oppression—there may be a shared sense
of collective memory and response around cultural trauma experiences.
These experiences exacerbate disparities in health, wealth, and educational
attainment and may present as maladaptive behaviors that affect emotional
and behavioral development (Office of Minority Health, n.d.).

The effects of disenfranchisement are also evident in the Navajo Nation,

who were hard hit by COVID-19—surpassing New York and New Jersey
for the highest per capita coronavirus infection rate in the U.S. Historic
disparities within the Navajo Nation have long existed, with 30 to 40
percent of residents not having access to running water, and with residents
having access to few to no grocery stores (Silverman, Toropin, Sidner, &
Perrot, 2020). The Navajo Nation continues to struggle with systemic
challenges that are directly tied to historical disenfranchisement and the
legacy of their community’s experience with cultural trauma in the U.S.

When children, adolescents, and their caregivers are directly or indirectly

exposed to traumagenic events such as these, it can lead to a myriad of
challenges, including sadness, grief, pain, panic, confusion, despair, anxiety,
and depression (Ayden, 2017). In the current era of COVID-19, these
mental health challenges have been compounded by the widespread school
closures that forced 90 percent of global learners (1.5 billion young people
worldwide) out of school (Joyce, 2020). Schools provide important mental
health resources for students, and these widespread closures resulted in
students not receiving the needed care they would have otherwise received.
Although we do not yet have data regarding the long-term mental health
effects of COVID-19 on children and adolescents, the unprecedented scale
of this health crisis underscores the importance of monitoring its effects and
providing effective interventions for all affected.
CASE SCENARIO*

Review the following case study. Then attempt to apply some of the
ACTION approaches discussed throughout this book.

Name: Christina
Setting: Community-Child Family Services
Age: 10

Christina is a 10-year-old, Taiwanese American girl who is currently

residing in a pre-adoptive home with her younger sibling. Her
biological mother was born in the U.S., while her biological father
emigrated to the U.S. from Taiwan and had been living in the country
on a Green Card until recently. Christina’s biological mother had
significant mental health issues, and her biological father struggled
with substance abuse. When Christina was 5 years old, her parents
separated, after which Christina’s biological mother became her
custodial parent, and Christina spent summers with her father’s family.
After one particular summer visit with her father, Christina’s mother
abandoned her and her younger sibling at a nearby school. Their
mother simply placed the children outside of the vehicle and drove off.
During this time, Christina’s biological father returned to Taiwan for a
few weeks to take care of family affairs. He was subsequently barred
from reentering the U.S. due to multiple felony warrants and lost his
Green Card status. At this point, Christina’s parents relinquished
parental rights for both Christina and her younger sibling, and the
children were placed in a pre-adoptive foster home.

As a result of these multiple traumagenic disruptions, Christina

experiences anxiety, nightmares, emotional distress, and defiance. Her
defiance is currently directed at her pre-adoptive parents. When school
was in session prior to the COVID-19 pandemic, I worked with
Christina’s teachers and support team to ensure she had support for her
anxiety. She received early intervention services that included an
individualized pre-adoptive family service plan and an individual
development program (IDP), along with evaluations and a family
history. Although Christina was a good student in school, she
struggled to complete her schoolwork at home. She reported that
staying at home made her feel like she was confined to a box.

As a result of the pandemic, Christina’s anxiety is heightened, and she

is afraid that she will catch the virus or that her friends will catch it. In
addition, Christina experienced significant worries when the COVID-
19 outbreak first began because she could not get in touch with her
biological father. He was residing in Taiwan, which was near the
epicenter of the outbreak, and she became very concerned and worried
that he had fallen ill with the virus. As a result, she experienced
increased anxiety, panic attacks, acts of defiance, and insomnia. She
also frequently woke up screaming in the middle of the night, causing
her to wake up the household. She would also often follow her
adoptive parents closely around the home from room to room.

Because the COVID-19 pandemic has currently forced Christina out

of school, she has not had a lot of peer-to-peer face time. She has some
acquaintances from her dance class, as well as members from her
father’s side of the family, with whom she remains in contact via video
chat. I also currently work with Christina and her family once a week
on a virtual basis to provide guidance and intervention. Because
COVID-19 has required families to coexist together under the same
roof for months at a time, I have witnessed an increased need for
practitioners to implement more interventions and to assist families
and children like Christina.

____________
* Case study by Roxanne McPherson, MSW
 PROVIDER WORKSHEET
CASE ANALYSIS

In this chapter, we have reviewed background information on social

and cultural trauma. After reading through Christina’s case, see if you
are able to connect the adverse events in her history to her current
functioning. Use the following worksheet to analyze the case.

Task #1: Use the Adverse Child Experiences (ACE) Questionnaire

from chapter 1 to determine Christina’s ACE score. List the adverse
events you acknowledged here.

What is her total ACE score? _______________________

Task #2: Write a reflection for Christina’s case story. Did you notice
any themes of trauma in her story? As a result, what challenges would
you suspect or anticipate?

Task #3: What are the next steps? How could you address Christina’s
trauma to enhance the success of your services?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

ORGANIZATIONAL TRAUMA
Trauma is not relegated to individuals, families, or communities.
Organizations are ecosystems—systems built on a shared mission, vision,
and values. These prescribed systems are sustained through a complex
combination of organizational dynamics, norms, behaviors, ethics, and
beliefs. Equally as important, these systems are predicated on the people
who sustain and fuel them. Therefore, just as individuals are susceptible to
trauma, the organizations in which we work are susceptible to trauma. In
particular, organizations are vulnerable to the unresolved traumas of those
who work and operate within its structure. Much like structural trauma,
organizational trauma is emotionally and cognitively overwhelming. “It can
fracture our self-protective structures, making us feel vulnerable and
helpless” (Resource Sharing Project, 2016).

An organization can be traumatized as a result of sudden devastating events

or be subjected to ongoing wounding (Vivian & Hormann, 2013). For
example, a catastrophic event, such as the COVID-19 pandemic, can
overwhelm an organization’s already stressed culture and climate,
devastating coping systems that normally provide a sense of control for the
organization and its members. When coping systems fail, healing from
these traumatic events is difficult, and sometimes impossible, causing the
organization’s people and culture to suffer (Table 9). In health care settings
in particular, working with patients who have experienced trauma puts both
clinical and non-clinical staff at risk of secondary traumatic stress
(Menschner, Maul, & Center for Health Care Strategies, 2016). Indeed,
many in the helping professions may have their own personal trauma
histories, which may be exacerbated by working with others who have
experienced trauma (Menschner et al., 2016).
Emotional Temporary feelings of shock, fear, grief, anger, resentment, guilt, shame,
Reactions helplessness, hopelessness, emotional numbness
Cognitive Confusion, disorientation, indecisiveness, worry, shortened attention span, difficulty
Reactions concentrating, memory loss, unwanted memories, self-blame
Physical Tension, fatigue, edginess, difficulty sleeping, bodily aches or pain, starling easily,
Reactions racing heartbeat, nausea, change in appetite, change in sex drive
Interpersonal Feelings of distrust or irritability toward others; conflict, withdrawal, or isolation;
Reactions feeling rejected or abandoned; being distant, judgmental, or overcontrolling of others

Table 9. Symptoms of Organizational Trauma During a Crisis (Young, Ford, Ruzek, Friedman, &
Gusman, 1998)
Fundamentally, organizational trauma occurs when physical or emotional
stress overwhelms the workplace. This stress can affect productivity,
culture, and climate as individuals struggle with emotional exhaustion,
become detached from clients or the work itself, and exhibit a reduced
sense of personal accomplishment or commitment toward the workplace
(Venugopal, 2016). Some of the many causes of work-related stress include
long hours, unfair treatment, heavy workload, job insecurity, lack of
communication and support from management, unreasonable time pressure,
and conflicts with coworkers or bosses. Many organizations are facing an
employee burnout crisis, with recent research finding that 23 percent of
employees feel burned out at work (Wigert & Agrawal, 2018).

The following worksheet can help you assess your own susceptibility to
burnout. If your score indicates that you are at high risk for burnout, it is
imperative to develop a personal action plan to address your well-being.
This may entail seeking professional assistance, making career and lifestyle
modifications, and using tools and techniques to help you re-center (see
Table 13 later in this chapter).
 PROVIDER WORKSHEET
BURNOUT SUSCEPTIBILITY
ASSESSMENT

Age Range: Adult

Objective: To determine susceptibility to burnout

Directions: For each statement listed here, put a check mark in the
appropriate column to indicate whether you agree or disagree with
each statement. Then tally the check marks for each column to
determine your relative risk for and susceptibility to burnout. The
column with highest number of check marks indicates your relative
burnout susceptibility.
Agree Disagree
(low risk) (high risk)
I am motivated and productive at work.
I have feelings of hope and helpfulness about my position.
I enjoy going to work.
I contribute to my workplace and am fulfilled by my work.
I am patient and engaged with my clients and coworkers.
I am engaged and alert at work.
I am currently supported in my role.
My work life and home life are balanced and healthy.
My work volume is balanced and manageable.
I am in relatively good health.
I get adequate sleep and wake up feeling refreshed and well rested.
I feel safe and respected in my work environment.
Total
 Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Organizational trauma is not part of the normal organizational life cycle. It

is a disruptive occurrence or pattern outside the usual organizational
experience. In environments where the organization’s mission is related to
assisting individuals who have experienced trauma, an organizational
culture that is not reflective, responsive, and adaptive to its environment can
become a source of trauma. In fact, many systems that were created to assist
individuals at some of the most vulnerable times in their lives can cause
harm or unintentionally re-traumatize them. This principle is applicable to
both client-facing services and internal business operations.

Unresolved trauma in the workplace creates barriers to communication and

innovation, and it can negatively affect productivity. Unresolved trauma
draws with compound interest, ultimately creating toxic spaces full of
unsettled and unhealthy conflict, which eventually compromises the
integrity of the organization’s mission. Across time, the organizational
system “can become reactive, change-resistant, hierarchical, coercive, and
punitive. Traumatized organizations may begin to exhibit symptoms of
collective trauma similar to those of their clients, creating a ‘trauma-
organized culture’” (Bloom, 2007, p. 3).

Therefore, changing organizational practices to fit trauma-informed

principles is necessary to create and sustain a healthy and safe
organizational environment. Doing so ensures that we are living up to our
professional ideals, standards, and obligations so we can create and sustain
outcomes in alignment with our stated mission, vision, values, and goals.
When an organization commits to being trauma-informed, a stakeholder
committee, including individuals who have experienced trauma, should be
organized to oversee the process (Menschner et al., 2016). Being trauma-
informed also requires a continuous process of reflection (at the self and
organizational level), assessment, and process improvement. Reflection and
assessment are an essential part of the continuous feedback process, which
allow organizations to acknowledge and correct systemic barriers that may
impede its ability to heal, execute its mission, and facilitate its goals. When
there is a healthy organizational culture and climate, it creates optimal
therapeutic outcomes for clients and staff alike by promoting emotional and
social well-being.

A safe, supportive, welcoming, and respectful environment is essential for

optimal outcomes. Our organizations—be they private practice settings,
rehabilitation centers, hospitals, schools, or corporate settings—are
enhanced when they are equipped to handle clients with skill, empathy, and
competency. An environment that is restorative and ACTION-focused
requires foresight and purposeful planning. However, before attempting to
transform, adapt, or optimize a culture or climate, we must first understand
it.

SAFE SPACES

The prevalence of structural trauma in current society—specifically the

social trauma stemming from the COVID-19 pandemic—is unprecedented
and underscores the need for trauma-informed care and safe spaces where
clients, families, staff, and others can heal, recover, and thrive. As we
described in chapter 1, trauma-informed care lays the foundation for our
ACTION-from-Trauma approach, and it is thus a necessary starting place
for organizations and systems as well. A trauma-informed perspective is
one in which program staff, agency staff, and service providers:
1. Routinely screen for trauma exposure and related symptoms
2. Use culturally appropriate evidence-based assessment and
treatment
3. Make resources available to children, families, and providers on
trauma exposure, impact, and treatment
4. Engage in efforts to strengthen the resilience and protective factors
of children and families impacted by and vulnerable to trauma
5. Address parent and caregiver trauma and its impacts on the family
system
6. Emphasize continuity of care and collaboration across systems
 7. Maintain an environment of care for staff that addresses,
minimizes, and treats secondary traumatic stress and that increases
staff resilience (National Child Traumatic Stress Network, 2016)

In addition, ACTION-focused organizations evaluate clients and staff using

trauma-informed principles, including safety, collaboration, cultural
inclusivity, empowerment, and choice. It is then necessary to follow up by
creating growth and teaching neuroeducation. By conducting a trauma-
informed organizational self-assessment, organizations can examine their
current practices and take specific steps toward ACTION (see section on
Organizational Assessment). This self-assessment is a critical step in
developing and sustaining an organizational climate and culture that is
equipped and prepared for today’s real and pervasive challenges.

Once an organization and its practitioners are knowledgeable about the

prevalence and dimensions of trauma, the onus is on the organization and
its leadership to sustain safe spaces that are reflective of its intentions to
care for individuals with compassion, empathy, and skill. Establishing the
integrity by which they create and maintain these spaces is necessary to
provide optimal therapeutic outcomes and interventions for clients,
families, staff, and others who have experienced trauma, including social or
cultural trauma.

A safe space hinges not simply on cognitively understanding the

dimensions of the lived experience but on understanding that the
presentations of the experiences will be as nuanced as the individual. A
culturally competent and safe organization allows providers and
organizations to effectively tailor their services to meet the social, cultural,
and linguistic needs of all clients. Safe spaces are empowering,
collaborative, and transparent, and they garner and maintain trust.

CULTURAL SAFETY

Creating and sustaining cultural safety necessitates an organizational culture

that embeds, encourages, and fosters reflective practices so the system can
determine how the values of its own culture may be in conflict with
another’s culture or experience. Foundational in creating and sustaining
culturally safe spaces is understanding the role of cultural competency,
cultural inclusivity, diversity, and implicit biases in an organization’s ability
to deliver its standard of care. In creating safe spaces, we must ask
ourselves:
1. How do we create and sustain safe spaces (for both our staff and
clients)?
2. What is cultural competency and its connection to trauma
dynamics?
3. How do diversity and cultural inclusivity influence trauma
dynamics?
4. How do our implicit biases affect our delivery of care and
intervention?
5. How does our organization handle conflict when it arises?
6. How do we as practitioners show up in spaces?

Creating safe spaces requires that organizations and practitioners make a

commitment to continuing education on topics related to cultural
competency, diversity and cultural inclusion, and implicit bias. They must
also create space for both professional and personal reflection and
development. This fosters an educated, responsive, and adaptive
organizational culture.

Cultural Competency
People are not monolithic, and even if they have similar cultural, linguistic,
or historical affiliations, trauma expresses itself differently across
individuals. Therefore, when serving individuals from similar cultural,
ethnic, religious, or linguistic backgrounds, it is critical to appreciate their
many differences. This can include differences in their lived experiences,
socioeconomic status, English language proficiency, and educational
attainment—among many other attributes. It is particularly important to be
knowledgeable about a group’s cultural trauma or lived experiences when
creating interventions that produce optimal outcomes. Failure to do so can
result in stereotype threat, which involves reducing others to group
stereotypes that commonly operate within the health care domain, including
stereotypes regarding unhealthy lifestyles and inferior intelligence (Abdou,
Fingerhut, Jackson, & Wheaton, 2016). The following paragraphs provide
several considerations to create growth in our ACTION-from-Trauma
approach.

Cultural competence is the integration and transformation of knowledge

about individuals and groups of people into specific standards, policies,
practices, and attitudes used in appropriate cultural settings to increase the
quality of services, thereby producing better outcomes (National Prevention
Information Network, n.d.). Culture refers to human behavior, such as
language, thoughts, communication, actions, customs, values, and beliefs,
as well as racial, ethnic, or religious backgrounds. Competence implies the
ability to enact those esteemed behaviors, attitudes, policies, and procedures
effectively (National Prevention Information Network, n.d.). When it is
well executed, cultural competence facilitates effective cross-cultural
communication, learning, and interventions, which produces a more agile,
adaptive, and inclusive environment.

The goal of cultural competency is not simply to understand diverse cultural

expressions but to harness those diverse perspectives effectively in our
spaces to produce better outcomes. The prevalence of physical and
structural trauma—and in particular cultural trauma—makes creating and
sustaining culturally competent safe spaces imperative for the outcomes we
seek.

Principles of Cultural Competence

(National Prevention Information Network, n.d.)

1. Define culture broadly.
2. Value clients’ cultural beliefs.
3. Recognize complexity in language interpretation.
 4. Facilitate learning between providers and communities.
5. Involve the community in defining and addressing service needs.
6. Collaborate with other agencies or organizations.
7. Professionalize staff hiring and training.
8. Institutionalize cultural competence.
9. Assess the organization or agency culture and climate.

Understanding that each client’s, family’s, or staff member’s lived

experienced is unique is the foundation of effective cultural competence.
Effective cultural competence is an essential proficiency at both the
individual practitioner and organizational levels (see Table 10).
Individual Organizational
Be aware of cultural differences Embrace diversity and inclusion
Understand your culture Conduct a culture and climate organizational
assessment
Conduct a personal self-assessment Manage the organizational dynamics of differences
Acquire cultural competency knowledge and Embed cultural knowledge within the organization
skills
View interactions within a cultural context Adapt to diversity
Continuous process assessment, feedback, and improvement

Table 10. Elements of Cultural Competence*

Cultural competence is a continuum toward ACTION with the ultimate

objective being cultural proficiency. As practitioners, the first step we can
take is to train ourselves to increase our awareness and understanding of the
presence of culture among those we serve. As we learn the unique cultural
nuances and norms of our clients, it is vital that our understanding does not
lead to an overreliance on cultural archetypes, which can lead to
stereotyping or generalizing, the result of which may inadvertently affect
health care efficacy and even prompt some patients to avoid care. Moving
toward ACTION, we hold each other accountable and provide support
where needed.
Diversity and Cultural Inclusivity
Diversity and inclusion have pivotal roles in creating and sustaining safe
spaces for those impacted by social or cultural trauma. They build trust,
establish purpose, and create understanding. Cultural competency is the
framework, while diversity and inclusion are the practice. When
implemented thoughtfully, diversity and inclusion initiatives can enhance
collaboration, empowerment, and overall well-being, while also fostering a
sense of belonging and purpose for both clients and practitioners. We
understand diversity as the proverbial melting pot, where individuals across
lines of differences are represented in key roles within the organization.

Diversity does not simply involve respect for physical lines of difference
(e.g., race, gender, age, ability, religion, sexual orientation). It also involves
attention to cognitive, relational, physical, and occupational diversity.
However, diversity is moot without inclusion. To have both a diverse and
inclusive team of practitioners is a practical goal in creating and
maintaining safe spaces. If diversity is the proverbial melting pot, then
inclusion is a gumbo. Inclusion is a tapestry made from our diverse
domains. Inclusion has to do with the involvement and empowerment of
others, where an individual’s inherent worth and dignity are recognized,
harnessed, and leveraged. Cultural inclusivity thus recognizes, appreciates,
and utilizes the diversity of people of all cultural orientations.

As we have discussed, many of the well-meaning systems, practices, or

principles created to assist individuals at some of the most vulnerable times
in their lives can and will inadvertently cause harm or re-traumatize clients.
These same systems, practices, or principles may also inadvertently damage
an organization’s internal operations, such as recruitment, retention, morale,
and cohesiveness. Lack of diversity and inclusion in an organization creates
blind spots and ultimately impacts the organization’s ability to create and
sustain cultural safety for those it serves. In creating systems and
environments for individuals who have experienced structural trauma, and
in particular cultural trauma, it is critical to appreciate the effect that
diversity and inclusion can have on healing and recovery.
Implicit Bias
Although the limbic system or “emotional brain” controls our fight-or-flight
response, it also controls our automatic assumptions about what is the
“other.” Developed to assist humans in assessing danger, it is the center of
our implicit biases. Implicit (or unconscious) biases can be understood as a
“form of rapid social categorization,” whereby we routinely and rapidly sort
people into groups (Spectra Diversity, 2017). The implicit biases we harbor
in our subconscious affect our feelings and attitudes about other people
based on their characteristics, such as their race, ethnicity, age, and
appearance. These associations develop over the course of our life,
beginning at a very early age, and occur through exposure to direct and
indirect messages about the “other.” In addition to our early life
experiences, the media and the news are often-cited origins of implicit
biases (Staats, Capatosto, Wright, & Jackson, 2016).

Uncovering our implicit biases is a lifelong process, but it is central to

building bridges across our lines of difference. The ability to see, assess,
and treat those with whom we interact as individuals is fundamental to
implementing authentic interventions that have lasting effects. In examining
the five dimensions of trauma, we understand the underlying mechanisms
and manifestations of trauma, and we also recognize the organizational
climate, culture, and systemic barriers that may impede our noblest of
efforts to treat it. However, if we cannot connect with those we serve on an
individual level, then we will create well-meaning interventions that do not
produce optimal outcomes.

What Is the Difference Between a Bias,

a Prejudice, and Discrimination?

• A bias is an inclination toward one way of thinking that is often

based on how you were raised. A bias lacks a neutral viewpoint
(e.g., “_____ people are _____.”)
• A prejudice is an opinion, prejudgment, or attitude about a group
or its individual members. A prejudice can be positive, but in our
 usage it refers to a negative attitude that is often accompanied by
ignorance, fear, or hatred. Prejudices are formed by a complex
psychological process that begins with attachment to a close
circle of acquaintances or an “in-group,” such as a family, with
prejudice then aimed at any “out-groups.”
• Discrimination refers to behavior that treats people unequally
because of their group memberships. Discriminatory behavior,
ranging from slights to hate crimes, often begins with negative
stereotypes and prejudices.

Implicit biases are persistent in that they are related to, but have distinct
mental constructs from, our explicit biases. We must understand that they
do not necessarily align with our declared beliefs, and they generally favor
our own in-group (e.g., people of the same race, sex, religion, or spiritual
faith). However, these implicit biases have been found to contribute to
disparities in health care access and treatment among racial and ethnic
minorities. These disparities persist even when controlling for a wide
variety of sociodemographic factors (Snowden, 2002). Therefore, it is
imperative to understand how our implicit biases affect our ability to
provide culturally competent care. Implicit biases color the way we connect
with, address, and treat others.

Given that our implicit biases are part of our subconscious programming,
they are often difficult to unearth. They are a part of the fabric of who we
are at our core, and they develop as we develop. However, the good news is
that these biases are still malleable. Because our brains are incredibly
complex and plastic, we can gradually unlearn implicit biases through a
variety of de-biasing techniques. The first step in this process is to develop
awareness of our own implicit biases. We can take all the training in the
world, routinely assess our organizations, and hire well-informed and
diverse staff, but if we are not aware of how we show up in spaces, our
organizations and clients will suffer. As practitioners, we are ambassadors
for our values. Many of us entered our respective profession to effect
change, to serve, or to heal. Authentic life application of these ideals
requires commitment to personal development. Without self-awareness, we
are running on subconscious programming. The desire to transform our
connections, our workspaces, and ultimately our communities is built on the
foundation that healing is possible. As in the first step in our ACTION-
from-Trauma Approach, we cannot address what we do not Acknowledge.
The following are some de-biasing strategies to develop this self-awareness:
1. Acknowledge that we all harbor implicit biases, and commit to a
desire to evolve through them.
2. Take an Implicit Association Test (IAT) or equivalent, which
provides you with a basic understanding of your implicit bias. It is
a starting point for understanding how you show up in spaces.
Table 11 provides a short list of these assessments.
3. Pay attention when stereotypical responses or assumptions come
up.
4. Practice new tasks designed to break automatic associations:
• Retrain your brain.
• Actively doubt your objectivity.
• Be mindful of snap judgments.
• Oppose your stereotyped thinking.
• Deliberately expose yourself to counter-stereotypical models
and images.
• Look for counter-stereotypes.
• Remind yourself that you have implicit bias.
• Engage in mindfulness exercises on a regular basis.
• Engage in cross-difference relationships.
• Shift perspectives.
• Examine your personal blind spots using a tool like the Johari
Window (Nalty, 2016).
Our lived experiences shape our worldview, and if you have lived on the
planet, you have implicit biases. These implicit biases fuel policies,
behaviors, norms, and attitudes that can inadvertently re-traumatize staff
and clients. To create culturally competent trauma-informed care, we must
actively work to assess our inner organization, as well as the greater
organizational culture. No two people experience reality in the same way. In
order to transform a system, we must commit to evolving through our
implicit biases.

On the next page is a sample assessment tool that you can use to examine
your own implicit biases using the Johari Window. This simple tool
provides a useful demonstration that our perception of self is often at odds
with how others perceive us.
 PROVIDER WORKSHEET
THE JOHARI WINDOW*

Age Range: Adolescents and adults

Objective: To assist practitioners in improving communication,

interpersonal relationships, self-awareness, and group dynamics

Description: The Johari Window is a simple self-awareness tool for

organizing and inventorying personal characteristics from multiple
perspectives. Created in 1955 by Jospeh Luft and Harry Ingram, the
Johari Window contains a horizontal and a vertical axis. The
horizontal axis describes our perception of self, while the vertical axis
describes the group’s (or a peer’s) perception of us. Perceptions can
be known or unknown along either axis, creating four distinct
quadrants:
1. Open Area: Represents your perception of self
2. Blind Area: Represents any aspect that you do not know about
yourself but that others within the group have become aware of
(called your “blind spot”)
3. Hidden Area: Represents aspects about yourself that you are
aware of but might not want others to know
4. Unknown Area: Represents what is both unknown to you and to
others
The Johari Window uses 56 adjectives as possible descriptions to
emphasize behavior, empathy, and interpersonal development in each
of these quadrants:

• Able
• Accepting
• Adaptable
• Bold
• Brave
• Calm
• Caring
• Cheerful
• Clever
• Complex
• Confident
• Dependable
• Dignified
• Empathetic
• Energetic
• Extroverted
• Friendly
• Giving
• Happy
• Helpful
• Idealistic
• Independent
• Ingenious
• Intelligent
• Introverted
• Kind
• Knowledgeable
• Logical
• Loving
• Mature
• Modest
• Nervous
• Observant
• Organized
• Patient
• Powerful
• Proud
• Quiet
• Reflective
• Relaxed
• Religious
• Responsive
• Searching
• Self-Assertive
• Self-Conscious
• Sensible
• Sentimental
• Shy
• Silly
• Spontaneous
 • Sympathetic
• Tense
• Trustworthy
• Warm
• Wise
• Witty

Directions: The Johari Window activity is conducted in pairs. For

optimal use, the tool requires partners to have some knowledge of
each other. It is best suited for established teams as opposed to being
used as an ice-breaker with a new group of employees or during
orientation or onboarding.

After pairing off, select 6 adjectives from the provided list of 56 that
best describe you. Ask your partner to select 6 adjectives that they
believe describe you from the same list. Then plot the adjectives onto
the quadrant template as follows:
1. Place adjectives that were selected by both you and your
partner into the open quadrant.
2. Place adjectives that were selected by you (but not your
partner) into the hidden quadrant.
3. Place adjectives that were not selected by you (but were
selected by your partner) into the blind spot quadrant.
4. Place adjectives that were not selected by either you or your
partner into the unknown quadrant.

Understanding the Results: We are often unaware of our behavior or

how our behavior can impact others. The Johari Window can assist
you in understanding how you show up in spaces and can allow you
to discover aspects of yourself that you may not have known or
appreciated in the past. The tool is not static, and the balance between
the quadrants can change over time. For example, you can
incrementally grow your “open area,” or reduce your “blind spot”
area, by seeking constructive, honest feedback. Similarly, sharing an
aspect of yourself that you have previously kept hidden can assist in
opening your “hidden area.”

Personal Reflection: Self-reflection a critical step in understanding

our implicit biases. Through the use of this tool and tools like it, we
have an opportunity to appreciate ourselves through the eyes of others
and to build new pathways of self-reflection and personal
development. Take a moment to reflect on what you uncovered about
yourself. In a quiet space, take a moment to capture your reflections
here.
1. Was this your first time using this tool?

____ Yes ____ No

2. What did you discover about yourself?

3. Describe why you selected the six adjectives used to describe

yourself.

4. Did you have difficulty selecting six adjectives to describe

yourself? Why or why not?

5. How did you feel reviewing the six adjectives your partner
selected to describe you?

6. How closely did your partner’s perception of you match your

perception of self?

7. Were you in agreement with the adjectives your partner selected

to describe you? Why or why not?

8. What activities or actions could you take to lessen your “blind

spot” quadrant?
 9. What three activities will assist you in opening your “hidden”
quadrant?

____________
* Adapted from https://www.selfawareness.org.uk/news/understanding-the-johari-window-
model

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

CONFLICT RESOLUTION

Even after learning and applying the framework of cultural competency,

diversity, and inclusion, as well as understanding the role of implicit biases
in our interactions with others, conflicts may arise. Therefore, conflict
resolution is a key component toward ACTION. Conflict is often
exacerbated in times of high stress and unrest, raising the need for a means
to mitigate organizational conflict. Toxic spaces are full of unhealthy
conflict, which compromises the integrity of our spaces. The health of a
space depends on the health and well-being of its people. Employing
methods to mitigate conflict is vital to creating and maintaining safe spaces,
as well as to reducing the creation of a toxic work environment or hostile
workplace.

Conflict is an inevitable part of the human-to-human experience.

Navigating it with skill, compassion, and competency takes practice.
Organizations can assist in mitigating conflict by first understanding its
source. The use of conflict coaches, trained mediators, employee assistance
programs, or ombudsmen can assist organizations in getting to the root
cause of conflict, as well as in developing best practices that assist the
organization in creating better outcomes.
ORGANIZATIONAL ASSESSMENT
Organizational transformation is an inside job. At the heart of effective
organizational transformation are its people. Effective organizational
cultures thrive on empathy and are sustained through reflection, assessment,
communication, and a continuous commitment to process improvement.
Proper diagnosis of organizational trauma and dysfunction is made using
validated assessment tools and instruments (Nevis, 1987/2001).
Organizations whose intent is on intervention, healing, recovery, and
growth engage in a continuous process of self-reflection, assessment, and
process improvement. It is crucial that we assess our organization’s climate
and culture routinely, specifically when caring for individuals impacted by
structural trauma. When assessing an organization, we often think of its
systems, but secondary trauma and organizational trauma are often
intertwined, thus underscoring the need for full system assessment.

An organizational assessment follows a systems science approach to assess

organizational dynamics, and it is accomplished in three phases: data
collection, analysis, and action planning. There are several validated tools
and frameworks used to assess organizational culture, climate, and implicit
biases, as well as trauma-informed indicators. Table 11 provides a short list
of these assessments.
Organizational Culture and Climate Implicit Bias Assessment
Assessment
Organizational Culture Assessment Instrument Implicit Association Test (lAT)
(OCAI)
Denison Organizational Culture Survey Affect Misattribution Procedure (AMP)
Gallup Q12 Employee Engagement Survey Implicit Relational Assessment Procedure (IRAP)
Relational Responding Task (RRT)
Trauma-Informed Organizational Assessment
Trauma-Informed Care Top Ten: A Checklist for Behavioral Health Organizations*

Table 11. Tools to Assess Organizational Culture, Climate, and Implicit Biases

TRAUMA-INFORMED ORGANIZATIONAL GOVERNANCE

Becoming a trauma-informed organization requires steady support from
senior leaders (Menschner et al., 2016). Like all organizational change,
organizational transformation is a top-down initiative, with leadership
support required at all levels. This support is necessary to successfully
implement trauma-informed governance, in which we can begin to move
toward ACTION by defining an organization’s trauma-informed mission,
vision, and values. The organization’s trauma-informed mission statement
defines the organization’s “why.” This short, concise statement defines why
the organization exists, what its overall goals are, and what type of service
it delivers. The organization’s vision statement defines the organization’s
aspirations and solidifies “what” the organization will achieve. Finally, its
values reflect the organization’s collective judgment. Values define and
underscore “how” members of the organizational system interact with one
another. A strategic implementation plan that aligns with the organization’s
mission, vision, and values puts ACTION into the trauma-informed care
approach.

Next, the organization engages key stakeholders in the planning phases of

this work. It is important to receive input from those impacted by the
trauma we treat. This feedback is gathered in various ways, including
stakeholder roundtable discussions, stakeholder sensing sessions, a
stakeholder needs assessment, or individual stakeholder interviews. After
assessing and reviewing key stakeholder responses and gathering trauma-
informed community best practices, we create the policies and procedures
that will govern implementation of trauma-informed protocols. Such
policies and procedures should include monitoring strategies to create
growth toward healing.

Creation of trauma-informed organizational governance ensures that the

program has clear, concise instruction for consistent delivery of care that is
inclusive for all. Standard operating procedures assist the organization in
maintaining quality assurance and quality control over its trauma-informed
care initiatives. It is also important to obtain feedback from key staff
members who will be responsible for implementing the governance. After
the organization creates trauma-informed governance, it moves into
ACTION by training all staff on its mission, vision, values, trauma-
informed policies, procedures, and governance. This must include
neuroeducation, even if at the most basic level. Finally, after
implementation, a commitment to continuous process improvement is
required, which should begin with an annual trauma-informed culture and
climate assessment and ACTION re-education on creating growth and
neuroeducation. Table 12 provides a checklist for this plan of action.
Phase Action Intent
1 Engage in planning • What are our organization’s strengths, weaknesses,
opportunities, and threats?
• What is our trauma-informed mission?
• Who are our stakeholders?
• What resources are needed to implement this plan of action?
• What is our time frame for program implementation?
2 Define the organization’s Mission, vision, and values are foundational in establishing
trauma-informed mission, trauma-informed care:
vision, and values • Mission is the organization’s “why”
• Vision is the “what”
• Values is the “how”
3 Conduct key stakeholder • Trauma presents differently in the individuals we serve. When
needs assessment establishing a trauma-informed organization, it is imperative
that we include stakeholders who have experienced the trauma
we seek to treat. Their voices are valuable and critical in
creating appropriate and successful interventions.
4 Create trauma-informed • Trauma-informed policies, procedures, and governance establish
policies, procedures, and best practices for maintaining cohesiveness of care and its
governance implementation.
• Seek feedback from key staff members prior to finalizing the
trauma-informed policies, procedures, and governance. This
feedback allows staff to have a stake in the policies and
procedures they will implement. It also ensures connection
between planning and application.
5 Train clinical and non- • Disseminating the principles of trauma-informed governance to
clinical staff on trauma- all the organization stakeholders ensures alignment with the
informed mission, vision, organization’s stated mission, vision, and values.
values, policies, • Training enhances staff skills, capabilities, and knowledge.
procedures, and
governance
6 Conduct annual culture • Assessment allows the organization to benchmark efforts and
and climate assessment document progress in pursuit of their stated mission, vision, and
values.
• A trauma-informed assessment assists an organization in
identifying its strengths, challenges, and areas for optimization.
 • Assessment is crucial to the program’s continued success and
ability.

Table 12. Trauma-Informed Plan of Action Checklist

CASE SCENARIO*

Review the following case study. Then attempt to apply some of the
ACTION approaches discussed in this chapter.

Organization: Public School District

Setting: School-based

This particular public school district is located in a large, populous

city. It has learners from kindergarten through 12th grade and has 111
schools in its portfolio. At the time of our assessment, 36 percent of its
students demonstrated proficiency in mathematics, and 34 percent
demonstrated proficiency in reading, with 42 percent on track to
graduate in the year of our assessment. The school system had 4,113
teachers servicing 46,498 students. The poverty level for the district
students was 22 percent. The school system had invested time and
money into improving student performance by closing underutilized
schools and reorganizing underperforming schools. The state
superintendent’s office and the school system took many steps to
improve accountability and performance. At the request of district
leadership, our team conducted an organizational climate assessment
with the school’s administrative staff six years post September 11,
2001, as the district was located near the epicenter of the attacks.

Due to its proximity to the events on 9/11, many of the administrative

staff, support staff, teachers, and students were directly impacted by
the events. At time of our assessment, about one-fifth of the district’s
teachers and a quarter of its principals had resigned, had retired, or
were terminated. The school district’s achievement shortfalls and
systemic leadership mismanagement were constant topics of public
discourse, both in the media and in the minds of many of its
constituents. This public discourse—among many other challenges,
such as the pressure of massive school reorganizations and budget cuts
—assisted in fueling low morale, internal conflict, and uncertainly in
the district offices. In turn, the district office saw an increase in
grievances filed alleging a hostile work environment, discrimination,
and unfair labor practices. The purpose of our district office
organizational climate assessment was to get to the root of the
concerns regarding low morale, discrimination, conflict, and hostility.

____________
* Case study by Nikki Harley, MSOD
 PROVIDER WORKSHEET
CASE ANALYSIS

In this chapter, we have reviewed background information on

organizational trauma. After reading through the case study regarding
the school district, use the following worksheet to analyze the case.

Task #1: Define the elements presented in the public school district
case scenario that constitute organizational trauma.

Task #2: In a district leadership position, which tools would you

utilize to assist in mitigating allegations of discrimination and a
hostile or toxic work environment?

Task #3: What are the next steps? What would you recommend to
ensure the school has addressed the noted challenges and traumagenic
events impacting its work environment?

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

SELF-CARE STRATEGIES FOR THE TRAUMA-

INFORMED PRACTITIONER

Using an ACTION-from-Trauma approach allows value-centric

organizations to create, sustain, and promote a culture and climate in which
wellness and well-being are intentional, comprehensive, and integrated into
its values. Whole people arrive in our spaces. People with illnesses, worries,
loves, obligations, commitments, dreams, and aspirations. The better
equipped we are to honor the whole person, the more balanced, aligned, and
productive our organizations become. Total well-being matters. We must
nurture our own minds, bodies, and spirits as much as we nurture the
individuals we serve. Well-being encompasses multiple domains, including
emotional, environmental, financial, intellectual, occupational, physical,
social, and spiritual domains (Swarbrick, 2006).

Thus far, we have defined social and cultural traumas and discussed their
respective impact on treatment interventions. We have also discussed
organizational trauma and its impacts. Now we will examine how we, as
practitioners, show up in spaces. The true work of a practitioner is one of a
healer, but in order for practitioners to create a pathway toward healing for
others, we must first be willing to take care of ourselves. This requires
empathy, vulnerability, authenticity, commitment, and reflection.

Creating organizations that work harmoniously in times of great stress

requires team members who are resilient and centered. As practitioners, we
serve people who have experienced any of the dimensions of trauma we
have discussed. We also work in organizations and spaces that can cause or
reactivate trauma. Over time, this traumatic exposure can cause us to
experience secondary trauma, resulting in anxiety, depression, and PTSD,
among other experiences. These times of high stress and crisis can lead to
stress and burnout. Just as we have recognized the diverse manifestation of
structural trauma in those we serve, organizations must recognize the
symptoms of stress, burnout, and secondary trauma among its practitioners.

Organizations can assess and mitigate employee burnout through multiple

system interventions. At the individual level, it is imperative to
acknowledge and communicate your needs. Communicate with your
coworkers, supervisors, and employees about job-related stress. In addition,
there is a pervasive cultural pressure to keep pushing ourselves and to
ignore our physical and emotional needs, which leads to burnout, stress, and
depression. However, self-care is not just good for you, it vital for your
well-being. It is necessary in order to balance your emotional,
environmental, financial, intellectual, occupational, physical, social, and
spiritual well-being (Figure 14).

Figure 14. Domains of Well-Being*

On the next page is a worksheet you can use to assess your own well-being
across these eight domains. The intent of this exercise is to assist you in
establishing a baseline for your personal well-being while providing you
with a foundation to move to sustained wellness.
 PROVIDER ACTIVITY
WELL-BEING ASSESSMENT*

Age Range: Adults

Objective: To assess well-being across these eight domains:

emotional, environmental, financial, intellectual, occupational,
physical, social, and spiritual

Directions: Rate the extent to which you agree with each of the
following statements by placing an X in the corresponding column.
For any statements that you somewhat agree with or disagree with,
describe three practical action steps you will take to move this domain
into full agreement. Make certain that each action step is SMART:
specific, measurable, achievable, relevant, and time-bound. For any
statements that you agree with, define three action steps you will take
to ensure this domain remains in agreement.
Reflection: Our well-being is influenced by many factors, some of
which are outside of our control or sphere of influence. Our personal
well-being is dynamic and constantly evolving, thus requiring
continual assessment and reflection. Take a moment to reflect on your
responses to this assessment.
1. Based on your assessment, which domains require immediate
attention and nurture? In what ways?

2. For the domains that you rated as agree, describe their importance
to your overall well-being. What personal practices do you
currently implement to maintain alignment in those domains?

3. For those domains that you rated as somewhat agree or disagree,

how long has each domain required attention (less than 6 months,
6–12 months, or greater than 12 months)?
 4. For those domains that you rated as somewhat agree or disagree,
do you have the skills, knowledge, and ability to align them into
agreement? Why or why not?

5. For those domains that you rated as somewhat agree or disagree,

what actions can you take to align them into agreement?

____________
* Adapted from Swarbrick (2006)

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Creating Sanctuary
Given that we are often bombarded with our roles and responsibilities—
multitasking and juggling many priorities and obligations—how do we
cultivate safety in our lives? Where do we go to recharge, release, and
refocus? We create sanctuary. A sanctuary is a place, space, or moment that
is created just for you to reconnect and re-center. Creating sanctuary is an
opportunity to take a moment to honor you. You define what sanctuary
means to you. In this space, you can practice any exercises that allow you to
re-center. In the previous chapters, we have provided activities and
exercises that support our ACTION-from-Trauma approach. We summarize
some of these strategies in Table 13.
Breathwork Breathwork is a general term used to describe any type of therapy that utilizes
breathing exercises to improve mental, physical, and spiritual health.
Yoga or The gentle movement associated with yoga helps develop body awareness and reduces
mindful over-reactivity to internal sensations. These practices recalibrate the threat detection
movement system from the top down and bottom up, giving individuals with trauma control of
their healing.
Mindfulness Mindfulness activities can mitigate symptoms of PTSD by increasing activity in the
prefrontal cortex and hippocampus and toning the amygdala. At its core, mindfulness
is simply the basic human ability to be present. A simple mindfulness exercise
involves the use of a stethoscope to center on the beauty of our heartbeat. For those
 who struggle with formal meditation or mindfulness practices, you can simply
incorporate mindful awareness into your daily routines.
Gentle While music cannot cure PTSD, it has demonstrated positive results in helping to
music alleviate secondary symptoms of trauma, such as depression and insomnia (Blanaru et
al., 2012).
Diet and Good nutrition and physical activity are important parts of leading a healthy and
exercise balanced lifestyle, which can dramatically assist in maintaining overall health and
well-being.
Regular Lack of sleep can lead to insulin resistance, cardiovascular disease, mood swings, poor
sleep immune function, hormonal imbalances, and lowered life expectancy. Therefore, get
on a regular sleep-wake schedule, and keep a journal by your bedside to capture any
last-minute thoughts for the day. You can also perform light stretching or yoga before
bed to prepare the body for sleep.

Table 13. Practical Ways for Practitioners to Re-Center

The following handout gives some additional ideas to create a sanctuary

within your organization.
 PROVIDER HANDOUT
CREATING SANCTUARY

Age Range: Adolescents and adults

Objective: To provide mindfulness strategies to increase self-

awareness and decrease physical and psychological stress among the
members of an organization

Directions: Consider the following strategies to develop opportunities

for contextual mindful practices within your organization. This
includes adapting the environment and providing moments within
scheduled activities for mindfulness exercises:
• Schedule mindful breaks: Encourage members of your
organization to identify a daily time when they can take a
mindfulness break. For example, they can incorporate
mindfulness into their lunch break by practicing mindful
eating. For academic settings, schedule a time during the day,
or even within a lesson, to stop and perform a mindfulness
exercise.
• Make a sensory room/space: Identify an available room or
space (e.g., a vacant office, an unused section of a classroom,
or an empty cubicle) where you can create a sensory room. If
possible, decrease artificial light in this space by using a floor
lamp instead of overhead lighting or by purchasing calming
lighting, such as a lava lamp. Provide comfortable seating,
such as beanbag chairs, and place a docking station to allow
the use of personal devices to play music. You can also
consider using a diffuser for aromatherapy.
 • Create a virtual sensory space: Seek out opportunities
within the schedule to introduce mindfulness breaks. To do
so, use a virtual meeting platform where you can set up a
variety of virtual breakout “rooms.” Within each room,
provide specific sensory activities. For example, you can
have a virtual room that provides a slideshow of scenic
views, another virtual room that plays music, and another
that offers stretching and yoga poses.
• Take the meeting on the road: Take a walk with the team if
you plan to have a meeting with a small group.

Copyright © 2021 Varleisha Gibbs & Nikki Harley, Trauma Treatment in ACTION. All rights
reserved.

Our clients’ lived experiences demand our full attention, expertise, and
empathy. Routine and adequate self-care is critical in ensuring we are able
to meet and exceed the level of service, commitment, and attention our
positions require. Your well-being and personal alignment are paramount
for optimal client outcomes, personal happiness and well-being, and career
longevity. Self-care is not a luxury in these unprecedented times; it is a vital
commodity. By making a commitment to utilizing practical ways to re-
center and align every day, you ensure that both you and your clients thrive.

____________
* Centers for Disease Control and Prevention, as of January 21, 2021
(https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html)
† Johns Hopkins University, Coronavirus Resource Center, as of January 21, 2021
(https://coronavirus.jhu.edu)
* Adapted from Cross, Bazron, Dennis, & Issacs (1989)
* Available at https://www.thenationalcouncil.org/wp-content/uploads/2013/05/Trauma-Top-Ten-
Checklist.pdf?daf=375ateTbd56
* Adapted from Swarbrick (2006)
 CHAPTER 6
NOW IS THE TIME FOR
ACTION

At the start of this book, we discussed the importance of expanding the

concept of trauma-informed care to move into ACTION. In this chapter, we
aim to encourage the development of an ACTION plan that includes
specific action steps you can take. Society is now beginning to receive the
message that traumatic experiences have the potential to penetrate every
aspect of life. Now that we have begun to pay attention to the impact of
trauma, there are still issues we need to address to move toward action.
Here are some steps toward an ACTION plan:
☐ Communication: We must change our language and personal
biases. Instead of neglecting our previous training, we must expand
our view. Statements such as “He should be able to…” or “She just
does not want to listen and chooses not to” must exit our
vocabulary. Replace that language with statements of empathy,
respect, gratitude, and growth.
☐ Person first: We must focus on the person first—not the trauma
that happened to them. Individuals are resilient and have strengths
that supersede trauma. Therefore, include strengths-based and
evidence-based strategies in your work. While we have presented a
multitude of activities in this book, make sure that your treatment
plans are person- and family-centered as well.
☐ Advocacy: Attending expensive workshops and trainings is a
beginning, not an ending. Reading this book is a start. The real
work is in advocacy at every level. Advocate for your clients by
acknowledging their unique needs and by aligning resources that
fit those needs. Educate those who work with individuals with
trauma. Advocate for resources to decrease the financial and social
impacts of trauma. Establish mentorship programs and training for
primary care, childcare, and eldercare providers.
☐ Avoid re-traumatization: Employ the use of de-escalation
techniques versus the use of physical restraints. Many of the
challenges individuals present with occur when they do not feel
validated. Start by acknowledging their perspective and by
recognizing the trauma lens of protection through which they view
the world. Listen to what they have to say! Avoid making
assumptions and judgments. Ask for and provide clarification by
repeating and rephrasing statements. Apologize for any
misunderstandings or misinterpretations. Provide choices rather
than dictating rules.
☐ Assess your knowledge of trauma: Be aware of your personal
experiences. As you work with clients, check in to see your level
of acute stress. Utilize some of the techniques provided here to
keep your mind-body connection healthy.
☐ Establish a team: Develop trauma stewardship, and establish a
team of champions under a unified vision. Identify key individuals
to be advocates for the family or client. Seek buy-in, and provide
mentorship for team members (Fette, Lambdin-Pattavina, &
Weaver, 2019).
☐ Promote physical activity: Performing gross motor activities,
such as sports, can improve positive outcomes and behaviors.
Support the development of structured activities and access to such
programs (Cahill, Egan, & Seber, 2020).
☐ Address organizational trauma: Complete organizational
assessments for trauma-informed care. Develop a mission
 statement that includes inclusivity; cultural sensitivity and values
around safety; trustworthiness and transparency; peer support and
mutual self-help; collaboration and mutuality; empowerment,
voice, and choice; and cultural, historical, and gender issues.
☐ Incorporate a reflective practice: With any clinical practice, it is
necessary to incorporate a reflective practice on the services you
provide. Be sure to revisit the events of therapy sessions by
maintaining proper notes. Revisit your own thoughts and feelings
during the session. Analyze what seemed to work and what did not.
Consider other activities and approaches you could have taken to
assist in revising treatment plans. In addition, revisit the
Practitioner Readiness for Trauma Care Checklist from chapter 1
to make sure you are best supporting your clients’ needs.

Now is the time for you to call others to ACTION!

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