Trauma Affect Regulation: Guide for Education and Therapy (TARGET)

TARGET is an educational and therapeutic approach for the prevention and treatment developmental trauma disorders, posttraumatic stress disorder, and other stress-related disorders. TARGET provides a seven-step sequence of skills - the FREEDOM Steps - that are designed to enable youth and adults to understand and gain control of trauma-related reactions triggered by current daily life stresses. TARGET is a manualized intervention that provides: (1) a neurobiologically-informed strengths-based meta-model of how stress-related information is processed by the “learning brain” (Ford, 2009), and how this is altered when posttraumatic stress disorder (PTSD) and complex traumatic stress disorders (CTSDs activate the “survival brain” (Ford, 2009); and (2) a practical algorithm (the “SOS” and “FREEDOM” sequences) for restoring the “learning brain” by intentionally engaging executive functions, self-reflective processing, and emotion regulation.

The goal in TARGET is to help youth and adults recognize their personal strengths using the FREEDOM Steps, and to use these skills consistently and purposefully when they experience stress reactions in their current lives. TARGET’s psychoeducation is designed to enable clients (and therapists) to understand and mentalize (i.e., visualize the internal workings of) the networks within the brain that are responsible for stress reactivity and emotion dysregulation in PTSD and DTDs. Clients are provided with pictures and a technically-accurate but non-technical description of how stress reactions involve an interaction of the stress/salience network (represented by the amygdala), the self-referential memory encoding/retrieval network (represented by the hippocampus), and the executive function network (represented by the prefrontal cortex). Additional pictures show how these neural interactions are altered in PTSD/DTDs. With this framework, trauma processing can be understood as a logical way to return control to the executive network by activating the brain’s “thinking center” and thus re-setting the brain’s “alarm” (i.e., the stress/salience network) so that it returns to its normal role as an alerting system rather than as an emergency responder.

TARGET draws on emotion regulation research to explain that the brain’s thinking center is activated by deployment “of attentional processes that might allow individuals to disengage from rigid patterns of regulation … -[so that,] rather than seeking to replace maladaptive strategies for adaptive strategies, emotion regulation interventions … help individuals … learn to implement strategies flexibly and appropriately … [which] is consistent with the concept of developing a mindful awareness” (Aldao & Nolen-Hoeksema, 2012) (p. 498). In TARGET, mindful awareness/acceptance of emotions is described as occurring when the brain’s thinking and memory systems are activated sufficiently to re-set the brain’s alarm, such that the amygdala alarm is no longer hijacking the memory and executive systems.

TARGET provides a practical sequence of emotion regulation skills that is distilled from the empirical literature that demonstrates that emotion regulation involves: (1) awareness of bodily states; (2) inhibition of impulsive emotional reactions, (3) maintenance of bodily arousal within a window of tolerance (i.e., neither too intense nor numbed/dissociated); (4) tolerance of distress, (5) awareness of one’s own emotion states; (6) translation of feelings into words; (7) making meaning of emotions; (8) intentional modulation of emotion states, (9) awareness of others’ emotions states, (10) empathic validation of one’s own and others’ emotions, (11) expression of emotions in a personally and interpersonally meaningful manner, and (12) translation of emotions into self-enhancing prosocial goals TARGET distills this complex array of skills/functions into a seven-step sequence for emotion regulation that is summarized by the acronym, FREEDOM.

Attachment Regulation Competency Framework (ARC)

The Attachment, Regulation and Competency (ARC) Framework is a flexible, components-based intervention developed for children and adolescents who have experienced complex trauma, along with their caregiving systems. ARC’s foundation is built upon four key areas of study: normative childhood development, traumatic stress, attachment, and risk and resilience. Drawing from these areas, ARC identifies important childhood skills and competencies which are routinely shown to be negatively affected by traumatic stress and by attachment disruptions, and which – when addressed – predict resilient outcome.

ARC is designed as both an individual level clinical intervention,  to be used in treatment settings for youth and families, and as an organizational framework, to be used in service systems to support trauma-informed care.  The concepts identified by ARC may be applied to individuals from birth through young adulthood, and have been effectively used with youth with a range of developmental and cognitive functioning levels, and with a wide range of symptom presentations. Caregiver goals are designed to translate across many different types of caregiving systems, including primary (i.e., biological, kin, and foster parents), milieu (i.e., residential, group home), and organizational (i.e., teachers, youth program providers) systems of care.

Integrated Treatment of Complex Trauma for Adolescents (ITCT-A)

ITCT-A is an evidence-based, multi-modal therapy that integrates treatment principles from the complex trauma literature, attachment theory, the self-trauma model, affect regulation skills development, and components of cognitive behavioral therapy. It involves structured protocols and interventions that are customized to the specific issues of each client, since complex posttraumatic outcomes are notable for their variability across different individuals and different environments.

A key aspect of ITCT-A is its regular and continuous monitoring of treatment effects over time. This involves initial and periodic evaluation of the youth’s symptomatology in a number of different areas, as well as assessment of his or her ongoing level of support systems and coping skills, family/caretaker relationships, attachment issues, and functional self-capacities. The client’s social and physical environment is also monitored for evidence of increased stressors or potential danger from revictimization or broader community violence.

Unlike most structured trauma treatment approaches for children and adolescents, ITCT-A does not have a pre-established number of sessions to be applied for every client. Instead, therapy may range from several months to a year or more, although most clients appear to require an average of approximately six to eight months of treatment. Although the USC-ATTC provides information and training on ITCT-A, there is also a child version of ITCT (ITCT-C) for clients ages 8 to 12.

Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS)

Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) is a 16-session group intervention that was specifically designed to address the needs of chronically traumatized adolescents who may still be living with ongoing stress and may be experiencing problems in several areas of functioning. These areas include difficulties with affect regulation and impulsivity, self-perception, relationships, somatization, dissociation, numbing and avoidance, and struggles with their own purpose and meaning in life as well as worldviews that make it difficult for them to see a future for themselves.  Overall goals of the program are to help teens cope more effectively in the moment, enhance self-efficacy, connect with others and establish supportive relationships, cultivate awareness, and create meaning in their lives. Group members learn and practice each of the core SPARCS skills throughout the intervention and frequently report use of these skills outside of group. Core components of this intervention include Mindfulness practice, relationship building/communication skills, Distress Tolerance, and Problem-solving and Meaning Making. Treatment also includes psychoeducation regarding stress, trauma, and triggers.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was developed by Drs. Anthony Mannarino, Judith Cohen and Esther Deblinger. TF-CBT is an evidence-based treatment that has been evaluated and refined during the past 25 years to help children and adolescents recover after trauma. Currently, 21 randomized controlled trials have been conducted in the U.S., Europe and Africa, comparing TF-CBT to other active treatment conditions. All of these studies have documented that TF-CBT was superior for improving children’s trauma symptoms and responses. TF-CBT is a structured, short-term treatment model that effectively improves a range of trauma-related outcomes in 8-25 sessions with the child/adolescent and caregiver. Although TF-CBT is highly effective at improving youth post-traumatic stress disorder (PTSD) symptoms and diagnosis, a PTSD diagnosis is not required in order to receive this treatment. TF-CBT also effectively addresses many other trauma impacts, including affective (e.g., depressive, anxiety), cognitive and behavioral problems, as well as improving the participating parent’s or caregiver’s personal distress about the child’s traumatic experience, effective parenting skills, and supportive interactions with the child.The federal government’s Substance Abuse and Mental Health Services Administration has recognized TF-CBT as a Model Program due to the extensive outcome data from randomized controlled trials that support its effectiveness in improving a variety of problems. While TF-CBT was originally developed to address the needs of children who experienced sexual abuse, over the past 15 years it has been used and studied for many other populations of traumatized youth. Research now documents that TF-CBT is effective for diverse, multiple and complex trauma experiences, for youth of different developmental levels, and across different cultures.

Trauma and Grief Components Therapy for Adolescents (TGCT-A)

TGCT-A is a manualized group or individual treatment program for trauma-exposed or traumatically bereaved older children and adolescents that may be implemented in school, community mental health, clinic, or other service settings. It is a modularized, assessment-driven, flexibly tailored treatment manual and accompanying youth workbook that includes detailed instructions for conducting individual or group sessions. Specific treatment modules (and specific sessions within modules) are selected, prioritized, sequenced, and emphasized based on clients’ specific needs, strengths, circumstances, and informed wishes. The intervention contains a variety of components organized into four modules.

Trauma Systems Therapy (TST)

Trauma Systems Therapy (TST) is a model of care for traumatized children that addresses both the individual child’s emotional needs as well as the social environment in which he or she lives. TST is about breaking down barriers between service systems, understanding a child’s symptoms in the context of his or her world, and building on a family’s strengths and dreams. TST is about leaving a better system.