From "Trauma-Informed" to "Adversity-Resilient"
It's time for a major shift in our thinking about youth who have experienced adverse childhood experiences.
There’s a very exciting sea change happening in psychology I want to tell you about.
Many of you have heard of “Adverse Childhood Experiences” (ACEs). They are potentially traumatic events that consist of things such as verbal abuse, physical abuse, sexual abuse, neglect, parental divorce, witnessing violence, felt discrimination, living in an unsafe neighborhood, and being bullied.
There’s no doubt that ACEs can have a harmful effect on the emotional, cognitive, social, behavioral, and neurobiological functioning of youth. While there are many well-meaning “trauma-informed” practitioners who are dedicated to mitigating the negative effects of ACEs, psychologists have started to become aware of the potential disadvantages of viewing youth solely through the trauma lens. “Benevolent childhood experiences” can co-exist with adverse childhood experiences and those positive experiences can be ignored if the focus is primarily on the adverse experiences. Many of those experiences can be built upon to help the child survive and thrive.
Additionally, too much of a focus on the adverse experiences themselves can ignore the strengths of the child and prevent them from having hope for the future. There is growing research support that while there are ACE trends at the group level, the correlation between individual ACEs and lifetime maladaptive development is not actually that strong. Children are a lot more resilient than we think.
More recently, psychologists are highlighting the potential for a different approach, one that is “strengths-based” and “resilience-enhancing”, and which clinicians and youth service providers can incorporate into “ACE-informed” youth services. Leading the way on this exciting new “strengths-based, resilience-enhancing” (SBRE) approach is clinical psychologist Dr. Kevin M. Powell. Dr. Powell’s mission is to “educate, energize, and promote hope” among youth. I resonate with this model at a very deep level and see so many synchronies with the self-actualization coaching program I developed with my colleagues.
Let’s look at some of the major treatment components of the SBRE model:
Greater Caution About the “Trauma” Label
Dr. Powell advocates for using the phrase “adversity” rather than “trauma” and I completely agree with this approach. As he notes, using the phrase “adversity” allows clinicians to remain more neutral and meet youth where they are. This is important because youth perceptions and reactions to childhood adversity can vary quite a bit from one child to the next. Not every adverse experience will necessarily be “traumatic”.
That’s why why my colleague George Bonanno uses the phrase “potentially traumatic events” (PTEs). His research has found that resilience after an adverse event is a lot more common than we tend to realize. Why assume that trauma occurs in every single incident of childhood adversity? Dr. Powell advocates asking more neutral questions to the child, such as: “You have coped with a lot of challenges, how have these experiences influenced the way you go through life?”.
The second reason for this change in terminology is that shifts the focus to a surviving and thriving lens. That’s why I personally prefer the phrase “adversity-resilient” to describe youth who have experienced ACEs. Research shows that children who focus too much on their victimization and the need to receive support often struggle psychologically and socially.
Normalize and Reframe ACE Coping Responses as Adaptive and Resilient
Many responses to ACEs can cause embarrassment or shame, which can further impede treatment. However, these responses are often adaptive and resilient ways of coping with an unsafe and abusive environment. Dr. Powell advocates normalizing and reframing “problematic coping responses” as adaptive and resilient, decreasing a youth’s feelings of shame and increase their inner confidence in treatment to openly address the maladaptive aspects of the behaviors in their life.
Ensure a Safe, Nurturing and Predictable Living Environment
While the child’s immediate environment may feel unsafe and unpredictable, the clinician can do their best to ensure a safe and predictable environment while they are with the child.
Develop Positive Relationships
It’s crucial for the practitioner to form a positive, trusting relationship with youth and families. This includes establishing a positive alliance with youth, employing unconditional positive regard and communicating with warmth, acceptance, understanding, empathy hope, and crucially— POSITIVE EXPECTATIONS!
As Dr. Powell notes,
“Every youth possesses unique attributes (e.g., life experiences, strengths, ethnicity, culture, religious/spiritual beliefs, sexual orientation gender identity, life goals), and when given opportunities to share their self-identity and personal views of the world, positive relationships grow.”
Provide Information about Healthy Relationships
Teach youth about attributes linked to healthy relationships and how to acquire the skills for establishing and maintaining positive relationships. These include being supportive, kind and responsive, being honest and trustworthy, allowing for autonomy, having good conflict management skills, being a good listener, and being playful and fun.
Respond in a Supportive & Neutral Manner to ACE Disclosures and Problematic Symptoms
Communicate in a supportive and neutral manner when treating childhood adversity. While the clinician may be upset by hearing about abuse, try to stay nonjudgmental and listen to how the children is currently thinking and feeling about the experience. Also expect wide fluctuations in moods and interpretations by the child, treating that as a normal part of the process.
As Dr. Powell puts it,
“Maintain a neutral, supportive response that meets youth where they are with the experience, not where we are with it.”
Meet Basic Human Needs
Look out for how to satisfy physiological, safety, social, and self-esteem needs. During each psychotherapy session, Dr. Powell suggests asking themselves: What needs are currently not being met for this youth and how can I help meet their unmet needs?
Increase Agency
Promote personal control beliefs (hope & self-efficacy). As children age, their agency naturally increases and we must give them that hope that this will happen. Even at their current age, show that they have some personal control over what happens in their life. Teach them the importance of a personal growth mindset and teach them the idea of neuroplasticity.
Another key aspect of this is providing a rationale for services, including what, when, where, how and why the services are happening. This can increase their sense of safety, engagement, and ability to regain some predictability over their environment.
Ongoing Assessments
Assess strengths, protective factors, relationships/supports and a functional behavioral assessment of positive, resilient behaviors. Various protective factors that already exist in a child’s life can not only mitigate adversity but also counteract adversity and even help the child grow from adversity. The “Resilience Protective Factors Checklist” is a 34-item questionnaire that can assist in the exploration of proactive factors within a youth’s life. It includes items such as self-regulation skills, positive self-concept, positive home life, education, and community relationships, activities, and neighborhood supports.
Identify and Reinforce Talents, Interests, & Life Goals
With “trauma-informed” therapy there is often a tendency to overly focus on avoidance goals (STOP being aggressive, STOP self-cutting, etc.). However, this can lead youth to become defensive and shut down. In contrast, Dr. Powell advocates exploring “approach goals” such as:
What do you like to do in your free time?
What things do you do that make you most happy?
What are some of the things you do well?
What do you hope to be doing in 1 year, 6 years, 10 years from now?
After those questions are answered, additional questions can help inform how youth services can help them reach their goals.
Identify and Reinforce Traumatic Growth/Post-Adversity Growth
Youth can grow in a number of ways from adversity, from increased personal strength, increased relationships, enhanced appreciation of life, enhance spirituality, new view of possibilities in life, and enhance empathy and prosocial behaviors. Allow discussions about different forms of growth to occur organically over the course of treatment. However, be aware that PTG may not occur for all youth with a history of ACEs and that is OK.
Correct Misperceptions about Past Adversity (“Narrative Exposure Therapy”)
Assist youth in constructing new meanings to memories and life experiences. Help youth to look back on their childhood adversity with a developmentally older lens and think about what messages they would like to share with their younger self. Retelling personal stories of adversity in ways that recall their strength and resilience as survivors can reduce anxiety and PTSD symptoms.
Teach Emotional-Regulation Skills
Exposure to ACEs can continually activate the body’s stress response system. SBRE treatment helps youth in acquiring the knowledge and skills for regulating emotions and incorporating self-care strategies that can help them cope with life.
Teach Mindfulness Skills
Teach children the skills of focusing attention on the present moment with an open and accepting attitude. Help them with “grounding skills” such as staring at an object and focusing all attention on it.
Normalize Some Adversity & Stress Responses
Not all adversity is necessarily bad. Teach children that a certain level of adversity can strengthen a person’s ability to cope with future life stressors. Also, teach children that a certain degree of anxiety, insecurity, and sadness is a normal part of life and can even be adaptive for resilience. Not every feeling of anger or anxiety is a “trauma response”.
Utilize Distraction and Thought Substitution Strategies
While validating a youth’s anxiety about their past and future, you can teach children that there are times when distracting away from these thoughts and feelings is the best way forward. Sometimes a disproportion focus on the youth’s feelings and anxiety can unintentionally heighten their maladaptive responses!
It’s also possible to interrupt distressing thoughts with reassuring thoughts to help the child self-regulate. Cognitive reappraisal strategies can be particularly helpful for emotion-regulation.
Promote Good Self-Care
Teach children self-care strategies such as getting proper sleep, health and nutrition, seeking out social supports, journaling, physical exercise, and other relaxation-oriented practices. Let the child know that this is not “selfish”, it’s essential. Healthy selfishness can be OK!
Help Youth Take Power Over ACEs with Gradual Exposure Therapy (when indicated)
For some youth, exposure to ACEs can certainly results in common symptoms of PTSD, such as intrusive memories, flashbacks, and nightmares. Gradual exposure therapy can help them overcome these symptoms. Note that not all children will need exposure therapy; not all children will have symptoms of PTSD.
Help to Stop Childhood Adversity Before it Even Starts
There are also some prevention oriented aspects of SBRE, such as promoting benevolent childhood experiences, increasing knowledge and skills to reduce the risk of future victimization and abuse and counteracting the higher risk that ACE-exposed youth have for being victimized again in the future. Dr. Powell also advocates creating a supportive work environment for youth providers and focusing on reducing the risk of clinicians burning out and/or experiencing compassion fatigue (sometimes referred to as “vicarious trauma”).
As Dr. Powell puts it,
“Setting up supportive, collaborative work environments that provide relationship-based clinical supervision can help prevent burnout.”
Conclusion
There is no doubt that ACEs can lead to many negative life outcomes. However, children are far more resilient than we tend to think they are. Research shows that youth can draw on a wide range of resources and strengths (individual, family, community strengths) to be resilient and empowered.
I think SBRE is a HUGE step forward for the field and each of these components can be integrated into already-existing ACE-informed (formerly called “trauma-informed”) services. As Dr. Powell put it, the goal of SBRE is to assist “youth in not only surviving childhood adversity, but also thriving in ways that will positively impact their lives and the lives of the next generation.”
I’m all in on this approach! For free resources on this exciting approach, see here.
What do you think? Leave a comment below.
I appreciate your ackinowledgement that trauma does not have to define one's life trajectory. As a clinical psychologist, I am well aware that there has been a trend toward sometimes an overidentification with one's diagnosis or label or the assumption that trama defines them. In a recent literature review I did for a special issue on resilience for Gifted Education International, it seemed clear that many children do not suffer long-term consequences from ACE's, even though some do. An appreciation of the struggles some have endured, yet encouragement to recognize their strengths, is essential to avoid feeling "damaged" by their experiences and recognize that they can move past them and even thrive.
I'm pleased to see that there's increasing attention on ACE, especially since cPTSD is not yet included in the DSM. I recognize that everyone experiences trauma differently, both in terms of level and severity. However, I believe we should categorize trauma into three groups for clarity.
I've worked with clients who have cPTSD, those who experienced trauma after age 18 without military involvement, and others with combat-related trauma. While all these experiences are valid, my therapeutic approach varies significantly depending on the type of trauma. For instance, a client who experienced sexual trauma as a child requires a different approach than someone who has faced combat trauma. Additionally, there are individuals who have experienced trauma after 18 without any military context, less common, but still needing a different approach.
I always start by asking clients to identify their trauma. I inquire about their earliest emotional memories, focusing first on positive experiences before exploring what they consider their first traumatic memory. Some clients may have repressed memories that emerge later, especially with techniques like EMDR.
I also delve into their attachment styles and the roles their parents played in their upbringing. I find it helpful to refer to Erik Erikson's model to determine if there are stages where they might have become stuck. I have found, more often than not, they don’t recognize this.
I also incorporate a reality, existential, and logotherapy approach in my work. While I begin by addressing their past, my goal is to shift their focus to the present. I believe that their past experiences shouldn't weigh them down; instead, we work on transforming that energy into something positive and constructive for their current lives.
Anyhoo, this makes me happy to see this shift. Research is increasing and stigma is decreasing. 🎉