Trauma in Adolescent Populations

Introduction
This paper will describe the many different modalities for treating trauma in an adolescent population. Therapeutic treatment is designed to encompass the whole person in a holistically healing manner. It takes into consideration the body, soul and spirit in the trauma experience. All trauma affects the whole person: spirit, body and soul. Therefore, we cannot have complete healing from any trauma until we deal with how we have been affected emotionally and spiritually by the trauma.
Trauma Defined

Trauma has been defined by Levine and Kline (2007, p. 4) as “…any experience that stuns us like a bolt out of the blue; it overwhelms us, leaving us altered and disconnected from our bodies.” They go on to say that “While the magnitude of the stressor is clearly an important factor, it does not define trauma. That is because (p. 4) “trauma is not in the event itself; rather, trauma resides in the nervous system.” Lee, Taylor, and Drummond (2006, p. 105) state, “…that PTSD occurs when an event is sufficiently arousing to prevent its transfer from encoding as an episodic memory to a semantic memory.
The core of PTSD is extreme stress that causes hyperarousal in the body’s nervous system and makes it possible to fight, freeze, or flee as a result of threat or danger. This is a normal response under most circumstances. However, if the bodily symptoms of this heightened state of arousal do not subside after hours, days, or weeks PTSD can develop (Rothschild, 2003). In an article by Clinton (2006, p. 98) trauma is defined as,

“…any occurrence which, when we think of it or it is triggered by some present event, evokes difficult emotions and/or physical symptoms, gives rise to negative beliefs, desires, fantasies, compulsions, obsessions, addictions, and/or dissociation, prevents or hinders the growth of positive qualities and spiritual connections and development, and fractures human wholeness.”

The Brain and Trauma
We have many communication systems within our body and brain that help the different parts to work properly. In the 1980’s, medical science became aware of a communication system in our body called the ligand-receptor system that involves communication between the neuronal, hormonal, gastrointestinal, and immune system, that is passed on to the rest of our body via peptides and messenger specific peptide receptors (Smith, 2002). It was also found that the white blood cells manufacture all of the peptides that the other parts of the system make (serotonin, dopamine, norepinephrine, endorphins, etc.) and that a person’s thoughts can directly influence the functioning of the ligand-receptor system (Smith, 2002). Negative thoughts can increase the level of cortisol (stress hormone) and decrease the production of immune cells, while positive thoughts can increase production of immune cells, endorphins, dopamine, sex hormones, and others in the blood stream (Smith, 2002). Smith (p. 5) writes, “It is becoming increasingly clear that our control center is not only a place, but a process involving the interrelationship between the brain, our hormones, our biochemistry, and the environment.”
It is the intense, unpredictable and ongoing stress that creates a chaotic biochemical environment that keeps the brain from full maturation and information from traveling from one brain center to another (Stein & Kendall, 2004). When this information is constantly short-circuited, brain systems (right to left hemisphere, cognitive to emotional) fail to mature adequately. When you take these trauma related malfunctioning brain processes and add them to the adolescent brain, as described below, there needs to be careful consideration as to what therapeutic modality one should use to treat the traumatized youth.

The Body and Trauma
Acute threat or danger cause the neurotransmitters that are released from the brain’s limbic system to signal an alarm to the body’s autonomic nervous system (ANS), which, in turn, cause the sympathetic nervous system (SNS) to activate in preparation for fight, flight, or flee. Blood flows from the skin and organs into the muscles to activate this response. However, when fight or flight is not an option, the limbic system may signal the ANS to activate the peripheral nervous system (PNS). In this situation, the SNS continues its high state of arousal while the PNS freezes the action of the body (Rothschild, 2003). When a person freezes, it appears to cause more psychological damage than the fight or flight response and is a major predictor to who will develop PTSD as somatic symptoms caused by the (Rothschild, p. 7) …”hyperarousal in both SNS and PNS persist chronically or are easily set in motion by internal or environmental triggers”.
Body memory, as spoken of in many theories of psychology, is an intercommunication between the brain and the body’s nervous systems. The hippocampus and the amygdala are the two parts of the brain that are involved in the memory of traumatic events. The amygdala is responsible for registering highly charged emotions and the body sensations that identify them (Rothschild). These memories are not stored in the amygdala, they need to be processed through the amygdala in order to be recorded as implicit memories in the neocortex. The hippocampus is necessary to store information so that we can make cognitive sense of our memories in time and space. Memory is not stored here either, but needs to be processed through this brain system to be recorded as explicit memory in the cortex (Rothschild). Stress hormones can suppress the activity of the hippocampus, keeping context from attaching to a memory, and preventing that past experience to be (p. 11) “…anchored in time. They seem to float freely, often invading the present”. Rothschild writes (p. 11),

“In the absence of hippocampal activity, memories of unresolved traumatic incidents may remain in the implicit memory system alone. There images, sensations, and emotions can all be provoked, but without engagement of the explicit memory system, they cannot be narrated (cohesively recounted) or understood. It is this mechanism that is behind the PTSD symptom of flashback – episodes of reliving the trauma as if it is happening now.”

Unique Aspects of Adolescent Development
Dr. Jay Giedd, chief of brain imaging at NIMH, studied the brains of 1,800 teens and found that the point of brain maturation is somewhere near 25 years of age and that impulsive behavior during adolescence is due to raging hormones and late development of the decision-making part of the brain (Howard, 2006). At the age of puberty and then around the age of 25 are the ages a person has the highest amount of brain density (grey matter) and it is also when pruning takes place, making one lose capacity and gain efficiency (Howard, 2006). Due to this pruning, we gain speed of transmission but we lose the capacity to recover from trauma (p. 95).
Howard (2006) writes that the adolescent processes emotions and instructions differently than adults, with more activity in the amygdala (emotion center), as opposed to adults, who normally process their emotions in the frontal lobe (rational center). Teens also find it more difficult to explain these emotions to other people.
During the adolescent years there are elevated levels of dopamine that increase the desire to engage in risk-taking behaviors. It is the combination of “…excess brain capacity, maturity of the sensory cortex, flooding of sex hormones, elevation of dopamine, and late development of the maturity module…” that can lead to problematic behaviors (Howard, p. 94). Stein and Kendall (2004, p.137) stress the importance of helping children process trauma through as many modalities as possible (e.g., images, thoughts, emotions, sensations, and movement) and to help children to gain access to both hemispheres through various activities to assist in trauma integration.
Another major problem that an adolescent, as well as people of all ages, can encounter is recurrent nightmares. A meta analysis (Levin & Nielsen, 2007) of nightmare processes have revealed some startling facts about the differences in dream states and the after effects of nightmares, including specifics in the adolescent population. Levin and Nielsen (p. 489) write,

“Both clinical and research studies call attention to the importance of assessing nightmare distress as integral to defining pathology and of distinguishing the number and severity of traumatic precursors. Research studies further emphasize the importance of distinguishing nightmares, which awaken the sleeper, from bad dreams, which do not.”

This is important when it comes to the adolescent population. The age groups of youth through adolescence has three to four times more frequent nightmares than older age groups and these nightmares can be reenactments of the actual trauma and all of its physiological and emotional distress (Levin & Nielsen). The actual waking is similar to the freeze state, avoiding the processing of traumatic material. Another finding from dream research is that these traumatic nightmares can have long-lasting effect, heightening negative arousal and distress in the hours and days following (Levin & Nielsen).
Nightmares appear to be more frequent and are found more often in psychiatric populations and there is a link between frequent nightmares and psychosis and can immediately precede psychotic episodes (Levin & Nielsen). The frequency of nightmares can be up to six times a week and, if treatment is not sought, can last up to 40-50 years after the trauma. Nightmares can set off certain neurotransmitters, stress hormones, and alter numerous bodily systems. The startle reflex is higher after a nightmare and can remain elevated for days. Levin and Nielsen state that these hyperarousal reactions may involve more defensive reactivity and reduced visual perception. Levin and Nielsen (p. 502) go on to say, “…PTSD patients may expend so much more cognitive, behavioral, and emotional effort managing hyperarousal and reactivity that they exhaust or deplete their emotional and neurochemical resources, such as catecholamines.”
Therapists, teachers, and parents should take these factors into consideration when working with youth and adolescence. The developmental level functioning in clients with complex PTSD, stemming from early childhood abuse and neglect, in most cases, show that almost every developmental line has been disrupted (Segall, 2005, p. 148) writes,

“… there are disturbances in the biological regulation of affective arousal, the hypothalamic-pituitary-adrenal axis, and the autoimmune system; in the stability and continuity of memory, attentional processes, and consciousness; in the regulation of sleep, appetite, and libido; in self-soothing, identity formation, and the regulation of self-esteem; in the planning, self-regulation, and performance of health-maintenance, house-keeping, budgeting, academic and vocational activities; in the self-regulation of intimacy and control, and the maintenance of boundaries and stable affectional bonds in interpersonal relations.”

EMDR Body Centered Counseling
Major constructs
Eye Movement Desensitization and Reprocessing (EMDR) incorporates elements of other psychotherapies such as psychodynamic, cognitive-behavioral, person-centered, body-based, and interactional therapies into a treatment approach that guides the client through different elements of trauma while at the same time moving their eyes back and forth (Shapiro & Maxfield, 2002). EMDR is composed of an eight-phase treatment that works a client through body sensations, emotions, and cognitions associated with the trauma, in such a way as to slow down the cognitions enough to process the somatic and emotional sensations at the same time and create an explicit memory. This primarily nonverbal method stimulates interhemispheric activity and makes it possible to recall the body and cognitive memories into an integrated whole (Maxwell, 2003).
Intervention strategies
The intervention strategies involved in EMDR include an eight-phase treatment approach. The first phase focuses on gathering a client history and treatment planning. The second phase involves the explanation of EMDR treatment protocol and theory. The third phase is an assessment of baseline levels of emotional trauma. Forth is desensitization of emotional and physical responses. Fifth is the installation of reprocessed material. Sixth, residual body tension and emotion is resolved. Seventh is closing and debriefing and eight is evaluation. A big advantage to using EMDR treatment is that a therapist does not have to work only with an actual trauma, but can treat nightmares as well. This protocol works for the reprocessing of traumatic material, regardless of the form, and also for the installation of positive material such as a ‘safe place’ image, complete with color, sight, sound, smell and temperature.
The process of change
In research conducted by Lee, Taylor, and Drummond (2006), it appears as if the process of change in EMDR involves dual focus of attention in the desensitization phase and distancing. Pairing eye movements with memory helped clients reduce the vividness of images and the negativity of emotions and the eye movement may produce a relaxation response (Lee, et al.). Foa, Keane, and Friedman (2000) reviewed seven published, randomized, controlled efficacy studies on EMDR and found it to be more efficacious for PTSD than wait-list, routine-care, and active treatment controls.

Transpersonal Theory
Major constructs
Transpersonal theory differs in many ways from other psychological theories because it holds a very different philosophical worldview (Capuzzi & Gross, 2007). This theory does not exclude other therapeutic modalities; rather they include all therapeutic interventions (behaviorism, psychoanalysis, humanism, Jungian analysis, and Eastern philosophy) as needed in the course of therapy (Capuzzi & Gross, 2007). Even though this theory is inclusive of other theories, it maintains that other theories are limited in their view of human experience and potential. Higher states of being are strived to be reached in the course of the therapeutic intervention and transpersonal theory (p. 394) “…primarily encompasses the dualistic and monistic approaches in an effort to reconcile the divine and human qualities of humankind (dualistic) as well as to uncover one’s true source of being and the underlying unity of all existence (monistic).”

Intervention strategies
The intervention strategies from this theory that are advantageous for dealing with adolescent trauma include meditation, mindfulness, intuition, yoga, biofeedback, breath training, contemplation, inward focusing, visualization, dream work, guided imagery, and altered states of consciousness (Capuzzi & Gross). Mindfulness is being in a state of pure attention to the process of experiencing and improves trauma conditions due to a person’s increased ability to become aware of body processes, emotions, sensations, thoughts, and affective cues (Segall, 2005). This expansion in the state of consciousness has helped individuals find a new sense of aliveness and can eventually discontinue using numbing, dissociative and avoidance behaviors to cope with their trauma. Since mindfulness and meditation practices help a person to monitor their thought processes, somatic and affective experiencing can be an additional focus of these practices. In the adolescent population, “The regulation of social behavior requires awareness of internal affective states such as attraction, anxiety, shame, or anger, and awareness of external cues such as facial expressions, body language, and vocal inflection (Segall, p. 149).”
The process of change
The process of change with transpersonal theory focuses on overcoming one’s life problems so that the primary work of spiritual integration and/or self-actualization can begin, leading the client toward higher qualities of creativity, compassion, selflessness, and wisdom (Capuzzi & Gross). In order to reach these levels of personal transformation, however, one will first need to be able to have a complete sense of self. Mindfulness is one of the most helpful ways to get to this point because it allows a person to proceed at his or her own pace as his or her own tolerance allows (Segall, 2005). Consciousness is similar to mindfulness and is a kind of energy in itself, related to the cellular expression of the physical body, participating in the continuous creation of either health or illness (Gerber, 2001).

Somatic Counseling and Expressive Arts
Major constructs
Somatic (body-centered) and expressive art approaches to counseling focus on reuniting the body and mind by using a variety of modalities such as meditation, massage, art, dance, drama, writing, sound, taste, sight, touch, and voice (Capuzzi & Gross, 2007). Pointon (2004, p. 10), from an interview with Bessel Van der Kolk, writes:

“The imprint of trauma is the imprint on people’s senses, on people’s systems…that becomes particularly important because these sensations stay in people’s memory banks and stay unprocessed. If you do effective trauma processing, the individual smells, sounds, images and physical impressions of the trauma slowly disappear over time and that is something that doesn’t happen with talking. It happens by working with people’s bodily states.”

The constructs of this theory focus on the integration of experience involved in the trauma.

Intervention strategies
There are two types of interventions primarily used in this approach and they include focusing the mind in order to listen and feel the body and moving the body to physically discharge traumatic material. Focusing the body and mind is achieved by modalities such as meditation, yoga, T’ai chi, and visualization. Moving the body is accomplished through dance, drama, reenactment, etc. Pointon (p. 12) writes, “With children and young people, this work may take the form of dance, movement or martial arts training – all aimed at empowering, and helping them to remain grounded and embodied.”
Another modality is narrative story telling and/or writing. In this strategy the person attempts to make sense of what has happened to him or her through story writing or story telling.

The process of change
Peter Levine (Pointon) talks about the process of change involves being able to discharge the trauma energy from the areas of the body that have ‘locked’ it in and can be accomplished by accessing this energy somatically and discharging it through many different types of somatic and expressive interventions. With children, the use of the self-expression of drawing, the prefrontal cortex is active and provides another way to symbolically represent the trauma and may help restore the lost capacity for imagination (Pointon). Wieland (1998) suggests somatic therapy as a way for children to reconnect to normal developmental processes that have been disrupted.

Diet and Exercise
Due to the stress involved in traumatic experiences, the body’s hormones and neurotransmitters are altered by stress hormones, disruptions in sleep patterns, and somatic sensations among other things such as medications and psychiatric instability. Stress can deplete the body of vitamins and minerals and weaken its defense systems substantially. It is important to eat a balanced diet and supplement vitamin and mineral intake with natural supplements. The stronger one’s body is, the more easily it can deal with stress and the emotional distress that accompanies most trauma.
Along with diet, herbal supplements can help relax and restore the nervous system. Mabey (1988) writes about two main classes of herbs that help the nervous system; relaxants and restorative, with stimulants having a more limited use. Herbal relaxants include passion flower, valerian, crampbark, hops, and chamomile. Herbal restoratives include vervain, skullcap, wild oat, and ginseng. Restoratives help restore your nervous system when it is run down and debilitated, such as often happens after trauma. It is always important to talk to your doctor before starting any new diet, exercise program and/or herbal supplement.
Exercise is another important aspect of a healthy lifestyle and helps strengthen the body and brain centers. Exercise elevates serotonin and other neurotransmitter levels in the brain and gives one an overall sense of well-being. Most health experts recommend exercising at least thirty minutes a day at least four days per week.

Case Study
This case study focuses on an 11-year-old male (Steven) that, at first meeting, resided in a group home for psychiatrically unstable children. Steven had been adopted at age seven by a single male who lived alone in a one-family home. Prior to being referred to a psychiatric residential facility, Steven had been in and out of therapy, in and out of crisis centers, and hospitalized several times for emotional breakdowns. Steven held a diagnosis of Bipolar disorder, ADHD, Conduct Disorder, and PTSD. Steven was on several antipsychotic medications and ADHD medications. In Steven’s early years he was subjected to physical and sexual abuse by adult males, physical and emotional neglect by his mother, domestic violence, drugs, and transient living conditions.
The therapist in charge of Steven’s case quickly suspected that most, if not all, of Steven’s behavioral and emotional problems were a result of severe childhood trauma. The therapist had several individual sessions with Steven and several family sessions with Steven and his adoptive father and it was decided to try EMDR with Steven. Steven reacted well to this intervention as well as many other modalities of play therapy. The therapist worked with the psychiatrist and slowly eliminated all of the psychotropic medications that Steven was taking. Steven reacted well to taking no medication and psychiatric diagnoses were changed to only PTSD.
Steven was discharged to home after 6 months of treatment and the therapist continued on with this case as an in-home therapist. Steven’s adoptive father was very supportive and dedicated to try every therapeutic technique the therapist suggested. However, the school was not as patient with Steven and his PTSD was triggered often in the classroom atmosphere. Among the triggers that set Steven off into an uncontrollable tantrum were (1) being yelled at by an adult male, (2) being teased by other children, (3) having to read or give answers out loud in class, and (4) angry facial expressions. Steven was suspended from school on several occasions for disruptive behaviors. The therapist worked with Steven on these triggers by using guided imagery, meditation, hypnotic audio tapes geared to raise self-esteem, and hours of learning to express emotions and where these emotions were held inside of his body. Steven responded well and the problems at school decreased a little at a time.
Unfortunately, after about a year and a half of treatment, puberty hit rapidly. Steven grew taller and taller and started asking a lot of questions about sex and how babies are born. Steven’s father asked the therapist to talk to him about sexual issues due to the fact that Steven had been sexually abused multiple times as a small child. The therapist talked with Steven and dad about puberty, how babies are born, and sexual relationships. Steven responded with a normal degree of embarrassment, but continued to ask questions. The therapist explained the difference between good touch and bad touch and this led into a conversation about sexual abuse. Steven talked about some very abusive things that had happened to him and the therapist helped him understand that this was not his fault and that some people do very bad things to children. The therapist used visualization to help Steven find a happier and safer place before finishing the session.
That night Steven had a nightmare that was very powerful and his father helped him to calm and feel safe again. However, in school the next day, Steven had several melt downs and had to go home early. The therapist came back to help Steven through this experience and brought him a sound machine to help him sleep better at night and used visualization to help Steven visually create a container with a padlock on it in his bedroom so that he could put all of his scary thoughts in it before going to sleep at night. He also started taking his calming CDs to school for when he felt stress or upset. The next several sessions focused on body awareness and sensory triggers. Steven did much better in school and very rarely had problems. If problems arose, he was able to calm much quicker.
Steven is now a year older and continues to function well without medication, showing no signs of ADHD or conduct disorder. He has joined several sports teams to help with body work and awareness and does well. His father, a school teacher, tutors him every night and Steven has caught up academically with his grade level. His father has followed the advice of the therapist and has taught Steven to eat healthy, exercise, and use natural herbal products to help Steven maintain an even hormonal balance in his teen years.
Recently the therapist had a session with Steven and Steven discussed a bad dream that he had had the night before. He told the therapist that his (imaginary) padlocked box in his bedroom was full and he didn’t have any room to put in his bad dream last night. The therapist asked him to go get the box and she would take it home with her and put it somewhere safe. She then had Steven visualize another bigger box with a padlock to put in its place.
Steven has come a long way in his recovery from complex PTSD and is now able to lead a normal life as a normal teenager. However, he has not worked through all of his trauma, due to his age and comfort level, so will need to do so as he feels he is able. Fortunately, he has the psychological tools and the support of a loving father to help him through whatever lies ahead. Not very many children make it through the degree of abuse that Steven has made it through. He has a strong spiritual base that his adoptive father has shared with him and a support system that understands the importance of a body/soul/spirit connection.

Conclusion
Regardless of the modality of change that one utilizes, it is important to realize the place that defense mechanisms, such as numbing, dissociating, etc. have served in the client’s life up to this point and to be gentle and go slowly in substituting new, healthier practices into their life (Etherington, 2005). “Rapidly operating emotional reflexes are unconscious and do not have a feeling tone, except perhaps during the period of arousal after the reflexive response has diminished (Panksepp, 2002, p. 226).” Due to this factor, an individual, especially an adolescent, may not understand why they did something until after the behavior is past. Helping the adolescent find sensory and emotional awareness is an important first step in trauma therapy. All of the above therapeutic modalities are geared to serve this purpose. These strategies, aimed at helping the adolescent process trauma at the level they are currently functioning, will need to be tailored slightly to fit that developmental phase of emotional, cognitive, psychological and social functioning. To do this it will be important to be able to integrate other therapeutic modalities such as CBT as an aid in teaching skills and identifying developmental levels.

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