Dr. Bruce Perry uses humor to punctuate and bring relief to what is otherwise the most serious subject matter: how trauma interrupts human development.
“I don’t mean to sound ungracious, but I hate the term ‘trauma-informed care,” Perry said, in his opening remarks for the Southern Texas Trauma-Informed Care Conference, which was held this month in downtown San Antonio.
The audience tittered, briefly thrown off balance by his candor. They laughed harder later on as the man who was recently interviewed by Oprah Winfrey on 60 Minutes did his best infant imitation.
By the end of the day, and several swear words later, most people seemed to be on board the Perry train. Day one of the conference was devoted entirely to the work Perry and his colleagues have done to better understand what therapists, social workers and others can do to actually help kids who have experienced trauma.
“This is the true achievement gap,” Perry said, after describing a hypothetical child who lives with an unreliable caregiver, experiences violence in his home, and then has trouble taking a test at school the next day.
“That gap is not about race, shitty teachers or bad curriculum; it’s about a sensitized stress response system, by and large caused by poverty, not trauma,” Perry said.
Perry hates using “trauma-informed care” partly because, over the course of his career, he has found that effective treatment for the impact of trauma on development is more complex than the phrase implies.
It’s as complicated as the human brain.
The threshold of actually helping kids is important, as Perry will explain, because evidence supporting much of the services offered to this population – and probably to adults in public mental health systems – is thin.
“You can’t have a kid who’s lived with daily humiliation and neglect for six years and think your authorization for 20 sessions [of therapy] is going to fix the problem. It’s not, and it’s bullshit,” he said.
How to recalibrate someone’s stress response is only recently understood. The human stress response system can become unhelpfully sensitized when it is repeatedly exposed to stressors, such as chronic hunger, violence or emotional abuse, and is never given the time or support it needs to recover from those exposures.
For boys, Perry said, this often looks like hyper-arousal: inability to focus, becoming angry quickly, or showing aggression. For girls, this more often presents as disassociation, which, in a school setting, can look like shyness, or zoning out.
But the big takeaway from Perry’s workshop is that traditional therapy models – some of which are considered “trauma-informed” – might be getting a few key details wrong about how to best help kids heal from trauma.
Relationships, Perry says, are key to a person’s ability to process a bad experience and move on. Years ago, before figuring this out, he was examining all the data he had to try to determine why some kids he and his colleagues treated got better, or at least didn’t get worse, and others didn’t.
Finding no answers, he finally plugged in ZIP codes to see if he could spot a possible correlation. It turned out there was one: kids who lived furthest from Perry and his staff at the clinic saw the best outcomes.
The audience laughed, but Perry was serious.
In order to get to treatment, those kids had to ride in a car with a caring adult longer than those who lived closer to the clinic. The rhythm of riding in a car is naturally soothing because it mimics human experience in utero, he explained, and allows a kid to feel safe while engaging with a trusted adult.
These car rides, week after week, were themselves therapeutic.
Perry had seen this demonstrated earlier when he and a multidisciplinary team were called in days after the siege to work with dozens of kids who were released from the Branch Davidian cult in Waco, Texas.
When the team started mapping its interactions with the Davidian kids, looking at frequency and duration of contact, what they saw was that kids were taking charge of their own healing processes, and doing what they needed to in order to calm down or self-regulate along the way.
“The kids were controlling who they talked to, how long it lasted, and what part of their experience they wanted to revisit,” Perry said. Dosing, meaning how long the youth allowed the traumatic memory to be reactivated, was seconds long – not 50 minutes, like a typical therapy session.
At first, Perry didn’t trust what he was learning: “That therapeutic web, or relational milieu, matters. It can be regulated and rewarding, or it can be a source of distress,” he said.
This is another reason traditional therapy doesn’t work for everyone, he argues. If a child is supported by a strong social fabric, they might move through their own healing process naturally, using the people around them as needed. Interrupting that process by forcing a child to attend a therapy session with a stranger – where their traumatic memories are activated longer than the child can handle – can be counterproductive.
Perry and his team conducted a study that backed that up. They found that therapy can help kids who live with relational poverty, meaning they lack meaningful connections to other people. But it can have the opposite effect for those who have a healthy relational community.
Perry concluded the workshop by talking about neurosequential intervention, the model he and his colleagues have developed through decades of data collection at the Child Trauma Academy, which Perry founded in Chicago in 1990 and now oversees in Houston.
This method maps a kid’s functioning across different domains; maybe a 14-year-old has the motor skills of an 8-year-old, the social skills of a 6-year-old, and so on. In the example Perry gave, a kid who had been left alone for long periods of time as an infant had trouble with “sensory integration,” or touch.
A neurosequential treatment starts by straightening out the disorganization, or malfunctioning, present in the lowest level of the brain, and it is often used with struggling parents as well as children.
In the 14-year-old’s case, Perry’s team started by getting the youth used to touching his own hand. They monitored his stress response by tracking his heart rate. Gradually they introduced touch from the youth’s mother until they reached a point where the two could exchange hugs without triggering a stress response in the youth.
Then they moved to the next level. Ultimately the youth was able to get off the four medications he’d been prescribed and stop attending a social skills class along with seeing various therapists and specialists.
At this point, Perry said, a similar treatment has helped 35,000 kids around the world, including some who have been told they would never live outside an institution.
The key to continuing to move this work forward, Perry said, is a commitment to collaboration and not quibbling over the limited resources available to support the most vulnerable children and youth.
“As long as we fight with each other, as long as we damn each other with faint praise, we aren’t going to make much progress,” Perry said.
CORRECTION: The final line in this story quoted Perry as saying fake, rather than faint, praise.