by Jana Pressley, Psy.D., & Joseph Spinazzola, Ph.D., The Foundation Trust
North Atlantic Press’s 2020 publication of the long-awaited book: Transforming Trauma in Children and Adolescents: An Embodied Approach to Somatic Regulation, Trauma Processing, and Attachment-Building was a welcome ray of sunshine during what will be remembered for generations to come as an exceptionally dark year. Co-authored by recognized traumatic stress experts Elizabeth Warner, Anne Westcott, Alexander Cook and Heather Finn, this book serves as the definitive clinician resource and comprehensive manual for the Sensory Motor Arousal Regulation Treatment (SMART) complex trauma therapy model for children, adolescents and their caregivers.
SMART is a comprehensive approach that features embodied, sensory experience as its primary mechanism of therapeutic change. SMART is congruent with other somatically driven trauma treatment models that have been more widely used with adults, such as Sensorimotor Psychotherapy and Somatic Experiencing. A notable distinction of SMART from other sensorimotor approaches is its extensive incorporation of occupational therapy concepts, techniques, and equipment into a trauma-focused psychotherapy treatment model that can be practically implemented by mental health professionals. Therapeutic skills in SMART blend “internal” therapist processes, such as attuned observation and nonverbal tracking, with “external” techniques enabled through use of specific occupational therapy-informed equipment. View a video of SMART here.
Youth often communicate and reenact past traumatic experiences --through dysregulated bodily movements, posture, tone of voice, and actions—that cannot be captured in words or symbolic play. Chronic developmental and complex trauma can profoundly shape bodily experience. SMART was explicitly developed to alter chronic patterns of trauma-induced somatic dysregulation by incorporating sensory inputs from the vestibular system, proprioception, and touch (tactile system) to facilitate the healing process. Through poignant case examples, the authors illustrate how these “movement senses” contribute to an individual’s sense of agency, self-regulation, groundedness, and identity across time.
Preliminary empirical research on SMART has been promising. A matched control study of adolescents in residential treatment with histories of complex trauma and serious associated emotional and behavioral difficulties found that youth receiving SMART demonstrated significant reduction in somatic complaints, indicators of anxiety and depression, and overall Internalizing Symptoms on the Child Behavior Checklist at post-treatment assessed compared with youth receiving treatment as usual.
These findings are especially noteworthy considering that while somatically-based trauma treatments for adults have been in widespread clinical use for over two decades, SMART was the first model to demonstrate its potential effectiveness through controlled research, and became the only somatic regulation-focused trauma intervention model to be acknowledged by the U.S. Substance Abuse and Mental Health Services Administration's former National Registry of Evidence-based and Promising Practices.
Dr Margaret Blaustein, co-Developer of the Attachment, Regulation, and Competency (ARC) framework and Director of the Center for Trauma Training underscores the importance of this accomplishment:
“Treatments that engage and address the body have been increasingly well-accepted within the trauma field, particularly for adults. Ironically, though, given children’s innate tendency to process experience through action and physical engagement, treatments that specifically address somatic experience in childhood have been lacking. The empirical data emerging in support of SMART highlights the critical role that somatic treatments can play in addressing the range of symptomatic expressions of childhood traumatic stress.”
The SMART manual details three foundational and intersecting components of treatment: Somatic Regulation, Trauma Processing, and Attachment Building.
In the Somatic Regulation treatment component, therapists work to expand the child’s window of tolerance and develop self-regulation and co-regulation skills. Specific techniques guide clinicians to build and enhance regulation capacity through incorporating an optimal level of tactile and movement input, engaging in rhythmic movement, and assisting a child in developing a safe space in the therapeutic environment. SMART clinicians are trained to attune to a client’s unique arousal states, with a focus on lowering the intensity of hyperarousal into the child’s window of tolerance; or alternatively elevating the energy of a child who is in a state of hypoarousal.
Attachment Building assesses child and caregiver capacity for relational engagement and works to support caregivers in learning to be in sync with child’s needs and expressions. Treatment incorporates rhythmic activities that build attuned connection between child and caregiver. It also emphasizes tracking and utilization of nonverbal communication strategies that tap into the human social engagement system to promote positive client-therapist and caregiver-client interactions.
SMART has been implemented with a wide range of clients and service settings, from outpatient and home-based work with mothers and their toddlers and young children, to older adolescents with developmental impairment or severe emotional disturbance in residential treatment settings. It has also been incorporated into nontraditional programming, including psychosocial child-care, and play groups in community center, pastoral, and aftercare programs.
Colleen Sharka, MA, LMHC, Director of the Cory Johnson Program for Post-Traumatic Healing at the Roxbury Presbyterian Church Social Impact Center, describes the innovative uses and value of SMART at her center:
“SMART has brought increased connection and emotional awareness between children and their parents, essential ingredients in the trauma healing journey. Whether in our program's childcare room using SMART equipment to help children express and understand their feelings during play, or family sessions with our SMART psychologist, children and parents have a greater understanding about emotions and behavior that ultimately leads to relationship building.”
The Trauma Processing component of the SMART model is distinct from narrative work or memory processing techniques utilized in traditional trauma-focused psychotherapy models in its embodied format, de-emphasizing the need for language-based expression. This approach may be particularly relevant with more implicit traumatic experiences, as well as for those with preverbal trauma.
The latter phenomenon was illustrated in the fascinating case study paper entitled: “The boy who was hit in the face: The role of somatic regulation and trauma processing in treatment of preverbal complex trauma” published in the Journal of Child and Adolescent Trauma. As noted in that study and throughout this book, the model developers have reported numerous anecdotal observations that as children and youth begin to sustain more regulated physiological states over the course of SMART intervention, therapists may notice increased ability of their clients to name emotions and develop a verbal trauma narrative.
Finally, the book includes helpful charts and beautiful colored insets that summarize therapist skills and illustrate various youth trauma symptom characteristics and state shifts. Overall, it is an extremely valuable clinical resource for therapists undertaking complex trauma intervention with children, adolescents, and their caregivers.
Finn, H., Warner, E., Price, M., & Spinazzola, J. (2018). The boy who was hit in the face: The role of somatic regulation and trauma processing in treatment of preverbal complex trauma. Journal of Child & Adolescent Trauma, 11(3), 277-288.
Pressley, J., & Spinazzola, J. (2018). The developmental consequences of exposure to complex trauma in childhood and adolescence. In J. Osofksy & B. McAlister Groves (Eds.), Violence and trauma in the lives of children (Vol 1.). Santa Barbara, CA: Praeger.
Spinazzola, J., Habib, M., Knoverek, A., Arvidson, J., Nisenbaum, J., Wentworth, R., & Pond, A. (2013). The heart of the matter: Complex trauma in child welfare. Child Welfare 360o. Special Issue: Trauma-Informed Child Welfare Practice. Winter 2013, 8-9, 37.
Spinazzola, J., Habib, M., Blaustein, M., Knoverek, A., Kisiel, C., Stolbach, B., Abramovitz, R., Kagan, R., Lanktree, C., & Maze, J. (2017). What is Complex Trauma? A resource guide for youth and those who care about them. National Child Traumatic Stress Network.
Warner, E., Koomar, J., Lary, B., & Cook, A. (2013). Can the body change the score? Application of sensory modulation principles in the treatment of traumatized adolescents in residential settings. Journal of Family Violence, 28(7), 729-738.
Warner, E., Spinazzola, J., Westcott, A., Gunn, C., & Hodgdon, H. (2014). The body can change the score: Empirical support for somatic regulation in the treatment of traumatized adolescents. Journal of Child & Adolescent Trauma, 7(4), 237-246.
Warner, E. Finn, H., Westcott, A., & Cook, A. (2020). Transforming Trauma in Children and Adolescents: An Embodied Approach to Somatic Regulation, Trauma Processing, and Attachment-Building. North Atlantic Books.
*Several of these articles and resources can be downloaded from the Resources section of this website.