Healing Systematically: A Q&A With Dr. Glenn Saxe

(Editor’s note: This article from the Spring 2018 issue of Brain World magazineIf you enjoy this article, consider a print or digital subscription!)

Dr. Glenn Saxe grew up in Montreal, Canada, earned his undergraduate degree in psychology at McGill University, and attended medical school at McMaster University in Hamilton, Ontario. He then moved to Boston to complete psychiatry training at Harvard Medical School where he became introduced to ideas about trauma, and began to provide care to adults who were traumatized as kids. This work helped Saxe to see how much these individuals would have benefited had they received the care and protection they needed when they were children.

It was for this reason that he decided to train in child and adolescent psychiatry. Once Saxe completed this training he began to study factors that contribute to risk, and resilience, to trauma in acutely traumatized children. In the late 1990s Saxe became chief of child and adolescent psychiatry at the Boston Medical Center and Boston University, where he established a clinic specializing in the care of traumatized children — many of whom experienced ongoing adversity related to poverty, parental mental illness, and substance abuse, and ongoing neglect and abuse. “One of my most important priorities was to provide treatment that really addressed the needs of the highly vulnerable children and families who came to us for care. Unfortunately, available treatments at the time primarily focused on the individual child without giving much attention to what goes on around them, and what goes on around them hugely determines whether they will recover from trauma and respond to treatment,” says Saxe.

He found a real gap in the field, and around 1999, began developing Trauma Systems Therapy (TST) to address this gap. TST later became a model of caring and healing for traumatized children and families at the systemic level. In 2005, the first book about TST was published, and in 2010, Saxe was recruited to be the chair of the Department of Child and Adolescent Psychiatry at the New York University School of Medicine and the director of the NYU Child Study Center. He stayed in that position until about a year and a half ago, and left that position mainly to have the time to focus on helping to make Trauma Systems Therapy available to as many children as possible. Brain World recently had the opportunity to sit down with Saxe and speak to him about his life’s work and the importance of working with trauma at the systemic level.

Brain World: How did you transition from working with adults to working with kids? What impacted your decision?

Glenn Saxe: The adults I worked with at the time were frequently struggling with events that happened to them many years in the past, often within their family and when they were kids. I frequently found myself wishing that they had received help at that time because it could have prevented the years of pain and suffering that brought them to the point that they decided to seek treatment with me. Then I thought that if I received that sort of training, to provide care for traumatized children, I could help prevent years of pain and suffering by working with people around the time trauma happens. I wanted to really understand the experience of a traumatized child and how they process what happens to them and — with that understanding — provide the care that would help them. Those were some of the biggest reasons for my decision to train to become a child and adolescent psychiatrist.

BW: Could there be a traumatic condition where it’s too late to cure?

GS: It’s never too late. That was not my thinking, nor my experience with adults. I really felt they were benefiting from treatment, but they’d suffered for years with accumulating trauma. The impact from having trauma symptoms — flashbacks, nightmares, dissociation, avoidance of reminders — over years has a very strong impact on the individual’s development, and on how they see themselves, and on how others see them. It really struck me that I could have much more impact if I worked with people when the care could have the most impact on their lives.

BW: How would you define trauma?

GS: Trauma is an event that connotes threat. It threatens a person’s life. It threatens a person’s physical integrity. It threatens someone close to that person. What the traumatic event, or series of events, evokes are powerful systems in the brain and body that have been given to us through evolution to respond to threat so that we may survive. These are very strong, hardwired systems, and are necessary for our survival. Most of the time, they are working fine, and helping us to make decisions — usually unconsciously — about whether a signal we perceive connotes a threat, and — if threatening — what we do about it (fight, flight, etc.). These survival circuits are highly adaptive, but these are precisely the systems that go wrong in the individuals who end up developing traumatic stress.

In such individuals, these survival systems get evoked in situations in daily life that are not objectively threatening. You are not under actual threat, but you experience the situation as extremely threatening, and you respond to it accordingly. The signal that can evoke such extreme survival responses can be very subtle and is highly individualized based on a person’s actual memory of threat. The signal could be a tone of voice, a facial glance, an odor. It can be any signal, no matter how subtle, that brings the individual back to the context of real trauma. Within Trauma Systems Therapy, we call this response “survival-in-the-moment,” because it describes the moments in a person’s everyday life where they experience their environment as deeply threatening and they are acting to protect themselves from threat.

BW: What parts of the brain are activated?

GS: The amygdala is central — it provokes the body to fight, flee, freeze. The pathway from sensation to the amygdala is very fast and unconscious. Conscious processing takes a lot more time (like seconds). You want your amygdala to make decisions about threat very quickly because too much delay in processing may lead to harm, or even death. Your amygdala processes bits and pieces of sensory information that may connote threat, but not the contextual details of the signal that might indicate that the situation is actually safe.

Higher order systems of the brain, such as the hippocampus and areas of the prefrontal cortex, are involved in processing these contextual details. For example, you may momentarily have a startle response upon seeing a snake in a pet store, but then you quickly calm yourself when you become aware that you are in a pet store and the snake is in a glass enclosure. Your amygdala made you startle and the higher order systems calmed your amygdala (and you) by bringing context to the moment.

What underlies the traumatic stress responses that I have described is an amygdala that fires when you don’t want it to, and a hippocampus and other brain areas that are too weak to tell the amygdala to stop firing. So this problem becomes a very significant clinical issue for some people. For example, a child in a classroom is minding her own business, learning, when a teacher uses a tone of voice the child’s father used just before he assaulted her. The child then enters a survival state and is sitting in class quietly terrified — overwhelmed by flashbacks of assault — and staring out the window. The child is now back at the time and place of the trauma, the amygdala continues to fire, and brain systems that are supposed to bring context to the situation are not doing their job.

BW: Can you elaborate on the Trauma Systems Therapy model?

GS: The model that we developed builds on the ideas that I’m talking about. The core part of it is a child who has a brain wired to respond with extreme survival-laden emotion and defensive behavior in situations that are not objectively threatening. For such children, suddenly their entire context is experienced as extremely threatening and the child reacts — in the classroom, at home, anywhere, when they perceive these signals, even without being conscious of perceiving them. The brain and body go into survival mode. But that’s only one part of it. The other part that must be addressed concerns everyone and everything around the child — because what goes on — around the child — will make the situation better or worse.

The child I described, for example, responded to a teacher’s tone of voice with a survival-in-the-moment response; the teacher had no idea that his tone of voice had precipitated such an extreme response in the child, and frankly, was not that aware that she was experiencing survival-in-the-moment. All that teacher saw was a child who was staring out the window. Wouldn’t it be great if that teacher were made aware about the child’s vulnerability to that tone of voice, and for that teacher to be helped to be more aware of what might be going on for that child when she stares out the window?

The child also needs help to see that when she hears such a tone of voice from an adult male, it does not mean that she is about to be sexually assaulted. In the bounds of reality we cannot prevent this child from ever hearing such tones of voice, nor should we. Within TST we also work with children to build their emotional regulation skills so that they are better able to calm themselves when they perceive a stimulus that we know reliably leads to survival-in-the-moment. This work is highly individualized, based on a child’s specific vulnerabilities. And with all this knowledge, we build a specific treatment plan to help the child and relevant people around them to help the child manage their states of emotion so that survival-in-the-moment is prevented.

(Editor’s note: This article from the Spring 2018 issue of Brain World magazineIf you enjoy this article, consider a print or digital subscription!)

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