Trauma Systems Therapy

1. Introduction

Version followed: Trauma Systems Therapy (TST) as set out in Saxe, Ellis & Brown, Trauma Systems Therapy for Children and Teens, 2nd ed. (Guilford, 2016), the manual the Title IV-E Clearinghouse reviewed, read through the developer-approved NCTSN "At-A-Glance" sheet (Saxe, Brown & Hansen, 2024, NYU Langone TST Training Center), the CEBC profile and the Virginia CSA training summary. The refugee adaptation TST-R (Boston Children's Hospital) is covered where noted. Only the book's table of contents is drawn on, so chapter-level details (the full list of Ten Treatment Principles, the assessment grid levels, the intervention guides' internal steps) are marked [uncertain] or [synthesis] below. [source: NCTSN 2024; Clearinghouse; Guilford TOC]

TST was developed in the early 2000s at Boston Medical Center by Glenn Saxe and B. Heidi Ellis (with Julie Kaplow on the 2007 first edition). It now runs from the NYU Langone TST Training Center (Saxe, Adam Brown, Susan Hansen). It is both a clinical model and an organisational model: it tells agencies how to organise teams and services, as well as how to treat. It serves children aged about 3–21 and their caregivers, after any type of trauma, in homes, foster and kinship care, residential care, schools, juvenile justice and refugee services. [source: NCTSN 2024; CSA 2024; CEBC; TST-R sheet]

Core idea of change. The target is a trauma system, not the child alone. A trauma system has two interacting parts: (1) a traumatised child who shifts into survival-in-the-moment states (survival states, SS) when threat signals appear in the present environment; and (2) a social environment or system of care that cannot help the child regulate those states, or keeps exposing the child to threat. A survival state is an episode in which the child subjectively experiences the present as threatening survival, with linked changes in thought, emotion, behaviour and neurophysiology (fight, flight, freeze). A recurring pattern of survival states set off by particular threat signals is a Survival State Problem or Priority Problem. Change comes from working on both halves at once: social-environmental work to remove or buffer threat and to help the child regulate, plus child-focused work (skills psychotherapy, and medication when needed) to build regulation. The balance between the two shifts across three phases as the environment becomes safer and the child's regulation improves. [source: NCTSN 2024; CSA 2024; Brown et al. 2013 J Fam Violence]

2. Framework

Pre-treatment (intake). CSA training material gives about 2 weeks each for Assessment, Treatment Planning and Treatment Engagement. TST-R allows up to one month for intake. Treatment does not start until engagement (Ready–Set–Go) is achieved. [source: CSA 2024; TST-R sheet; CEBC]

Assessment that sets the phase. The team rates two things: the child's emotional and behavioural regulation (how often survival states occur and how much they impair functioning, and whether they are dangerous) and the stability or safety of the social environment. The combination places the trauma system in one of three phases. The assessment is repeated at regular intervals, and the phase changes when the ratings change. The book organises this as an assessment and treatment-planning grid; its exact level labels and cell-to-phase rules are not drawn on [uncertain]. The Child Ecology Check-In (CECI), a 9-item tracking tool, follows regulation and environmental stability over time; higher scores mean worse. [source: CEBC; NCTSN 2024; Brown et al. 2013]

Total length. Sources differ [uncertain]: NCTSN 2024 gives 6–12 months if starting in SFT, otherwise usually 4–7 months; the Clearinghouse and CEBC give a typical 7–9 months. The model expects the child to reach BTT ideally; under time-limited child-welfare contracts, phase-based follow-up care is used. Psychopharmacology may be added in any phase, and a psychiatrist or psychiatric nurse practitioner is always on the team. Homework runs through every phase: environmental-stability tasks in SFT, regulation-skill practice in RFT, cognitive processing and meaning-making tasks in BTT. [source: NCTSN 2024; Clearinghouse; CEBC]

Movement between phases. Movement is two-way. A new threat (for example a placement disruption, renewed contact with an abuser, or a return of dangerous behaviour) sends the case back to SFT; improvement moves it forward. The phase follows the latest repeated assessment, not the calendar. [source: CEBC; Clearinghouse] Using a fixed reassessment interval (for example, monthly or at each placement change) is [synthesis].

Team and organisation. Every case has a multidisciplinary TST team: therapist, home-based clinician, psychiatrist or nurse prescriber, case manager or advocate (sometimes an advocacy attorney), and, in residential settings, direct care staff as full members, with weekly team meetings per case. The four service modules (home- and community-based care, outpatient skills-based psychotherapy, psychopharmacology, services advocacy) are each held by a team member. [source: Clearinghouse; Brown et al. 2013; CEBC]

Certification and licensing before delivering "TST". Delivery is contracted to agencies, not individuals, usually as a year-long consultation:

• Organisational readiness and an Organizational Planning form.
• About 22 hours of provider training over three sessions (or 2–3 days on site), with a follow-up training about 10 months later.
• Weekly consultation for the length of the contract, plus a TST book review and quizzes.
• Provider and Expert certification: at least 5 cases, at least 4 meeting fidelity, and at least 85% on the book quizzes. Supervisors become Experts through a 12-month-plus Experts Program, after which they rate fidelity and can train others.
• Organisational certification: at least 15 cases through at least one phase, 5 of them through BTT; review of 10 random cases for fidelity; at least 2 certified Experts and 3 certified Providers; recertification every 3 years.
• Contracts also require a data-reporting and fidelity-monitoring structure.

[source: NCTSN 2024; Clearinghouse; CEBC] TST-R adds clinician–cultural-broker dyads and multi-year team training. [source: TST-R sheet]

3. Guiding principles

The manual anchors practice in Ten TST Treatment Principles (book ch. 6). Only some are confirmed in the sources; the full wording of the ten is not given and is not reconstructed here [uncertain].

Confirmed in the sources:

• "Don't go before you are ready" (principle 5, per CEBC): do not start active treatment until the family and team agree on the problem and on the solution (Ready–Set–Go). [source: CEBC; CSA 2024]
• "Insist on accountability, particularly your own": quoted as TST language in the residential paper. In practice, when the milieu or service system is part of the trauma system, the team looks at its own contribution first. [source: Brown et al. 2013] Whether this is the exact wording of one of the ten is [uncertain].

Operating principles stated in the sources (described by the developers, but not presented here as the numbered ten):

• Treat the trauma system, not the child alone. Every plan has a social-environment arm and a child-regulation arm. [source: CSA 2024; CEBC]
• Read problem behaviour as survival states. Behaviour labelled "bad" or conduct-disordered is first assessed as dysregulation set off by a threat signal. Use the shared language of survival states with staff, caregivers and the child. [source: Brown et al. 2013]
• Base plans on facts, nonjudgmentally. Find what "flipped the switch" through moment-by-moment assessment from several viewpoints, and do not assume. [source: CSA 2024]
• Focus on a few priority problems. Choose a small number of priority problems that link specific cues to specific responses, rather than treating a symptom list. [source: Brown et al. 2013; CEBC]
• Safety before regulation, and regulation before processing. Phase order follows the state of the environment and the child's regulation; processing the trauma narrative waits until BTT. [source: NCTSN 2024; Clearinghouse]
• Caregivers are essential. Caregiver engagement and caregivers' own goals and pain drive the plan. [source: CEBC; Brown et al. 2013]
• Put scarce resources where they will work. TST is designed to run on existing agency resources and to use them efficiently: intensive home-based work only when the phase calls for it. [source: Guilford description; CEBC]
• Measure and adjust. Track how often survival states occur and how much they impair functioning, rate fidelity throughout, and change the plan from the data. [source: NCTSN 2024]
• Look after the team. Supporting the team includes managing secondary traumatic stress. [source: NCTSN 2024]
• Innovate within minimum fidelity. Under the "lead-user innovation" approach, sites adapt tools and share them through the monthly Innovation Community call while keeping core standards. [source: NCTSN 2024; CEBC]
• Build trust over time in culturally distant communities. In TST-R, trust and safety can take years, and cultural brokers bridge the gap. [source: TST-R sheet]

4. Intervention inventory

The manual has detailed intervention guides for each phase and named forms: the Moment-by-Moment tool, the Priority Problem Worksheet, the Emotion Regulation Guide and the Child Ecology Check-In. The forms are published as reproducibles by Guilford and are not reproduced or paraphrased item by item here. The procedures below follow the published structure. Where the internal steps of a guide are not given in the sources, the steps are marked [synthesis]. [source: CEBC; Guilford TOC]

4.1 Organisational planning and forming the TST team

• Purpose / when: Before any case is seen. TST will not run without administrative commitment and a team that covers the four modules. [source: CEBC; NCTSN 2024]
• Steps:
  1. Complete the Organizational Planning process with leadership: who fills each module, what each role costs, and how cases are referred.
  2. Name the team for each case: therapist; home-based clinician; prescriber; advocate or case manager (legal advocate where available); and, in residential care, direct care staff and a lead clinician. Residential sites may also add a TST coordinator.
  3. Protect time for a weekly team meeting on each case.
  4. Set up data reporting and fidelity monitoring.
  5. Train every team member, including direct care staff and foster parents, not just clinicians. Uneven training splits teams. [source: Clearinghouse; Brown et al. 2013; NCTSN 2024]
• Example language (illustrative): "For TST to work here, each of these children needs someone who can go into the home, someone doing skills work, a prescriber and someone who can fight the systems. Who is that for each of them?"
• Watch for: A lone therapist trying to "do TST" without a home-based or advocacy arm. That breaks the model, because the social-environment half has no one working on it.

4.2 Dual assessment: child regulation and social environment

• Purpose / when: At intake and repeated throughout. It decides the phase and tracks benefit. [source: NCTSN 2024; CEBC]
• Steps:
  1. Gather information from the child and caregivers through written tools, interviews and behavioural observation. Add teachers, caseworkers and unit staff.
  2. Rate the child: how often survival states occur, how much they affect functioning, and whether they are dangerous to self or others.
  3. Rate the environment: is there objective threat (abuse, violence, unsafe contact)? Can caregivers protect the child and help the child regulate? How much distress and instability is there (housing, placement, caregiver illness or substance use, resettlement stress)?
  4. Combine the two ratings to assign the phase (see section 2).
  5. Track with the Child Ecology Check-In or the agency's measures. Research versions also used the UCLA PTSD Reaction Index, CBCL, CANS and CAFAS. [source: NCTSN 2024; Brown et al. 2013; CEBC] The grid's exact level labels are not drawn on [uncertain].
• Example language (illustrative): "I need two pictures: how often and how badly your son gets overwhelmed, and what is going on around him at home and school that makes that more or less likely."
• Watch for: Rating only the child. A calm child in a dangerous home is still an SFT case.

4.3 Moment-by-moment (MxM) assessment

• Purpose / when: To understand a specific episode of dysregulation and find the trigger. Use it from intake onward and after every significant episode. [source: CSA 2024; Brown et al. 2013]
• Concepts: The 3 A's describe what changes: Affect (emotion), Awareness (focus of attention, orientation, sense of self, access to memory) and Action (behaviour). The 4 R's describe when it changes, in sequence: Regulating, Revving, Re-experiencing, Reconstituting. [source: CSA 2024]
• Steps:
  1. Pick one recent episode.
  2. Step 1 (starting point): reconstruct the sequence. What was the child doing, and how did they seem, while still regulated? What changed as they revved up, during the peak (re-experiencing), and as they came back down?
  3. Step 2 (detail): at each R, record the 3 A's. Find the moment and the stimulus that "flipped the switch".
  4. Gather the same episode from several perspectives (child, caregiver, teacher, classmates or staff).
  5. Keep a nonjudgmental stance throughout.
  6. Repeat across episodes to see the recurring cue–response pattern. [source: CSA 2024; Brown et al. 2013]
• Example language (illustrative): "Let's slow Tuesday right down. Before lunch you were okay. What was the first thing you noticed changing in your body or your thoughts? And just before that, what happened around you?"
• Watch for: It is working when the team can predict episodes, as in the published case where suicidal episodes clustered on Friday afternoons when peers left for home visits. Blame-laden accounts mean the nonjudgmental stance has slipped. [source: Brown et al. 2013]

4.4 Priority Problem formulation

• Purpose / when: To define the clinical target that every team member works on. It is written after MxM assessments and reviewed as patterns change. [source: CSA 2024; CEBC]
• Steps:
  1. Write the child's name and the specific threat signal(s), the present-day cues.
  2. Describe the survival-in-the-moment response: the 3 A's at the re-experiencing stage.
  3. Add the relevant past environment that makes the response understandable.
  4. Keep to a few priority problems.
  5. Share the formulation in plain language with caregivers and staff, so that everyone means the same thing. Published example, paraphrased: when food is withheld, a boy panics and then rages and assaults; food withholding was linked to his past sexual abuse. [source: CSA 2024]
• Example language (illustrative): "When Jeffrey sees food taken away, his body reacts as if he is back in danger. He panics, then fights. That is the pattern we are all going to work on."
• Watch for: A diagnosis or a vague label ("anger issues") in place of a cue→state→history link.

4.5 Treatment planning: the five questions and phase assignment

• Purpose / when: After assessment (about 2 weeks). It turns the formulation into an assigned set of interventions. [source: CSA 2024]
• Steps:
  1. For each priority problem, answer five questions: which problem(s) to focus on; why they matter and to whom; which interventions will address them; which strengths will be used; what will interfere.
  2. Assign the phase from the dual assessment.
  3. Allocate modules and team members for each problem, both social-environment interventions and child-regulation interventions.
  4. Set the measures and the date for reassessment. [source: CSA 2024; CEBC]
• Example language (illustrative): "What's going to get in the way? Let's name it now: the bus schedule, the visits with dad, the school suspensions."
• Watch for: A plan with no social-environment arm.

4.6 Ready–Set–Go engagement

• Purpose / when: Before treatment proper, with child and caregivers. It prevents dropout. [source: CEBC; Clearinghouse; CSA 2024]
• Steps:
  1. Ask about the caregiver's and the youth's own life goals and their main sources of pain.
  2. Reach agreement on the problem: an important source of pain the family wants relieved.
  3. Reach agreement on the solution: the family believes this treatment is likely to relieve that pain.
  4. Identify barriers (practical ones, stigma, earlier bad experiences of services) and say how TST will deal with them.
  5. Begin only when both agreements are in place. If they are not, keep engaging rather than starting. [source: CSA 2024; Brown et al. 2013; CEBC]
• Example language (illustrative): "You said the worst part is the school calling every day and you might lose your job. If we could make those calls stop, would that be worth working on together?"
• Watch for: Engagement is working when the family names the target in its own words and turns up. The developers' trial reported that most TST families stayed in treatment at three months, compared with very few controls. [source: CEBC] When the team's goal is not the family's goal, engagement has not been reached.

4.7 Weekly TST team meeting

• Purpose / when: Weekly per case, in every phase. It coordinates the modules and reviews data. [source: CEBC]
• Steps [synthesis built on published elements]:
  1. Review new episodes and MxM findings.
  2. Check the current ratings (CECI or local measure) and decide whether the phase still fits.
  3. Have each module report on its tasks.
  4. Agree next steps and who owns them.
  5. Note any team-integrity or secondary-stress concerns.
• Example language (illustrative): "Three episodes this week, all after phone calls with mum. What does the home-based worker need to change about those calls?"
• Watch for: Meetings that discuss the child but never the environment, or that drift without data.

4.8 Safety-Focused: home- and community-based care and safety planning

• Purpose / when: SFT phase, when there is objective threat or dangerous survival states that adults cannot contain. Delivered at home or in the community at least twice a week. [source: CEBC; Clearinghouse; NCTSN 2024]
• Steps (published aims; the sequence is [synthesis]):
  1. Identify every actual threat: abuse, violence, unsafe contact, unmet basic needs. Act through the team, child protection or placement decisions to protect the child from them.
  2. Write a safety plan with the caregivers for the priority problem. It covers what the known threat signals are, how adults will remove or buffer them, what adults do as the child revs up, and who to call when the child reaches a dangerous state.
  3. Shield the child from threat signals the child cannot yet manage, for example by changing the visit format, the classroom seat, the bedtime routine or the staff handover.
  4. Support the caregivers themselves: their own stress, their mental health and substance-use treatment, and concrete needs.
  5. Set homework that creates or maintains environmental stability, such as keeping the routine, keeping logs, attending appointments and arranging benefits. [source: CSA 2024; Clearinghouse; CEBC] Suicide or self-harm risk: use the service's standard risk assessment and safety-planning protocol, with lethal-means counselling (secure storage or removal of means). [synthesis]
• Example language (illustrative): "Until Maya can handle these reminders herself, our job, the adults' job, is to keep them away from her or be right beside her when they happen. Let's list the three moments in the week that set her off."
• Watch for: Working looks like fewer dangerous episodes and caregivers carrying out the plan without the worker there. Watch for secondary threats the worker brings in, such as unannounced removals and conflicting messages from agencies.

4.9 Caregiver psychoeducation and the shared language of survival states

• Purpose / when: All phases, central in SFT and RFT. It helps adults see behaviour as survival states, so they respond in ways that help the child regulate rather than escalate. [source: Brown et al. 2013; Wikipedia (secondary)]
• Steps [synthesis built on published concepts]:
  1. Explain the trauma system and the 3 A's and 4 R's, using the child's own priority problem.
  2. Help caregivers spot revving early.
  3. Agree what adults do at each R. While the child is revving: reduce the cue and stay calm and close. At the peak (re-experiencing): keep everyone safe, use few words, make no demands. As the child reconstitutes: repair, and review without blame.
  4. Practise the plan by role-play.
• Example language (illustrative): "When he swears and throws the chair, his brain is in survival mode. That isn't the moment for consequences. It's the moment to make things safe and quiet."
• Watch for: Caregivers who hear this as excusing the behaviour. Pair it with clear limits and a plan for safety.

4.10 Services and legal advocacy

• Purpose / when: Any phase where systems keep the environment unstable: school exclusions, housing, immigration, benefits, court or child-welfare decisions. [source: Clearinghouse; Brown et al. 2013]
• Steps [synthesis built on published module]:
  1. List the systems around the family and what each is doing that adds threat or instability.
  2. Have the advocate, or an advocacy attorney where available, pursue the specific remedies.
  3. Bring the adults together so that they understand the priority problem and give consistent responses. A secondary source describes "Family Collaborative Meetings" for this [uncertain].
  4. Remove practical barriers to attending: transport and language access.
• Example language (illustrative): "The school's repeated suspensions are pushing him back into SFT. I'll ask for a meeting so we can share the plan with them."
• Watch for: Advocacy that turns into a tug-of-war between agencies. The goal is fewer threat signals for the child, not winning.

4.11 Residential milieu assessment and repair

• Purpose / when: In residential and congregate care, where the milieu is the social environment. [source: Brown et al. 2013]
• Steps:
  1. Assess whether the milieu is distressed or threatening.
  2. Treat any boundary violation by staff (threats, abuse) as needing immediate administrative action.
  3. Repair team integrity: make rule enforcement consistent across shifts, improve communication, and stop staff discussing colleagues or youths in front of youths.
  4. Review caregiver contact: calls or visits that upset or endanger the youth, and contact that is missed. Plan support around these.
  5. Make direct care staff full team members, and apply "accountability, particularly your own" in team review.
  6. Use the published adaptations as needed: a TST coordinator, a lead clinician and protected planning time. [source: Brown et al. 2013]
• Example language (illustrative): "Before we look at what Deshaun did on Friday, let's look at what we did on Friday: staffing, who left, what he saw."
• Watch for: Restraints and incidents falling. Defensiveness in staff review means it is not yet safe to discuss milieu problems. [source: Brown et al. 2013, barriers]

4.12 Regulation-Focused: psychoeducation and emotion regulation skill-building

• Purpose / when: RFT phase, in office-based weekly sessions, once the environment is safe enough. It builds the child's capacity to stay regulated when reminders occur. [source: CEBC; Clearinghouse; NCTSN 2024]
• Steps (the published structure is psychoeducation, skills and practice; the session-by-session order is [synthesis]):
  1. Teach the child their own survival-state pattern (3 A's, 4 R's), using their priority problem.
  2. Build awareness: recognise and label feelings and body signals at the revving stage.
  3. Teach and rehearse coping skills to use while revving. Choose them from the child's preferences (calming, distraction, movement, music, communicating the need to an adult). A secondary source cites music-based coping. [source: Wikipedia (secondary)]
  4. Practise communicating feelings to caregivers and staff.
  5. Use the Emotion Regulation Guide as the manual's tool for this work. Its content is [uncertain].
  6. Homework: practise skills between sessions. Other team members cue and reinforce the skills at home, at school and on the unit. [source: CEBC; Wikipedia]
• Example language (illustrative): "Your signal is your fists getting tight. When that happens, what's one thing from your list you could do, and who could you tell?"
• Watch for: Working looks like the child noticing revving earlier, using a skill, and fewer re-experiencing peaks. Skills used only in the office mean generalisation (4.13) has not happened.

4.13 Generalising skills through the team

• Purpose / when: RFT. Skills must be used where the threat signals actually occur. [source: CEBC]
• Steps [synthesis built on published element]:
  1. Share the child's skill list and early-warning signs with caregivers, teachers, caseworkers and direct care staff.
  2. Agree a short cue phrase that adults use when they see revving.
  3. Have adults praise skill use.
  4. Log episodes with MxM to refine the plan.
• Example language (illustrative): "When you see his shoulders go up, just say 'check your list' and step back a little."
• Watch for: Adults using the cue as a threat ("use your skill or else").

4.14 Beyond Trauma: cognitive awareness and coping

• Purpose / when: BTT phase. The child is regulated and the environment stable. The aim is to understand how trauma shaped thoughts about self, others and danger. [source: CEBC; Clearinghouse]
• Steps [synthesis built on published component]:
  1. Identify thoughts that occur during survival states, for example "adults will hurt me" or "it's my fault".
  2. Examine the evidence and test these thoughts against the present, now-safer environment.
  3. Develop alternative, more balanced thoughts and practise them.
  4. Homework: notice and record these thoughts, and practise the alternatives.
• Example language (illustrative): "When the teacher raised her voice, what did your mind tell you she was about to do? How true has that been this term?"
• Watch for: Thinking work started before regulation is solid, which brings survival states back. If that happens, step back to RFT.

4.15 Beyond Trauma: trauma narrative

• Purpose / when: BTT only. It is therapeutic processing of the trauma memory, aimed at lasting meaning and recovery. [source: NCTSN 2024; CEBC]
• Contraindications and safety [synthesis]: do not start while there is ongoing objective threat, active legal proceedings where the narrative's evidential status has not been checked, unstable placement, recent dangerous survival states, or without caregiver readiness. Obtain the youth's informed assent and the caregiver's consent, agree a stop signal, and check regulation skills first.
• Steps (the TST manual's own procedure is not drawn on [uncertain]; generic trauma-narrative practice follows [synthesis]):
  1. Agree the format with the youth (written, drawn, spoken).
  2. Build the account in graded pieces over sessions, from less to more distressing parts, including thoughts and feelings at the time.
  3. Use regulation skills within sessions and end each session regulated.
  4. Review the narrative for unhelpful beliefs and work on these (4.14).
  5. When appropriate and the youth agrees, prepare and hold a caregiver session in which the caregiver hears or receives the narrative.
• Example language (illustrative): "We'll go at your pace. If it gets too much, say 'pause' and we'll use your skills before deciding whether to go on."
• Watch for: Working looks like distress during retelling falling over sessions and the story becoming more coherent. A return of survival states outside sessions means pausing and reassessing the phase.

4.16 Beyond Trauma: meaning-making and future orientation

• Purpose / when: End of BTT. It helps the young person "grow into the future" without being consumed by the past. [source: CSA 2024; CEBC]
• Steps [synthesis built on published component]:
  1. Explore what the young person now understands about what happened and about themselves.
  2. Identify values, strengths and relationships to build on.
  3. Set concrete future goals (school, work, relationships, culture or faith) and the steps toward them.
  4. Plan for future reminders and stress, including which skills and which people the young person will use.
  5. Homework: meaning-making tasks, for example a letter to the future self or a goals map.
• Example language (illustrative): "What do you want the next chapter to be about, now that this chapter isn't running everything?"
• Watch for: Goals imposed by adults rather than owned by the youth.

4.17 Psychopharmacology module

• Purpose / when: Any phase where symptoms (for example severe anxiety, sleep disturbance or impulsivity) block regulation. It supports the child's capacity to regulate and does not replace environmental work. A prescriber is always on the team. [source: CSA 2024; CEBC; Guilford TOC ch. 15]
• Steps [synthesis]:
  1. The prescriber attends the team meeting.
  2. Medication decisions use the same priority problem and MxM data as the rest of the team.
  3. Review medication as the phase changes. A secondary source says medication is used sparingly and reduced over time [uncertain]. No dosing is given here.
• Watch for: Medication used to manage a threatening environment, which is a social-environment problem, not a pharmacological one.

4.18 Progress monitoring, phase review and fidelity

• Purpose / when: Throughout. [source: NCTSN 2024; CEBC]
• Steps:
  1. Track how often survival states occur and how much they impair functioning (CECI or the web-based system).
  2. Re-run the phase assessment at regular intervals.
  3. Have a supervisor or TST Expert complete case-based fidelity review.
  4. Change the plan from the data.
• Watch for: Ratings that do not change for weeks. Revisit the priority problem and the engagement agreement.

4.19 Team care and secondary traumatic stress

• Purpose / when: Ongoing. Supporting the team, including managing the risk of secondary trauma, is one of TST's three stated goals. [source: NCTSN 2024]
• Steps [synthesis]:
  1. Make a standing agenda item for team strain.
  2. Debrief after critical incidents.
  3. Share out the highest-intensity cases.
  4. Supervisors watch for loss of nonjudgmental stance as an early sign of strain.

4.20 Group format (residential adaptation)

• Purpose / when: Residential sites have adapted TST for groups of about 5–8 youths. [source: CEBC] Group content is [uncertain]. A reasonable use is RFT skills groups that share the survival-state language [synthesis].

4.21 TST-R: tiered refugee adaptation

• Purpose / when: Refugee and immigrant youth, where stigma, distrust of authority, language and basic needs block ordinary services. [source: TST-R sheet; Abdi PPT]
• Steps:
  1. Pair each clinician with a cultural broker: a community member who shares the language and lived experience and knows youth-serving systems, and who adds context rather than only interpreting. Brokers work at every tier.
  2. Tier 1, community engagement: 2–8 events or activities a year to build trust, provide mental health education and learn about community needs.
  3. Tier 2, skills-based groups: weekly for 8–14 weeks, often in schools, aimed at acculturative stress and social support. Formal versions exist for Somali, Bhutanese, Central American and multi-ethnic groups.
  4. Tiers 3 and 4, clinical TST: Tier 3 covers regulation-focused and beyond-trauma work; Tier 4 is safety-focused. Sessions are every other week to twice weekly, at home, school, office or telehealth.
  5. Assess trauma across pre-migration, migration and resettlement.
  6. Include concrete resettlement services alongside the clinical work. [source: TST-R sheet; Abdi PPT]
• Example language (illustrative): "(Broker to parent) In our community, people worry that talking to a counsellor means the family has failed. Here it is more like getting help with school stress."
• Watch for: The broker being used as an interpreter only. Trust is expected to take a long time, possibly years. [source: TST-R sheet]

5. Handling problems

The sources address dropout and engagement, milieu problems, staff buy-in and phase regression. Most other responses below are [synthesis].

• Family won't engage, or drops out [source: CSA 2024; CEBC; Saxe et al. 2012 as summarised by CEBC]: go back to Ready–Set–Go. Has the problem been defined as the family's pain, or only as the referrer's concern? Re-anchor the plan on what the family wants relieved, and remove practical barriers (home visits, transport, language). Do not start skills or narrative work without the two agreements in place ("don't go before you are ready").
• Mandated family whose goal differs from the referrer's [synthesis]: find the overlap, usually getting the agency out of their lives. Make that the shared problem, and say openly what has to be reported.
• Stuck in SFT [synthesis]: list the specific objective threats still present and who owns each. If the team cannot change a threat (for example court-ordered contact), escalate through advocacy and shield the child around it. Do not move to RFT to show progress.
• Regression to an earlier phase [source: CEBC, repeated phase assessment]: treat it as expected, not as failure. Re-run the dual assessment, return to the indicated phase, and tell the family it is a temporary shift in focus.
• Overwhelm or dysregulation in session [synthesis]: name the R the child is in. If revving, reduce demands and use a rehearsed skill. If re-experiencing, ensure safety, use few words and no processing, and stop processing content. During reconstituting, do a calm repair. Afterwards, run an MxM on the episode and adjust the pace. In BTT, frequent overwhelm means regulation was not ready: step back to RFT.
• Skills learnt in the office but unused at home or school [source: CEBC, team reinforcement]: check that caregivers and staff know the cue and the skill list. Practise in the setting where the trigger happens, and log uses.
• Caregivers or staff see survival-state framing as excusing behaviour [source: Brown et al. 2013, common language] plus [synthesis]: pair the framing with clear limits and a safety plan. Show the MxM data that predicts episodes. Emphasise that changing the cue reduces incidents.
• Milieu or team is part of the problem (inconsistent shifts, staff talking about youths in front of them, punitive responses) [source: Brown et al. 2013]: raise it in team review using "accountability, particularly your own". Boundary violations by staff go straight to administrative action and safeguarding reporting.
• Low staff buy-in, cost, or fear of discussing milieu problems [source: Brown et al. 2013]: build TST language into existing meetings, train all staff and not only clinicians, and build trust before asking for open critique.
• Rupture with the youth or caregiver, for example after a removal, a report or a broken promise [synthesis]: acknowledge it directly. Separate the team's safety duty from the relationship, invite their account, and agree what will be different. An unrepaired rupture is itself a threat signal for the child.
• Non-adherence to homework [synthesis]: shrink the task, link it to the family's Ready–Set–Go goal, and check whether environmental chaos (housing, shifts) makes it impossible. If it does, that is an SFT-type problem for the advocate.
• Disclosure of new abuse or ongoing danger [synthesis]: follow mandatory reporting and safeguarding duties, move to SFT, and update the safety plan.
• Suicidal or self-harm survival states [synthesis consistent with the residential case in Brown et al. 2013]: use the service's structured risk assessment and safety plan, with lethal-means counselling (secure storage or removal). Use MxM to find the timing and cues, then change the environment at those times (for example extra adult time and a structured schedule).
• Refugee families distrust services [source: TST-R sheet; Abdi PPT]: lead with community engagement and concrete help, work through the cultural broker, and allow time.
• Agency cannot staff all four modules [synthesis]: use partnerships to fill the gaps (the developers say partnerships can fill missing services [source: CEBC]). Without a home-based or advocacy arm, do not describe the service as TST.
• Running out of contract time before BTT [source: CEBC]: plan phase-based follow-up care, and hand over the priority problem, safety plan and skill list to the next provider.

Sources

Sources:

• The Trauma Systems Therapy (TST): At-A-Glance (Saxe, Brown & Hansen, NCTSN, 2024)
• Trauma Systems Therapy for Children and Teens, 2nd ed. – Guilford table of contents
• Trauma Systems Therapy – Title IV-E Prevention Services Clearinghouse
• Trauma Systems Therapy (TST) – California Evidence-Based Clearinghouse for Child Welfare
• Trauma Systems Therapy 2024 – Virginia Office of Children's Services training summary
• Trauma Systems Therapy in residential settings (Journal of Family Violence, 2013)
• TST-R At-A-Glance (NCTSN)
• Improving Mental Health Services for refugee youth: TST-R presentation (S. Abdi, Univ. of Minnesota)
• Trauma Systems Therapy – NCTSN intervention page
• Trauma systems therapy – Wikipedia (secondary)

Further reading (not drawn on): the Guilford sample-chapter PDF and the developers' TST Basics blog.

Books and papers cited:

• Saxe, G. N., Ellis, B. H., & Brown, A. D. (2016). Trauma Systems Therapy for Children and Teens (2nd ed.). Guilford Press. Known only through its table of contents and the summaries above.
• Saxe, G. N., Ellis, B. H., & Kaplow, J. B. (2007). Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach. Guilford Press.
• Saxe, G. N., Ellis, B. H., Fogler, J., & Navalta, C. P. (2012). Preliminary evidence for effective family engagement in treatment for child traumatic stress: the trauma systems therapy approach to preventing dropout. Child and Adolescent Mental Health, 17(1), 58–61. Known only through the CEBC summary.