Real Life Heroes (RLH): Resiliency-focused Treatment for Children and Families with Traumatic Stress

About This Program

Target Population: School-age children between ages 6-12 and adolescents who have experienced traumatic events, have a breakdown in emotionally supportive relationships, and show symptoms of traumatic stress/Complex Trauma including high risk behaviors and developmental delays; can also be used alongside other programs to engage/sustain engagement of children and caregivers with Complex Trauma, intellectual deficits and developmental delays

Program Overview

Real Life Heroes (RLH) provides practitioners with easy-to-use tools including a life storybook, manual, multi-sensory creative arts, yoga, ‘improv,’ and mindfulness activities, and psychoeducation resources to engage children and caregivers in trauma treatment. Tools and procedures were developed with children and adolescents in a wide range of child and family service programs including children with Complex PTSD who lacked stable relationships with caregivers they could count on to provide a safe home and work with them in therapy and children referred for high-risk behaviors that threatened the safety of children, families, organizations, and communities. RLH helps practitioners reframe referrals based on behavior problems and blame into a shared ‘journey,’ a ‘pathway’ to healing and recovery focused on restoring (or building) emotionally supportive and enduring relationships and promoting development of affect regulation skills for children and caregivers. To do this, the model utilizes the imagery of the ‘heroes journey’ and stresses the importance of engaging caregivers and a collaborative team of caring adults working together with an integrated trauma and resiliency-centered framework to help children with Complex Trauma. Creative arts and shared life story work provide a means for children and caregivers to develop the safety and attunement needed for re-integration of traumatic memories coupled with development of increased security and affect regulation.

Program Goals

The program goals of Real Life Heroes (RLH): Resiliency-focused Treatment for Children and Families with Traumatic Stress are:

  • Increased well-being and safety for children and caregivers
  • Rebuilding (or building) of emotionally supportive relationships with caregivers committed to nurturing, guiding, and protecting children and decreased likelihood of temporary placements or psychiatric hospitalizations
  • Self- and co-regulation development for children and caregivers including cognitive, emotional modulation, focusing/concentration, and social skills and decreased likelihood of high-risk behaviors including self-abuse, suicide attempts, and aggression to others
  • Trauma memory reintegration matched to the child and caregivers’ capacity
  • Development of a positive self-identity for child linked to child’s family and cultural heritage
  • Prevention and management of disruptions of important relationships

Essential Components

The essential components of Real Life Heroes (RLH): Resiliency-focused Treatment for Children and Families with Traumatic Stress include:

  • Use of trauma-informed resources throughout model:
    • Incorporation of the ‘Core Components in Evidence-Based Trauma Treatment’ and the ‘Essential Elements of Trauma-Informed Child Welfare’ developed by the National Child Traumatic Stress Center (NCTSN)
    • Use of phase-based components outlined by the NCTSN Complex Trauma Workgroup and the 2009 recommended practice guidelines for treatment of Complex PTSD in children by Ford and Cloitre as a framework for Life Storybook chapters and session structure.
    • Use of strategies and step-by-step procedures and worksheets provided in the Practitioner’s Manual and training curricula to promote:
      • Safety for the child and child’s family (psychological, physical, and emotional)
      • Strengths and relationship-focused assessments and service planning
      • Self- and co-regulation development in all phases of treatment for the child and caregivers
      • Trauma memory re-integration matched to the child and caregivers’ capacity utilizing components from Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Eye Movement Desensitization Reprocessing (EMDR), and Progressive Counting
      • Prevention and management of disruptions of primary relationships and crises including trauma reactions using Youth and Caregiver Power Plans; interventions and activities prioritized based on the child’s level of self-regulation and the strength and availability of emotionally supportive relationships
    • Provision of a structured toolkit to promote relational healing for relationship-based traumas
    • Incorporation of tenets from desensitization therapies that have demonstrated that enabling children to remain safe and modulated with a trusted therapist during prolonged safe exposures to ‘tough times’ can lead to reduction in traumatic stress reactions
  • Four primary components for strengthening resiliency skills and resources:
    • Relationships (Emotionally Supportive Relationships with caregivers, family members, mentors, & peers)
    • Emotional self- and co-regulation (planning, calming, focusing)
    • Action Cycles (family interaction patterns)
    • Life Story Integration (desensitization and development of a positive identity)
  • Assessments and treatment including:
    • Developmentally based and resiliency-focused assessments
    • Service planning
    • Session structure
    • Fidelity
    • Evaluation
    • Real-time, in-session measures designed to guide session interventions
  • Integrated treatment sessions, review conferences and trauma-informed home, school, and clinic-based services involving:
    • Caregivers (e.g., birth, kinship, foster, and adoptive parents and residential counselors)
    • Educators
    • Family court workers
    • Child protective services workers
    • Home-based support workers
    • Other service providers
  • Real Life Heroes Session Structure, Life Storybook, and Toolkit Materials:
    • Engage children and caregivers to work together to:
      • Develop emotionally supportive relationships, and the self- and co-regulation necessary to make desensitization and life story reintegration possible
      • Learn to recognize clues in their own bodies and how to share these safely
      • Share feelings nonverbally on thermometers for stress, self-control, and feeling mad, sad, glad, and safe
      • Utilize movement, focusing, yoga, ‘improv,’ and mindfulness activities to learn and practice self- and co-regulation skills, to reduce stress, and to change family interaction patterns (Action Cycles)
      • Help children develop their own strengths, resources, and coping skills, building on increased emotional support and increased security and confidence from sharing stories of caring and overcoming ‘tough times’
      • Use shared activities that help children grow stronger than their fears and to change old ways of coping that got them into trouble
    • The Life Storybook helps children change how they see themselves from feeling hurt, unwanted, damaged, or hopeless, to feeling that they can move through the traumas of the past to experiences of security with emotionally supportive adults committed to helping children. This RLH activity-based workbook and an emphasis on creative arts help children and caregivers to:
      • Develop affect modulation skills with art, rhythm, music, movement, yoga, mindfulness, and ‘improv’, and movies
      • Build the skills and interpersonal resources needed to re-integrate painful memories, reduce the power of traumatic stress reactions that have led to high-risk behaviors, and to foster healing after serial traumatic experiences
      • Share both positive and stressful experiences as drawings and then develop drawings into ‘three- or five-chapter’ stories (or movies) with a beginning, middle, and an end so children learn they can move through both good times, and later ‘tough times,’ and make things better in their lives, instead of feeling helpless, stuck, ashamed, or overwhelmed
    • The Life Storybook chapters target recommended phase-based components of complex trauma therapy:
      • Chapter One: The Heroes Challenge; Trauma Psycho-education & Initial Safety Plans
      • Chapter Two: A Little About Me; Affect Recognition, Modulation & Expression
      • Chapter Three: Heroes; Restoring Hope, Inspiring Change
      • Chapter Four: Power Plans; Developing Resiliency-Centered Safety Plans
      • Chapter Five: My Family; Remembering People Who Cared
      • Chapter Six: Important People: Promoting Emotionally Supportive Relationships
      • Chapter Seven: Mind Power; Making Things Better with Mindfulness and Self-Regulation
      • Chapter Eight: Changing the Story; Changing Beliefs & Action Cycles to Achieve Goals
      • Chapter Nine: Timelines and Moves; Making Sense of the Past
      • Chapter Ten: Through the Tough Times; Desensitizing Traumatic Memories
      • Chapter Eleven: Into the Future; Identifying Goals and Important Relationships
      • Chapter Twelve: ‘My Story;’ Creating an Integrated Life Story with a Past, Present and Future

Program Delivery

Child/Adolescent Services

Real Life Heroes (RLH): Resiliency-focused Treatment for Children and Families with Traumatic Stress directly provides services to children/adolescents and addresses the following:

  • High-risk behaviors; exposure to physical, sexual, or emotional abuse, neglect, or domestic violence; and symptoms of traumatic stress including emotional instability, avoidance, reenactments, lack of social skills, distorted beliefs, and shame

Parent/Caregiver Services

Real Life Heroes (RLH): Resiliency-focused Treatment for Children and Families with Traumatic Stress directly provides services to parents/caregivers and addresses the following:

  • Caregiver stress; lack of understanding of the impact of traumas on children’s behaviors and how to help children develop skills and change destructive cycles of family interactions; unavailability of emotionally supportive caregivers or neglect; and symptoms of traumatic stress including affect dysregulation, avoidance, reenactments, lack of social skills, distorted beliefs, and shame
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: This program involves the family or other support systems in the individual's treatment: RLH emphasizes engaging and empowering caregivers to help their children (and themselves) heal after experiences of traumatic events. Parents, family members, resource parents, and other supportive adults are encouraged to become the heroes children need to restore safety, develop self- and co-regulation and other needed skills to increase resiliency, and succeed in school and areas of interest for children. Caregivers who meet safety criteria are involved in conjoint sessions to strengthen (or build) the attunement, nurture, guidance, and protection children need. Structured creative arts activities engage caregivers with both respect and fun to rebuild attunement and attachments with their children by sharing memories and experiences with art, rhythm, music and movement. Psychoeducation and activities help broaden the ‘window of tolerance’ for caregivers to share their own experiences of overcoming hardships, to share stories of strength from the family’s heritage, to link the child to strengths in their cultural heritage, to validate their child’s experiences, and to work together to become stronger than past traumas.Separate sessions are provided with caregivers who do not meet safety criteria with structured opportunities for children to share their work and rebuild safety and trust.RLH can also be used as a means to search for lost caring adults and to build new attachments with substitute caregivers when necessary as part of permanency work for children in placement.

Recommended Intensity:

Weekly 30-90 minute sessions are held with children and caregivers dependent on child’s capacity, availability of safe caregivers, and funding source requirements. Separate 30-45 minute sessions with caregivers are also held as needed to empower caregivers to use a trauma and resiliency perspective to help their children and for caregivers who do not meet safety criteria to be involved in conjoint sessions.

Recommended Duration:

The program can be offered in flexible formats adapted to program parameters and continued by different therapists when children move from program to program or experience transfers between therapists. Duration is typically 25-40 sessions, weekly, but can be reduced to meet program constraints or extended for children and caregivers as needed. Length of treatment depends on number and severity of traumas experienced, frequency of sessions, service program capacity to provide sessions, and, to a large extent, on the time needed to engage (or find) safe, nurturing and protective caregivers who are able and willing to help children develop security in relationships and reduce the impact of traumatic experiences.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Community Agency
  • Day Treatment Program
  • Foster/Kinship Care
  • Hospital
  • Outpatient Clinic
  • Residential Care Facility

Homework

Real Life Heroes (RLH): Resiliency-focused Treatment for Children and Families with Traumatic Stress includes a homework component:

Children and caregivers are encouraged to practice self- and co-regulation and attachment-building activities between sessions that are related to each chapter (phase) of the treatment. Activities are designed to be fun, matched to developmental ages, and linked to building skills, safety and emotionally supportive relationships. For instance, to build affect recognition capacity (Chapter 2), children and caregivers are encouraged to take pictures of family members and of themselves showing a wide range of emotions and then to use these in later sessions and games. Self-regulation skill building at home is encouraged through-out the treatment. Whereever possible, in-home support workers and case managers are involved in promoting RLH homework and assisting therapists in helping children and families develop skills matched to each chapter of the RLH Life Storybook.

Languages

Real Life Heroes (RLH): Resiliency-focused Treatment for Children and Families with Traumatic Stress has materials available in a language other than English:

Chinese

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • A private room is needed for clinic, residential treatment, or home-based services.
  • The The Real Life Heroes Toolkit for Treating Traumatic Stress in Children and Families provides a wide range of tools and activities. The Toolkit lists recommended inexpensive creative arts equipment (and low cost supplies) including:
    • Markers
    • Colored pencils
    • Paper
    • Two-octave xylophone
    • Materials useful for self-soothing, centering and mindfulness exercises such as peacock feathers
    • Drums for rhythm expression can be hand-made or purchased
    • Peacock feathers
    • A copy of the Real Life Heroes Life Storybook, 3rd Ed. is needed.
    • Use of family-owned smart phones or an inexpensive digital camera is also recommended
  • Psychoeducational materials are included in the Practitioner’s Manual and additional recommended psychoeducational materials are available online from the National Child Traumatic Stress Network and from booksellers, e.g. guides to use of yoga and mindfulness with children.
  • Access to recommended therapeutic books in the HEROES Library linked to children’s reading level and cultural heritage is also encouraged.

Education and Training

Prerequisite/Minimum Provider Qualifications

  • Master's degree in psychology, social work, or related social services
  • Supervised experience working with children and families with traumatic stress
  • Training in treatment of Complex Posttraumatic Stress Disorder (PTSD) and application of the RLH treatment model
  • Participation in 10-month small group and individualized consultation recommended

Education and Training Resources

There is a manual that describes how to implement this program , and there is training available for this program.

Training Contact:
Training is obtained:

Training is obtained by contacting the model developer (above) and is typically provided on site and tailored to the needs of organizations or associations. Introductory workshops are presented at regional, national and international conferences.

Number of days/hours:

Training is developed to match organizational needs and resources and typically includes an initial three-day workshop, monthly one-hour small group content- and case-focused consultation using ‘reflective supervision’ for 10 months with video or teleconferences, and monthly consultation with on-site supervisors. When possible, individualized consultation is also provided.

Relevant Published, Peer-Reviewed Research

This program has been reviewed and it was determined that this program lacks the type of published, peer-reviewed research that meets the CEBC criteria for a scientific rating of 1 – 5. Therefore, the program has been given the classification of "NR - Not able to be Rated." It was reviewed because it was identified by the topic expert as a program being used in the field, or it is being marketed and/or used in California with children receiving services from child welfare or related systems and their parents/caregivers. Some programs that are not rated may have published, peer-reviewed research that does not meet the above stated criteria or may have eligible studies that have not yet been published in the peer-reviewed literature. For more information on the "NR - Not able to be Rated" classification, please see the Scientific Rating Scale.

Kagan, R., Douglas, A., Hornik, J., & Kratz, S. (2008). Real Life Heroes pilot study: Evaluation of a treatment model for children with traumatic stress. Journal of Child and Adolescent Trauma, 1, 5-22.

Type of Study: One group pretest-posttest study
Number of Participants: 41

Population:

  • Age — Range: 8-15 years. Mean: 10.5 years
  • Race/Ethnicity — 65% European American, 26% African American, 22% Hispanic or Latino, and 9% Bi-racial
  • Gender — 59% male and 41% female
  • Status — Children in residential treatment centers, foster family, prevention or outpatient mental health clinic programs who had trauma histories

Location/Institution: Albany, NY

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study evaluates the Real Life Heroes program, an integrated attachment and trauma therapy for children in child and family therapy program. Measures utilized include the UCLA PTSD Checklist, the Parent Report of Posttraumatic Symptoms, the Children’s Perceived Self-Control Scale, the Hopelessness Scale, Multidimensional Social Support Scale, the Trauma Symptom Checklist for Children, the Security Scale, the Working Alliance Inventory, and Connors Parent Rating Scale. Results showed significant levels of improvement on child-reports of trauma symptoms and fewer problem behaviors reported on caregiver checklists at 4-months and 12-month intervals. This study is limited due to lack of a control group and small sample size.

Length of postintervention follow-up: None.

Kagan, R., Henry, J., Richardson, M., & LaFrenier, A. (2014). Evaluation of Real Life Heroes treatment for children with complex PTSD. Psychological Trauma: Theory, Research, Practice, & Policy, 6(5), 588-596.

Type of Study: One group pretest-posttest study and exploratory comparison study
Number of Participants: 119

Population:

  • Age — 6-18 years
  • Race/Ethnicity — 54 Caucasian/White, 41 African American, 18 multirace, and 6 not reported
  • Gender — 60 boys and 59 girls
  • Status — Participants were children who had trauma histories and were from outpatient mental health clinic, day treatment, home-based intensive counseling (to prevent placement), foster care, community residence, and residential treatment programs

Location/Institution: Albany, NY

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The efficacy of Real Life Heroes (RLH) treatment was tested with 119 children in seven child and family service programs, ranging from home-based family counseling to residential treatment, and compared to children receiving trauma-informed “treatment as usual” (TI-TAU) provided by practitioners trained in RLH in the same programs during the same time period.  Measures utilized include the Child Behavior Checklist (CBCL) 6-18, UCLA PTSD Index (Parent Version and Child Version), CDS Trauma History Profile Trauma Symptom Checklist for Children, and Resiliency Scales for Children and Adolescents. Results showed children receiving RLH treatment demonstrated significant improvements in trauma symptoms and behavior problems; however, the control group was not assessed with these same measures and no comparisons are made between the RLH and TI-TAU on these measures. Children receiving RLH did not have placements or psychiatric hospitalizations, a positive, but not significant trend, compared with youth in the TI-TAU. This study is limited due to lack of a randomly assigned control group and lack of comparison between the RLH and TI-TAU group on most outcome measures, and possible selection bias in the RLH sample.

Length of postintervention follow-up: Not specified.

Additional References

Kagan, R. (2016). Real Life Heroes toolkit for treating traumatic stress in children and families (2nd ed.). New York, NY: Routledge.

Kagan, R. (2016). Real Life Heroes life storybook (3rd ed.). New York: Routledge.

Kagan, R., & Spinazzola, J. (2013). Real Life Heroes in residential treatment; Implementation of trauma and attachment-focused treatment for children and adolescents with complex PTSD. Journal of Family Violence, 28(7), 705-715.

Contact Information

Richard Kagan, PhD
Agency/Affiliation: Training Programs on Traumatic Stress
Website: www.reallifeheroes.net
Email:

Date Research Evidence Last Reviewed by CEBC: December 2015

Date Program Content Last Reviewed by Program Staff: November 2017

Date Program Originally Loaded onto CEBC: September 2012