Sunday, July 13, 2014

What Does a Trauma-Informed Culture Look Like?

We just finished a Joint Commission survey. We did very well. One of my best moments was when the surveyor remarked that this was a special agency. A staff member asked him what he saw that made it special. He replied, "many agencies teach their staff about trauma-informed care. In this agency, that approach is deep in the culture."

So I have been thinking: what did the surveyor observe that enabled him to know that?

He experienced:

The outpatient therapist talking about how the mother of her client had suffered early trauma, and how this was complicating her response to her daughter.

An in depth discussion of a diabetic girls' eating a large muffin snack at school, that included systems issues, peer issues, biological factors, her loneliness and hopelessness, and the pediatrician's personal experience with diabetes and eating muffins.

A group home therapist who was worried that a client who was " doing everything right" still wasn't letting any one get close to her.

Leadership response to discovered problems that focused on systems issues rather than scapegoating.

A discussion of whether a girl with a self- harm history should be allowed to work with knives in the kitchen that reject the simplistic solution of trying to keep her away from any sharp objects.

Group home staff sharing the pain of watching a girl make plans to live with her father and being afraid he will disappoint her.

An in home service discussing their struggles to implement an evidence based practice while maintaining the provision of concrete help they know makes such a difference to families- even when getting new beds is nowhere in the formula.

The longevity of staff at the agency.

The willingness of a program to take a kid back after a lengthy hospitalization despite their doubts to save her from placement in a shelter.

Foster parents who readily related the behavior of their foster son to his past experiences of being hurt.

The warmth and connection between staff, and staff with clients.


And there are probably many more things. I felt proud observing all this. It was one of those times when I could appreciate all that we have accomplished.

Sunday, June 15, 2014

My Head is Spinning!

I have recently attended two high powered conferences in a row. The first was Bessel van der Kolk’s 25th Annual International Trauma Conference: PSYCHOLOGICAL TRAUMA: Neuroscience, Attachment, and Therapeutic Interventions on May 28 - 31, 2014 in Boston. The theme was What We Have Discovered Over The Past Quarter Century About Traumatic Stress and Its Treatment.

Then I presented at Bruce Perry’s Neurosequential Model of Treatment Inaugural Symposium:
Brain Development and Trauma: Implications for Interventions and Policy, June 10 – 12, 2014 in Alberta, Canada at the Banff Centre. What a lovely place!
So my head is spinning with new ideas and new takes on old ideas, which I will be sharing with you in the upcoming weeks.
First let me focus on a basic premise of the Neurosequential Model. We cannot think when we are dysregulated. We can think best when we are in relationships to others. So, in every situation, for us and for our clients, follow the sequence:

Regulate

Relate

Reason

We can use many methods to regulate ourselves and our clients. The best are “bottom up”; that is, using the body and rhythmic, repetitive activities. This includes rocking, walking, petting animals, doodling, jumping, music, throwing a ball back and forth, etc. Regular small doses of such activity can keep us regulated throughout the day and avert many crisises.
Once someone is regulated, emphasize relationship. Connected people are at their best. People who feel noticed, heard and safe can think creatively.
Then, and only then, problem solve.
And as soon as problem solving becomes stressful, return to regulation and repeat the sequence again.
More to come….


Monday, May 26, 2014

Five Benefits of Risking Connection© Training

This week I taught a Risking Connection© Basic three-day training for a Connecticut agency. 


This agency provides various types of home-based services, school-based mental health clinics, out patient clinics, parent resource centers, and day care. It was a joy to teach such caring and thoughtful people. At the end of the training we did an exercise that involved people saying what they would keep from the training. Here are the top five things staff will keep:

  1. I learned tools that help me understand my clients’ behaviors in a new way
  2. I have new ideas for how to help my clients more effectively.
  3. I feel more connected to my agency and the individuals within it.
  4. I feel more valued by my agency.
  5. I learned it is okay to be a human being with human feelings, and how to take care of myself to remain energized and hopeful.


It is always inspiring to participate in the increase of hope and energy that this training creates.

Sunday, May 18, 2014

Participate in Improving our Field

My colleagues and I are engaged in an effort to develop a reliable and validated measure of beliefs favorable to trauma-informed care. When complete, this measure will help establish the effects of training, will assist in agency self-assessment, may be used in hiring decisions, and could have many other uses. As part of the process we are asking many professionals in the field to take a longer version of the survey, which will help us determine which questions work best. Would you like to join us?

Dear Colleague,

At this time, there are no reliable and valid measures of trauma-informed care. For this reason, we are working on an instrument to measure staff beliefs related to TIC. When finished, this could be used to measure such things as the extent to which a school or agency is trauma-informed or the outcome of trauma-informed change interventions.

We need your help. We need as many health and education professionals as possible to participate in a brief online survey. The online survey takes 20-30 minutes and has been approved by the Tulane University Institutional Review Board. All participants who complete the online survey will have the option to enter their name into a raffle. After the study is over, four participants will be randomly selected to win a $25 giftcard to Barnes & Noble.

If you are interested in participating, please click on the appropriate link below.

Please also distribute to other listservs or to health care and education providers in your agencies.  

I work in HEALTH CARE or HUMAN SERVICES:  https://qtrial.qualtrics.com/SE/?SID=SV_9vGkmqaAckMxbiB


OR


Thanks in advance for your help.

Sincerely,

SteveB_Signature[1]

Steve Brown, Psy.D.
Director, Traumatic Stress Institute
Coordinator, Risking Connection Training Program


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Courtney N. Baker, Ph.D.
Research and Methodology Consultant, Risking Connection Training Program
Assistant Professor
Tulane University

Sunday, May 11, 2014

How to Help Kids With Discharge

Jennifer's home passes have been going well. She and her mom Nancy have had some fun together. When disagreements have occurred they have worked them out. Jennifer has been going home for long weekends and even a week over school vacation. The team decided it is time to set a discharge date, and chose the end of the school year. Then Jenn blew up. On her next home pass she went out and didn't come back until late. Her mother was clear she had been drinking and smoking. When Nancy came to visit, Jenn told her she hated her and didn't ever want to go home. She said she wanted to go to independent living. As soon as Nancy left Jenn called her and begged her to come back and take her home immediately, and started swearing at her when she wouldn't.

Going Home is Hard

The ambivalence our kids feel about going home is agonizing and acute. What are some of the contributing factors? They all involve various sorts of fear.
  • Fear that they will not be able to handle it, will hurt the people they love.
  • Fear that the people they love can't handle it and are happier without them.
  • Fear of reconnecting and being hurt again.
  • Fear of school, expecting shame and being an outcast.
  • Fear of not being able to do the academics.
  • Fear of the outside world, being unprotected, violence.
  • Fear of being unable to resist the temptations of peers and the world.
  • Fear that the people who hurt them are still around.
And we could go on. How can we best help our kids survive and accomplish a positive discharge?

Don't Do This

Here's what we shouldn't do:
  • Tell them they have to decide
  • Persuade or pressure them to go to their family.
  • Threaten them.
  • Be upset that they are deteriorating.
  • Punish them.
What we should do, in a word, is explore. Help the child express all the complicated feelings they are having. Maintain a totally validating stance- after all, their mixed feelings are completely understandable and legitimate.

How We Can Help

How can we explore? It sometimes helps to talk about other kids or some kids- move it a few steps away from them. Here are some techniques:
  • Divide a big flip chart size paper into quarters. Title one quarter "what some kids like about home"; another "what some kids find hard about home"; another "what some kids like about... (Whatever the alternative is)" and another "what some kids find hard about (alternative)". Generate as many ideas as possible.
  • Draw a picture of a road branching into several roads. Label them with the youth's possibilities. Have her draw whet she imagines on each road.
  • Tell her some things you have heard from other kids about what makes going home scary.
  • Try and get the world (state worker or whoever has this power) to be clear about what the steps are if she does not go home. Be realistic not threatening.
  • Remember she knows more about her home than you do and she may have some very good reasons to be concerned.
  • If possible help mom to talk with her about ambivalence and how to get through it.
  • Explore what she gets from her mom and what she doesn't. Normalize that no one has perfect parents. Talk about ways she can manage when mom drives her crazy, and where she could get whatever mom cannot give her.
  • Work on helping her become more comfortable where ever she would go to school. Can she start there while still living with you?
In other words don't judge, don't hurry, resist the pressures of the world to fix her ambivalence and decide. Explore. I swear that will be actually FASTER than trying to pressure her to decide.

Continue as much contact as possible between her and her mother. As time goes on, this will resolve. Either she will get past her understandable terror, or she will let you know in words and actions that home is not possible at this time. If that is the outcome, try to preserve as much connection as possible between her and her mother and help them figure out how they can love each other even if they are not living together now.

And you will have given this youth a priceless gift.

Sunday, May 04, 2014

ReMoved



Have you seen the moving new video ReMoved yet? It is available at: http://fstoppers.com/removed-an-incredible-film-by-nathanael-matanick


It is about a young girl’s journey into and through foster care. It is $25 to purchase for training use. I have now used it in quite a few training settings. 

Here are some discussion questions I have used:


1.    When Zoe was living with her family what was one of her sources of satisfaction?
2.    What did you notice during the scene when the police came?
3.    Why did Zoe throw the record player over the fence?
4.    What do you notice about Zoe's feelings management skills: feelings management, sense of worthiness, and inner connection?
5.    What happened when Zoe's foster mother gave her the dress?
6.    What did Zoe think when she saw her foster mother on the phone? What did you think?
7.    What did Zoe's foster mother give her that helped her heal?


Let me know what you think of it and how you use it by clicking on “comment” below.


Sunday, April 20, 2014

An Integrative Work-Life Balance

A very important part if the message that I teach is that working with trauma survivors is emotionally difficult, and that it is imperative that we take care of ourselves and each other. We are daily immersed in the pain of our client's lives. This includes sharing their past stories of abuse and neglect and their present experiences of rejection and inadequate resources. It includes being the recipients of the symptoms our clients have evolved to survive. It includes the anguish of caring for clients who connect and then leave. All these and many other experiences combine to create vicarious traumatization ( VT).

We have written extensively about how agencies can imbed attention to VT into their practice. This is essential. Recently people in our field have been paying more attention to VT, or burn out, or compassion fatigue. I am worried about an approach in which an agency says: here is a large caseload, and you are expected to work extra hours, and you will be on call, and we can't give raises for years. But we care about you and know this work is hard- so please take care of yourself and get a massage. On your own time and with your own money, of course.
Agencies must be responsive to the many ways in which they can help decrease VT in their employees.

Today, however, I want to challenge another part of standard anti-VT wisdom. One piece of advice that we often include is: learn how to leave your work at work, don't bring your work home.

However, this does not reflect the reality of any one that I know. Especially not anyone in a managerial position. These days our work and personal lives intertwine. We may be on call or provide back up in emergencies. We often work on projects at home. We can access our files and information from any where. We can always be reached. And our work interests us. Our minds are often engaged in solving a work problem, creating a new service, figuring out how to help a certain client more effectively.

It is important that we acknowledge and grapple with this current reality, rather than pretend that there could or even should be a clear and simple dividing line between work and life. Let's try to figure out this more complex question: how do we honor and protect all parts of our selves within this system?

The first step is to acknowledge the reality. Leaving work at work is not the goal for many of us. Then, consider your own unique self. What is energizing for you? How would you like this balance to be in your life? For some, it might be carving out certain time periods to step away from work. For others, it might be a mindfulness practice that increases one's skills at staying in the moment. Identify activities and connections that are essential to your own happiness and be watchful that these are not neglected. Maybe it includes thinking about what kind of work you do best at home, and scheduling time for that.

It is also important yo look at the at-work part of the equation. If there are projects (for me it is concentrated writing) that are best done at home, can you stay home during the work day? Can you adopt a Seize-the-Moment philosophy and actually leave when there is nothing urgent pressing? Can you incorporate flexibility during work hours to accomplish home chores?

Develop an awareness of what is creative thinking and what is obsessing. What are your techniques for ending obsessing, whether it be about work or home problems?

And cultivate the opportunities for weaving the best of yourself and your greatest joy into both work and home. Do you love nature? Can you figure out a perplexing work problem while walking in the woods? Do you create music? How can you bring that into your work place? Did you learn a new skill at work? Would it help with your own kids? Does seeing the kids you treat heal inspire you? How can you utilize that inspiration in your own struggles?

Let's continue this conversation about how we can stay sane, hopeful and energetic within our real work- life intertwining. Please share your thoughts by clicking "comment" below.