Tuesday, October 23, 2007

Questions from Guest Bloggers

I am delighted to feature this guest response from the staff of Devereaux, Mass. Please all readers: post your answers to the thoughtful questions they raise by clicking on "comments".


On behalf of countless readers to this blog, we’d first like to extend our sincere appreciation to you for your willingness to speak to the needs of some of society’s most vulnerable children as well as for your consistently compelling and thought-provoking challenges to the status quo in residential treatment. As mental health professionals who have been immersed in attempting to facilitate culture change toward a trauma-informed model of care at our place of employment, we’ve been truly grateful for the leadership you’ve provided your fellow administrators and clinicians who struggle to match contemporary trauma and attachment theory to the pragmatic challenges of healing traumatized youth in congregate care settings.

Not unlike many of your blog entries, your latest spoke directly to our experience in residential treatment. The scenario you described was very similar to events that take place at our campus school from time to time, including the ‘ripple effects’ among staff following an aggressive incident and the difficulty of providing an administrative response that honors the client’s therapeutic needs while not dismissing the staff’s charged emotions.

Upon discussion we agreed that our preferred response to the scenario in your blog would include: a) an emphasis on maintaining the safety of both client and staff, b) a thorough assessment of the situation which should identify any critical yet underdeveloped skills and capacities that played a role in the client’s response, as well as any other setting events and/or environmental circumstances (including staff behavior) that may have played a role in the incident, and c) based on the results of the assessment, a creative intervention that combines teaching the needed skills while also attempting to heal the relational breach between the client and staff member. In short, we did not view as necessary the need to institute any consequences that would serve purposes other than those listed: safety, skill-building and relationship-enhancement.

To be completely honest, what compelled us to write to your blog was not to endorse Klingberg’s Restorative model of treatment and/or the Risking Connection curriculum. As both residential administrators and treatment team leaders, we’d really be interested in hearing from others who not only believe in these approaches to treatment but also are attempting to implement them. As such, we’d like to broaden the questions you’ve posed in the above scenario in an effort to invite fellow providers to respond from a more systemic perspective.

In the aftermath of a significant aggressive outburst toward a staff member such as the one you describe between Aaron and Charles, our experience has been that staff seem less inclined to embrace a trauma-based framework and, instead, drift toward adopting more punitive, response-cost methods of facilitating change if: Aaron is physically large and imposing, Aaron has no documented trauma history, he appears to have had a "good day" and was quite calm leading up to the moment of aggression, Charles and other staff members appeared to have avoided any actions that could have been misconstrued as a posture of intimidation towards Aaron (e.g., inadvertently surrounding the client), Aaron boasts after the incident (often viewed by staff as a ‘lack of remorse’ and seemingly inviting ‘power-over’ responses from staff), Aaron was heard making threats toward Charles earlier in the day/week (suggesting planfulness rather than merely becoming overwhelmed in the moment by intolerable feelings), Aaron is gang-involved, or if Aaron assaulted an equal-sized or physically smaller female staff.

We’d like to hear how other providers increase the likelihood that their staff (i.e., clinical, residential, educational, medical, and administrative) collectively hold to a trauma-informed model of care when these type of countertransference-heightening factors are present. How do other providers temper the contagion of staff fear, anger and/or silent wishes for retribution? What efficient mechanisms do others use to regularly remind their staff of the role of shame in driving many incidents of disruptive behavior? Do other providers use ‘crisis staff’ (as Pat referred to them) in their schools? How do you define their roles and does your funding allow you to maintain sufficient numbers of these staff so that they have time to engage in restorative work rather than merely reactively running about putting out fires? How do you avoid becoming complicit in over-relying on physically large, male crisis staff who typically become, over time, the primary repository for vicarious traumatization at residential centers?

In addition, do other providers anticipate there are limits to a restorative approach or its effectiveness with certain populations (e.g., clients diagnosed with autism spectrum disorders)? We recognize that neither the restorative model nor the Risking Connection curriculum have, as yet, been subjected to randomized controlled studies and we are interested in the experience and thoughts of other providers.

Lastly, the success of facilitating this type of culture change also seems dependent on a host of other culture-congruent circumstances. In Massachusetts, for example, many providers are witnessing fewer residential referrals with a concomitant decrease in overall census. As a result, providers are often forced to limit expenses for many activities that do not involve direct work with clients, namely trainings, staff meetings, supervision, correspondence with interdisciplinary team members, keeping shift supervisors free to supervise rather than be assigned clients, etc. In addition, staff turnover, while improved in our setting since introducing the Risking Connection curriculum, still requires further stretching of resources. While we’re certainly proponents of adopting restorative approaches and providing Risking Connection training to staff, without the necessary structures to reinforce these concepts and practices on a day-to-day basis, culture change becomes an even greater uphill battle. Since most models of trauma-informed care rely heavily upon staff members’ own ‘relational skill set’, it comes as no surprise to us that some staff working in fiscally strained environments tend to drift toward utilizing generic, predetermined and punitive responses to client aggression and disruptive behavior.

(Note: We were pleased to recently learn of the American Psychological Association’s strong support for the effectiveness of a related model of intervention, i.e., ‘restorative justice’ approaches, over ‘zero tolerance’ approaches to reducing violence in schools. We viewed the report as providing additional support for utilizing a restorative model of care in residential treatment, even for treatment of youth without documented histories of trauma or attachment disruptions.)

Thanks, again, Pat for being a national leader in trauma-informed care. Your work has been a catalyst for change in our setting. We also look forward to hearing about the experiences, positive or negative, of other treaters who are evolving toward trauma-informed approaches.

Bob Davis, Psy.D., Director of Clinical Services
Jennifer Bergeron, Psy.D., Program Director
Mike Healey, M.A., Clinician
Devereux Massachusetts

Sunday, October 14, 2007

Would More Severe Punishment Have Helped?

Everyone is talking about it- staff and kids. Yesterday at school Aaron punched Charles, and Charles has a black eye. The kids are agitated, worried, and making fun of Charles. Aaron is bragging: "yeah I really showed him". The staff are furious. Charles is feeling helpless and humiliated.

It was during math class, and Aaron was being his usual loud, obstructive, insulting self. The teacher tried many times to redirect him. Finally, she called the crisis staff and asked that Aaron be removed from her classroom. Charles came and talked with Aaron, and he seemed to calm down a bit. He walked out with Charles- did not require any physical intervention. But ten minutes later in the intervention room Aaron became agitated again, and hit Charles in the eye.

The worst part is, the staff is saying, that Aaron did the same thing two weeks ago- he hit another staff, a friend of Charles’.

Some of the talk is:
Did Aaron get off too lightly the first time? If he had been punished more severely, would he have been less likely to hit again?
He seemed calm and he walked out of the classroom on his own. Doesn’t that mean that this attack was planned and thought out, not an emotional reaction?
What is Charles supposed to do when the other kids make fun of him? He is feeling low and stupid, like he has been made a fool of or like Aaron has gotten the better of him. If only the administration hadn’t been on this trauma-informed-treatment kick Aaron would have been punished more the first time and so would have known not to do this again. Doesn’t the administration even care what staff goes through?
What should happen to Aaron now?

So- what do we think about this?

If Aaron had been more severely punished the first time, would that have resulted in his not hitting Charles this time? It is possible that if Aaron had a threat of jail, or parole, or had been some how more severely consequenced, he would have been able to keep that in his mind during this incident and use that to help himself control his impulses. It is also possible that severe punishment would have left him more angry, more shameful, less connected, more hopeless and less able to feel any reason not to hit. What do you think?

What about the fact that he seemed to calm down for ten minutes or so after his agitated behavior prior to this hitting incident? Does that mean this was not an emotional reaction and trauma-related? Does that distinction even make any difference? Should the fact that he appeared calm lead to him being held responsible for this incident in some way? If the incident was emotion and trauma based does it mean he should not be held accountable?

What about Charles? He is feeling pretty lousy now. Is he right to blame the administration for not punishing Aaron more the first time? How should he handle the kids’ teasing? How can he use what he is going through to understand Aaron better?

What about Aaron? If we had control of what happens next, what should it be? Should he leave the program? What interventions would actually contribute to his being less likely to hit again?

Please contribute your thoughts on these questions by clicking on "comments" and leaving a comment. We will thus continue this discussion.

Friday, October 12, 2007

Presentation at Alliance Conference

I will be presenting at the National Conference of the Alliance for Children and Families next week. If any one reading this plans to be there, please stop by and say hello.

The conference:

Alliance National Conference: Join the best peer national network of nonprofit human service leaders at the Alliance’s premiere event in Anaheim, CA at the Anaheim Marriot Hotel. This conference promises to expand your national peer connections and equip you, your senior management team, and your board with knowledgeable solutions to the many timely issues and opportunities facing the nonprofit human services sector. Learn more at the conference Web site.

My workshop:

Session C: Thursday, October 18 - 10:30 a.m. to Noon

C6The Creation, Enhancement, and Maintenance of a Trauma-Informed Treatment AgencyThis presentation explores the transformation of a large behavioral health, child welfare agency into a trauma-informed, relationship-based treatment program. It explains how unique approaches were used to establish trauma-informed treatmentintegrated with Dialectical Behavioral Therapy, implementing it in group homes, a school, and various community-based treatment programs. The workshop further explores the enhancement of trauma-informed treatment through client-generatedindividual crisis management plans, psycho-education on trauma for children and parents, and integration of sensory interventions. These approaches reduce the use of restraints and seclusions, increase staff job satisfaction, and reduce staff turnover. The agency enhances its ability to effectively treat severely damaged children and their families with successful outcomes.
Presenter: Patricia D. Wilcox, vice president, strategic development, Klingberg Family Centers, Inc.