The Boy who was Raised as a Dog by Bruce Perry

I highly recommend the book The Boy Who was Raised as a Dog by Bruce Perry (Basic Books, New York, 2006). (http://www.amazon.com/Boy-Who-Was-Raised-Psychiatrists/dp/0465056520/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1195999799&sr=1-1)

Dr. Perry also has a very helpful web site at: http://www.childtrauma.org/default.asp which contains other articles he has written.

Dr. Perry uses the stories of many abused and neglected children to illustrate and develop his points about the effects of trauma. This book is an excellent way of sharing this knowledge as it is quite readable and fascinating.

Here are some notes I took about points I found important. If you want more information or don’t understand a note- read the book! Or, click “comments” and ask questions.

Brain sets down a “template”- how life is supposed to be and go- and reacts particularly to any thing out side that template, anything new

Thus our early experiences contribute the template: our definition of “normal”

Could also contribute to under-reaction to danger: since brain is particularly paying attention to what is new, what doesn’t fit the pattern- danger is not new

Brain changes through repetitive, patterned activity:
Use dependent development of brain

To change muscle (exercise) must have moderate, repeated, patterned extra stress- brain decides, oh, we are going to be doing this now, better develop some new muscle cells
Same with brain cells
Stress is signal to cortex- something new going on here
Moderate stress is good for brain and body, develops ability to handle stress

However, imagine going to gym and trying to lift 200 pounds- would not build muscle or teach body anything
Would hurt yourself
This is similar to stress children receive from trauma

Brain constantly processing info from senses
Becomes habituated to the familiar
Reacts to the new

Critical to survival to remember those things that led to negative experiences
Often must remember after ONE bad experience
Negative emotions burn events in to memory

Lower brain compares in-coming data with laid down patterns- one question- does this data suggest danger?
Makes immediate response while sending to higher brain for further refinement
Become more alert, look for more information

What the brain does in danger:
1. focused alertness
2. shut down cortex chatter
3. more vigilant and more concrete
4. heart rate increase- blood to limbs
5. focus on social cues- is help available?
6. muscle tone increases
7. hunger/digestion disregarded

Dissociation- freeze- response when you cannot flee or fight
1. curl up
2. make yourself as small as possible
3. prepare for injury:
4. blood shunted away from limbs
5. heart rate slows to reduce blood loss from wounds
6. body flooded with opioids to protect against pain
7. produces feeling of calm and a sense of distance from what is happening
8. some times can help with functioning

Both hyper arousal and dissociation help people survive trauma.
Both can be harmful if prolonged and habituated.

Stress without control is most harmful
Rat experiment- some rats were shocked when they pressed a lever (had control); some were shocked when the other rat pressed a lever (no control): animals who do have control develop strengths, those who do not develop ulcers, lose weight, compromised immune systems, become more sensitized to shock, can’t recover

Stress with control leads to habituation (developing new skills and coping mechanisms)
Stress with lack of control leads to sensitization (disorganized intensifying response, immobility)

Flash backs, re-enactments- an attempt to have small doses of trauma within one’s control to develop habituation or tolerance
If trauma is too much cannot be mastered this way

Brain develops sequentially- certain tasks at certain ages
So traumas at different ages have differing effects depending on what the brain was working on at the time

Terror early in life can shift person to a less thoughtful, more impulsive, more aggressive way of responding to the world- thinking has been shut down too much just when it was time for it to develop

Humans develop through relationships
Relationships necessary for survival
Humans are also our most dangerous predators

Stress responses very closely tied to systems that read and respond to social cues
We are very sensitive to moods, expressions, gestures of others

We have mirror cells in our brains that fire when OTHERS express emotions, creating similar emotions in us
Mother-baby
Basis of empathy
Human society built on this interactivity

Infants born dependent
Parenting is pleasureful
Infant associates touch with pleasure- needs met, relief from distress, calming anxiety
Sensory patterns of human interaction associated with pleasure
Template established
Brain develops in use-dependent manner
If sensitive period is missed, may be hard/impossible to do later- if a kitten’s eye is kept closed during a certain period of sight development, may never develop sight even if opened later
Need repetitive, patterned interactions

If touch has not been associated with pleasure this needs to be addressed in systematic, careful way, starting with less scary touch
Touch own hands
Chair massage
Using heart rate monitor to monitor fear

Importance of rhythms
Rhythm is very important to human functioning
Sleep/wake, when to eat, heart rate, cycles
Use music, movement, dance, drumming to re-train

Using psycho-ed with kids, enables them to help each other

Let me know if you read or have read this book and what your reactions are!

Our Presentation at ISTSS

I was extremely proud to be part of a pre-meeting institute at the recently completed Annual Conference of The International Society for Traumatic Stress Studies. Our presentation was entitled:
Preventing Trauma by Applying Theory to Change the World
The premise was that theory based on science provides a road map to guide practice, and theory-based practice leads to effective and lasting change in the world.

The first presenter was Laurie Pearlman, PhD, who discussed the creation of her trauma theory, Constructivist Self Development Theory. (For more information see: McCann, I.L., & Pearlman, L.A. (1990). Psychological trauma & the adult survivor: Theory, therapy, and transformation. New York: Brunner/Mazel and Pearlman, L.A., & Saakvitne, K.W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: W.W. Norton.) Laurie described the need for this theory, the context at the time it was developed, and how it was developed using the Boulder model (theory-research-application). The assumptions of CSDT are Constructivist: trauma effects individuals differently; Developmental: trauma effects the development of self; Relational: relationships are the context for trauma and recovery; and that symptoms are adaptations. CSDT articulates that trauma affects: self capacities (ability to manage the inner world); ego resources (ability to manage the interpersonal world); and psychological needs and cognitive schemas: safety, trust, esteem, intimacy, and control; as well as the frame of reference (big picture) including identity, world view, spirituality; and the body and brain.

Kay Saakvitne, PhD. then spoke of the process of converting this theory into a teaching manual, Risking Connection®. Risking Connection® arose out of a grass roots movement in Maine in which survivors sued the state claiming that mental health services were making them worse. They won, and Risking Connection® was developed to train all mental health workers about trauma. Kay covered the basic outline of Risking Connection® and the collaborative process necessary to make the theory into a teachable curriculum for people at all levels of experience. (Risking Connection: A Training Curriculum for Working With Survivors of Childhood Abuse by Karen W. Saakvitne, Sarah Gamble, Laurie Anne Pearlman, Beth Tabor Lev Sidran Press; Spiral edition January 2000)

Steve Brown, PsyD and I then discussed our work using Risking Connection® to train child serving agencies. We reviewed the reasons agencies feel a need to change from traditional points and levels and rule oriented systems, and how hard that change can be. We described our dual approach of Risking Connection® trauma training combined with the Restorative Approach™ "how-to-do-it" method. Agencies that make these changes are experiencing a drop in restraints and seclusions, better outcomes and better staff job satisfaction.

Esther Giller, MA, described a fascinating project in which Risking Connection® was used to unite faith based and treatment agencies in Baltimore. Risking Connection® training was used to develop a common language and understanding to break through barriers and connect diverse service organizations. Esther described a slow process of forming relationships, developing common terms, and training people separately that was needed before the groups could be brought together. The RICH framework from Risking Connection® provided a structure for respecting each other, sharing information, forming connections and developing trust and hope. The project was evaluated and give high marks for collaboration and sustainability, and remains active today. (DeHart, D. (2006). Collaborative Response to Crime Victims in Urban Areas: Final Evaluation Report. Columbia, SC: Center for Child & Family Studies, University of South Carolina.
Giller, E., Day, J., &Vermilyea, E., (2007). Congregational Clergy Responding to the Spiritual Needs of Trauma Survivors: Risking Connection in Faith Communities. In press, Haworth Press, Journal of Trauma Practice, vol.6.
Full report of findings available at: http://www.sc.edu/ccfs/research/FaithReport.pdf)

Ervin Staub, PhD, then presented his theories of Prevention and reconciliation in mass violence: The theoretical bases for intervention; and the origins and prevention of violence between groups. His theories demonstrate how difficult life conditions and frustration of the fulfillment of basic needs can create a climate in which hatred between groups can grow. He described continuums of conditions which push towards violent or more peaceful solutions of problems (such as devaluation of other vs. humanizing the other; destructive, exclusive ideology vs. Constructive, Inclusive Ideology; Unhealed Wounds vs. Healing of Past Wounds; uncritical respect for authority vs. moderate respect for authority; monolithic society vs. pluralism; unjust societal arrangements vs. just social arrangements; and passive bystanders vs. active bystanders. He described conditions which promote the healing of past wounds. Ervin has also been studying altruism born of suffering: what makes some people who have been hurt turn to helping, instead of hurting, others? Also, what promotes active bystanders who have the courage to object to evil? (Staub, E., Pearlman, L.A., Gubin, A., & Hagengimana, A. (2005). Healing, reconciliation, forgiving, and the prevention of violence after genocide or mass killing: An intervention and its experimental evaluation in Rwanda. Journal of Social and Clinical Psychology, 24(3), 297-334.
Staub, E. (1989). The roots of evil: The origins of genocide and other group violence. New York: Cambridge University Press
Staub, E. (2003). The psychology of good and evil: Why children, adults and groups help and harm others. New York: Cambridge University Press
Staub, E. (2006). Reconciliation after genocide, mass killing or intractable conflict: understanding the roots of violence, psychological recovery and steps toward a general theory. Political Psychology, 27,(6), 867-895.)

Finally, Ervin Staub PhD and Laurie Pearlman PhD presented how Ervin’s theories are combined with CSDT and Risking Connection® to intervene in genocide torn Rwanda to promote reconciliation and healing. They have used the RICH messages to inform a radio drama show which teaches about trauma and healing. Their work has special emphasis on preventing those who have been victimized from vicitimizing others.(For an overview of Staub and Pearlman’s work in Rwanda, see
Staub, E., & Pearlman, L.A. (2006). Advancing healing and reconciliation. In Barbanel, L. & Sternberg, R. (Eds), Psychological interventions in times of crisis. New York: Springer-Verlag.)

For me the most exciting part of this presentation was the connections between the various projects. For example, there were similarities between the careful processes necessary in Baltimore to those needed in Rwanda. And Ervin Staub’s work on promoting healing, and promoting those who have been hurt from hurting others, there lies the blue print for the work we are doing in child serving agencies.

It was an honor to be part of such a distinguished panel; and I think that all such theory-based work in its turn informs and transforms the theory.

Note: descriptions of theories and projects were taken from the words of the authors.

The International Society for Traumatic Stress Studies Presentation

Note: I will be presenting as part of a pre-meeting institute at The International Society for Traumatic Stress Studies’ 23rd Annual Meeting which will be held in Baltimore, Maryland on November 15-17, 2007, with pre-meeting institutes on November 14.Wednesday, November 14.

Half Day
8:30 a.m. – noon
Trauma Prevention as Social Change: From Trauma
Theory to Real Life Practice (Abstract #178942)
Pre-Meeting Institute (commun)
Technical Level: Intermediate
Pearlman, Laurie Anne, PhD1; Saakvitne, Karen, PhD2; Wilcox, Patricia, MSW3; Brown, Steven, PsyD3; Staub, Ervin, PhD4; Giller, Esther, MA5
1Trauma Research and Education Institute, Inc., Holyoke, Massachusetts, USA
2Private Practice, Northampton, Massachusetts, USA
3Klingberg Family Centers, New Britain, Connecticut, USA
4University of Massachusetts Amherst, Amherst, Massachusetts, USA
5Sidran Institute for Traumatic Stress Education and Advocacy, Baltimore, Maryland, USA

In this institute, we present three theory-based initiatives in trauma prevention and treatment. We describe two central theories and three initiatives based on them, highlighting the process, challenges, and benefits of attempts to put theory into actual practice. The theories are constructivist self development theory (McCann, Pearlman, 1990; Pearlman, Saakvitne, 1995), a relational trauma theory which provides a framework for understanding the psychological impact of traumatic life experiences, and Staub´s model for understanding the origins and prevention of group violence (1989, 2003). The three projects all emphasize the importance of theoretical frameworks, the healing powers of RICH relationships (that include respect, nformation, connection, and hope; Saakvitne, 2000), and the ethical imperative to address the experience and needs of the healer in trauma work. Saakvitne will describe the translation of psychological theory into a training curriculum, Risking Connection. Esther Giller will present Baltimore´s Spirituality and Victim Services Initiative using the CSDT-based Risking Connection (Saakvitne 2000) and Risking Connection in Faith Communities (Day 2006) curricula as training and collaboration-building tools to bring together multidisciplinary
community resources to trauma survivors. Wilcox and Brown will describe efforts to create trauma-informed care systems for young adults, adolescents, and children in mental health systems. This initiative has taken place largely in congregate care settings. It combines training and consultation using Risking Connection, and the restorative approach (Wilcox, 2006), a treatment approach emphasizing relational rather than behavioral management techniques. Pearlman and Staub describe a project that combines CSDT with Staub´s Origins and Prevention model to promote healing in Rwanda. Staub´s work identifies the psychological,
social, economic, and historic forces that set the stage for group violence. It emphasizes understanding the sources of violence and the necessary components of reconciliation after mass violence. A controlled evaluation of their approach found decreased trauma symptoms and more positive orientation toward the other group. The approach has been used with groups from community members to national leaders, and is the basis of radio-based public education
in Rwanda, Democratic Republic of Congo and Burundi. Each presentation will discuss research, challenges, and successes.

If you are going to be at ISTSS, stop by and say hello!

Increasing Readiness for Trauma Informed Care

If you work for a treatment agency that is just beginning to think about trauma informed care, there is an important step you can take to increase your readiness to make this change.

This step is: increase the likelihood that staff will consider what is behind a behavior that a kid is displaying before taking action to respond to that behavior.

A key concept of trauma informed care is that symptoms are adaptations: that people do things for a reason. The behaviors the kids do that are problems for us, are solutions for them. Behaviors such as aggression, self harm, destroying property, bullying, screaming, running away, throwing chairs- they all serve an immediate purpose for the child, and what’s more, they work. The purpose is usually to escape some sort of intolerable feeling. Because the child has no reliable attachments to help her calm down, her emotions over whelm her. Because she has a changed biology and a sensitized nervous system, a small problem feels like a catastrophe. And because he doesn’t know any feelings management skills, he does not know how to identify or handle the feelings, does not believe any one cares, and does not think he is worth the trouble any way.

So instead of staying with over whelming feelings of fear and hopelessness, the child does something. And the problem is temporarily solved- even though there are long term negative consequences.

Every behavior is adaptive. And if we understand the benefits a child is getting from a behavior, we open up many more ways to help the child. This is much more powerful than just trying to punish the behavior away.

How can an agency develop a culture in which the adaptive function of a behavior is routinely considered and discussed?

I believe the clinicians should take the lead here. Shortly after a child is admitted (like 2-3 weeks) the team should hold a meeting in which members of all disciplines (teachers, child care workers, nursing, etc) are present. The therapist should convey a beginning formulation of the case- a theory of what happened to the child and why they are acting the way they do. This formulation could be summarized in a treatment theme such as "learning to trust adults" or "learning to manage feelings" that highlights the most important thing the team will work on. The child should also be part of determining the treatment theme when appropriate.

Then for every behavior that occurs the therapist should lead the questions: why is she doing this? Why now? What problem is she trying to solve? What has happened recently? How do we understand this?

After a while this kind of thinking can become so pervasive in the program that everyone thinks this way, and child care workers, teachers, everyone starts asking the same questions.

So if a boy often has a tantrum before bed time, we are wondering what it is about bed time that is hard for him, and thinking more of night lights, staff presence outside his room, soft music- and less of punishing the tantrum.

Start thinking about what meetings, what occasions, what communication channels can be used to communicate ideas about the meaning of behavior.

After a while it will be automatic to ask these questions and use your theories to determine your responses. Then you can start the next steps in implementing trauma informed care.

As always, comments are strongly desired- it’s easy! Just click on the word “comment” below.

Call for Response and the Restorative Approach™ and DBT

First, I would like any one who is reading this to read the previous guest post from Devereaux and respond to the thought-provoking questions they pose through clicking on the "comment" button below.

Last week I attended the first week of intensive training in Dialectical Behavior Therapy (DBT). The State of Connecticut Department of Children and Families is providing this training for 18 agencies chosen through an RFP process. The trainers are from Behavioral Tech, the official training group of Marcia Linehan, who authored DBT. (http://www.behavioraltech.com/)

Several people asked the trainers how DBT fits with a relational model. The trainers stated, and I completely agree, that DBT is a relational model, and pays a lot of attention to the quality of the relationship between the treater and the client. DBT states that the relationship is our main source of power and reward, and our main vehicle for changing behavior.

Many aspects of DBT promote a relationship approach. First of all, the DBT assumption that the client is doing the best they can, and that we must adopt a stance of radical empathy and search for a non-prejorative, phenomenological empathetic interpretation of the clients makes a relationship possible. We are more able to form a relationship with the client if we are not blaming him for his behavior. Secondly, DBT promotes radical genuineness on the part of the therapist. It is okay (inevitable in fact) for the therapist to have personal limits, to be affected by the clients' behavior and to have reactions. These can be shared with the client in a real way. The emphasis on transparency, on teaching the client everything you are doing, on respect for the client's ability to learn and understand, also promotes a strong relationship. The therapists’ ability to respect her own limits decreases her becoming angry with the client.

A critical component of DBT is the consultation team, which supports the treater. The Consultation Team assumptions of fallibility and non-defensiveness, as well as the dialectical method of problem solving, create a strong and healthy team. Therefore, relationships with other providers enable the treater to have strong relationships with the client.

DBT pays very close and careful attention to what the treater does within the relationship. DBT speaks about positive and negative consequences for behavior, and emphasizes contingency management. But most often they are not referring g to 10 minutes more Nintendo time. They are asking us to closely notice what we do within the relationship. When do we spend time with the child? When do we smile, talk in a warm voice, pull back, frown, be closer, be more distant? All of these can reward or punish behaviors. And we need to use these contingencies carefully and planfuly, lest we inadvertently reinforce the very behaviors we are trying to change.

DBT even has a concept of restoring relationships after there has been a problem, and of over correction- doing more than you strictly need to to make sure the breach is healed.

Although there were some parts of the training I need to think more about to integrate with our current approach, over all I think that DBT and the Restorative Approach™ compliment each other.