Sunday, November 11, 2007

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.

1 comment:

Rosa Zubizarreta said...

Patricia, this sounds like a very practical suggestion to me. I find that the "story we tell ourselves" about a young person's actions (or the story that we share with others) really makes a difference... and attempting to understand the meaning of the behavior, seems to create many more options for responding than getting into a struggle for control.

I'm not too familiar with this particular model yet, but I'm wondering if in it, there might be room to consider that sometimes the meaning of the behavior, may actually be that the young person is asking for some limits or boundaries?

It seems to me that even in those cases, we would still respond differently if we are seeing the challenging behavior as a request for a "loving no" on our part, instead of taking the behavior personally as an invitation to a power struggle...

does this distinction make sense?

what do others think?