Monday, December 29, 2008

Eating at the Table

LaTasha came to the group home from a residential treatment facility where she had been for two years. Prior to that placement, she had been hospitalized seven times, was in a shelter for eleven months, had been in nine foster homes, and had suffered early abuse from her biological family. She pushed so hard to get out of the residential and was so eager to be discharged to the group home that both she and her staff were surprised at how hard the transition was for her. When she first came to the group home, she showed all the signs of feeling unsafe. She tested the staff, insulting and mocking them. She asked questions about the locks and security measures of the home. If ever a staff was uncertain about what to do or if the staff changed a rule (“yes, I guess you can go outside and hang out for a while before you do your homework”) LaTasha would say they were stupid, didn’t know what they were doing and were too young to be staff anyway. A couple of times LaTasha had become so escalated she had been taken to the local ER.

When LaTasha first arrived, she completely refused to eat. She said she didn’t like the food, it wasn’t her type of food, staff didn’t know how to cook. The Treatment Team wondered if she had an eating disorder, but there was no mention of it in her records. Then, she began taking food and smuggling it to her room, which of course was against the house rules and could bring bugs and all sorts of complications. She would some times eat snacks or make herself a late night peanut butter sandwich, but she would never sit at the table with the group. Occasionally she tried to eat her sandwich in the living room in front of the TV- another behavior that was against the rules.

Fortunately LaTasha’s group home was using trauma informed treatment and had an excellent treatment team. Led by the clinician they looked at LaTasha’s behavior and asked "why"? What function was LaTasha’s behavior serving for her? What was she expressing to the team? What emotion management capacities did she lack and need help with?

It was clear that LaTasha was scared and didn’t trust them. Being in the house and in a strange community, very different from any she had previously known, made her feel unsafe. She was in danger mode. She didn’t know the staff or the other kids. Many other people, both professional and not, had let her down and rejected her. She had gotten used to a residential setting with its inflexible structure, many staff, and locked doors. This new place seemed very weird to her and she was not sure what to make of it. She was not going to connect with these people, act like they were her family, only to be hurt once again.

The Treatment Team decided that all their efforts should be focused on helping LaTasha feel safe. One key to that would be validation- letting her know that her reaction was completely understandable, given her experiences, and in fact that anyone would feel uneasy in a new place. So, instead of insisting that she eat at the table with the group, staff began trying to support whatever arrangement felt comfortable for her, and expressing their hope that she would join them whenever she felt it was right for her.

So, they let her eat in the living room for a while- and started bringing her a tray of whatever they were eating, so she wouldn’t be stuck with peanut butter sandwiches. After a while, she began eating in the kitchen near where the others were, but not at the table. Then she came to the table, but she was wearing headphones and listening to music. Instead of telling her this was not allowed, staff welcomed her and ignored the headphones. Later, she began to wear the headphones around her neck at the table ("I am in control, I can retreat if I need to"). LaTasha now eats regularly with the group, and her overall agitation has also calmed down.

This is a perfect example of how we can implement trauma informed care in the daily details of life. The first step was for staff to move beyond "rules" and "misbehavior" and "defiance" to the meaning of what this girl was experiencing- and then to take it seriously, really let themselves feel what this move must be like for her. And then the whole team focused on helping her feel safe and welcome. They did not get caught up in worrying what if she always wants to eat in the living room-what if all the girls start doing it- soon no one will be following any rules. Instead they allowed themselves to honor the emotional reality of one particular girl, and had faith that as needs are filled people can move on.

This example is real, and was recounted by a participant in our recent Day of Learning and Sharing.


Day of Learning and Sharing Successful

This is a report on an event I helped plan and participated in.

On December 8, 2008 the Trauma Research Education and Training Institute (TREATI) and the Traumatic Stress Institute sponsored the Third Annual Day of Learning of Sharing. This event is provided to Risking Connection® trainers to increase their skills and knowledge in training and helping to implement trauma informed care.

The theme of this years’ event was Visible Mending, a Japanese practice in which broken bowls are mended with gold, making the repaired bowl more beautiful and more valuable than the original, unbroken vessel. The parallels to both our work and our care of ourselves and each other are obvious.

The day was attended by eighteen agencies, including agencies from Connecticut, Massachusetts, Kentucky and New York. In addition to Risking Connection® trainers, agency executives, CEOs and managers were invited to learn more about implementing trauma informed care.

The day started with each agency presenting what they were most proud of regarding training and implementing Risking Connection® concepts. These included reductions in restraints and seclusions, reduction in staff turnover, changes in agency cultures, more emphasis on relationships, implementation of evidence-based trauma treatments, and better outcomes for children. It was very moving to hear the transformation that is taking place in our field resulting in better treatment of our children.

The morning featured a presentation from Roger Fallot, Ph.D.  Dr. Fallot, Director of Research and Evaluation for Community Connections headquartered in Washington, D.C., consults nationally to agencies and mental health systems on the implementation of trauma-informed services.  He is co-editor (with Maxine Harris) of Using Trauma Theory to Design Service Systems. Roger presented on transforming agency cultures to meet the needs of traumatized clients. He emphasized the importance of five core principles: Safety, Trustworthiness, Choice, Collaboration, and Empowerment. Roger then facilitated a discussion on what agencies could do to improve their practice in each of these areas.

After lunch Patricia D. Wilcox, LCSW, Vice President at Klingberg, Risking Connection® Faculty trainer and Executive Director of TREATI, presented on

Healing the Hurt Brain: How we can use our knowledge about trauma and the brain to make our treatment as effective as possible. She connected current knowledge about brain development and plasticity with the implications for effective treatment practices. Pat focused on the role of attuned relationships, safety, understanding shame, and developing emotional skills.

Steve Brown, PsyD. Director of the Traumatic Stress Institute and Risking Connection® Faculty trainer led the group in a wonderful Vicarious Traumatization exercise using the Visible Healing metaphor. Many participants commented that this exercise was helpful to them and would be valuable to bring back to their agencies.

The day ended with a closing ceremony which emphasized our connections to each other and to the web of people trying to implement trauma informed practice and change the world.







Sunday, November 30, 2008

Does Our Discipline Threaten Our Relationships?

In a recent training we were talking about relationships, as we often do. A therapist asked the following question:

"I am often called onto the floor to intervene with a kid who is acting up. I take on the role of the child care workers. I end up giving him consequences. When that happens how can I preserve my relationship with him, and not seem to him like just one more person trying to manage his behavior?"

 I was struck by what I see as dangerous assumptions beneath that question, which I will exaggerate for purposes of discussion. I think in fact these assumptions often do underlie our thinking and actions in treatment programs.

This question assumes that the therapist has a special healing relationship with the child, which would be threatened by the therapist addressing the boy’s behavior in the normal way of the program. The child care workers, on the other hand, are expected to address behavior routinely and so whatever relationship they have with the child is expendable. They are those people who are just trying to manage behavior.

I would propose that there should be no people in a treatment program "just trying to manage behavior". The first priority of every person who interacts with the child should be to form, maintain and strengthen their relationship with the child. Every relationship can be healing. Every relationship is important.

I would also suggest that none of us, whatever our role, should ever be just managing behavior. Of course, in a crisis one has to direct traffic to restore safety. But with regard to any individual child, our constant focus should be to understand the meaning and adaptive function of every symptom, and teach the child more positive ways to meet those same needs. Our programs, and all our staff, should in every way promote a sense of safety and caring. We do not ignore behavior or remain paralyzed as the child becomes increasingly upset and out of control. We intervene actively and constantly from our base of relationship to help the child calm down, and, when he is calm, to figure out how to get what he needs. Our goal is not to control his behavior. It is to help him to feel calm and safe enough to try new ways of meeting his needs.

I seriously believe that everyone in the program should be thinking this way- every child care worker, every therapist, and every teacher. Everyone should be engaged with the child from a carefully formed relationship. Naturally, the child may be angry, unappreciative, nasty, upset and uncooperative with any one of the many people on his team. Any one should then acknowledge and validate his feelings, and (when he is calm enough to hear) share their experience of whatever happened from their heart.

When we acknowledge the central importance of all the relationships between the child and the team members; when we truly believe that the child is doing the best he can; when we see symptoms as adaptive; when we react by helping the child to learn better ways to meet his needs: then we can all do all parts of the job of treating and raising these children, and we can all enrich our relationships as we do them.

Sunday, November 23, 2008

Meeting Their Needs

In Risking Connection® training we focus a great deal on counter-transference, the helpers’ feelings while doing the work. Our basic point is that any feeling is okay, it is what you do with it that matters. In order to illustrate this, we use scenarios. In each scenario, the questions are: what is the staff member feeling? How could they use their feelings to enhance the treatment? How could their feelings get in the way of the treatment?

Here is one of the scenarios:

"Lucinda, a fourteen-year-old resident, told you that her aunt had called her and told her that her mother was very sick. She seemed quite distraught. You arranged with other staff for her to have an extra long phone call outside of phone time. Later you learn that she actually used that opportunity to call her boyfriend and her mother was never sick."

The usual response is that the staff member is feeling angry, betrayed, used, foolish, and ashamed. And maybe we had better think again about allowing Lucinda this relationship with her boyfriend, since it apparently gets in the way of her treatment. Our reaction is to toughen up, make sure we never believe this child again, that no child can ever trick us again. She has betrayed our trust and we will not trust her again for a long time.

We talk about noticing that this is how the kids we work with always feel. That moment when the staff member, feeling humiliated, decides never to open her heart and let any child trick him again is the place where our kids live.

In a recent training, however, a miraculous thing happened. One staff member said: what if we realized that Lucinda doing this was a sign that she was not able to trust us to meet her needs? What if we assumed that her wish to talk to her boyfriend was legitimate? It is developmentally appropriate, and also part of her understandable need to have connections, someone who cares about her, attachments.

What if we worked hard to assure Lucinda that we would like to meet her needs, and we would like to discuss how we can make sure she has regular access to her boyfriend without the necessity for lying to anyone?

What if we thought that more important than the phone rules was a chance to teach a child that adults care and that you can turn to other people to help you get what you want?

I would love to live in a world in which this kind of thinking was even part of the conversation.

Monday, November 17, 2008


Let’s consider the topic of safety.

One of the most basic, immediate and continuous distinctions our brains are constantly making is: safe or not safe? Danger or no danger? This decision is made instantaneously in any new situation by the part of the brain known as the amygdala. Any change triggers a reevaluation. In a healthy brain, the amygdala’s instantaneous decision is combined with and moderated by information from other part of the brain, that add information regarding context, past experiences, reasoning, and observations from the sensory system.

If the brain concludes: Danger! Not safe! the body’s protective system is activated. Energy is directed to the parts of the body that will be needed for fight or flight. Non-essential systems, such as digestion and reasoning, are shut down. The activation chemicals in the body/brain are released, and the alertness system turned on. The person is alert, but focused only on signals of danger and safety. The heart is beating fast, the muscles are tense, ready for action.

Think of a time you can remember when you felt seriously unsafe. A near car accident? An encounter with a threatening person? A weather-related event? Even a common example like trying to drive home from work after an ice storm can be illustrative. In fact, an even more appropriate example would be being a passenger in a car when someone you didn’t know very well was driving through an ice storm.

What did you feel like? What did you do? What happened in your body?

If there was someone in the car with you, would you have been able to have a conversation about a movie you had seen, much less about something that was troubling you? If some one told you a joke, would you have laughed? Would you enjoy the songs on the radio? Could you take a nap?

To further elucidate the experience of danger, there is the experiment with the baby mice. (Panksepp, J. (1998) Affective Neuroscience: The Foundations of Human and Animal Emotions. New York, Oxford University Press) Some baby mice had been raised in cages. They had never seen or heard of a cat. Like all baby animals, they engaged in a lot of free play with each other. The experimenters put two cat hairs in the cage. Although the mice had no cat experience, the cat hairs were wired into their brains as signifying danger. Immediately, all free play stopped. And, also significant, when the cat hairs were removed after just a few days the mice play gradually returned, but it never returned to the level it had been before the cat hairs were introduced.

So what does all this have to do with our work? It is helpful to think of the children we work with as being stuck in the danger response. Because of early, overwhelming and unpredictable experiences of trauma, their brain chemistry was modified such that they can not come back to a relaxed state.

But the wonderful news of brain plasticity is that at any age, the brain can be rewired through attached relationships. In order to begin this process, and in fact in order to be available to attached relationships, the brain must sense "I am now safe". Since the brain patterns of danger are so deep, this will not happen quickly, but it can happen.

So it is important that we think closely and observe the ways in which our treatment environments are signaling safety to our clients, and the ways in which they signal danger. As part of this we must consider ways in which we as staff feel safe in our work places.

As you look around your environment, what safety and danger signals do you observe?

Danger signals could include sarcasm, not being allowed to speak ones’ side, restraints, loud noises, disorganization, emotionally dysregulated staff, belittling comments, physically ugly places, lots of damage and disrepair, creaky doors and funny noises at night, messages from other kids, boundary violations, bullying, messages from staff to other staff, blaming and scapegoating- the list could go on.

Safety signal could include warm tones of voice, respect, politeness, promises kept, organized environments, delight, fun, relaxed kids, caring messages when upset, physical protection such as locks, clear and observed boundaries, a sense that we are all in this together, team work, pleasant physical spaces, an appreciation of strengths and competences, a real voice in decision making.

It would be interesting to have a team discussion of this question. How safe does our environment feel to the kids- and to us? It would also be interesting to ask the kids to make lists of "things here that make us feel safe" and "things here that make us feel not safe".

And as we do this, it is important to remember that unless the body begins feeling safe, the person will not be able to begin the work of healing. It’s not that they will be resistant or unwilling- it’s that their brains will not be available for that work.

Thus it is very important that we pay more attention to this subject of safety.

Sunday, September 28, 2008

We Have to Hold Her Accountable… or How is She Going to Learn?

At the beginning of Risking Connectionâ training we discuss the differences between a traditional approach and a trauma informed approach. These include: The traditional approach maintains that the treater is the expert, and the client the recipient of this expertise; the main value in the traditional method is control and elimination of symptoms as opposed to collaboration and understanding the adaptive function of symptoms; and the idea that the treater should be unaffected by the work is replaced by understanding that all treaters are emotionally impacted by the work. 

As we finished this exercise in a recent training, one participant said: "I can see that in this method you do not hold the clients accountable. This will not work for me, I work in a juvenile justice facility and we have to hold the clients accountable or how will they ever learn?" Furthermore, she stated that she sees the clients as making choices, and her job to point out that there are consequences to these choices. 

This comment contains several of the most common fallacies or mis-beliefs about the trauma informed approach. We have to take these concerns seriously as they represent one of the largest obstacles to implementing this method. 

First of all there is the idea that we are recommending "not holding the client accountable". 

When you look up the definition of holding accountable you find it is associated with words like blame, find fault with, censure, to place the responsibility for, reproach, reprove, reprehend, criticize, to hold responsible; hold culpable. We don’t seem to speak of holding someone accountable for good things or positive achievements. 

We are as usual stuck in the middle of a dialectic- to use the words of DBT, the client is doing the best she can, and she needs to learn to do better. Our treatment must include both validation and a push for change. 

A child’s past and his current reality influence the choices he makes. If he is presented with the opportunity to steal a car and the urging of peers to do so, many things so influence whether he does or does not:

Does he have any self worth? Does he think there is any one who cares what he does? Has he learned values through loving attachments? Does he have a sense of hope for his life? Does he think he has anything to lose? Is he in the grip of intolerable anger, despair or fear and does he have any skills to manage whatever he is feeling? Is he mired in shame from other events and actions of his life? Does he have attachments with other friends or does he feel he will be alone forever if he alienates these friends? Does his mind have the capacity to think before he acts? 

If he decides to steal the car, gets caught, and is presented (involuntarily) to us for treatment, how can we best help him? What interventions on our part will result in him being more capable of turning away from him next opportunity to break the law? 

It would be neglectful to ignore the fact that he stole the car, to never mention it, or to act as though it was some how all right to have done so because of difficulties he has had in his past. 

It would also be neglectful to ignore the factors that contribute to his vulnerability to such actions. We would be less helpful if we did not offer treatment that increases his self worth, forms strong relationships, emphasizes the relationship consequences of behaviors, build up avenues for achievement and hope, helps him learn both emotion management skills and relationship skills, and teaches him how to calm his biology to increase his ability to think. 

A trauma informed approach confronts the behaviors directly. The treaters bring to the discussion respect, an assumption that every behavior is adaptive and solves a problem, information about change, a strong connection, and hope for a better future. 

In a trauma informed approach we answer the question: "how will he learn not to do this again?"

He will learn by a strong, respectful and straightforward investigation with his treaters of what happened and what contributed to his decisions.

He will learn through developing attached relationships. Within these he will learn values. He will have something to lose that matters. He will learn that he has strengths and talents. He will find hope. He will also learn through specific strategies to teach him emotion management and relationship skills. 

It’s not so much that we do not hold him accountable. It’s that caring and be cared about, skills and achievement offer so much more power for changes than simply explaining that if you steal cars you may go to jail. 

How would you answer this person’s comment? What are your views on this central concern about trauma informed care? We need to do much more thinking and talking about this. Click on “comment” and express your ideas.









Sunday, September 21, 2008

The Role of the Clinician and of Formulation

Trauma informed care depends on clinical thinking. What is clinical thinking? It is looking beneath the behavior of the moment, and asking why? What’s going on? It is understanding that symptoms are adaptations that behavior has reasons, that people are doing the best they can, and that their behavior is solving a problem for them. The job of the clinicians in a treatment program is to be the standard bearers for clinical thinking, to teach and train the team until this sort of inquiry is second nature to all members of the team.

So when a child care worker reports that Monique ran away last night, and wants to know what her consequence should be, the clinician should divert the discussion to the question of “why”. What was going on last night? What was the provoking incident? What is going on in Monique’s life? What are her sources of stress, her worries, her fears? What are her strengths, what good things are happening for her that could be brought into the equation? What internal and external resources does she have?

In a congregate care treatment program there is considerable pressure for a clinician to turn away from clinical thinking and become a “fixer”. Some times it seems that clinicians’ job is to take away a screaming child and bring her back calm. The clinician may be drawn into thinking that what she is supposed to do with the child is talk to him about what he has done wrong and how if he stopped doing it his life would be much better.

The problem with this approach is that it doesn’t work. If it did, the kids would be much better already because this has been done a thousand times before. The job of the clinician is first of all to form a healing relationship with the child, then to use this relationship to help the child learn their own worth, develop connections that can be accessed even when the clinician is not present, and learn emotion management skills.

The clinician should have a complex and ever increasing understanding of the child, what their experiences have been, and how those experiences have shaped them. The clinician should hold in his mind a clear picture of the healed child- of who this child can become. He holds the hope for the child, even when the child can see no hope.

Similarly, in family therapy the clinician can get trapped into endless discussions of behavior and consequences. Instead, she must understand and honor the rich complexities of the family’s life. What is their history, their trauma, their pain, their strengths? What are the dynamics between family members, including extended family? What are their resources? What are their fears, what paralyzes them? The healing relationship, connection, developing self-worth and emotion management skills are equally important with the family.

Clinicians should be taught the art of formulating a case. A formulation makes explicit the clinician’s best understanding of the child’s history, their current circumstances, the effects these have on the child, how we understand their current behavior in light of their situation, and what we think will be the path for growth and change necessary to develop healthier methods for meeting needs.

The formulation should be one to two paragraphs which provide a clear road map for understanding and for treatment. Of course it is ever changing and evolving as we come to understand the child and family better.

In one program I heard described (Germaine Lawrence in Boston, they have a practice that every time they talk about a child, they start with a quick repetition of the formulation by the clinician, just to remind them of their road map and where they are on it. I thought this was a great idea.

Here are some examples of formulations:

1. Sarah suffered early neglect and abuse followed by repeated moves. Her siblings were adopted but she failed the placement. She struggles to maintain safety by keeping her fears hidden in oppositionality. She sees danger every where and over reacts with physical and verbal aggression. Her processing difficulties contribute to this misapprehension of events. She responds to care givers with suspicion but does react to limits. She will need to develop safety and trust in order to be able to relax, to explore her past and decrease her conviction that what has happened to her is her fault.

2. Thomas is a young man whose genetic heritage suggests that he might be vulnerable to a mood disorder. Multiple stressors have apparently exacerbated this biological predisposition. These stressors have included inconsistent parenting, being a witness to domestic violence, physical and emotional abuse, emotional, medical and educational neglect, and the death of his mother. Thomas’ most likely felt overwhelmed by these stressors and developed a negative coping style that resulted in his trying to “shut down” or avoid painful thoughts and experiences. When he was forced to be reminded of these painful experiences and when he had to incur more stress during times when adults were not able to limit his exposure to it, Thomas would rapidly become disorganized and resort to primitive defenses as evidenced by his becoming aggressive, suicidal, and even by his reporting psychotic symptoms.

Based upon reports of his progress in previous programs, Thomas seems to be able to utilize the structure of residential treatment to afford him the predictability and safety he needs in order to organize his thoughts and demonstrate his desire to behave in a socially acceptable way. His treatment goals should focus on increasing his ability to identify and practice positive coping skills to manage overwhelming affect, and on developing age-appropriate social skills.

3. Vanessa had early experiences with severe neglect and observing domestic violence because of her mother’s drug addiction. She learned to take care of herself. The loss of several family members combined with mom’s addiction and unavailability sent Vanessa and her sister into a crisis culminating in their removal from the home. The family seems to now be on a positive track as the mother is in recovery and the girl’s have made improvements. However Vanessa understandably still has difficulty trusting her mother and other adults, and does not let adults help or guide her.

4. Latasha’s symptoms and level of functioning seem consistent with her admission diagnosis of Reactive Attachment Disorder, Posttraumatic Stress Disorder, and Oppositional Defiant Disorder. She experiences chronic and pervasive shame as a result of her past abuse, separation from family, disruptions from foster care, and multiple placements. These feelings of shame are overwhelming and cause her to react with a well-established pattern of oppositionality and defiance. In addition, considering that her developmental stages were disrupted by her trauma, she may be struggling with issues of competency and trust leading her question her own safety and sense of belonging as well as her ability and to learn new skills and grow in her functioning.

Latasha will benefit from the routines and structure of daily living in residential treatment. Latasha will benefit from a restorative approach in treatment to help her gain confidence and trust in her caretakers and to allow her to develop her strengths, which include good verbal skills, a sense of humor, and an ability to engage positively others, in the context of healthy relationships.

5. Stephanie is a bright and insightful child who has suffered immense abuse and neglect in her formative years. She was witness to horrendous domestic violence, substance abuse and sexual activity. Stephanie was often the caretaker of her brother and biological mother while her own needs went unmet. As a result, she learned that it was not safe to trust adults to care for her. Upon her adoption to the Anderson family, Stephanie struggled to adjust to this environment. Her adoptive parents appeared to accept her need to be in control and for a while went along with her behavior. However, over the years, Ms. Anderson grew increasingly worried and angry. As she became more vigilant in monitoring her daughter, Stephanie grew increasingly oppositional and detached. Ms. Anderson felt Stephanie was deteriorating and influencing her other children whom she felt were connected and settled. As a result, Ms. Anderson gradually began to disconnect from her daughter. Stephanie impacted by fears of abandonment responded accordingly and became increasingly withdrawn and detached from the family.

Ms. Anderson raises her foster and adoptive children primarily on her own without much spousal support and is looking to meet her needs through her children. Her husband is largely unavailable and detached. She expects her children to “love back” considering how much effort she puts into caring for them. Stephanie’s lack of attachment to her, therefore, is intolerable. It is also complicated by the fact Stephanie is entering adolescence. Ms. Anderson has limited experience with this stage of development and since her own childhood was unremarkable, she expects the same from her children. Ms. Anderson is also angry at Stephanie due to the conflict it has raised with her own parents, who criticize her parenting skills and lack of nurturing with Stephanie. Her perception of their withdrawal of support has been extremely painful, which she blames on her daughter. Ms. Anderson feels that she needs a break from this child and treatment will focus on whether the relationship can be restored in order to support Stephanie’s return home.

The formulation articulates our theories, our understanding of what causes problem behaviors and what helps to heal them. The formulation leads directly to the treatment plan. In the treatment plan we describe the problem behaviors, we describe their positive opposites, the behaviors we would like to see, and we describe the steps to get there. The treatment plan, again, is a theory: it makes concrete our understanding of the steps that would help a child heal. Thus if Latasha is feeling shame, what will help her? Experiences of competency, positive relationships, identifying strengths, developing skills to master her own emotions. These should be clear in her treatment plan.

If Vanessa cannot trust adults and use their help, what will change that? Small experiments in trust. Using her leadership and self care skill to accomplish things. Positive trustworthy relationships. An understanding of her past and it’s effect on her. Developing emotion management skills to withstand the fear she experiences when she beings to trust.

If Stephanie and her foster mother are locked in a painful cycle of unmet needs, what will help? The relationship between the therapist and Ms. Anderson may begin to meet some of her needs, allowing her to relax with Stephanie. Perhaps her mother will be part of the family work. Helping mother and daughter share their experience and listen to each other may be part of the healing. Structuring positive experiences between them may begin to rebuild their connection. These interventions would be clear in the treatment plan.

So the clinician’s job is to gather information respectfully and understand the experience of the child and family, then to use that to develop a formulation. The formulation articulates what has happened, what is going on now, how these factors produce these behaviors, and what steps may help move towards more effective meeting of needs. Then, the clinician must convey this formulation to the entire treatment team, including the child and family (in understandable and respectful language).

Then, and perhaps even harder, the clinician’s job is to keep the formulation alive. Whenever a new behavior happens, or the four hundredth repetition of the old behavior, or an accomplishment, or something bewildering, return to the formulation. Is this still how we understand this child and family? Do we need to adjust our thinking? How do the new events fit into our theories? Where does this understanding lead us- what new interventions are suggested?

For this to be a viable and vibrant process the clinicians need administrative support. They need excellent clinical supervision. They need access to on going training of many sorts. They need opportunities to replenish them selves and their work. They need reasonable caseloads which allow time to think about their kids.

This clinical leadership will gradually develop a more knowledgeable and sophisticated team, in which all the staff will assume the child is doing the best they can, routinely wonder what is behind a behavior, and seek ways to help the child develop new skills. This thinking will produce more creative and caring intervention possibilities. And this will lead to more deep and lasting healing for the children and their families.

Thursday, September 18, 2008

Improving Restorative Tasks

Three ideas have recently occurred to me related to making restorative tasks more meaningful to both kids and staff.

1. Mapping the Effects of Behaviors: In a workshop I just attended on Restorative Practices in a school the presenters emphasized that after each incident they meet with the child and create a map of who was affected by the child’s recent actions. Include any one who was affected positively! Then the child has a chance to think about how to make it up to them. Some children would be unable to do this because their shame would produce overwhelming and intolerable emotions. But for those who could, taking this step formally might be a way to underscore the meaning of the restorative tasks.

2. Practicing Positive Ways to Meet Needs: A key tenant of trauma informed care is the belief that symptom are adaptive, that every behavior is a person trying to meet their needs the best way they know how at that moment. The behavior (hurting yourself, running away, throwing a chair) may be an escape from intolerable feelings of despair and hopelessness. It may be a way to draw humans closer and avoid deep aloneness. It may be a mask for desperate fear or unacceptable confusion. But the behavior serves a function, and it helps in the moment. It actually makes things better for a time, even if it also brings long tem negative results.

Led by the clinician, the Treatment Team should try to understand the needs that this child’s behavior is meeting. They can do this by talking with the child, by noticing patterns, by knowing the child and her history, even by guessing. And then their job is to teach the child how to meet these needs in ways with less negative consequences.

So how about using the learning part of restorative tasks as ways to discover and practice these new ways of meeting needs? So Yolanda is angry and destructive many nights before bed, and the team speculates that night time is hard for her and she has trouble falling asleep due to racing unhappy thoughts. What if her restorative task is to read a story to a younger girl on the unit every night? Or (with staff help) to put together a CD of soothing sounds and make copies for some other girls whose lives she disrupted? Or to make a stuffed animal for someone filled with lavender- and make one for her self too?

Get the idea? Yolanda learns some ideas of how to fall asleep, while making amends to others.

What if we postulate that Andre becomes aggressive and assaults staff whenever he feels afraid. What would we like him to do when he becomes afraid? Probably tell some one. So how could he practice that? He could talk with three of the male staff about times they felt afraid, and what they did about it (experience modeling of the desired behavior). Could he read or write a story about a boy who was afraid and handled it well? What else occurs to you?

In treatment team, think about the needs a behavior is meeting and what the desired way of meeting those needs is. Then think of some possible ways the child could experience or practice that more positive alternative.

3. Peace offerings: In a novel I just read when one character hurt a friend, she brought her friend a peace offering when she went to apologize (I think it was cookies). It occurred to me that the concept of peace offering conveys what we want to accomplish in the making amends part of the restorative task. The things we ask the kids to do to make amends can never be as big as the things they have done wrong (at least, not if we want to stay licensed). So using the phrase "peace offering" might help convey the spirit of what we want them to accomplish- a gesture of apology.

Click on the comment button below and let me know your reactions to these ideas.

Monday, September 08, 2008

How Much Restoration is Enough?

In a recent training I did, I was asked a familiar question: how do you know how much restoration is enough? When a child does something that hurts another person or threatens the community, how do you decide how many or how large the tasks assigned for restoration should be? And how do you decide whether the child has completed these tasks with enough sincerity, effort or seriousness?

I think that some of the impetus for this question comes from thinking of restorative tasks as punishments in disguise, and from believing that their effectiveness comes from their being aversive. In other words, that (like punishment) the tasks should not are fun to do, and the child will change his behavior in order to avoid having to do them. In this framework, the tasks should be "as big as" the offense, and take a lot of effort and time, especially if the behavior was very serious or hurtful. The learning or relationship nature of the tasks is secondary. People often speak of staff feeling like the child "got away with" his behavior because what he had to do was not hard enough. The person who was hurt by the child does not feel sufficiently paid back, and thus feels resentful and disrespected.

In order to think further about this, let’s turn to our own lives. We all have had experiences of forgiving people who have hurt us, and continuing the relationship. Imagine that a friend has done something that hurt you. What would that be? Told a secret, let you down, forgotten to meet you for a planned appointment, said something thoughtless or mean to you, cancelled a plan with you at the last minute in order to do something else, borrowed money and not paid it back: what else?

In order to restore this friendship and for you to truly feel better about this friend, what would you want from him? First, I guess, an apology and an acknowledgement of what went wrong and his part in it. You might want him to listen to you speak of how this behavior affected you and to seem to actually care and take in what you said. Then, you would want him to act differently from now on, or try to, or at least start to.

So these are the skills and behaviors we want our kids to learn.

The first thing that gets in the way is shame. In order for a person to deal directly with something they have done wrong, they have to be able to tolerate the bad feelings involved. In order to admit you have hurt some one and to face them, you have to have some inner core of believing you are okay. You have to believe that forgiveness is a possibility.

Stop here for a moment and think of a time when you did something wrong, hurt some one you cared about, or made a mistake you were ashamed of. As you were trying to convince yourself to face up to the mistake and deal with it, what were you feeling? What got in the way of your honestly going to the person you hurt and admitting what you had done? What helped you to do so?

When our kids realize they have made serious mistakes, their sense of hopelessness comes crashing down on them. All is lost. There is no hope of forgiveness or redemption. They remember everything that has gone wrong in their lives, which they believe is totally their fault. When feeling this horrible despair and seeing no way out of it, their impulse is to run away from the events. This running can take many forms: actual running, denying responsibility, blaming or attacking others, aggression, self harm, retreat to bed, and many others. Often it takes the form of the child demanding to get out of this stupid place: send me to detention! Hospitalize me! All of this reflects self loathing, despair and lack of hope.

So- back to the restorative tasks- in treatment we are trying to help the child grow and be able to feel hope, to believe in the possibility of things working out, and to have some skills that will provide steps towards that outcome.

Traditional punishment, such as confinement to your room for a period of time, has exactly the opposite effect- it leaves the child feeling worse and without any adult support or steps to reconnect with others.

The restorative tasks should aim towards helping this particular child, with her particular abilities, needs, and treatment formulation, to become slightly better at:

  • Acknowledging what went wrong and her part in it.
  • Listening to the hurt other speak of how this behavior affected them, caring and taking in what that person says
  • Acting differently from now on

In order to do any of these, the child has to develop some sense of being a worth while person, someone who deserves the air she breathes; some one others could care about and could forgive. Much of our treatment is designed to accomplish this in many different ways.

How do you get better at acknowledging your mistakes, and listening to the other describe the effect on them? Practice, mostly I think, and discovering that the world doesn’t end and in fact you can often repair the relationship. So, for some child the whole making amends could be a short conversation with the person hurt- that could be a huge step for her. Another child can’t do that, the shame is too intense. But he can draw a picture of the steps leading up to the event, and how he was feeling, and give it to the person hurt. Maybe she could respond by drawing a similar picture of the events from her point of view and how she was feeling- and he could further respond with some communication that shows he paid attention to what she said. The goal here would be: what are this kid’s current abilities to face her mistakes, and what action would be one small step further than she usually can go? In the past in this child’s life, making mistakes has led to abuse, and often to the person hurt disappearing all together. Our goal is to make this time different, a restorative relationship experience, to create a new template which includes the possibility of healing.

We’d all like the kids to then act differently. Preferably completely and immediately. In fact, that is one difficulty people report with the Restorative Approach- when you engage in a heart felt exchange with a child and the child still repeats the behavior, it feels worse than when you punish them and they repeat the behavior. We all know it takes a long time for these children to change, to un-learn the lessons of their life times.

But what will it actually take for the child to be able to behave different? Emotion management skills. Developing a sense that there are people who care about him, and that thy still exist when they are not physically present. Developing a sense that he is worth the air he breathes. And developing the ability to recognize, name and manage emotions, including the ability to self-sooth.

Thus, the learning aspect of the restorative tasks. This part is aimed to teach some small part of emotion management skills. This could be describing what I was feeling, or what else I could do, or listing ten good things I have accomplished, of drawing pictures of people who care about me. Again, what are this child’s current emotion skills strengths and deficits? What are the next steps in her treatment, what are we currently trying to teach her? Let’s give her some chance to practice as part of her restoration.

So back to the question we began with- how much is enough? It is enough when the staff feel the child has made any little step on any of these dimensions. They have talked about what happened sincerely. They have actually listening to the person they hurt. They have explored the feelings that led up to their actions. It doesn’t have to be the whole solution- just one tiny step, one new interpersonal experience, one moment of feeling "I am worth worrying about"- one building block in creating a new reality for the child.

Next questions- how do we as a team decide this? How do we teach it to new staff? How do we convey it to the children? Let me know your thoughts.

Thursday, July 10, 2008

Article in Children's Voice Magazine

I am very excited to announce that I have an article in the latest issue of Children's Voice magazine, the Child Welfare League magazine. The article is titled: A Restorative Approach to Residential Care. Please check it out and let me know what you think. The magazine is not on line yet, but when it is (later this summer) I will post a link here.

Dare to Transform 2008

I am leaving today to present at the Dare to Transform Conference sponsored by the National center for Trauma Informed Care, a part of the Center for Mental Health Services. I will be presenting with my colleague Dr. Steve Brown, a co-worker Samantha Morris and an adolescent consumer Ashley.

This is the official description of the conference:
Dare to Transform capitalizes on the momentum building since 1994 for trauma informed systems change to bring about a revolution in human services delivery. The Center for Mental Health Services (CMHS) has been sponsoring conferences that have defined the agenda of what needs to be done to recognize, understand, spark, and speed the healing and recovery process from violence and trauma. From Dare to Vision in 1994, to Dare to Act in 2004, and now Dare to Transform in 2008 we are moving closer to real action for positive and lasting change. At the National Center for Trauma-Informed Care (NCTIC).

With the Dare to Transform trauma summit, the stage has been set for a revolutionary learning exchange devoted to trauma-informed innovation and systems transformation. Joining in this experience are consumers and survivors; policy makers; administrators and those providing staff support; service providers; and other advocates who have a stake in this transformation. Dare to Transform is the boldest expression yet of what needs to and can be done to bring about change - and you are a part of it!

Our Goal: Revolutionizing Human Services with Trauma-Informed Care

Find out more about the conference at:

Our workshop:

Friday 1:15 pm to 2:15 pm Workshop Sessions
Georgian Room Creating a TIC Culture of Connection in Child Serving Agencies
Pat Wilcox, Klingberg Family Centers
Steven Brown, Director, Traumatic Stress Institute of Klingberg Family Centers

This presentation explores the joys and struggles of implementing and providing trauma-informed, relationship-based treatment to children and adolescents. This approach utilizes Risking Connection® trauma training and the Restorative Approachtm implementation model. One agency's process will illustrate the reasons change is necessary, how the trauma-informed model compares to a traditional control-oriented model, how to utilize training, how to facilitate the process of changing an agency, barriers to change and how to address them, and long-term benefits of transformation.

Please come by and say hello!

Sunday, July 06, 2008

What We Know About Trauma…

The Restorative Approachtm creates a milieu management system that is based on what we know of the effects on a person of early repeated trauma and attachment disruptions. The following makes that connection more explicit.

Biological Disruptions in the Brain and Body

Less developed pre-frontal cortex
More easily over whelmed by emotion
Over developed response to danger
More difficulty accessing verbal memory
Confused, few or no rhythms
Less integrated, has more trouble with generalization
Less connections and conductivity
Lives at a hyper aroused state
Is always very alert
Sees danger every where, therefore misses a large part of what goes on due to focusing on danger

Create the Need To:

Staff has to act as cortex for the time being
Actively teach problem solving rather than punishing
Help the child with selective attention, working memory, self observation, and response inhibition
Don’t respond to dysregulation with thinking interventions- respond instead with calming and soothing
Reassure, don’t get into power struggles, don’t back child into corner
Do not rely on verbal planning
Use multi-model interventions such as art, dance
Maintain predictable structure
Offer rhythmic activities such as yoga
Be clear in communication
Make connections between various aspects of life explicit
Practice new skills in many arenas and settings
Be aware that child will notice everything
Actively stress safety
Look for ways to help child relax such as night light, reading, music

Negative Assumptions about Self and the World

The child has learned that no effective action is possible in his life
Blames self for the events in his life
Feels worthless and less-than others
Feels hopeless

Create the Need To:

Avoid shaming interventions or interventions that dictate passivity
Develop competencies
Build trusting relationships
Develop a sense of safety in which child can share that which he finds shameful
Allow many opportunities for active participation in decisions involving the youth
Respond to problems by guiding the youth to fix damage they have created, repair relationships they have damaged
Point out strengths and achievements, skills and gains

Difficulties with Relationships

Has under-developed ability to sort out social cues
Has difficulty trusting adults
Values control above all else
Expects rejection
Does not know how to handle problems in relationships
Has trouble asking directly for what they want
Is uncertain about boundaries and tests them
Evokes strong feelings in others around him

Create the Need To:

Be reliable and stick around
Be aware that child will notice everything
Be clear in communication
Teach social interpretation through movies, etc.
Emphasize trustworthy relationships
Use the language of the heart and communicate the relationship effects of behavior
Provide relationships that stick with you
Give child control whenever possible
Provide paths to work through relationship difficulties and to restore damage done, to make amends
Staff model relationships skills and actively teach social skills
Practice and model assertiveness
Say yes when possible
Maintain firm and flexible boundaries
Be aware of complexity of boundaries in child’s life
Staff discuss boundary issues openly with each other and with kids
Culture of self awareness and team development

Lack of Learned Emotion Management Skills

Unable to recognize or identify emotions
Does not know how to sooth themselves
Does not know how to handle something going wrong without making it worse
Has many negative coping tactics for handling pain
Moves from extremely aroused to extremely shut down
Covers up vulnerable feelings such as fear and sadness
May experience flashbacks and dissociation

Create the Need To:

Teach names of emotions
Teach recognition of bodily sensations of emotions
Help child develop awareness of own emotions and their stages
Develop tactics for each stage
Actively teach and model self soothing
Teach distraction and calming techniques
Develop a list of distress tolerance tactics
Offer child alternatives not consequences when child is becoming agitated
Look for adaptive function of symptoms
Collaborate with child in developing other strategies to solve problems
Create safety to share vulnerability
Model having vulnerable feelings while remaining strong
Teach grounding techniques

Thursday, July 03, 2008

Notes from the Trauma Conference 2- Effective Action

Another concept stressed at the trauma conference was effective action.

Why do we have emotions in the first place? Why is it evolutionarily beneficial to feel?

Emotions are there to create action. An organism that can move about in the world has to have some way of evaluating various choices and what the impacts will be. It has to be able to move towards actions that will keep it and its species alive, and move away from those that are harmful. So the goal of emotion is to make the body move. The brain is the organ that moves the body. So the body sends signals to the brain, known as emotions, and the brain evaluates these signals on many levels. There is the emergency response of the amygdala: quick, but not too subtle. Just am I in danger? If so, can I run away? Fight? Or do I need to freeze?

The woman on a hike is dreaming of her new boyfriend when she sees a curvy dark object in the path ahead. She jumps back before she is even aware she has seen it. Her heart is beating fast. Her attention is focused on the object. All thoughts of her boyfriend are gone.

If the organism has time the higher brain can step in and make more subtle decisions. Is this situation relevant to me? How does this compare with other sensations I have felt? What is the most effective action in this situation? Should I suppress my habitual fear response and do something else?

Cautiously the woman approaches the object and gathers more data. It isn’t moving. It has bark. It’s a stick! She is able to move it out of the path and keep hiking, but it is several minutes before she feels relaxed again.

The emergency response is essential to the survival of the human race. Its goal is effective action to survive the threat. We spend stress hormones on effective action- that is what they are for. One part of the emergency response is to seek attachment- the human attachment needs go up in danger mode. This too makes sense from an evolutionary point of view, as the other person can help over come the danger.

The goal of emotions is to effect physical movement and regain equilibrium.
Through effective action and through connection we return to homeostasis.

But the traumatized child is blocked from any action. And the people to whom he looks for attachment help are the people who are hurting him. Fight or flight reactions with no effective action leaves the body stuck. Successful action returns the body to homeostasis. With no action possible, the person is left with a template that nothing you can do makes any difference.

One writer who has explored this concept extensively is Peter Levine, whose newest book is Trauma Through a Child's Eyes: Awakening the Ordinary Miracle of Healing
by Peter Levine, Maggie Kline
North Atlantic Books; 1 edition (December 26, 2006)

So how can we integrate these concepts into our treatment settings?

Let’s think carefully about how we can expand our children’s experience of effective action.

In every day life we can use all the principles of youth driven treatment: student councils, consulting youth on decision making, peer mediation, etc.
We can give the kids ways to help the greater community through volunteering and social action.
We can help them develop competence in many areas and act for themselves through making their own phone calls, arrangements, advocating with their DCF worker, writing letters, attending meetings about their life, etc.

And when something goes wrong, the Restorative Approach(tm) promotes effective action. Through restorative tasks and making amends, the child learns how to solve their own problems and make up for the harm they caused.

A child who assaults some one and then has to spend hours alone in a room has just had one more experience of no effective action being possible, one more experience of "there is nothing I can do". He feels more shame than ever. He is suck with all the danger action hormones with no where to go.

A child who assaults some one and then works it out with them, does a chore for them, works on a chart about what happened, and heals the relationship is left with a feeling of "there is something I can do". He still feels bad about what happened, but feels he is a person who can accomplish something, and make things better.

The principle of encouraging effective action will be a great guide for us if we keep it in the forefront of our treatment decisions.

Notes from the Trauma Conference: Emotional Awareness

I have recently returned from Bessel van der Kolk and the Trauma Center at JRI’s ( annual conference ( It is my second year attending, and again I found it a fascinating and rewarding experience. The overall theme was trauma and the body, with a heavy emphasis on understanding the brain, the roles of various parts, and the impact of trauma. The JRI group are becoming more and more convinced of the importance of including body work in therapy for traumatized patients, and have recently received an NIMH grant to study the use of yoga in trauma treatment. They also recommend EMDR, dance, drama, art and other non-verbal therapies.

One concept stressed by many of the speakers that seemed important to our work is the concept of emotional self-awareness. Regulation of emotions is not possible unless you are aware of emotions.

Trauma causes people to become disconnected from their bodies and numb to their emotions. People keep active, display symptoms, engage in risky behavior, all in the service of not feeling what they are feeling, as they only associate feelings with intolerable pain.

Lane and Schwartz have identified stages of emotional awareness- awareness of:
Physical sensations
Action tendencies
Single emotions
Blends of emotions
Complex emotions

The higher stages recruit higher levels of the brain.

Emotions are felt as bodily sensations. The vagus nerve carries information from the body to the brain, however it is two-way. Therefore you can change how you feel by moving your body. Thus the efficacy of dance and rhythmic movement in helping change our emotions.

How do we become emotionally aware? Through a securely attached relationship with other human beings. Through attuned interactions in which the other person names emotions, recognizes them, expresses them in sync but with a little twist. Through small ruptures in attachment which are soon mended. Through caring others connecting our bodily sensations with the names of emotions and with the suggested action steps. Through people validating our emotions, exploring them, paying attention to them. Through valued others taking our emotions- and theirs- into account when making decisions. Through these complex and oft-repeated processes, we develop the ability to notice our feelings, to name them, to reflect on them, to use our higher brain (pre-frontal cortex) to inhibit our immediate emotional responses when necessary, and to take effective action.

We do incorporate many of these processes in treatment. Most therapists have a feelings chart, for example. But I think we could be much more deliberate and conscious about it. If we understand that one of the basic problems our clients face is the lack of emotional self awareness, we can purposefully incorporate this training into all aspects of our interactions. This can be done through naming emotions we observe, validating, asking for the bodily sensation, teaching Wise Mind (DBT concept), feelings charts and thermometers, and many other ways. Treatment teams could discuss clients in terms of this skill (the first step in the Risking Connection® feelings management skill) and make plans as to specific actions to take for each client.

We cannot teach emotional regulation until the clients can recognize an emotion when they see one.

Friday, June 13, 2008

Feeling Sorry For Her

A central assumption of our approach is that symptoms are adaptations- these kids are doing these crazy things for a reason. The problem behavior is a solution for the child. It is accomplishing something, getting the child’s needs met, in the short term, even though there are longer term negative consequences.

In order to practice this thinking, we give training participants a scenario:

Alexandra is a 14-year-old-girl who has a history of trauma and multiple separations from her mother. She has a history of self-injury and suicidality. She has been placed in this home for six months, and her foster mother has noticed that in the last month she’s been opening up to them in a new way that she has not before. Last week, it was announced that one of the other kids in the home was going to be leaving to go to a group home. This morning her mother observed that she was wearing long sleeves even though it was 90 degrees out. When her mother asked why, she told her to "f__off." She eventually revealed that she had been scratching herself with a paperclip.

We ask people to consider:
What are 2 or 3 hypotheses about how Alexandra’s self injury might be adaptive for Alexandra? What problem (s) might it solve, how might it help in the moment, even though it leads to negative consequences in the longer term?

And then to:
Choose one hypothesis. If this hypothesis was true, what are possible ways the foster mother might help Alexandra to solve that same problem with fewer negative consequences?

In a recent training that I did, people responded (as they often do) "she is doing it for attention". So why does Alexandra need attention? (She may be scared of opening up to the foster mom and then possibly losing her as the other child is going to.) Why doesn’t she ask directly for what she needs, or express her fear directly? (She doesn’t know how, she can’t be that vulnerable especially now when the relationship feels tenuous.)

One participant added: "she just wants the foster mother to feel sorry for her."

Do you agree that the phrase "feel sorry for her" connotes an illegitimate need, something that she shouldn’t want or need? Doesn’t it imply that she is trying to get some kind of unwarranted or excessive response?

Also, this phrase implies that we should resist feeling sorry for her- and by extension resist coddling her, fussing over her, or being sympathetic. Yet some cuddling and caring may be just what Alexandra needs.

Of course, there is every reason to feel sorry for Alexandra, or to feel sorry about what has happened to her. She has had a very difficult life, and terrible things have occurred that were not her fault. Her basic needs have not been met. She has not been safe. These experiences have changed the basic biology of her brain. Her life has not included much relaxation and fun. She has not been taught that she is worthwhile, special, and that people love her. She has not been shown the feelings management skills she needs for life.

Yet when we say "she wants us to feel sorry for her" we are forgetting that Alexandra is doing the best she can, that her fears and needs are legitimate to her, and that she is using the only means she has to meet them. She will only be able to change when she feels safety within a committed relationship, and when she gradually learns new skills.

Although using the phrase "feeling sorry for her" seems like a small thing, it is important to stop and challenge ourselves. This phrase can lead to an entire attitude that will infect our response to the child and interfere with her healing.

Sunday, June 01, 2008

Was He In Control?

Luke and Jason ran away last night. But they didn’t go far- they broke into the school and destroyed the kitchen. They broke several appliances, wrote mean things on the walls, and dirtied the place.

As staff discussed this incident one question that came up was: were the boys in control of their actions?

This often seems to be a key question for staff. It has many ramifications as to how they feel the incident should be handled. Although people do not articulate their assumptions, I think that they are:

The more we decide that a kid is "in control" the more we feel we should respond with punishment.

The more we think the kid is not in control, the more we can be understanding and respond in a more "helping" or "treatment" way.

Our sense of how "in control" they are is based on factors like whether they generally are psychotic, whether they appear emotionally dysregulated, whether the act is an impulse or planned, etc.

I think this is a false dichotomy.

First of all, I think we can all identify acts which require planning, but in which the person is not in control- compulsive sexual or other addictive behavior for example.

There is also a moral component here. The "in control" side includes elements of being deliberate, doing this on purpose to hurt others, and slides rapidly into labeling the boy a bad kid.

But most importantly- I don’t think that saying a child is "in control" answers any questions or even changes the questions.

Let’s postulate that those two boys had total control of their actions, planned this event for weeks (although in fact they didn’t), and were not apparently dysregulated at any time.

The question still remains: why?

With all that control, why did they choose this particular action? How was it adaptive to them? What needs was it meeting? What message was it expressing? What kept them from meeting those needs or expressing that message in a more positive way?
I would still assume that their attachment disruptions, lack of consistent positive parenting and early trauma is relevant to the needs they are meeting and to their inability to meet those needs in other ways.

And, I would assert that the response does not change. What would make a child be less likely to consider trashing a kitchen? After all, most kids don’t. Why not?

I think that this behavior would be less likely if the child:

Felt loved
Cared about some people and did not want to disappoint them
Knew that others expected the best from him
Expected that adults would most often meet his needs
Felt hopeful
Cared about the people who would suffer from his actions
Even knew that people would suffer
Had a sense of a future, of goals and a trajectory towards them that seemed possible
Had some skills to manage sad, disappointed, scared and hopeless feelings
Felt that he was a good person who doesn’t do things like this
Had a sense of belonging to a community and being responsible to that community

How can we increase these things? Mostly in day-to-day life, before and after the behavior, through all our treatment strategies which honor and build relationships, help children internalize relationships, increase self worth, and create feelings management skills.

But in response to the behavior? Will punishment increase or decrease these feelings and life assumptions?

Restorative tasks, making amends, working with people to fix the damage, and looking at what was going on will increase the above protective attitudes.

And the question of whether or not the boys were in control will fade into insignificance.

Sunday, April 27, 2008

The Brain- Short Version

Brains are formed through interactions with others

The thinking part of the brain is formed through caretakers taking care of baby- organizing, meeting needs, creating a predictable life.

If these things aren’t done reliably, the thinking brain will be under developed, and the child will be more impulsive, less planful, and may have a learning disorder.

Through early attachment experiences the brain develops a template or pattern for how human relationships are going to be throughout life.

Events with a strong emotion attached are most strongly remembered.

The brain and body automatically respond to danger- alertness, focused attention, increased muscle tone, decreased ability to think.

If action is not possible body freezes, withdraws blood from limbs, releases opiods to prepare for injury.

Too much stress- the brain can get stuck in these modes.

When the brain is in survival mode, thinking interventions do not work. Thinking is shut down and not available.

Early positive attachment develops the ability to calm down, self sooth, and regulate response to danger. Inconsistent attachment leaves the person with less of these abilities. They are stuck in survival mode and their thinking brain is not kicking in to send safety messages or to realistically evaluate safety.

The brain can change and grow throughout life. It changes through use and attachments, especially through repetitive, rhythmic experiences.

What We Need to Know About the Brain

In order to offer the most complete healing possible to children with histories of trauma and attachment disruptions, we have to understand something about the brain, how it develops and how trauma effects that development.

Human beings develop through relationships. We have mirror cells in our brains that fire when OTHERS express emotions, creating similar emotions in us. This happens countless times between a mother and a baby. It is the basis of empathy. Human society is built on this interactivity, because relationships necessary for survival.

Infants are born dependent. Luckily, parenting is pleasureful. The infant associates touch with pleasure. She gets her needs met, gets relief from distress, which calms anxiety. Her brain develops a sensory pattern of human interaction associated with pleasure. A template is established. Thus our early experiences contribute the template: our definition of "normal".

Attachment and the Brain
Early attachment relationships sculpt the brain’s survival circuits and make them more or less able to regulate emotion when faced with stress. Secure attachment facilitates thoughtful processing, counters the survival-in-the-moment reactions to stress. We have evidence that loving relationships can help change the brain, regulate the amygdala and the survival-in-moment circuits. The nature of the child’s early attachment is etched in lower levels of the brain. Children respond from that place without awareness.
Although attachment is necessary for safety, humans are also our most dangerous predators. Therefore we are very sensitive to the moods, expressions, and gestures of others. Our stress responses very closely tied to systems that read and respond to social cues.

Principles of Neurodevelopment

The brain grows most rapidly from birth to age four. At 4, its 90 per cent of adult size.
Implication: The greatest opportunity to grow and influence the brain is with the developing child. This period also presents the greatest vulnerability to the destructive impact of threat, neglect, and trauma.

The brain develops from brainstem up to the more complex parts of brain. The primitive parts of brain are the most difficult to change (least plastic).
Implication: Change is possible, but is slow with early trauma. To change, we need repetition, repetition, repetition.

The brain neurons grow in a "use dependent" fashion. The brain sets down a "template" for how life is supposed to be and go. The brain and reacts particularly to any thing out side that template, anything new. To change a muscle through exercise, we must have moderate, repeated, patterned extra stress. Then the brain decides, oh, we are going to be doing this now, better develop some new muscle cells. It is the same with brain cells. The stress is a signal to the cortex- something new is going on here. Moderate stress is good for the brain and the body, it develops our ability to handle stress. However, imagine going to the gym for the first time and trying to lift 200 pounds. It would not build muscle or teach the body anything. You would hurt yourself. This is similar to the stress children receive from trauma.
Implication: Interventions need to be consistent, predictable, patterned, and FREQUENT. Kids with attachment problems need many, many positive nurturing interactions. The number of repetitions needed for change is so high that most adults become discouraged. We have unrealistic expectations about pace of change.

Trauma-related symptoms originate in brainstem and lower parts of the brain.
Implication: When brainstem-driven, the brain processes and functions differently (Perry, 2006). The child’s responses are mostly unconscious, old brain fear responses (not intentional). Cognitive, rational, highly verbal interventions generally don’t work. Conventional therapies will fail if the brainstem poorly regulated. Therapeutic interventions must influence the brainstem and lower parts of the brain.

The brain develops in sequential fashion from brainstem up to cortex. If a sensitive period in brain development is missed, may be hard or impossible to re-create later. For example, if a kitten’s eye is kept closed during a certain period of sight development, may never develop sight even if opened later. So traumas at different ages have differing effects depending on what the brain was working on at the time.
Implications: CBT, insight-oriented will fail if the brainstem is poorly regulated. Once the brainstem is regulated, the child can benefit from more traditional therapies. Just like healthy development, healing from trauma starts from the bottom up. The sequence of interventions matters. We must match interventions to child’s level of neurodevelopment. Examples of interventions to regulate brainstem are music and movement activities like dancing and drumming; EMDR; patterned massage; repetitive, consistent positive interpersonal interactions.

In order to develop, we need repetitive, patterned interactions. Rhythm is very important to human functioning. We need reliable internal cycles to sleep and wake, when to eat, heart rate, etc. The brain changes through repetitive, patterned activity. Rocking is a human comfort response, as exemplified by a person in crisis rocking back and forth or a chair.
Implications: Healing is facilitated by repetitive, rhythmic activities such as drumming, dance and music. Regular structured predictable schedules are also important.

Emotion is the central organizing mechanism of the brain. Humans are hard-wired to pay attention to sex and danger. Advertisers know this!

Although many things are learned through repetition, it is critical to our survival to learn quickly those things that led to negative experiences. We often must remember after ONE bad experience. We don’t have the luxury of taking many repetitions to learn that a snake can be poisonous. Intense negative emotions burn events in to memory.

Humans are programmed to identify danger. Some hard-wired danger cues are: darkness, sudden loud noises, and being alone

Humans are also programmed that comfort and protection is found in: closeness, rocking, and stroking. Note that many of these are found in sexual activity, hence the difficulty at times in differentiating comfort and sexuality.

Trauma sensitizes the nervous system. Extreme, repeated and intermittent stressors are the most likely to result in sensitization (although single stressors may also). When the nervous system is sensitized, relatively small triggers in the present cause extreme survival-in-moment responses. Children "make mountains out of molehills".

Extreme stress without control is the most harmful. This was shown in rat experiments- some rats were shocked when they pressed a lever (had control); some were shocked when the other rat pressed a lever (no control). The experiment found that animals who do have control developed strengths, those who did not developed ulcers, lose weight, had compromised immune systems, become more sensitized to shock, and couldn’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).

We now know a great deal about the functions of different parts of the brain.
Our brain has three tiers: the Cerebral Cortex (Human Brain); the Limbic System/Diencephalon (Mammalian Brain or Midbrain); and the Brain Stem and Cerebellum (Reptilian Brain). We can refer to them as the Old Brain vs. New Brain. The old brain is the lower order systems, which are responsible for survival. They develop first, and are located in the more primitive parts of brain like the brain stem. The new brain is the higher order systems. It develops last, and gives us our flexible adaptive capacities. It is located in the cerebral cortex.

The pre-frontal cortex is created by a caretaker doing cortex-functions (care taking, safety, meeting needs, figuring out problems). If no one is doing these things, the cortex will be under-developed. The cortex is responsible for complex thinking, analyzing, and using cognition to control emotional impulses.

The amygdala screens for threats, adds emotional valence to events, and activates the danger response when an event is a change from what is expected and appears threatening. It compares in-coming data with laid down patterns- asking one question- does this data suggest danger? It activates an immediate response while sending the information to the higher brain for further refinement. It makes the body become more alert and look for more information. It gets bigger when it is used more.

The hippocampus is involved with retrieval of verbal and emotional memory. It gets smaller as amygdala gets bigger.

The cerebellum is responsible for balance and rhythm.

Low Road vs. High Road of Emotional Processing (Le Doux, 1998, 2002)

"Traumatic stress is about "survival in the moment". The brain processes stimuli that are potentially life threatening and translates this perception into life sustaining responses." (Saxe 2006)

The brain receives sensory input into the sensory thalamus. The brain starts processing the stimulus in two ways, which we can refer to as the "ow road" and the "high road". The low road utilizes the more primitive, older brain; the high road uses the more complex newer brain.

The Low Road

Stimulus/Trigger sent to Sensory Thalamus then to Amygdala yields Response

The Advantages of the Low Road:
It prepares body for an emergency response, and very quickly gives the organism info about danger. It is reflexive, unconscious, and does not contain contextual info. It sacrifices details for speed

Disadvantages of the Low Road:
It responds rapidly to incomplete bits of information. There is no context to the information. It facilitates memory storage in an incomplete way. This memory may produce flashbacks, which are "flashes of emotionally-laden memory." It leads to misperception of triggers and to overreaction, making mountains out of mole hills.

The High Road

Stimulus/Trigger to Sensory Thalamus to Amygdala and to Prefrontal Cortex to the Medial Temporal Memory System (Hippocampus) to the Sensory Cortex leads to a Response

A "Cognitive Wedge" is inserted between stimulus and response

Advantages of the High Road:
This type of processing leads to the most adaptive response in the moment. The high road pathway can maintain the low road survival-in-moment response if needed. With the help of our cortex (higher brain), we respond at a level appropriate to the level of danger. Determining the level of safety or danger via high road is also often unconscious and rapid. The cortex adds a context to the information, and (if appropriate) sends safety signals to the amygdala. The cortex facilitates memory storage in continuous complete way.

Parts of Cerebral Cortex Used in High Road Processing:
The sensory cortex retrieves and engages information from long term memories that contain experiences with similar stimuli (accurate perception). The medial temporal memory system (which includes the hippocampus) places the stimulus in the proper time and context. The prefrontal cortex puts information into the individual’s direct awareness for considered action to occur. The person inserts a "wedge of cognition" between the stimulus and the response.

What the brain does in danger (hyper arousal):

  1. Focuses alertness
  2. Shuts down cortex chatter
  3. Becomes more vigilant and more concrete
  4. Heart rate increases- blood sent to limbs
  5. Focuses on social cues- is help available?
  6. Muscle tone increases
  7. Hunger/digestion disregarded

When unable to fight or flee, a person is left only with the option to freeze. If action does not seem possible, the brain sends a "freeze" response to the body. This response too is self-protective. This response is related to later dissociative responses. It is common in infants and young children. It is more common in females than males. It is driven by the most primitive parts of the old brain. In the freeze response, the brain prepares the body for injury. This response is also graded and occurs on a continuum. The person has a sense that time slows and what’s happening isn’t real.

In the freeze response (dissociation) the person:

  1. Curls up
  2. Makes her self as small as possible
  3. Prepares for injury
  4. Blood is shunted away from limbs
  5. Heart rate slows to reduce blood loss from wounds
  6. Body is flooded with opioids ("brain’s heroin") to protect against pain which produces a feeling of calm and a sense of distance from what is happening (Some times this can help with functioning, such as a soldier functioning without feeling)

Fight/Flight AND Freeze
In both responses, the person has their foot on the gas and the brake at the same time.

Some Clinical Implications
Fight/flight (hyperarousal) often looks like AD/HD, hyperactivity, oppositional defiant disorder. Freeze (dissociation) look like inattention, spaced out, defiance to adults because child literally cannot respond.
Both hyper arousal and dissociation help people survive trauma. Both can be harmful if prolonged and habituated.
Flash backs and re-enactments may be seen as an attempt to have small doses of trauma within one’s control to develop habituation or tolerance. However, if trauma is too much it cannot be mastered this way.

Our brains have two halves. The right hemisphere handles the gestalt, the big picture, and initial impressions. It is responsible for negative emotions such as anger and anxiety. The left hemisphere takes care of details and analysis. It holds positive emotions. Generally the left hemisphere is larger; in children with trauma histories the right is larger. The corpus collosum connects the two, and it is smaller in trauma victims. Therefore, they experience less integration and generalization in learning. For example, a child works on methods for not fighting with his room mate, but he doesn’t think to use these methods to avoid fighting with another person.
Humans are hard-wired to seek attachment, especially when danger is present. The primary goal of attachment for humans is safety. However, we cannot forget that one method of engagement is aggression and provocation.

If there are persistent stressors in the early years of life, neurons do not grow and connect in prefrontal cortex, less inhibition is available.

Less developed pre-frontal cortex leads to:

  1. Short attention span
  2. Memory problems
  3. Distractibility
  4. Impulse control difficulty
  5. Social and test anxiety
  6. Poor judgment
  7. Hyperactivity
  8. Lying
  9. Problems reading social cues
  10. Poor organization and time management

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.

The brain develops a template that danger is normal. This 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 to this brain.

Also, researchers have identified a kindling effect in which a trauma survivor over-screens for danger, over identifies threats. This interferes with reading social cues, distorts his perception of others.

People with "good enough" childhoods have arousal/relaxation cycles and know ways to calm down. Trauma survivors start at a higher base-line arousal, have rapid spikes, and rely on the external environment to help them calm down. This leads them to have to do something to draw in external control (i.e. cutting).

Trauma victims have 40% higher prevalence of learning disabilities especially language: auditory processing and expressive language (Receptive/expressive language disorder). This may be due to under-development of both the cortex and the corpus collosum.

Trauma Damages the Ability to See into the Future
The ability to calculate the potential risks and benefits of an action is a very important human function, and to children growing up in abusive households it is essential and life saving. However, due to the unpredictable nature of events, the over-exposure to danger, and the struggle to survive, this ability will be compromised. The child may both over and under estimate danger, and also may over and underestimate potential pleasure. They may not be able to see any future for themselves.

Healing From Trauma
Moving to high-road processing also depends on environmental interventions to help remove triggers (when possible) and reduce risk of continued exposure to trauma. In addition, the environment must provide the child many "signals of care", which work to counteract the "survival-in-the-moment" crisis mentality.

Selected Resources: Trauma and the Brain
Perry, B. and Szalavitz (2006). The Boy Who Was Raised As a Dog. New York: Basic Books.
Perry, B. (2006). “Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized Children.” In Webb, N.B. Working With Traumatized Youth in Child Welfare. New York: Guilford.
Saxe, G.N., Ellis, H.B., and Kaplow, J.B. (2007). Collaborative Treatment of Traumatized Children and Teens. New York: Guilford.
Vanderkolk, B.A. (1996). “The Body Keeps the Score: Approaches to the Psychobiology of Posttraumatic Stress Disorder.” In Vanderkolk et. al. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society.