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.