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.