Sunday, February 15, 2009


Come and see our poster at the CWLA Annual conference poster session in Washington on February 24th! In addition to our beautiful poster which illustrates the change to trauma-informed care and the results, a client, Ashley will be joining us and sharing her viewpoint about this change. We would love to see you!

Making Connections by Having Problems

We don’t know what to do for Katrina! She keeps cutting herself, putting cords around her neck to hang herself, and recently she has begun using an eraser to create serious burns in her skin. She has given up running away and having sex with strangers, but she keeps up the unremitting self harm. Staff can work with her for hours, and she seems better, but an hour after they leave, she cuts and they feel the whole effort was useless. We are getting so exhausted and depleted. Please help!

Discussion with Katrina, her mother and her treatment team made clear how three facets of the effects of trauma interact to create dilemmas both for the child and the treatment team.

Katrina had a history, as so many of our children do, of repeated moves, changes of caretakers, and of serious abuse in each new home. Following her adoption at age seven she had many treatment episodes such as hospitalizations, emergency shelters, in home interventions and finally residential treatment.

This history had left Katrina with the following three characteristics (as well as others):

A deep sense of shame and self hatred, resulting from blaming herself for all the abuse, the moves, the symptoms and failures she had experienced: Her self hatred combined with a lack of a sense of self- who was she really? She has a tendency to take on the personality of whomever she is with. This lack of self and deep self revulsion results in her conviction that no one could possibly just like her. It also produces the conviction that she does not deserve anything good, or to have any fun, which results in sabotaging whenever something good does happen.

A lack of inner connection to others: for Katrina, when a person is not physically present it is as though they never existed. She cannot keep a representation of them in her mind to encourage her and help her, because she has not had the relationship stability in her life that would be necessary to develop that ability. So when a staff moves away from helping her it is although they disappear completely.

No self soothing skills: Katrina had not been taught how to manage life’s ups and downs. Her models had used drugs and violence to manage emotions. She has not been taught to recognize or name her own emotions, or what to do when she feels them. Through DBT Katrina is learning some of those skills, and she can name and describe them when she is calm. However, due to her over-active nervous system, when something goes wrong she becomes so over whelmed with emotions that her skills desert her.

Like all of us, Katrina needs connection, attention and support. However, both in her homes and in the many treatment programs she has experienced, it has been hard to engage adults by doing well. Early on Katrina learned that the easiest way to draw adult connection was through problems. Although her caretakers were absorbed in their own life pain, when Katrina was suicidal they had to pay attention to her. It is almost as thought she becomes addicted to having problems.

And this becomes harder and harder to change.

Start with Katrina’s conviction that no one would want to be with her just for herself.

Then, something happens, and Katrina becomes upset. Her need for help is intense and unbearable. Life feels hopeless and frightening, and she blames herself. So she does something to hurt or erase herself, which has the added benefit of bringing in the resources she needs.

In an adult’s calming presence, Katrina can some times gradually calm down. And when she does, what happens? The adult leaves. For Katrina, they disappear completely, never to return.

And Katrina does not know how to re-engage them in a positive way. She does not even have any idea this is possible.

So- she tumbles into another problem.

The intervention strategy that will help to change this is to give Katrina a lot of attention whenever she is doing well, and to be less emotional, less intense and less involved when she is doing self-destructive things. But this turns out to be quite difficult. One reason is that Katrina is rarely doing well. When ever she does start having fun or succeeding, she stops herself, because this is not her and she doesn’t deserve happiness. However, staff can still catch the moments in which she is more relaxed or more normal and engage with her then.

And this takes incredible stamina, planning and thoughtfulness of the staff, and demands much reinforcement and praise from those supporting the staff. Because if a child this needy is NOT calling your name, is doing well and enjoying life, who would want to approach her? Better to stay back and enjoy the momentary respite. And yet, this perpetuates the pattern- that she only gets attention and caring by having problems. Staff will have to work hard for quite a while before this pattern changes- but what a gift they will give Katrina! The gift is the repeated experience (more powerful than any words) that she is a normal girl who can be competent and can receive attention, caring and connection through achievement and every day life activities. This is what she needs to experience in order to move towards a life worth living.






Sunday, February 01, 2009

Brain Research and What To Do: Program Questions

I have recently been giving a presentation on brain research and how it can guide us to what to do in our treatment programs. I will be giving this presentation with my colleague Steve Brown at the Healing the Generations conference at Foxwoods in CT. this week. The following is a summary of some of the main points with questions for programs to consider. 

Connections between parts of the brain are necessary for emotional stability and thoughtful decision making. Brains grow and connections are created within relationships that are attuned and emotionally significant.

            What actions between people in our environments create attunement?

            What happens that strengthens relationships and adds to their significance?

            How can we increase this? 

Feelings of danger focus a person only on danger and safety. A person cannot form relationships unless they feel safe.

            What are the signals of physical and psychological danger in our treatment programs?

            What are the signals of safety?

            How can we decrease danger and increase safety?

Shame is a major barrier to relationships. The shame-based child is sure that any one who gets to know his horrible inner core will reject him, and hence relationships will only lead to pain. Shame leads to attack, to move away from others. Taking responsibility for ones actions is not possible when to do so means experiencing ones utter worthlessness.

            What do we do in our programs that adds to shame?

            What can we do to decrease shame?

            How can we talk about problems in non-shaming ways?

            The antidote to shame is sharing…To tell the secrets- what is shareable is bearable. 

Traumatic and neglectful experiences are characterized by the impossibility of effective action. There is nothing the child can do to change the situation and make it better. The child gives up on the possibility of effective action.

            What do we do that discourages or prohibits effective action?

            How can we give the child practice in effective action, to heal relationships, correct mistakes, and accomplish goals. 

Feelings management skills are the key to managing life’s ups and downs. They are learned in consistent, attuned care taking relationships which our children did not have.

            What do we do that discourages feeling awareness and communication?

            How can we actively teach and encourage the use of feelings management skills? 

When something bad happens and a child has no reliable attachments internally or externally to turn to for help; when a child is already hyper aroused and feeling in danger; when a child feels worthless, hopeless and scared; and when a child does not know how to recognize or sooth their feelings; a child is left with action. The action makes them feel better in the moment even if it has long term negative consequences. These actions that we call symptoms are adaptive for the child.

            What things that we do make this pattern worse, by leaving the child with less connection, more shame or more fear?

Which of our responses help break this cycle through understanding the symptom and helping the child the skills she needs? 

To do this difficult work and remain hopeful and healthy we need to take care of each other and ourselves.

            What do we do in our programs that decreases the opportunity and encouragement for self care?

            What can we do to take good care of each other and ourselves?