Organizational Structure

Using both our own experience here at Klingberg and the experience of other agencies we consult with, we have been thinking about what organizational structure best supports a trauma informed care treatment model. We have come to believe in a structure in which a clinically trained person (a coordinator) is in charge of a treatment unit, the clinicians are assigned to that unit, and both the child care staff and the clinicians report to the coordinator. There may be a child care supervisor who reports directly to the coordinator supervises the child care staff. There is a leadership group consisting of the coordinator, the therapists, and the child care managers that meets regularly to create and implement the treatment vision. 

Recently we were meeting with an agency which was trying to adapt this recommendation to its own needs and personnel. This discussion prompted me to think about why I think this structure is best; or what I am trying to achieve through this structure. 

The ideal treatment team to implement trauma informed care will have these characteristics: (remember- I said the ideal) 

1. Clinical thinking will be integrated into every moment of the work- through every daily activity, every assignment of consequences for actions, every structural decision. What is clinical thinking? It is looking beneath the outward behavior of the child and considering why. How does this behavior relate to his past experiences? What problem is he trying to solve? How is this behavior adaptive for him? What skills does he need in order to behave differently?
   
   
2. Relationships will be emphasized at every level. Staff will be encouraged to form strong relationships with the children, and be given time and mechanisms to do so. There will be close relationships among members of the treatment team, members from all disciplines- child care workers, teachers, therapists, psychiatrists, nurses… These relationships will hold the children in a safe net. They will also provide the humor, sustenance, honesty, caring and support necessary to provide the stamina to do this hard work.
   
   
3. The treatment environment will belong to all, and decisions will be made together by the team: should our bed times be later? How can we get the kids to brush their teeth? What should we do about this recent bunch of run-aways? How do we react to the kids attempts to split us? What should we do about anger developing between the first shift and the second shift? All these questions are everyone’s business and everyone’s responsibility.
   
   
4. The team will develop the ability to discuss hard questions with each other. They will be able to accept help when a team member tags them out. They will ask each other for help. They will be able to discuss whether a given response to a child was too harsh- or too lenient. They will feel safe enough to discuss their individual reactions to certain children- those they want to kill and those they want to adopt. They will talk about how the work is affecting them personally.
   
   
5. The model for the provision of therapy will not be through once-a-week appointments in the clinician’s office. Instead, the therapists will be responsive when the kids need them or are having a crisis. The therapist will be regularly present on the unit and in the kids’ lives, and will take advantage of opportunities when the kid is receptive to connecting. They may also have appointments in their offices for those kids who can accept this, but many discussions will be held on walks, or while playing a game, etc. The therapists will participate when they can in unit fun events like celebrations and some activities. Furthermore, information about the child will be shared within the team, and the child will know this. If the child wants the therapist to not share a certain item, the therapist can honor this while hoping the child will be ready to share with a few soon. Or the therapist can work with the child to create a version to share. For example, the child may not want the staff to know the details of past abuse she is currently discussing in therapy. But she could agree that the therapist tell the staff that she is currently exploring some hard stuff from her past, so they can be prepared to help her with any reactions she may have. This communicates to the child that the entire team is part of her treatment and is there for her.
   
   
6. Every one on the treatment team will have regular opportunities to talk and think about the work, they will not be expected to just be doing it every minute they are at work. This includes individual supervision (weekly for clinicians and full time child care workers), treatment teams, staff meetings, etc. In these forums they will have a chance to learn about the child, his back ground, his issues, his plans, and current happenings in his life. They will have a chance to explore their own reactions to the child. They will share things the have observed, learned, and found helpful. They will participate in setting the course of treatment, as all will understand that every minute of the day is part of the treatment.
   
   
7. The reporting structure will be clear and organized. Every staff member will know who his direct supervisor is, what his job description is, and what his own responsibility is and what the responsibility of other team members is. The direct supervisor is responsible for guiding the professional development of her supervisees- handle performance issues, providing needed training, encouraging and praising, and helping the staff member reach his own goals. 

I’m sure some of these suggestions are controversial- and altogether they may seem impossible. Yet even within all our constraints it is possible to get quite close to this ideal. 

What do you think? Please click on “comments” and tell me your opinion.