Monday, October 26, 2009

PLEASE Participate

Please please please participate in our discussion of how to react to the boy with the cruel pictures. Remember to first answer the question: how is this behavior adaptive for Marcus? What is it accomplishing for him- what problem does it solve? Then give your opinion about what the best treatment approach is that will help Marcus change and heal. I REALLY want the opinions of everyone who is reading this. Just click "post a comment". Thank you.

Saturday, October 24, 2009

Marcus and the Scary Pictures-What Would Your Team Do?

Marcus came into residential after having been ejected from a previous residential. He is adopted, and his current adoption is actually his second as he was removed from his first home because of abuse. He is small for his age and a bit strange looking. In the month he has been here he has not made any friends, in fact the other kids seem to pick on him. Several times he has said inappropriate sexual things to female clients and to female staff, which does not increase his popularity. Generally he is the kid who is always doing what you just told him not to do, then accusing you of only talking to him when he does something wrong. Staff is finding it hard to engage with Marcus.

However recently a more upsetting issue has emerged. Tony and Jarell, two of the other boys, and Amber, one of the girls, separately came to staff to complain that Marcus has been showing them some very disturbing pictures that he drew. A search of his room in fact produced many of these pictures, which are very graphic (and skillfully drawn) renditions of men torturing naked women, complete with blood and gore. Amber said to her staff that she thinks Marcus is going to grow up to be a murderer and the staff who have seen the pictures tend to be worried about the same thing.

At first when this was discovered, staff gave Marcus a sketch book and said he could draw the pictures in there, but not show them to anyone. However yesterday his roommate Tim told staff that Marcus had been showing him his latest creation. It is one of the bloodiest yet. Lisa, Marcus’s therapist, finds that the pictures make her very uneasy and she does not know what to do to help Marcus. In fact lately she has been avoiding meeting with him. In the staff meeting the most popular suggestion is that Marcus be forbidden any access to paper and writing or drawing materials in an attempt to prevent him from making these drawings.

Do you think this is the best approach? Why or why not?

How do you understand Marcus’ behavior? In what way are these pictures adaptive for him- what positive results is he getting from drawing and sharing them?

What does Marcus need? What approach would you recommend?

What should be done to support Lisa and the staff in helping Marcus to heal?

Share your answers by clicking on "post a comment" below. I strongly encourage you to participate in this discussion. Let’s generate a robust list of possible answers. I will write more about this in my next post.

Sunday, October 18, 2009

The Persistence of Punishment

Why is it that no matter how much we know, when we are concerned about a behavior our first thought about how to change it seems to always be punishment? Is it our Puritan heritage? Our religious backgrounds that emphasize Heaven and Hell? Is it that our parents used to ground us when we did something bad? Maybe our entire culture reinforces the idea that punishment solves problems. After all, we do keep building all these jails.

If you are interested in learning more about exactly how to use both reinforcement and punishment, I recommend a book called Don't Shoot the Dog! The New Art of Teaching and Training by Karen Pryor Ringpress Books Ltd; 3rd edition (March 2002). This was recommended to us in our DBT intensive training. The author states that punishment is not as powerful as reinforcement, and must be used precisely- for example, it must happen immediately after the undesirable behavior.

Let’s go back to our own upbringings. I certainly did not like it when my parents grounded me for sneaking out to see my boyfriend. However, much MUCH more difficult was when they sat me down for a talk that began: "Young lady, your mother and I are deeply disappointed in you." In other words, it was the relationship. That they loved me, and I had let them down. That is what I really wanted to avoid.

In out programs we could be much more deliberate about relational rewards and punishments, making sure to convey both our delight and our sadness about the events that take place.

But let’s remember that no matter how well done, rewards and punishments affect motivation. They make some one want to do something more, or want to stop doing it to avoid the punishment.

But if you do not know how to do anything different, it does not matter how much you want to. You need to learn the skills.

In my training I ask participants to think of a time they have tried to do something they really wanted to do, but they were not able to. The examples have included playing tennis, rollerblading, knitting, learning a language. People readily see that more punishment for not playing tennis well would not have helped- in fact it might have made the situation worse, and/or contributed to the learner giving up. If someone wants to learn to play tennis, they need lessons from a kind and patient teacher, who will teach them the many small skills that go into the game.

In some ways our punishments render our children LESS likely to achieve better behavior. They often contribute to shame and hopelessness, thus increasing the intolerable negative emotions that currently overwhelm the child’s ability to think. They accentuate passivity- I have messed up and there is nothing I can do about it. They undermine self worth.

But if not punishments, then what? We often turn to punishment when we ourselves are feeling overwhelmed and helpless.

Increase the child’s sense of safety
Build strong relationships that the child can trust so the child can ask for help
Help the child remember that people care about him even when they are not present
Teach the skills of emotion management
Increase the child’s self worth
Help the child learn to sooth her over-active danger system
Give the child opportunities for effective action and for fixing problems
Give the child opportunities to play and have fun
Create a strong community
Help the child create a positive plan for moving forward in life- create hope

These things are harder than assigning two days of room time, but they are more meaningful and they create lasting change.

Remember- children do well if they can. And remember also- children act better when they feel better.

Please let us know your thoughts by clicking on "post a comment" below and adding a comment.

Sunday, October 11, 2009

Exercise about Taking Responsibility

I developed this training exercise to teach people how shame interferes with taking responsibility, and how a simple conversation between a Callie care worker and a client can go wrong.

I will ask for two volunteers, one reads part of Latasha, one of Callie
Latasha- Staff
Callie- Child


Callie is sitting playing electronic game, Latasha walks into room

Latasha: Thoughts: Oh, there is Callie. I heard she had a hard time in school today; I’d better talk to her to see what happened.

Callie: Thoughts: Oh, here comes Latasha. I know she heard I screwed up AGAIN in school today. I know she’s mad at me. I hope she doesn’t see me. I’d better hide.

Latasha: Thoughts: I am really getting discouraged, Callie doesn’t seem to be changing, I wonder what I am doing wrong.
Says: Hi Callie. Let’s talk about what happened in school today. Can you tell me what went on?

Callie: Thoughts: I knew it, she hates me now, I never should have started to like her, I bet they are getting ready to kick me out; nothing is ever going to work out in my life.
Says: It’s those stupid teachers. They are no good. I want to get out of this dumb place and go to a place with a real school.

Latasha: Thoughts: This kid will never take responsibility for her own actions. If she never learns to accept what she has done she is going to end up in jail. We have to make her understand that her actions are her own choice. Maybe she is right, maybe she doesn’t belong here. We do not seem to know what to do to help her.
Says: But Callie you must have done something to get yourself into a fight. It can’t be all the teacher’s fault.

Callie: Thoughts: See I knew it she blames me for the whole thing. And she is right I will never be smart enough to learn math, I am such a loser, and when Kristi made fun of me I just could not stand it. And now (name) hates me too I have to get out of this place!!!
Says: I hate all you people and if you get any nearer to me I am going to hit you so leave me alone!!!!

Latasha: Thoughts: She is really just impossible I cannot have a simple conversation with her. She really has to learn that she cannot talk to me that way.
Says: That’s threatening. You have to go to your room now if you are going to be so disrespectful.


Callie is sitting playing electronic game, Latasha walks into room

Latasha: Thoughts: Oh, there is Callie. I heard she had a hard time in school today; I’d better talk to her to see what happened.

Callie: Thoughts: Oh, here comes Latasha. I know she heard I screwed up AGAIN in school today. I know she’s mad at me. I hope she doesn’t see me. I’d better hide.

Latasha: Thoughts: I know Callie has so much trouble in school, especially in math. We have been working on how to ask for help when she is confused but it is so hard for her. And I know that Kristi, the girl she had a fight with, can be so mean and pick on people’s weaknesses.
Says: Hi Callie. How are you? I heard that this weekend you made that beautiful bulletin board over there, it really adds color to the unit.

Callie: Thoughts: I know she is going to talk about school and she is mad at me, but at least she noticed the bulletin board I made. Might as well get it over with.
Says: Yeah but today really sucked.

Latasha: Thoughts: I’m glad she brought up what happened. I know this kind of discussion is really hard for her because she always feels so hopeless.
Says: Yeah, I heard you had a problem with Kristi in math, that staying calm thing and asking for help thing didn’t work out as well as we hoped today, but I also heard you calmed down and did well in art afterwards.

Callie: Thoughts: Well, maybe she doesn’t hate me, but I know I screwed up big time. I wonder if they are going to kick me out of here now? I never should have trusted these people.
Says: So I suppose I’m kicked out now right and that is fine with me because I hate this place anyway and this is a stupid school that doesn’t know how to teach kids.

Latasha: Thoughts: Is that what she has been afraid of all day? It’s even more amazing she was able to calm down. Maybe she is making progress.
Says: Oh no Callie, we are not kicking you out! Far from it! We see the progress you are making. You and I just have to figure out what went wrong today and how we can come up with some better ideas for next time.

Callie: Thoughts: That’s surprising. Well, I would like to know how to keep that Kristi from aggravating me so much- I know she was glad she got me going.
Says: Well, you can start by getting rid of Kristi.

NOTE: The difference between the two versions is not just that the Latasha mentions some positives. It is that the Latasha is operating from a THEORY, and her understanding of the meaning behind Callie’s action’s enables her to approach this event differently.

As usual I am interested in your ideas and reactions. Just click "comments".

Sunday, October 04, 2009

Visit to CA LO

This past week I visited a remarkable place. It is called the Change Academy, Lake of the Ozarks, ( and is in Missouri. CA LO is a residential treatment school formed on attachment principles. It was born two years ago from the dreams and convictions of its founder, Ken Huey, and its Clinical Director Landon Kirk. Both were working in more traditional treatment settings and felt that while good work was going on, the treatment methods did not fit their understanding of attachment and healing. So they determined to open an attachment based treatment center located in the middle of the country.

CA LO treats approximately thirty five teenagers, divided evenly between boys and girls. The youth come from all areas of the country, even Alaska. CA LO employs many creative ways to engage the families in treatment. CA LO does not use levels, points, or traditional rewards and punishments. Instead, they have developed a treatment model that describes the tasks the children must complete in order to have a life worth living, and they train staff in the empathetic responses necessary to help the children grow through these tasks. When a student does something particularly harmful, he or she is assigned a chore done with a staff, which provides reconnection with an adult and making amends to the community.

A unique feature of CA LO is their canine program. They have around 25 Golden Retriever dogs, from puppies through adults. The dogs are assigned to individual children ho provide all their care. The dogs go every where with the kids, except to meals- to school, to recreation, one free time. Youths can complete an entire process including references, a home study, etc and be approved to adopt a dog. Then they take that dog home with them when they leave! Many places have some form of pet therapy, but this is the first time I have ever seen pets so thoroughly integrated into a treatment process. The learning and love the children gain from this process is obvious.

CA LO’s model has four components: Trust of Care, Trust of Control, Trust of Self, and Interdependence. Trust of Care teaches children that that the caregivers around them will take care of their physical needs. Food, shelter, health, wellness, and hygiene will be provided by trusted adults. Trust of Control involves believing that the adults in your life can be trusted to help and guide you. Youth who are successfully humble and vulnerable enough to accept Trust of Control allow the adults and peers in their life to teach them life lessons. When youth accept Trust of Control it provides opportunity for adults and peers to provide emotional dysregulation, coaching, guidance, and physical and emotional closeness. Trust of Self occurs when a youth moves towards independently practicing and implementing what has been modeled and taught. In Trust of Self the youth moves from doing the right thing because s/he is "supposed to" or because it has worked a few times in the past, to an inner change and commitment to live life differently. Interdependence is the ultimate goal for a youth, which means learning to live life with interdependence or the ability to maintain healthy, reciprocal relationships. Interdependence defines a successful student transition from a false and selfish independence, to experiencing the value and joy of interdependence and mutual relationships. Clearly, interdependence is neither independence nor dependence but is connected living. It is a person understanding that his/her actions affect others. Instead of just taking, the youth is now also giving. (The previous paragraph was adapted from the CA LO web site.) The youth do not move up and down between these tasks such as phases. It is understood that we all have to move around and re-work parts of each over and over again.

CA LO also includes a school with many imaginative programs, and a Therapeutic Recreation department that utilizes an indoor ropes course as well as many waterfront activities. The staff at CA LO is warm and caring. They have their struggles like everyone else. However, it is very exciting to see a program that is founded on the principles I believe in.
I particularly recommend their blog, which can be found at: