Tuesday, December 28, 2010

The Holiday Monster

Everyone who works in a congregate care program knows that there are more behavioral problems during the holidays. The escalation usually starts around Thanksgiving. We explain it to each other: “you know, it’s the holidays.” Yet have we taken the time to look at the components of the holiday experiences of our children, and from that understanding plan how to best support them during this time?

Memories are a central part of the holidays. For our children, both good and bad memories can hurt. If they have warm and caring memories, they feel sad and angry that they are no longer with their families. Many children also have painful holiday memories of fights, alcohol, abandonment and other types of pain. These become vivid as the holiday season approaches.

We are all surrounded with media images of what the holiday season is supposed to be. On Christmas or Hanukah you should be surrounded by loving family and friends, eating huge piles of delicious foods, and opening wonderful gifts that change your life forever. It’s not just that our children’s holidays do not fit this picture. It is the meaning they ascribe to that difference. What does it mean about me that I have no family, no feast, such a different holiday? There is an underlying message in the media that suggests that if you do not have these things you are a loser and it is somehow your own fault. Our kids are prone to thinking everything is their own fault anyway. So holidays are not just disappointing, they are one more source of shame: I must have done something terrible because I am the only child in America that is not having a happy day.

Then there are the gifts. Many places like ours are inundated with generous donations during the holiday season. We receive more presents than our children can possibly use, and we save some for distribution throughout the year. The kids get to ask for specific presents, and then get many more they do not choose. So they should be happy they are getting all this very nice stuff, right?

But what is this gift receiving experience like for our children? They know the gifts were not chosen by someone who knows and loves them. They know that people give gifts out of sorrow and caring about their plight. They may receive gifts from family; they may not. Often the donated gifts are more than their family could afford. What does all this feel like? It is wonderful that people donate gifts and it means a lot to the child that receives them. Yet, there is a hollowness, a disappointment, because the gifts are not the same as love.

A child may build up expectations around the holidays. Maybe my mother will finally come and visit. My father said he would send me a video game. Often, these are disappointed. Luckily, some children are able to spend time at home. In fact, we facilitate them going home if it is at all possible. Sometimes our wish that the child be at home for this one important day may even overcome our common sense. So a child who has not gone home in a long time does, and may or may not have a good visit. Either way, it evokes a lot of complex emotion.

Then there is the inevitable let-down. The holidays are over. Nothing has changed. My life is still the same and I still have no plans for my future.

So what can we do to help our kids with this holiday season? The most important thing is to validate, rather than try to cheer them up. It might be helpful to share that there are many people who do not have a picture perfect holiday. And to acknowledge that gifts from strangers feel different from gifts from families; and that it sucks to be stuck in a residential at Christmas or Hanukah. Give them an opportunity to talk about their memories of past holidays, good and bad. Talk about their feelings about their families, any contact they are going to have, anything they are going through. Don’t try to point out the good things- at least not at first.

Another thing to watch out for is over-stimulation. In our efforts to offer many treats to our kids we can ignore the fact that too much good stimulation can be overwhelming to them. Getting over tired reduces their already limited coping ability. Lots of noise and activity can wind them up and they do not know how to calm down. For some kids, a low key mellow celebration might be best. If there are parties, make sure to alternate them with down time, time to relax, talk about what you are feeling, and to engage in quiet activities with people you know. Remember that strangers are scary to some of our kids. It is easy to underestimate how stressful it may be for certain kids when members of the public attend agency events. Will my abuser be one of them?

Schedules and predicting what is going to happen, where it will be, who will be there, how long it will last is helpful. Also predict any stressors or issues that might come up. The child may dismiss what you say, but it can still be helpful when the event happens. Involve the child in planning for success. Is there a signal he can give you if he has had enough at a party? Will it help if he sits next to you, or brings his stuffed animal, or takes a nap before the party? Remember in doing this you are not only helping the child with this particular event, you are teaching him a method to anticipate and conquer stress which he can use throughout his life.

The adults caring for the children are also often stressed out by the special demands of the season and the pressure to do more, plan more, accomplish more. They may be experiencing their own holiday stress outside of work. And on the actual holidays themselves, the children may be cared for by part time staff they don’t know as well. Furthermore, we experience vicarious traumatization from participating in the childrens’ pain. It can feel especially sad to see children managing without their families through the holidays. Anything we can do to support each other and acknowledge the pain to each other will help us offer regulation to the kids.

Most importantly, watch and listen. Pick up early signs of stress. Give the child plenty of time close to regulated adults, when he can talk, be validated, and just be connected with someone who cares. After all, isn’t this really what we are all looking for during the holidays?

Sunday, December 05, 2010

Working with Regulatory Agencies

Providing treatment for children in a congregate care setting is a complex job. There are so many parts to what we do, and we are constantly on the edge of disaster. Thank heavens most of the things that could go wrong don’t. But the behaviors are so dramatic and life threatening, the staffing so stretched, the tasks so many, and the stakes are so high. Every day includes many many interactions with the children, designed to help them get through the day, change and improve, have fun and relax, or just manage life. In addition we have all the physical care of our living spaces. We provide everything necessary to raise the children, from food, clothes, supplies and living space to medical care and education. We must document everything we do following regulations of various agencies and accreditation bodies. There is so much to do on a given shift!
Sometimes things do go wrong. These can range from egregious, deliberate wrong doing, to mistakes of omission by a harried staff, to errors in judgment, to just plain accidents. When something goes wrong, we are often visited by representatives of regulatory agencies. It is their job to investigate what happened, make sure that the care being provided meets acceptable standards, and make suggestions for improvement. It is essential that such agencies exist and that we maintain oversight of the care that is being provided to children.

However, I wonder if it would ever be possible to apply what we know about how people change to the relationship between regulators and service providers. I believe that care would be improved by maintaining a RICH© relationship between the regulators and the agency staff. RICH means treating each other with respect, sharing information, establishing and maintaining connection, and creating hope.

In the situation in which a basically sound agency did something wrong such as inadequate documentation or imperfect handling of an incident, and therefore needs to improve in some way, what actions on the part of the regulators would make improvement most likely to happen? I think that if the agency felt understood and respected, had information about better ways to do things, had a relationship with the regulators and felt hopeful about the possibility of change they would be most motivated to strive for excellence.

Both the treatment agency and the regulating agency have a common goal: providing excellent treatment and care for children. One essential component of the agency’s ability to do this is retaining committed, enthusiastic, hopeful staff. The work itself makes this difficult, as staff working with these children and families experience significant vicarious traumatization from the pain they share with the clients. If the staff feels constantly criticized; if they feel that nothing they do is ever good enough; if their good work is not noticed or appreciated; if they have to spend large parts of their time in meetings explaining what they have done; and if they feel that there is no way to win this vicarious traumatization is compounded.

In our training we stress that there are two sides to a relationship. If we feel that the relationship is our main tool of healing, we must pay attention to both sides. The staff cannot offer a caring relationship to the children if they themselves do not feel cared about and well treated. Just as it is crucial how agencies treat their staff, it is equally important how the staff is treated by the surrounding community. If the staff begin to feel that there is no way they can succeed within the child welfare system; if they experience constant criticism and no recognition, they will feel hopeless. And hope is a crucial component of our work with the children, who are often hopeless themselves.

So how could this be different? First, it would help if outside agencies instituted a method of praising and recognizing the hard work of treatment staff, and called meetings to convey positive impressions at the least often as those for negative issues. Another important factor is the attitude of inspectors when they are in the agency. They, too can mention good things they see and want to encourages, as well as acknowledging the hard work of individuals. They can express appreciation for extraordinary efforts, and display understanding of the complexity of the work.

Agency staff expects correction and suggestion, and is usually eager to improve. This can be offered in a spirit of respect and mutual desire to improve the lives of the children. And when changes are made, they can be acknowledged and celebrated by both agency and regulatory staff.

In short, it would be great if we adults treated each other in the way that we are advocating treating the clients.

What are your experiences with regulatory agencies? Has anyone had good, mutually respectful relationships you can share? Click “comment”.

Monday, November 29, 2010

Thoughts on Developing Resiliency

As I begin to write about resiliency, I have to mention what Geoffrey Canada said when I heard him speak at a National Council conference. He said he was not that interesting in studying what helped people succeed despite bad situations; he was interested in creating fewer bad situations.

Still, when I heard Mark Katz, PhD speak at the Joint Commission Behavioral Management Conference I was struck by the overlap between his presentation and our training. Dr. Katz is the Director of Learning Development Services, a Clinical and Consulting Psychologist in San Diego, California, and author of the book On Playing a Poor Hand Well, published by W.W. Norton and Company (1997). In the book, Mark explores the lessons learned from those who've overcome adverse childhood experiences, and discusses ways of incorporating these lessons into our existing system of care. http://www.learningdevelopmentservices.com/

In his presentation, Dr. Katz emphasized that the meaning people attribute to misfortune is a key factor in their ability to overcome it. He stated that: “The meaning we attach to adverse experiences can determine whether we view ourselves as resilient and courageous, or helpless and hopeless.”

Dr. Katz reported on a study that identified beliefs that interfere with the ability to overcome adversity. These are perceiving adversities to be permanent, pervasive and personal. (Seligman, 1992)

• Permanent – the perception that things will never change
• Pervasive – problems are evident not just in one life area, they’re pervasive
• Personal – It’s all your fault.

Seeing our adversities in these ways increases the likelihood of psychological problems; it may also weaken our immune system. Developing these beliefs when young may be especially impairing.

On the other hand, perceptions that foster resilience (Seligman, 1998; 1992) are that:

• Adversities are temporary – the perception that things will get better
• Adversities are limited – Things may not be going well in one area but they are going well in others areas
• Not personal – The person sees that he is doing the best he can under the circumstances and that it is not all his fault.

Dr. Katz identifies a key factor is resilience is fostering a sense of mastery. This includes highlighting, nurturing and expressing strengths and talents, and things you feel passionate about, feeling you’re making a contribution, and the belief that our actions can alter our destiny. So, people are able to rebound from a difficult past by learning to attach new meaning to adversities past and present, aided in large part by their ability to:

• Re-shape personal identities around longstanding strengths and talents,
• Re-frame personal limitations and vulnerabilities within the context of these strengths and talents, and
• Find or create social contexts where they felt valued for their contribution.

It is interesting to note that the three attitudes that Dr. Katz identifies as particularly harmful are exactly those that are created through trauma. His work highlights the importance of treatment programs deliberately organizing interventions to change these beliefs. The child who is experiencing abuse from his or her family does not see any hope, and thinks that their current situation is permanent. Because the neglect and abuse is so pervasive and repetitive, it affects every aspect of the child’s existence. And in our training we emphasize the role of shame. This child feels that the abuse is his fault, partly because that gives him some possibility of control, as well as to preserve his connection to his parents, and because he is told it is his fault.

What can we do in our programs to convey hope and to show the child that adversity is temporary? First and foremost we must create experiences in which the child is successful, is happy, and experiences joy. We must offer opportunities for the child to explore his strengths. We must coax the child to play. And then we must take care of ourselves and each other so that we can maintain our hope, and thus be able to show hope to the child.

If the child has these experiences of play and success, she can gradually experience that while some areas of her life may be troubled, other parts are not. The pain can be compartmentalized in an adaptive way.

Help a child to emerge from shame is a slow and meticulous process. We must be careful not to rush to reassure the child that whatever happened was not his fault. Instead, we must provide space for him to explore his thoughts and feelings, and share his secret fears and concerns. The antidote to shame is sharing and receiving and empathetic response.

It is important to note that Dr. Katz emphasized a sense of mastery as a key to resiliency. In our training we explore the concept of effective action. The essence of trauma is not being able to change it, control it, or have any power to influence what happens. In our treatment programs we must make sure we do not replicate a sense of powerlessness. Instead, we must offer children lots of ways to take effective action in their own lives. These can include having choices in activities, food and unit functioning; being involved in planning meetings for their lives and advocating for their own wishes; and participating in helping others, volunteer work, helping causes they care about, etc.

The overlap between the literature about beliefs that support resiliency and the evidence about healing from trauma strengthens our understanding of the importance of addressing these areas directly and planfully.

Sunday, November 21, 2010

Update on My Travels

In October, my colleague Steve Brown and I taught both Risking Connection© and the Restorative Approach© to Child and Family Service of Hawaii. This excellent agency is especially interested in improving the services in their group homes for girls. They also have an array of other programs which will benefit from being trauma informed, such as domestic violence shelters and in home services. The staff was eager to learn and felt that this approach was exactly what they had been looking for. And this was the first training in which I was given two leis, one at the beginning and one at the end of the training.

I also did a Risking Connection© training with Dr. Kay Saakvitne in at Elmcrest Children’s Center in Syracuse, New York. I appreciated the staff there who had the courage to embrace change in their methods and appreciate the possibilities within trauma informed care. It was also a treat to teach with Kay, one of the original authors of Risking Connection©. I always learn a lot from her. One highlight of this training was the flock of wild turkeys outside the window of the room in which we were teaching. I guess they were also seeking some knowledge!

Two weeks ago I was an invited speaker at the Joint Commission and Joint Commission Resources Annual Behavioral Health Care Conference in Chicago. I was proud to share the stage with such notables as Pamela S. Hyde, JD, Administrator, Substance Abuse and Mental Health Services Administration; Amy Dworsky, PhD, Senior Researcher, Chapin Hall – University of Chicago; Paul Schyve, MD, Senior Vice President, The Joint Commission; David A. Litts, OD, Director, Science and Policy, Suicide Prevention Resource Center; Mark Katz, PhD, Director, Learning Development Services, Clinical and Consulting Psychologist; Kim Masters, MD, Medical Director, Three Rivers Midlands Campus Residential Treatment Center and Mary Cesare-Murphy, PhD, Executive Director, Behavioral Health Care, The Joint Commission. There was some very interesting information about the future directions of SAMHSA, the ramifications of health care reform for mental health. It was fascinating to hear the latest research and prevention efforts regarding suicide. The discussion of resiliency had some intriguing ramifications for treating trauma- the subject of another blog post.

I received many compliments on my presentation and had some good conversations with folks about what they are doing. And, the Joint Commission staff treated me so well!

Then last week Steve Brown and I travelled to Whitehorse, Yukon Territory, Canada. We taught both Risking Connection© and the Restorative Approach© to the Child Assessment and Treatment Services of the Yukon government. Included in this group were staff from Residential Youth Treatment Services and Child Abuse Treatment Services (C.A.T.S.). Also participating were staff from Alcohol and Drug Services. First let me say that it is a long way from Connecticut to the Yukon Territory. And lost bags, delayed flights and phones that stop working do not help. But it was most certainly worth it all to work with these excellent treaters. Providers working in the Yukon deal with situations of multi-generational abuse, extreme poverty, long standing drug and alcohol use, and lack of resources. I was extremely impressed with their compassion for and commitment to their clients. Two social workers we have come to know each spent over a year living in (different) remote First Nation communities for over a year to get to know the people and their culture. In the residential programs, they never eject a child. If the child runs away, gets drunk, does anything, they are still welcome back. No one was focused on consequences and they did not use points and levels. All staff seemed immersed in understanding the adaptive nature of the behaviors, and could see clearly the pain beneath the behavior. We had many wonderful discussions within the training, and the staff eagerly soaked up our framework and methods as a way to organize their thinking and their work. Through the kindness of everyone towards us, we were able to explore some of the beautiful area surrounding the town, and even go cross country skiing. I look forward to our return in April for the Train the Trainer.

I am extremely fortunate that my work brings me to such diverse and beautiful places and introduces me to so many committed, caring and intelligent people.

Sunday, November 07, 2010

Explanation of the Restorative Approach for Parents

I am trying to create an explanation of the Restorative Approach for parents, to be given to them at admission. This is what I have so far. Any suggestions?

Welcome to Klingberg Family Centers! We appreciate the opportunity to work with you and your child. We hope the following explanation of our approach will be helpful to you in understanding how we do things at Klingberg.

We believe that all healing takes place within relationships. We will do anything we can to create a strong relationship with your child and with you.

We understand that children and adults do things to try to meet their needs in the best way they know how at the time.

Many of the children and families that we work with have experienced bad things in the past. These difficulties have changed them.

If people have been hurt by other people, they stop trusting. They do not believe that relationships can be a source of help and can be counted on. Instead they have come to see relationships as unreliable and painful. So, it is important that we try to show the children and families we treat that relationships can be trusted and that other people can help.

When bad things happen to people, they start seeing the world as a dangerous place. It feels important to always be alert and looking out for danger. This makes it hard to relax, have fun and sleep. We hope to offer our children and families as safe place where they can learn to relax and learn ways to stay calm.

Many of the youth we treat have not learned the feelings skills that we all need to get through the hard things in life. It is very important that we teach them these skills. Often, the children cannot remember that anyone loves them or is on their side. They have a hard time thinking about people who care when those people are not near them. So we hope to strengthen their relationships with people who care (especially you and your family) and teach them ways to keep those people with them in their hearts.

The children we work with have often come to believe that they are no good and that everything that has happened to them is their fault. We work with them in many ways to develop a strong and healthy sense of their strengths and abilities.

A lot of the children in our programs do not know how to deal with their feelings. They cannot notice their feelings when they are small, name them, or get through them without making things worse. We will ask you to join us in teaching the child how to understand and react to feelings, including teaching them some skills to calm down and get through bad times.

When something goes wrong for one of our youth, they do not trust that others can help them with it. They are already feeling hyped up and anxious. They do not know what to do with all the feelings they are having. So they start to feel very bad, hopeless, and scared. They do something that makes them feel better in the moment, like yell, hit someone, hurt themselves or run away. They feel better at the time but then they have made things worse.

We have to help the child learn better ways to meet their needs, ways that do not hurt them and others.

When one of our children does something that hurts others, we try to figure out why they did it. What need were they trying to meet? Then we think about what they would have to know in order to handle this situation differently next time.

We give them a restorative task that offers them a chance to learn or practice a skill that will help them next time.

Also, we believe that the children need to learn how to make up for damage that you cause. So, when a child hurts others we expect them to make amends, to do something good for the person or people they hurt. So the child will receive or create a restorative task to make life better for the people they hurt. We will help you use this approach within your family if you would like.

Sometimes it may seem that the learning and making amends tasks are not enough when the child does something hurtful. You may wonder if the child should also have a punishment or a restriction. We believe that punishments do not help the child change very much. Instead, what will help them change is to learn skills so that they can meet their needs in a better way.

We urge you to talk these ideas over with your therapist, and let them know any concerns that you have.

We look forward to being part of the healing journey for your child and you.

Sunday, October 31, 2010

What Should Be Earned?

In creating our traditional behavior management systems, we operated from the premise that earning rewards and privileges would be the principle motivator for the children in treatment to change. We expected the children to change their behaviors so that they could earn more points and go up in the levels. In order to interest them in doing this, we had to have as many aspects of daily living as possible be contingent. Because we couldn’t actually neglect or abuse the children, we were already limited in what parts of life we could make the children earn. We were not allowed to use food, for example. So, we looked through the day and considered what could be part of the level system. We asked the children. And each system ended up with lots of things that the children could not have unless they were on a certain level. These ranged from extra TV and Nintendo time, to later bedtimes, to posters on their walls, to trips and special events, to lining up first in lines, to contact and visits with their families. The theory was that the more important the privilege was to the child, the harder he or she would try to control their behaviors and earn the higher level.

However, we have now learned that this formulation ignores many aspects of what we know about trauma, how it affects people and how they heal. Points and levels approaches assume that the main problem for these children is motivation. Rewards and punishments increase motivation to do well. But these children are already motivated to do better, they just can’t. They do not have the skills. When you do not have skills, increasing rewards and punishments actually makes behavior worse, as you feel pressure and resentment at being rewarded and punished for something you cannot control. Imagine if some part of your paycheck was based on your flying from office to office. You might make a few tries, but quickly you would give up and be angry and resentful.

Another factors ignored by level systems is the role of shame. If a person has experienced significant trauma, they are often shame based, which means that they feel that they are no good, different and worse from others, and totally unlovable. Being on a low level reinforces this familiar shame, especially when the levels are posted on a public board. Since success seems so impossible, why even try.

What if we actually believe that children act better when they feel better? If children are safe, happy, enjoying life, feel cared about, and are surrounded by trustworthy relationships, they will in time be able to be kinder, calmer and more trustworthy themselves. This assumption would lead us to give the children everything we could as soon as they were admitted. We would make their rooms warm and welcoming and allow them to personalize them. We would offer them many fun activities and warm relationships. We would give them support so they can experience success. Our goal would be to make our units places where the child learns that life can be good, safe, warm, and happy.

More specifically:

Children’s contact with their families should never have to be earned. The greatest predictor of success after residential treatment is how often the child connects with his family during treatment. There are already so many barriers, both practical and psychological, between the child and his family. Our job should be to facilitate as much contact as possible. We should not have visiting hours, the families should be welcome at any time. We must try to provide whatever practical help we can in areas such as transportation and child care. And we must make sure the family feels welcomed and not shamed when they visit. If the child or family is unsafe, we can provide visits at our facilities, supervised if necessary. But contact should be a right, not an earned privilege.

Also, we must keep in mind that children need fun, leisure activities, and play for many reasons. It is through play that children learn and grow, experience success, develop friendships, and experience joy. Many activities such as music, electronic games, dance, art and crafts can also be ways to self soothe and to get through difficult periods without making things worse. How are children going to learn to use coping skills if we tell them that they can’t have coping activities until they show us through their behaviors that they have already mastered coping?

The only time it makes sense to have a privilege be earned is when a child needs skills to be able to use that privilege safely. For example, a child who is repeatedly running away should not be given the privilege of going on walks alone. More autonomy and less supervision should be a result of responsible behavior. As children achieve their treatment goals, and as they show increasing ability to let adults know when something goes wrong or is bothering them, they can be supervised at increased distances. If a program wants a formal system for this kind of earning, it is best handled through a long term phase system linked to treatment goals. Advancement through the phases should be a team and child decision reached after discussion, and not based on point totals. Children should not go down in these phases.

It is certainly a good idea to suspend a given activity in response to a child’s behavior. For example, a child just hit a staff, then wants to go to the mall. The staff should reply: “Of course we are not taking you to the mall today. I do not trust that you will be responsive and not have a meltdown like just happened. However, work on your restorative tasks, let’s figure out together what just happened, and I’m sure we will go to the mall together in the future.” How long this suspension lasts should not be based on a pre-set time period. It should be determined by the child completing his restorative tasks and his attitude.

People worry that without many things to be earned the child will have no incentive to get through the day. Why should he finish his dinner, do his chores, go to bed if there are no points to be earned by doing so? Well, he should finish his dinner because it tastes good and he is hungry, or, it should be fine that he does not finish his dinner. He should do his chores and go to bed because he is asked to and is part of the community, because he gets help and encouragement from those around him and because he will not be able to do the next fun thing until he does so.

Look over your own system. What is currently earned? Do those things need to be earned? What do you think would happen if we gave the children every joy we possibly could for free just because they are alive?

Click comment to let me know your reactions to these thoughts.

Sunday, October 24, 2010

The Characteristics of a Good Trauma Informed Residential Therapist

The most essential characteristic of a therapist that will succeed in a trauma informed congregate care treatment program is that he or she likes the children and their families. This probably cannot be taught. These children can be difficult, demanding, and try anyone’s patience. If the therapist does not find them delightful, cannot see their goodness, does not look forward to being with them, she will have nothing to help her get through the bad parts. The children generally feel hopeless. They do not see their own worth and cannot imagine a positive future for themselves. If the therapist cannot do that, who will? And at times the therapist holds the hope for the whole team. One role of the therapist is to see a picture of how this particular child would be if he were at his best, even while remaining aware of the child’s current reality. The therapist who genuinely cares about and appreciates the children and their families can do this.

A therapist in a congregate care setting must be flexible. The day never turns out as one expects. Things rarely go as planned. It is time for an important family meeting and the child is at the park. An individual session is scheduled but another child is threatening suicide. The therapist is going to do her paperwork and the licensing inspector drops in for an unscheduled visit. Roles shift between people. The child needs to talk with her now. A person who needs a predictable day would not be happy in this setting.

Working with a therapeutic team is a particular experience. For some, it feels wonderful to have so much help and support. For others, it is difficult to have to share everything, discuss everything and make decisions within a group. The therapist who enjoys teamwork will be the most successful in congregate care. Often the teamwork is frustrating. There are factions, problems, disagreements. The therapist tells twenty six people about something and the twenty seventh complains that she wasn’t told. Decisions are made and then not carried out. Interpersonal issues between team members can be intense. Yet the treatment team can be the most powerful intervention possible in helping a child to change. And as the therapist struggles with the pain and difficulty with the work, it can be sustaining to have a team to share with. The team can laugh together, cry together and care together about the clients. The therapist that flourishes working in this complex environment will have the ability to form relationships with other staff, will assume good intensions in fellow workers, will give and accept feedback, will handle disputes openly, and will notice and praise the positive efforts of others.

At this level of care, a therapist must be able to tolerate chaos and intensity. The symptoms that the children display are frightening and are often life-threatening. There is usually more than one child in crisis at once. The families too can be angry, demanding, sad and scary. The systems around the child are often inadequate and frustrating. The therapist must know how to stay calm herself in the face of the agitation of others. She must prioritize and respond to the problems step by step. She must also be able to tolerate strong emotions in the clients, and stay with the client as they experience their pain, longing, anger and sadness.

In order to do this the therapist must have or develop good self care skills. All therapists will experience vicarious traumatization. The therapist must use their team to help them through difficult times. Outside of work the therapist needs strong supports and connections in order to maintain a work/ life balance.

A sense of humor is crucial for surviving and thriving in these jobs. Self awareness is also essential. The therapist needs to notice her responses to individual children and families, and use these responses to deepen her work. She should accept seek out and accept help in this area from her supervisor and her team. She should monitor her vicarious traumatization and know when she needs a break.

There are many skills and much knowledge that a therapist should have, but these can be taught in supervision or through workshops and training. If the therapist is eager to learn and grow, the agency must only provide the opportunity. In addition, the therapist must know or learn writing skills and have the ability to document and do treatment planning. Of course, the therapist must be responsible, come in on time, and be self motivated in completing her job requirements. Often, some on call duties will be part of the job.

It would be wonderful if agencies had the ability to pay this paragon what she is worth!

Sunday, October 17, 2010

Recent Travels

On the first of October I presented a Keynote speech and a workshop to the Midwest Regional Conference of the National Association of Therapeutic Schools and Programs. It has been interesting and rewarding to get to know these programs, which include both therapeutic residential school and Wilderness Adventure programs. They are beginning to utilize trauma informed care in their treatment approaches in unique ways.

I then travelled to Hawaii with my colleague Steve Brown to provide Risking Connection and Restorative Approach training to an agency there, Child and Family Service. It was a wonderful experience. It is certainly the only training at which I have been presented with two leis, one at the beginning and one at the end. I loved the Aloha spirit of the people in our training- they were so welcoming and helpful. The emphasis on multi cultural awareness was very moving. We can all learn from the way Hawaii incorporates all cultures into daily life. We had both agency personnel and representatives of the State Department of Mental Health in attendance. With four separate trauma related national grants, Hawaii is working hard to change their practice and offer more trauma informed services. We look forward to our ongoing work there. And of course exploring the island was wonderful- those beaches, turquoise water and waves! I snorkeled with bright colored fish and sea turtles.

This week I will be presenting two guest lectures: one at Hampshire College in Amherst, MA and one at St. Joseph’s College in West Hartford, CT. I am looking forward to the interaction with the students. It is encouraging to see information about trauma being included in college curricula.

Then I move on to upcoming trips to Chicago, Syracuse and the Yukon territory of Canada.

It’s a busy fall!

Sunday, September 26, 2010

Succession Planning

This was the last week for Klingberg Family Center’s President of eighteen years, Rosemarie Burton. Rosemarie has retired to spend more time with her twin granddaughters, as well as to develop her executive consultation business, By Your Side Consulting (www.byyoursidenc.com).
Rosemarie has been an exemplary president for Klingberg. When she started eighteen years ago, Klingberg had 95 staff, two programs and one location. As she leaves now, we have over 400 staff, around 15 programs and seven locations. In addition, the agency has grown in skill, sophistication and expertise.

Rosemarie has set the tone for the agency by her unswerving commitment to the children and their families. Rosemarie has taken each of the children in our programs to lunch on their birthdays and other special occasions. She enjoys the children and is deeply committed to their quality of life. Therefore in addition to focusing on securing the latest Federal earmark for the agency, Rosemarie arranges for the kids to have baseball uniforms, or for a talented girl to obtain an acting scholarship, or for a boy who is interested in architecture to tour the office of an architect friend of hers. She has demonstrated daily that the children and their families take precedence over anything else.

Rosemarie models the fact that high ethical standards and a sharp, practical business sense are not incompatible; in fact they support each other. Financial integrity and a commitment to excellence reinforce each other.

Several years ago Rosemarie began to talk about her retirement. Although none of us wanted to hear about it, her long and careful process has resulted in an excellent transition for the agency. Our new president, Dr. Steven Girelli, was chosen after a careful national search, and he has been amply prepared to assume his new role. All the many people, from staff to Board members to kids and families to donors to legislators who will miss Rosemarie have had many opportunities and ceremonies to say good bye. Rosemarie’s retirement party is next week and should be a major event with people from all eras of her life. Everyone is of course anxious about a major transition and this process has helped with that anxiety.

But for Rosemarie, succession planning has not been limited to finding and preparing her own replacement. Throughout her tenure at Klingberg one of Rosemarie’s strongest commitments has been fostering the growth of her staff. She has paid attention to staff at all levels and offered them opportunities to grow, be promoted and meet their profession al and personal goals. She has done this by offering conferences, training, taking people with her as she participated in national forums, and by spending time with people, encouraging and guiding them. She has especially focused on the women and minorities on the staff. At every level of the organization people have been identified who are doing a good job and showing promise, and experiences they need to grow toward the next step have been offered to them. So not only has the Presidential transition been smooth, the growth of the organization has been facilitated. Another benefit is that if staff feel they have opportunities, they stay with the organization.

I am certainly one of the people who has benefitted by Rosemarie’s encouragement. Much of who I am and what I am doing professionally has been made possible by Rosemarie’s ability to embrace new ideas and find the resources to move towards the future. Knowing Rosemarie as a person and a friend has taught and inspired me. I will miss her in so many ways. I am also confident in Klingberg’s future as we move forward under the skillful leadership of my friend Steve Girelli.

This multi-facetted succession planning is one important source of strength for a non-profit agency.

Sunday, September 19, 2010

Trauma Informed Care in Wilderness Programs

I have just finished a presentation at the New England Regional Conference of the National Association of Therapeutic Schools and Programs (NATSAP). I think it went well, I received a lot of positive feedback. The members were very welcoming and kind.

I had an interesting discussion with a gentleman from Utah about the application of trauma informed care principles in Wilderness Programs. His program serves youth who have gotten in trouble, often with drugs but also many other things, and who are not adjudicated but would become so if no action was taken. These are self pay by parents. The kids and staff go on month long hiking and camping expeditions. Therapists come out to meet with the youth weekly.

Some of the principles I teach match very well with their philosophy. Certainly, the whole experience is about teaching skills. The concept of building self worth is also central. The experience of needing to depend on others and work as a team develops a new template for relationships, that they can be helpful and trustworthy. The staff have the skills that the kids need to survive, and so the kids have to depend on them, and may begin to learn that they can trust some adults.

Wilderness programs also demonstrate to the child that their actions affect individuals and the community, so the concept of responding to misbehavior with making amends to individuals and the community fits well. We discussed the possibility that a child who has delayed the group progress can do chores for the others or do extra work to make the trip move forward.

There is a sense in some programs that you can’t let the youth get away with anything, and that understanding the adaptive nature of their problems could be seen as an excuse.

I would be very interested in hearing from anyone who works in wilderness programs. Have you incorporated trauma informed care? In what ways do you think it fits with your thinking? What areas have been hard to incorporate? Let’s start a dialog.

I have two more NATSAP presentations upcoming, and look forward to deepening this discussion.

Saturday, September 11, 2010

When Chaos Strikes

It may be a call from our licensing agency, concerned about the number of incident reports. It may be reviewing our quality improvement numbers. It might come from staff complaints, or from all the meetings and discussions and panic among the team. But somehow we become aware that one of our programs, cottages or units is not doing well. Chaos has struck. There are an unusually high number of incidents such as restraints, runaways, hospitalizations, staff and child injuries, police calls, negative discharges or other signs of dysregulation. What should we do? Where should we start in our attempts to improve the treatment environment?

Usually these times are accompanied by a cry for increasing the severity of consequences. As staff feel more frightened and out of control, they reach for some sense of power. They turn towards more punitive responses as a way to feel in control and powerful. Similarly, the children are feeling frightened and out of control. They turn to violence, aggression and threats to give them a sense of power and control. A destructive cycle takes place.

In such times it is hard to take time to step back and think about what could be happening. Yet it is during these difficult periods that we most need to examine the patterns, think about how we understand the symptoms, and take measured, careful action. Also, in periods of crisis the very things that will help prevent crisis behaviors tend to disappear. Because staff are handling crisis’s or talking about them, regular activities are not done, routines break down, individual time for the children with their therapist or the staff is cancelled, and everyday positive interactions decrease. It is essential, but very difficult, to reinstate routines and activities during crisis times. Relationships, predictability, and positive activities are our most powerful interventions.

There is a tendency to blame the chaos on one or several particular youth. If we could only get rid of Marci! Joshua needs to be discharged, he needs a place with more structure.

However, as we consider what may be going wrong, staff related issues are the first things to think about. There are many staff problems that can result in program problems. All of these result in a feeling of less safety for both clients and staff, and thus create a greater need for control and aggression. Some of these are:

o An influx of new staff, not enough training
o Staff splits and tensions: different groups such as therapists/childcare staff/teachers; first shift/second shift; etc. are not getting along, blaming each other for the problems, and not talking about their differences directly.
o Therapists are staying in their offices, are not active on unit, are not in the middle of crisis’s, and are not working closely with child care staff to examine the meaning of the behaviors.
o Vicarious traumatization and no way to talk about it or take care of one’s self and others; no processing of the effect of painful events on the staff; over-working staff
o Paralysis created by not understanding new approach: at times when programs change their approach, child care staff become paralyzed. They know what they are not supposed to do, but they are not sure what to do instead. So, they ignore behaviors and don’t engage with the clients; instead they stand by feeling helpless as a child escalates.
o Understaffing: all programs have had experiences with times when we have open positions, and the staff we have (bless them) are working extra shifts and are extra exhausted. Supervisors may be working shifts and having little time to interview potential new staff. It is hard for anyone to have time to think.
o At times a culture develops in which staff do not interact with clients. They stay in the staff office, or (against policy) text their friends on their cell phones. They institute “quiet hours” or other times the children have to be in their rooms. This weakens the relationships that are the building block of treatment.
o It is amazing the power that one toxic person can have on a team, especially if that person splits staff and is underhanded.
o If the unit leadership is not strong, it is hard to address any problems. The position of unit supervisor is often filled by promotion from child care staff. This person is expected to manage complex staff issues and agency requirements. Often, they are not given adequate management training or supervisory support. This is a crucial position that needs many resources.

If we come to the conclusion that staff issues are at the center of our problem, what can we do?

This first thing is to talk about it. Bring any issues into the open. Bring groups together and hash out differences. Of course, this is hard to do when we are in the midst of problems, but it actually is our best way out. Part of the discussion should focus on staff’s emotional reactions to recent events, and their vicarious traumatization. Pain shared is decreased and better tolerated. Loss of hope and cynicism should be addressed directly. Another intervention could be training: do we need to train more on our new method? On management and supervision? On policies and procedures? There may be staff that must be addressed individually in supervision, perhaps placed on a specific performance improvement plan. And we may need to involve more agency resources in hiring.

Another area to look at is the schedule and structure of the program. It can be helpful to look at the program’s serious incident reports to search for patterns. Are there specific times, days of the week, staffing patterns that correlate with the most incidents? One must be careful in interpreting these results, as many factors can contribute to them. Still, such analysis can provide a place to start. Some trouble areas can be:

o Not enough structure or activities, too much down time, TV or electronics time, or time when the clients are forced to stay in their rooms. For clients with racing, hopeless and despairing thoughts, these times can feel awful. The client then will do something to distract himself from his thoughts, such as cause a commotion.
o One unit that did such an analysis discovered they were scheduling high energy gym activities right before bed time, and then having many problems while trying to get the clients to sleep. They reduced restraints by instituting quiet activities in the evening.
o The children become anxious in situations with unclear expectations, unpredictability of schedule, and confusion between staff about what happens next. Planned schedules that are posted for all to see help the children feel safe.
o Too much noise, activity, chaos can be overwhelming to clients.

If an analysis reveals patterns to the problems, we can change the programming and see if it helps.

Of course, some of the source of program distress is client related. It can relate to:

o A large influx of new clients
o Negative events that have affected clients and made them feel less safe, such as observing an out-of-control event that required police intervention.
o It is important to probe for secrets, things that may be going on that we do not know about. Sexual acting out and/or bullying and intimidation are prime candidates. Getting the truth out in the open can begin a change and a healing process that will result in greater safety for all.
o Individual or collective losses, such as staff leaving, especially those that have not been discussed or grieved, can lead to acting out
o The children are constantly facing overwhelming Individual life stresses
o All teams know that certain times of year, i.e. school starting or holidays, are difficult for the clients and thus lead to many symptoms.

In these cases, we may need to be active advocates for the clients. Again, talking collaboratively with the clients about what is going on, what is happening in our community, and what we want to do about it can begin a powerful and mutual process of change. And we may also need to institute extra precautions of supervision, observation and staffing to increase safety.

The common ground here is that we assume that the behaviors are happening for a reason, and the reason is not that the kids are obnoxious. We are certain that the symptoms are adaptive in some way, for the clients and for the staff. We assume that everyone is feeling unsafe and is doing the best they can to protect themselves. We start from these assumptions to think about what could be going on, and then to take directed action to enable everyone in our community to experience less pain and more joy.

Sunday, September 05, 2010

Book Review: Working with Children to Heal Interpersonal Trauma

Book Review: Working with Children to Heal Interpersonal Trauma- The Power of Play

Edited by Eliana Gil
Foreword by Lenore C. Terr
Guilford Press, August 2010
ISBN 978-1-60623-892-9

Eliana Gil is a well known specialist in helping children who have been abused. The Healing Power of Play: Working with Abused Children (Guilford, 1991) and Treating Abused Adolescents (Guilford, 1996) are two of her previous books which I have enjoyed. Her most recent book, of which she is the editor, is Working with Children to Heal Interpersonal Trauma- The Power of Play (Guilford Press, August 2010). In this book, Gil speaks out for the power of undirected play therapy, particularly sand tray therapy, to provide a vehicle with which children can heal themselves. The book comes at a time when more directive and prescriptive therapies are in favor, and when play therapy has been maligned as not sufficiently powerful for children with attachment difficulties. In addition, in this era of short term therapy, the book demonstrates the need for long periods of treatment (at times years) for children who have endured serious abuse.

The book starts with a theoretical section, in which contributors discuss the incidence of interpersonal trauma, how it impacts the developing brain and body of the child, and how children can use therapy to heal.

In the second section, Dr, Gil and her contributors tell eleven stories of children who had experienced serious, often unbearable, abuse, and who used play therapy to heal. The stories are very moving. In all cases, the therapy is non-directive: the child is shown a room full of toys, and is allowed to use them in whatever way he or she wishes. The therapist does not interpret their play, but instead witnesses and contains it. Within the stories the therapists weave theory, attention to symbolism, and their sense of what was happening with the child. A strong emphasis is placed on the feelings of the therapist (counter transference). The therapists repeatedly describe how they used supervision to understand and utilize their own strong reactions to the children. The stories are all hopeful, and in several cases in clued long term follow up which demonstrates continued progress by the child.

Working with Children to Heal Interpersonal Trauma is a reminder of the strength and resiliency that can be found in every child. It calls us back to the power of the therapeutic relationship, and the change that is possible when a child is provided the time, space and caring necessary for him or her to find her own way forward.

Eliana Gil

Sunday, August 29, 2010

The Difficulty of Taking a Break

In our Risking Connection© training, we emphasize the importance of vicarious traumatization (VT). Because VT can destroy our hope and optimism, and because hope and optimism are so crucial to our work, paying attention to VT is an ethical imperative. One aspect of the discussion is: what can we do at work to decrease VT? There are many answers, and one is: take breaks.

I have recently been experimenting with actually trying to take a break for lunch. Instead of eating while I do email, write or talk, I am trying to sit and eat my lunch. I brought in a placemat and a nice bowl, and I sit away from my desk. And what I have discovered is that this is extraordinarily difficult.

Some of the difficulties are within me. I am jumpy and want to keep working. I am thinking about what I have to do. I am responsive to all interruptions. I am interested in what I am doing and do not want to stop. I feel guilty. This segment on NPR (http://www.npr.org/templates/story/story.php?storyId=129384107&sc=nl&cc=es-20100829) relates

the physical addiction we get to responding to our many media.

Some of the difficulties are external- people want to talk, meetings are scheduled at noon, there are many things to be done. We have an “always available” culture.

When I do manage to take a break, I feel refreshed and calmer. I am more thoughtful in my work.

But it is hard.

Now I am on vacation- and for me, it is also difficult to tear myself away for the vacation. It isn’t that any one is pressuring me. It is more that I love my work, find what I am doing very interesting, and I am involved in some exciting initiatives right now. I do not want to miss anything! And yet I know the value of taking some time to turn my mind in other directions, relax and absorb some of this beautiful sunshine.

How about you? Do you take breaks during the work day? Is it difficult? If you have found good ways to do so, share them! Do you find it makes a difference? Click on “comment” and share your experiences.

Sunday, August 22, 2010

Visit to Seven Hills Foundation

This week I visited an agency in Massachusetts named the Seven Hills Foundation. This organization is helping us create and run our new unit, Webster House, which will serve children with both psychiatric and medical disabilities. The staff at Seven Hills have been universally generous, helpful, kind and knowledgeable with us. We visited the Seven Hills Pediatric Center, which provides long-term care. Children enrolled in their long-term care receive all the necessary medical, nursing, therapy, and leisure services to enhance their quality of life. Many residents come to them with a history of congenital birth defects, past infections, or trauma. Cognitively, residents are under the age of 12 months and non-ambulatory. The staff at SHPC has many years of experience working with residents who are ventilator-dependent, have tracheostomies, or require gastrointestinal feeding. For children who require additional monitoring, they have a state-of-the-art individual monitoring system. We also visited a group home in which six individuals live. This house looks like a regular house in a lovely neighborhood on the outside, but was specially constructed by Seven Hills to have space for reclining wheelchairs, tracks for lifts, special bathrooms and many other adaptations. The mission statement of the organization is “Dignity by Design.”

The children that are served in these two facilities are generally unable to respond differentially to life. A few may have the ability to signal yes or no. They may have some differences of responsiveness to people they have known a long time. Any positive changes in their condition are microscopic. They cannot say thank you or I appreciate what you did. It is not clear at all that what happens to them makes a difference in their experience.

Yet, the staff at these facilities are loving and interactive with the children. They constantly talk with them, interact with them. The children are well dressed, clean, and obviously cared for. Their rooms are decorated like any child’s room. They participate in school and make many trips into the community. When I asked where they go, I was told they go anywhere anyone else would go- the post office, grocery shopping, the hardware store. Staff was proud that the children had marched in the Memorial Day Parade this year. The children attend school, and the walls are lined with their art activities. When a child cooks or creates a craft project, that means that the staff moves their hand in order for them to do so. Yet these children’s lives are filled with activity, even though it is not obvious whether they can understand what is happening.

The staff was happy, friendly smiling and greeted us warmly. The facility was sparkling clean and attractive. It was an inspiring visit.

It seems to me that we can be inspired in our work by the work that Seven Hills does. We often tell staff to judge their day by what they did, not by how the kids responded. If they were caring, empathetic, playful, flexible, then it was a good day no matter how the kids behaved. At Seven Hills, staff have to do that. I am sure that they give each other a lot of support. But they cannot see immediate (or even long term) responses to their efforts from the kids. And they make the effort any way. How do they do that? How do they remain hopeful and find meaning in their jobs, when they cannot see results?

The second area is something I have written about before, in clear focus here. When a child has an obvious physical disability, we do not get angry at him for what he cannot do. We do not think that if we punish him for not doing it, he will change. Instead, we make modifications and change our expectations. At Seven Hills this is the essence of every activity. The staff finds a way that their efforts can make it possible for a child to do something or have a certain experience. They literally move the child’s hand so that the child creates art or food. They do not use rewards or punishments. If a child can get better, they gradually allow them to do more, in minute steps.

What if we could more clearly see the physical changes trauma has caused our children? What if we could see their damaged brains and body chemistry? Could we more easily lend them our brains, our thinking and planning, and provide them the support they need for success? Could we be surer that through positive experiences they would grow and that gradually they would become more capable?

Our visit to Seven Hills was moving and inspiring, and led to some thinking about how their philosophy could apply to the work we do.

Sunday, August 15, 2010

Restraint and Seclusion Experiences of Youth

In response to a previous post about our restraint and seclusion reduction initiative, one reader wanted to learn more about youth reaction to the experience of restraint. We asked several of our kids of all ages to fill in the end of open sentences about both being restrained and seeing others be restrained. We then recorded oth kids reading these aloud, and played them at our kickoff event for our “Got Restraint? More healing, less holding” initiative.
Answers from children to open ended sentences about their experiences of restraint and seclusion

When I get restrained, I feel scared.
When I am in a seclusion, I feel trapped.
When I get restrained, it reminds me of when they had to hold my uncle back.
When I am in a seclusion, it reminds me of watching my mom get in the police car.
When I get restrained, staff try to help.
When I am in a seclusion, staff ignore.
After a restraint I feel guilty.
After a seclusion I feel guilty.
When other kids get restrained I feel like I need to be in a restraint too.

When I get restrained, I feel even more angry than I did before.
When I get secluded, I feel really upset, mad, and angry.
When I get restrained, it reminds me of home, because I used to get into a lot of trouble at home and my mom would restrain me.
When I get secluded, it reminds me of my mother.
When I get restrained, staff get really mad and hurt you, a little bit, but not purposely.
When I get secluded, staff open the door quickly, most of the time, when I’m calm.
After I get restrained I feel scared, angry, and hot. I get scared it’s going to happen again, sad that it happened, and angry that it happened.
After I get secluded I feel even more angry.
When I see other kids get restrained it scares me.

When I get restrained, I feel scared because everything’s going so fast, and my emotions are a roller coaster, and hurt and frustrated. I feel angry because I start to hate the staff because they put their hands on me and they put me down and I don’t like to be touched. Sometimes I’ll purposely hit them so they’ll restrain me. Sometimes I’ll be like “why didn’t you guys just talk to me instead of going straight down.”

When I get secluded, I feel angry, I feel like hurting myself because I’m only by myself and there’s nothing for me to use to cope and there’s just walls. The quiet room would freak me out cause it was all scabbed up and had writing on it.

When I get restrained, it reminds me of the past, people hurting me.
When I get secluded, it reminds me of when I get grounded.
When I get restrained, staff can get hurt, and it depends on who’s in it, but sometimes staff hold onto me real tight or get frustrated with me.
When I get secluded, staff have to do paperwork.
After I get restrained I feel angry because I don’t like when people touch me.
After I get secluded I’m stressed still.
When I see other kids get restrained I feel no one should have to go through that.

When I get restrained I feel angry, like I’m going to pay them back, cause I hate when people put their hands on me. I don’t like to be a loser-it’s like getting beat up.
When I get secluded, I feel like I will I throw up.
When I get restrained, it reminds me of my past.
When I get restrained, it makes me angry.
When I get secluded, staff shut the door.
After I get restrained, I think F all you people, are you listening to me?
When I see other kids get restrained It makes me very upset and sad.

When I get restrained I feel like I can’t breathe.
When I get secluded, I feel like the walls are closing in on me.
When I get restrained, it reminds me of when I was hit as a little girl.
When I get restrained, staff grab me too hard. They should hold us down and talk, or just talk.
After I get restrained I feel I’m even more angry, and I still have trouble breathing.
When I see other kids get restrained I think staff do it right, sometimes kids hit them and they have to get aggressive back.

Good reasons to work hard and reducing or eliminating these practices.

Sunday, August 08, 2010

Transforming the Pain of Vicarious Traumatization

A central idea in the Risking Connection© approach to dealing with vicarious traumatization is the concept of transforming the pain. One important way that human beings deal with pain is to look for the good within it, to notice how going through a difficult experience changed our lives or strengthened us as people. An example of this would be the woman who says: "I certainly didn’t want to go through that breast cancer scare last year. But it did sharpen my sense of my priorities, and so I have gone back to school to finish my degree." If we can notice the transformative effects of the pain we experience in our work, we will be able to appreciate how the work changes us in positive as well as negative ways, and will build on those positive changes. This is an powerful way that we can combat vicarious traumatization and stay engaged and hopeful in our work.

One author and healer who has deepened our understanding of this process is Rachel Naomi Remen. Rachel Naomi Remen is medical director of the Commonweal Cancer Help Program, and a clinical professor of family and community medicine at the University of California Ð San Francisco School of Medicine. Her books include My Grandfather's Blessings, and Kitchen Table Wisdom. She was recently interviewed on Speaking of Faith with Krista Tippett (a show that has many episodes which illuminate our work). The podcast of the show, as well as supporting writings, can be found at:


In her RECAPTURING THE SOUL OF MEDICINE Rachel Naomi Remen speaks of the importance of finding meaning in one’s work:

In times of difficulty, meaning strengthens us not by changing our lives by transforming our experience of our lives, The Italian psychiatrist Roberto Assagioli tells a parable about 3 stone cutters building a cathedral in the Middle Ages. You approach the first man and ask him what he's doing. Angrily he turns to you and says, "Idiot! Use your eyes! They bring me a rock, I cut it into a block, they take it away, and they bring me another rock. I've been doing this since I was old enough to work, and I'm going to be doing it until the day that I die." Quickly you withdraw, go the next man, and ask him the same question. He smiles at you warmly and tells you, "I'm earning a living for my beloved family. With my wages I have built a home, there is food on our table, the children are growing strong." Moving on, you approach the third man with this same question. Pausing, he gives you a look of deep fulfillment and tells you, "I am building a great cathedral, a holy lighthouse where people lost in the dark can find their strength and remember their way. And it will stand for a thousand years!" Each of these men is doing the identical task. Finding a personal meaning in your work opens even the most routine of tasks to the dimension of satisfaction and even joy. We may need to recognize meaning for the resource it is and find ways to pursue it and preserve it.

Meaning is a human need. It strengthens us, not by numbing our pain or distracting us from our problems, or even by comforting us. It heals us by reminding us of our integrity, who we are, and what we stand for. It offers us a place from which to meet the challenges of life. Part of our responsibility as professionals is to fight for our sense of meaning — against fatigue and numbness, overwork, and unreasonable expectations — to find ways to strengthen it in ourselves and in each other. We will need to rebuild the medical system, not just on sound science or sound economics, but on the integrity of our commitment. It has become vital to remember the essential nature of this work and renew our sense of calling to preserve the meaning of the work for ourselves and for those who will follow.

Here are some quotes from her interview on the show:

You know, sometimes what appears to be a catastrophe, over time, becomes a strong foundation from which to live a good life. It's possible to live a good life even though it isn't an easy life. And I think that's one of the best-kept secrets in America.

I was going to say the great joys of working with people on the edge of life. The view from the edge of life is so much clearer than the view that most of us have, that what seems to be important is much more simple and accessible for everybody, which is who you've touched on your way through life, who's touched you. What you're leaving behind you in the hearts and minds of other people is far more important than whatever wealth you may have accumulated….

We thought we could cure everything, but it turns out that we can only cure a small amount of human suffering. The rest of it needs to be healed, and that's different. It's different. I think science defines life in its own way, but life is larger than science. Life is filled with mystery, courage, heroism, and love. All these things that we can witness but not measure or even understand, but they make our lives valuable anyway.

People who are physicians have been trained to believe that it is a scientific objectivity that makes them most effective in their efforts to understand and resolve the pain others bring them, and a mental distance that protects them from becoming wounded by this difficult work. It is extremely demanding training. Yet objectivity makes us far more vulnerable emotionally than compassion or a simple humanity. Objectivity separates us from the life around us and within us. We are wounded by that life just the same; it is only the healing which cannot reach us. Physicians pay a terrible price for their objectivity….

No one is comfortable with loss. Being that we're a technological culture, our wish or our first response — let's put it this way: Our first response to loss is try and fix it. When we are in the presence of a loss that cannot be fixed, which is a great many losses, we feel helpless and uncomfortable and we have a tendency to run away, either emotionally or actually distance ourselves. Yeah. And fixing is too small a strategy to deal with loss, you know.

We teach them the power of their presence, of simply being there and listening and witnessing another person and caring about another person's loss, letting it matter.

This is a quote from Krista Tippett, the host:

“The following passage from Naomi Remen's Kitchen Table Wisdom, … was written with physicians in mind. But it holds a resonant caution and challenge for all of us, I think, as we struggle to face yet not be overwhelmed or numbed by — the pain and suffering that are a fact of human existence near and far.”

"The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet. This sort of denial is no small matter. The way we deal with loss shapes our capacity to be present to life more than anything else. The way we protect ourselves from loss may be the way in which we distance ourselves from life… We burn out not because we don't care but because we don't grieve. We burn out because we've allowed our hearts to become so filled with loss that we have no room left to care."

Let’s begin a conversation about how these concepts apply to us within our work, and how we can create opportunities to discuss these ideas within our workplaces.

Sunday, August 01, 2010

Do You Like These Kids?

As part of our new restraint and seclusion reduction initiative, I recently completed two focus groups with clients to ask them what they felt staff could do to decrease restraints and seclusions. Their answers can be summed up in the directive: ask me what is wrong and listen to my response.

I was dismayed by the feeling that the kids had that the staff did not really like them or enjoy being with them. They spoke of staff wanting to get away from them, have breaks from them. They said staff were at times involved in their own interests and not willing to be interrupted by the kids. They noticed staff sitting and talking together. On the other hand, they described how much it meant when staff participated in games and activities with them. They felt close to staff who listened when they spoke, remembered what they said and asked them about it later. They were quick to blame themselves for staff not wanting to be with them, because of the way they acted. But they described acting better around staff who genuinely care.

One of my colleagues remarked recently that what our kids need, and have never had, is someone whose face lights up when they come into a room. Think of your own children or those of friends. They are celebrated in so many ways! Their pictures are on the refrigerator, their events are attended, their performances little and big are applauded. But more than that, they constantly receive feedback that they are delightful. Someone loves them, wants to see them, wants to hug them, and wants to hear about their day.

Some research has shown that a critical factor in school success is the proportion of positive to negative comments a child hears during a day. How many times do our children hear their own name used in joy, as in "Stephanie I am so glad to see you!" or "Stephanie what a wonderful math paper!" In contrast, how often is their name used as a warning: "Stephanie, stop that!" or "Stephanie, don’t do that!" In their lives I am afraid it has mainly been the later.

Martha Holden of the CARE project told me that she teaches staff that their main job is to make sure that the child they are caring for has a marvelous day. What if we organized everything we do around that goal? That our goal is to help the children be happy?

The children we work with are marvelous. Every day they demonstrate strength, courage, intelligence, wit, creativity and humor. Of course, they can also be obnoxious and even scary. But if we don’t see the marvel in them, who will? And how can they possibly change and grow if they have no one who is delighted by them?

The kids in my focus group were clear what they needed. What would it take for each of us to become that staff who listens, who joins with the children in games and activities, who laughs with them, who creates positive memories? How can we become the person who shows the child that she is worthwhile by looking forward to our time together, seeking her out and obviously wanting to be with her? This engagement can’t be faked and I am not sure it can be taught. But it is what makes our jobs meaningful and what heals the children.

Sunday, July 18, 2010

What Can We Learn about Trauma from Lizbeth Selander?

I have been reading Stieg Larsson's Millennium Trilogy Bundle: The Girl with the Dragon Tattoo, The Girl Who Played with Fire, The Girl Who Kicked the Hornet's Nest by Stieg Larsson (Knopf; 1 edition, May, 2010). I have seen the Swedish movies based on the first two books. This marvelous series features Lizbeth Selander. Lizbeth has been systematically badly abused and has experienced profound trauma. We root for her so strongly that in the theater when I saw the first movie, the entire audience burst into applause when she achieved revenge against one of her abusers. Yet Lizbeth is strange, difficult, hostile and quirky, much as many of our clients are. In our sympathetic engagement with Lizbeth, we can learn a lot about trauma.
How has Lizbeth been shaped by her experiences?

• She is strong, resourceful, and has many skills and strengths.

• She is fiercely independent. She refuses to take help from any one. Even when she is in the hospital she hates to call the nurse because she wants to take care of everything herself.

• Lizbeth is very private. Even with the person who is closest to a friend (Miriam Wu) she does not want to reveal anything about herself. To her, giving someone knowledge is giving them power they will probably use against her.

• She is covered with tattoos and piercings, and she presents herself as other, as an outsider. Her presentation pushes people away.

• She participates in sex in an anonymous, unconnected way, then disappears from that person’s life.

• She is fiercely protective of her mother.

• She is available for connection, but is very skittish. The guardian who treated her well earned her respect and love. But she put him through many tests, then left his hospital room and didn’t come back when she thought he was dying.

• She assumes people will treat her badly. When (in the third book) some policemen are actually respectful to her, she assumes they have ulterior motives and are trying to trick her. She doesn’t talk with them.

• She forms a strong connection to a man, but cannot trust it. When she sees him on the street laughing with another woman, she immediately assumes that she was crazy to think he would ever want her and assumes that he was just using her.

• She goes to extremes. She doesn’t check out her experiences with him. She refuses to ever talk with him again and runs away.

Do any of these things sound familiar and remind us of our clients? In the context of Lizbeth’s experience, they make sense and seem entirely understandable. If you read these books (and I highly recommend them) maybe we can use them to deepen our understanding of our client’s reactions.

I would love to talk about this further. If you are reading this series click on comment and tell me your reactions.

Saturday, July 10, 2010

Vicarious Traumatization and Foster Care

"I’ve been a foster parent for sixteen years" said Michelle. "And this is the first time anyone has ever asked about how this job affects me."

The last session in my six module training for foster parents was entirely focused on them. How does this very difficult work affect them? We started with the definition of vicarious traumatization (VT) from Risking Connection© (Sidran Foundation). It is:

"VT refers to the negative changes in the helper as a result of empathically engaging with and feeling, or being, responsible for traumatized clients." We can see these affects physically, emotionally, in our thoughts, in our sense of safety, in our relationships, our spirituality, and our sense of hope.

We did the Silent Witness exercise from Risking Connection© training. In this exercise, participants write anonymously on a piece of paper three ways that their job affects them in negative ways. On the back of the page they write three ways the job has affected them in positive ways. The leaders collect the pages and read them anonymously to the group. First, we read the negative ways, then we discussed them.

The foster parents spoke of not being able to sleep because of worrying what their child will do. They described the isolation of being alienated from friends and family who do not understand why they do not just punish the child more severely. A parent described how hard it can be when she has been desperately worried about a runaway foster daughter and then the girl returns and acts mean to her and seems to think her behavior was fine. A father talked about being with his son when a planned visit with the bio mother was cancelled due to her not showing up. A mother spoke about how tired she always feels, and how she no longer wants to go out with her friends or even do her favorite scrapbooking because she just wants to sleep. One parent said that for him the hardest thing is not knowing what to do, how to respond, and beginning to doubt himself. Several parents described the effects on their biological children, who resented the attention taken by the foster child and who at times had themselves been physically hurt.

As we discussed this list, several parents commented on how depressing it was. Then Arlene said: "but it is so good to know I am not alone in feeling this way." Several people said they could have written everything on the list. The parents felt that only others in this field could understand what it is like.

We then turned to the list of positive benefits. Many parents felt that they had become better people because of doing this work. They were more patient, more understanding, and more creative. They felt they had become better parents to their bio children. In fact, many also felt that their bio children had become better people because of the foster children. Repeatedly people spoke of how much it meant that your life had a purpose, that you were doing something very important, that you were making a difference in a child’s life.

The positives do not take away the negatives. They are both real. It is through the intensity of the work that personal transformation happens.

Again and again the parents said how important it was that they could talk about the affect of the work on themselves, with people who understood.

We have to make sure that it is not sixteen more years before they get another opportunity to do so.

Thursday, July 01, 2010

Born for Love: Why Empathy Is Essential--and Endangered

Book Review

Born for Love: Why Empathy Is Essential--and Endangered

Bruce D. Perry, Maia Szalavitz
William Morrow (April 6, 2010)

Bruce Perry’s new book focuses less on therapy and more on society. The book is a plea to us all to fight the many threats to the development of empathy in our children, and a passionate description of why empathy is essential to all human life.

From birth, when babies' fingers instinctively cling to those of adults, their bodies and brains seek an intimate connection, a bond made possible by empathy—the ability to love and to share the feelings of others.

In this provocative book, renowned child psychiatrist Bruce D. Perry and award-winning science journalist Maia Szalavitz interweave research and stories from Perry's practice with cutting-edge scientific studies and historical examples to explain how empathy develops, why it is essential for our development into healthy adults, and how it is threatened in the modern world.

Perry and Szalavitz show that compassion underlies the qualities that make society work—trust, altruism, collaboration, love, charity—and how difficulties related to empathy are key factors in social problems such as war, crime, racism, and mental illness. Even physical health, from infectious diseases to heart attacks, is deeply affected by our human connections to one another.

Born for Love describes the conditions that are necessary to produce compassionate adults. Although Perry and Szalavitz focus on society as a whole, it is also interesting to consider whether we are creating those conditions within our treatment programs. For example, empathy is created through the mirror neurons. Because these parts of our brain experience what we see others do, the children we treat will experience our caring responses directly. When we realize that the brain develops what it needs to be successful in the environment it faces, it is essential that we pay attention to what creates success in our environment. Does the child have to be loud and in distress to evoke empathy? If so, the brain will develop more distress.

Perry and Szalavitz emphasize the importance of safety, and how living with danger inhibits IQ development, makes it harder to fight infections, and floods the brain and so makes learning harder. This puts even more pressure on us to make sure that our treatment environments feel safe to the children who live in them.

We feel more empathy for those we think are more like us, for those who are part of "our group" and less for those we label "other". We are vulnerable to the influence of our group. What can we do to create a sense of belonging in our places? Rituals and rhythmic sharing help.

When children watch television and other media, they hear human voices but have no response to their own actions or talk. TV thus in some ways is a "frozen face" as in the famous experiments, in which a mother’s frozen face leads to escalation and then retreat in her baby.

Perry and Szalavitz report on how studying the hierarchical structure in baboons can illuminate our own response to leadership. The higher the perceived danger, the more likely animals are to blindly follow the leader. The larger the status differential between leader and follower, the more distress is seen in the follower. Sometimes depression becomes an adaptation to low status- a resignation to the impossibility of effective action. How does this relate to what happens between the youth in our programs?

Iceland, Perry and Szalavitz report, scores highest of all countries on all measures of happiness and social health. They attribute this to such factors as maternal/paternal leave and good child care but also to a feeling in that country that “We’re all in it together”. There are fewer difference and power differentials and more social cooperation. How can we develop communities like that?

In conclusion Perry and Szalavitz state that humans have a fundamental yet developmentally vulnerable capacity for empathy. In order to maximize it we need to practice love. We know that kind social contact relieves stress, and that developing empathy and relieving stress decreases both social and medical problems.

Do we practice love and offer kind social contact in our programs?

Sunday, June 27, 2010

Rituals of Passage

In Risking Connection© training we read a letter from a woman who grew up in the child welfare system in the 19950s. She was asked by her therapist, Dr. Kay Saakvitne, (one of the RC authors) what she would want people who worked in that system to know. In her letter she speaks eloquently of the lack of continuity when one is moved from place to place. It is very hard to develop a secure sense of self when there is no coherent narrative of ones life, no pictures, no one to remember the various parts. People appear and disappear. They each say something different about who you are.

This letter makes me think about all the ways we create that narrative for our own kids: we tell them the story of how Mommy and Daddy met, of their birth. We describe their ancestors and say they resemble Aunt Jane. We say "all members of the… family always…" We remind our teenagers of embarrassing things they did when they were kids. When the kids are 57 they are still expected to display the characteristics that were assigned them at age 5.

The author of the letter implores us to ask our clients about their pasts in conversational ways, to help them construct their story. When possible, create a life book with pictures and mementos. When they have to move, explain why, give them time to prepare, and relate the new place to the old- for example, point out both places on a map.

What can we do to help the child put her time with us into her story? One residential (Sunrise, Kentucky) reported some interesting rituals. One is to create a memory box for a child when they arrive. During their stay put in souvenirs, mementos, pictures. When they leave, add messages from staff and kids and send it with them. Another site described a ritual in which they buy the child a necklace. They pass the necklace around to each child and staff, and each states a wish which they are attaching to the necklace to go with the child.

What hello and goodbye rituals does your program do? How do you create a sense of meaning and continuity for your kids during these crucial times of passage?

Sunday, June 20, 2010

Dilemmas of Trauma Informed Care

Our difficulties in treating Mario exemplify some of the key dilemmas of trauma informed care.

Let me introduce you to Mario. He is twelve years old. He experienced severe early abuse including repeated violense both between his parents and directed towards his siblings and him, and has lost his entire family. He has been ejected from three foster homes. His IQ is low average, and his mother may have used substances during her pregnancy with him. He has been in residential treatment for a year and three months.

During the first few months of Mario’s placement, he destroyed a lot of expensive property at the agency. He trashed the gym, broke windows, destroyed a part of the school, and more. After each event he was deeply ashamed and further confirmed in his sense of himself as a horrible bad boy. He would hide under the furniture and refuse to talk with anyone. When he was not upset, he could describe some strategies he could use when something went wrong. But when something did go wrong, and it was often something very small, his emotions would well up and completely take over his mind. A staff member says that he has to wait ten minutes before going to dinner. Mario becomes overwhelmed with a sense of total hopelessness. He knows he will never eat again. His mind becomes muddled and he is unable to think. He is plunged back into his basic reality in which his needs are never met, no one can be trusted, and he has to fight for anything he gets. So he reacts- he throws something, breaks something, threatens someone. Anyone around him would be bewildered. What happened? Waiting ten minutes is no big deal. They try to explain this to Mario but he literally does not hear them. Mario’s pain gets worse and he tries to express and escape it by increasingly aggressive actions. Finally, he is contained and the storm passes. Afterwards, he feels worse than ever.

Elliot is Mario’s team mate (child care worker with a special relationship with and responsibility for Mario.) Elliot is a caring young man, and he sees Mario’s shame and pain. He works hard to form a relationship with Mario and not to give up on him no matter what he does. When Mario is calm, he and Elliot have some great times together. Elliot is proud that he is able to connect with this difficult child, and thinks that their relationship may be part of the reason that Mario has gone a month with no major episodes. Yet, yesterday Mario got into a minor argument with a peer that rapidly escalated into violence. When Elliot tried to intervene and get Mario to take a walk with him, Mario looked at him blankly and said: "I don’t know you. You don’t know me." Elliot felt hurt.

Over all Mario’s behavior improved, his property destruction decreased, and his episodes became further apart. The treatment team members were proud of what they had accomplished, and Mario himself was feeling more hopeful. So he was referred to a therapeutic foster home and began to visit a family. Almost immediately the aggression returned. After several episodes the family withdrew from consideration.

Now, Mario appears to be regressing. He has become aggressive towards people instead of just property. He has had several major, dangerous high-end events. He was hospitalized, and did well in the hospital. Staff felt hopeful and lifted all his restrictions when he came back. As one person described it: "We gave him a blank slate and he smashed that slate into pieces." Staff have noticed that he acts worse when there are fewer staff on duty, or when the shift workers are all female. Shortly after coming back Mario went on an agency trip to a baseball game. On the way back he got into such a major unstoppable fight that several policemen and supervisors needed to intervene. At this point, the team is investigating transferring Mario to a longer term hospital program.

It is always painful when we are not successful in our treatment of a child. When we have been working with relationships, with our hearts open, it can feel personally distressing. We doubt ourselves and wonder if there is more we could do. We feel hopeless for this child, and perhaps less hopeful about our work in general. In short, we feel much the way the child feels.

So how do we react to our pain? And how do we understand what is happening with Mario? It is easy to begin seeing Mario’s behavior as intentional: "he waits until staff are vulnerable and attacks." It is natural to think punishment would help: "he needs to go somewhere where he will get serious consequences for his behaviors. We are being too nice to him. He needs to understand that in the real world he cannot get away with these sorts of actions." It feels like Mario is uncaring: "We don’t have a relationship. When he is upset he does not even know me. He never seems to consider the needs and feelings of anyone else." A common reaction is to retreat, to treat Mario with distant politeness, and stay emotionally closed. It is natural to feel angry, betrayed, sad and hopeless.

Mario may need to be in the hospital. In a hospital adults can physically keep him and others safe using tools residential does not have (high staff ratio, locked doors, etc.) He probably did well in the hospital because right now he needs the feeling of safety that a hospital provides.

Yet I think it is important to re-consider what is going on here, no matter what the outcome. Here are some points for thought:

Mario is not deliberately planning his aggressive outbursts. When he says he is going to try some strategies, he means it at the time (just as I mean it when I say I am starting a new diet on Monday). When he is connecting with adults, he is not planning to trick them. When the chemicals in his muddled brain are calm, he can enjoy other people and plan a different future.

Mario is not looking for times when staff are vulnerable due to less people or all females on the shift. It is possible that at these times he feels less containment and safety, and thus more anxious and more vulnerable to over-reaction when something goes wrong.

I do not think that punishment will help Mario change this behavior. Of course punishment will make him feel worse and more shameful. Yet will it be a deterrent? I do not think that Mario would have access to an awareness of consequences when he is agitated. If he did remember them, he would not care or might feel that they would be just what he deserved. I honestly do not feel that when his brain chemicals are raging he can think to himself: if I do this, I will be in trouble so I shouldn’t do it. Unfortunately I do not think he can even remember: if I do this, Elliot will be disappointed. Instead he already feels that he is totally in trouble and already feels that Elliot is disappointed, or couldn’t possibly be trusted to like him. So what is there to lose?

I also think we overlook the role of stimulation, even from positive events. Staff were being caring and compassionate when they decided to bring Mario on the trip. However, it is possible that the excitement of the trip, although a pleasant experience, was too much for Mario. Keeping his world small and predictable might work out better.

What does Mario need? He needs to be kept safe so that he can experience positive relationships over a long period of time. He needs to learn and practice concrete steps he can take when he first starts to feel upset- and the first step is to realize when he is getting upset. He needs experiences of success and positive action. And he needs some hope- some pathway towards growing up outside an institution, some adults who will love him and stay with him.

These are all things that are very hard for our system to provide. And the pain of this situation leads Elliot to wonder: "Is there any hope for Mario? Are there some kids who never change, and who are destined to spend their lives in jail?"

Can a twelve year old be hopeless? That is a crucial question for us all.