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 (
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