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.

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.