Sunday, February 27, 2011

Responding to Martin’s Threats

In his fifteen years before his admission to residential, Martin has been repeatedly abused by multiple people, including horrifying sexual abuse. When first admitted he was primitive and reactive, unable to trust anyone, easily panicked and always alert for danger. Whenever he felt threatened he lashed out, often physically. Gradually however Martin began to feel safe and was able to form some relationships with staff. His outbursts became less frequent and less severe, and he was more often able to participate in fun activities. He demonstrated an ability to draw and created some amazing cartoons. Both he and the staff are beginning to feel some hope for his future. He and his therapist are talking about a possible move to a group home or a foster family.
It was very discouraging then when the report came from school that Martin was suspended for threatening his teacher. He became extremely agitated, would not go to his next class, threw some books, and told the teacher that he was going to kill her with a knife. He was so intense that the teacher was frightened, and a restraint resulted.

What happened here? How do we understand this behavior? What should our response be?

Martin will not have a life worth living if he often becomes so agitated that he threatens to kill people, destroys property and disrupts whatever is going on. There is no doubt that we need to help him change this behavior. What is our most powerful strategy to achieve that change?

Punishment is the first idea that occurs to everyone. Martin needs to learn that he cannot treat people this way. He should be suspended from school for three days, and not have any activities or fun events during that period. Then maybe next time he will think twice before threatening someone.

But will he? In fact, the problem is that Martin cannot think once when he is agitated, much less twice. The punishment will confirm Martin’s world view: that he is a horrible kid who continually does bad things, and that the world is a place where he has no role, where people do not like or accept him.

Because Martin has formed relationships with his treatment team he was able to tell them several days later what had happened in this incident from his point of view. First, Martin is feeling anxious because discharge is being discussed. He is facing leaving the first place he has experienced any success and formed connections. That day, Martin was scheduled to go to art class. He had been dreading art since the last class earlier in the week. Martin has decided that the art teacher, Mr. Howard, is a homosexual. Mr. Howard has been very nice to him and encouraged his drawing skills. Martin has started to like Mr. Howard. Last class, while helping him with a project, Mr. Howard put his hand on Martin’s shoulder. Martin knows this is the first step towards Mr. Howard molesting him. He is terrified. The only way he can protect himself is to avoid art. But Miss Lesley, his home room teacher, didn’t understand this (nor did he tell her). She kept insisting he had to go to art. Martin was terrified and flooded with feelings of being small, vulnerable and powerless to prevent abuse. So he tried to save his life by threatening people and getting them away from him. He did not have to go to art or see Mr. Howard.

It is quite likely that throughout his life Martin will encounter situations that evoke his previous abuse and make him feel desperately afraid for his life. What do we hope that he will be able to do when this happens?

We hope that Martin will feel safe enough and trust someone enough to turn to them for help. We hope he will have one moment of realizing what is happening to him, one moment of considering that it may not be the truth that the art teacher is going to molest him, it may be related to his past. In that moment, he could say to someone: can I talk to you? I need help.

What would Martin need in order to do this? He would need to trust people. He would need to experience that the world has safety in it, that there are people who will not hurt you, that in fact people may care and want to help. And he would need to develop some self awareness so that he can recognize when he is having feelings related to his past and be able to stop for a moment and consider whether in this case the present is different from the past. This is a very hard thing to do.

When Martin is in the grip of panic related to his past abuse, the thought that he will be grounded if he threatens this person is of no use at all. His cortex (analytical thinking) is not available to him. Even if he could remember that he will be grounded (and he can’t) being grounded would be infinitely preferable to being molested by the art teacher, an event he sees as a complete certainty if he does not get out of going to art.

So what can we do to help Martin?

When he is not upset, his therapist and others close to him can talk to him about these things, teach him about trauma, and help him understand the connection between past events and current behavior. Together with him, they can mourn and deplore the horrible things that happened to him. And they can begin to identify the situations that are most difficult and most likely to bring up feelings of the past. Martin can begin to observe what the first signs in his body are that he is becoming upset. Staff can also learn with him what are the early signs of anxiety, and can identify them to him.

In the crisis, it would be helpful if someone noticed when Martin was beginning to be agitated. There are many more options if we catch this event when it starts and before it has escalated into a full meltdown. In either case, it is helpful if staff approaches Martin asking what’s wrong, what’s bothering you, rather than by telling him what to do. Martin will not be able to tell anyone what is really bothering him when he is agitated. Their faces (even those he likes best) will be the faces of his past abusers. So staff should employ any calming techniques they know. Can Martin go for a walk? Can he draw? Can he play basketball? Does he need to be alone, be with someone? There should be no focus at all on making him do the next thing he is supposed to do. All the focus should be on helping him feel soothed, accepted, and calm.

What if this doesn’t work, and Martin threatens or hurts someone? What can we do afterwards? Remember that once Martin regains his sense of being in the present he feels very remorseful that he hurt someone. He also feels more shameful than ever. So what can he do to make amends to that person? He can talk with Miss Lesley. She can speak from her heart, in a modulated way, and tell him how scared she felt. She can relate that to how scared he must have felt as a little boy when people threatened and hurt him. Together they can plan some strategies for the next time Martin feels scared. Maybe Martin can also do something to make Miss Lesley’s life easier, like clean up the classroom or do some other chore for her. And what about learning? Could Martin draw a cartoon illustrating how the world looked to him right before this happened? Can he start a comic strip about a boy who is learning that the present is different from the past, and make different episodes as the boy learns new things?

The theme here is that Martin will not be less likely to threaten people if we make him feel worse. He already feels about as bad about himself and his life as a person can feel. He will be less likely to threaten people if we help him feel better. He will be less likely to threaten people when he trusts them, feels safe, and is relaxed.

There is a particular opportunity in this situation. If Martin feels up to it when he is calm, it would be great for him to meet with Mr. Howard in the presence of someone he trusts. He could plan this in advance. And of course Mr. Howard would have to be comfortable and at ease in this discussion. Mr. Howard could assure Martin that he will never in any way molest him. He could apologize for putting his hand on Martin’s shoulder, and say that he did not realize how scary that would be for Martin but he can completely understand how it would be given Martin’s experience. He could say that he hopes he and Martin can continue to work together as he sees that Martin has a lot of art talent. But he understands that might be scary for Martin, so could they set up any plan for when Martin gets nervous? Maybe he can leave the art room and go back to home room. Or is there anything else that could help that Martin can think of? This conversation and their subsequent work together can become an extremely important corrective experience for Martin. Maybe there are people in the world that are friendly and want to help you and will not hurt you. This is what we hope Martin can come to believe.

It’s not that we are letting Martin “get away with” threatening the teacher. Punishment is irrelevant here. What we are trying to do instead is to use our most powerful relationship tools to help Martin learn how to identify and cope with his understandable panic responses so he will not feel his life is in danger and thus will not need to threaten others in order to save his own life. It is a long process, requiring many repetitions. We have already seen progress in Martin and with this awareness we feel hope for his happiness.

Sunday, February 20, 2011

Revolutionary Ideas about Treatment

In my last two blog posts I have written about incorporating the ideas of Bruce Perry and those of Risking Connection to create a new approach to congregate care treatment.

Let’s see if I can put this all together.

Foundational ideas:

1. Our children were injured early in their lives, therefore their lower brains have been damaged. This part of the brain is involved with bodily regulation, the calmness/alertness cycle, the danger response and the regulation of emotion. It has tendrils into all parts of the brain.

2. Early experiences create templates or patterns of relationships deep in the lower brain. These templates are what the person expects from relationships, their deepest assumptions about what kind of world this is and how people treat you.

3. Brains can change and be healed at any age, and it takes a lot of repetition.

4. Parts of the brain change only while you are using them.

5. Whatever you use in the brain gets stronger; you get better at whatever you do most.

6. Things that happen together repeatedly become wired together, associated with each other and thus in the future the presence of one evokes the other.

7. Human connection is in itself reinforcing because it stimulates our reinforcing brain chemicals. If a person gets inadequate supplies of the reinforcement of connection they are more vulnerable to other activities that stimulate these same chemicals, such as self harm, drugs and risky behaviors.

8. Because of early trauma, neglect and attachment disruptions the biochemistry and brain structures of our clients have been changed. They have become caught in the human danger response, which leaves them hyper-aroused, over responsive, and with difficulty regulating and relaxing. They may also have developed a dissociative, freeze response to stress.

9. Because of early unresponsive and/or abusive caretaking, the children have developed templates or expectations that people are not trustworthy, will hurt you, and do not care about your needs.

10. Change is possible through repetitive healing experiences.

11. People act better when they feel calmer: safer, welcome, accepted, competent and at ease.

What does this mean about what we should do in treatment programs?

Every person in the treatment program must understand that their first and primary job is to help the client feel better. What can I do today to help this child feel safer, more appreciated, welcome, noticed, connected? Feeling better, less afraid, less hopeless will free the child to take the risk of acting better.

Especially at the beginning of treatment, we must deliberately fill the child’s day with activities that are physical, rhythmic, and regulating. This would include rocking, music, drumming, dance, Wii games, throwing and catching a ball, etc. The non-verbal connection with animals is also healing. As the child participates in rhythmic activities his own bodily rhythms and cycles will become more regular.

These activities must be done with active, engaged, hopeful adults. Using the body activates the lower brain. Pairing lower brain activity with positive relationships will gradually change the template the child has about relationships.

Since whatever a person does, they will get better at, we should make sure our children spend their time being successful, having fun, and enjoying positive interactions.

We should make sure every child experiences many positive human connections throughout their day.

What are the program implications of this way of thinking?

We can be much more deliberate and planful about our use of recreation- both recreation therapy and all the recreation/ down time in the day in our milieus. We can make sure the activities are tailored to develop the brains of the children we have, at whatever stage they currently are, and are fun and interpersonally rewarding.

What about therapy? Do we no longer need it? Nothing could be further from the truth. In the early stages of treatment, the therapist can e primary source of reparative connection. He or she can incorporate these principles by having a rocking chair in their office, using art and music, walking while talking, and making sure the appointments are positive and fun. As the child feels safer and calmer, he or she will be more available for cognitive approaches. The cognitive part of the brain inhibits immediate action on impulses, and needs increased strength to successful do so. Any discussion, reading, talking (about anything, like sports or the weather) builds this brain skill. Therapy interventions such as TF CBT or Target are still very helpful, especially after the child has made some progress. Therapists can also incorporate these principles into group and family work. They can assist the family and child in engaging in joyful games that may heal the brains of both. Groups that cook, read and discuss books, do crafts, take walks can build all parts of the brain. And with the team the therapist has an essential role in leading staff to think beneath the behavior, consider how it is adaptive and plan how we can help the child meet his or her needs in a less destructive way.

And perhaps most importantly this theory demonstrates in a new, more urgent way the importance of taking good care of our staff. If a child is playing Dance, Dance Revolution and the staff is at the side of the room texting his friends on his cell phone, the child may be having fun but her templates about human relationships are not being changed. The template that people really don’t notice or care is being strengthened. As an agency we must prioritize keeping our staff happy, hopeful, engaged and energetic. The staff’s ability to offer warm, rewarding, joyful connections to the clients is ultimately the only tool we have to use.

What is your reaction to these ideas? Please click “comment” and share your thoughts.

Sunday, February 13, 2011

These Kids Will Act Better When They Feel Better

In May I wrote about what it would mean if we really believed that children will act better when they feel better, and discussed what "feel better" would really mean. Feeling better includes:

• Feeling safer

• Felling calmer

• Feeling more connected:

• Feeling better physically

• Feeling less shame

• Feeling more competent

• Feeling more effective

I am struck with the connection between this way of thinking and our understanding about how the brain changes. The brain changes in a use dependent way: what happens often is strengthened; what is not used withers away. What happens together is associated, which means that one thing evokes the other. Many repetitions are needed to change something previously learned or associated. We also know that human interaction is intrinsically rewarding, and that if humans do not have enough of this reward they are more vulnerable to seeking other rewards such as those available from cutting, drugs, aggression, etc.

We want our children to associate human contact with pleasure and help. We want them to experience that life can be a fun, positive rewarding experience. We want them to know that when difficult things happen, you can turn to others for help and use your own skills to surmount them.

It is true, then, that our main function in treatment should be to help each kid have a great day. (Idea courtesy of Martha Holden, CARE project, Cornell). Because having a great day will establish new patterns and templates in their brains. Having fun with staff, repeated many many times, will begin to change their expectations of interactions with others.

I was talking this over with a friend, and he asked: does this mean we should just let the kids do whatever they want, and sit around and eat candy all day? No, it does not. For one thing, feeling better is a complicated phenomenon, and includes all the aspects above- so it demands many activities and challenges. Felling better necessitates lots of the delicious rewards available through social connectedness. For another thing, we have to consider the group. Each person has to have a great day in a way that does not impede the other people having a great day. And thirdly, there is the staff. In order for the child’s template of relationships to change, there must be a genuine, positive engagement with adults. To do this, staff must be feeling hopeful and caring. So promoting anything that hurts or pushes away the staff does not achieve our brain-changing goal.

Therefore, we should be discussing how to create a milieu containing the most possible highly engaged, physical, rhythmic fun for the staff and the kids. Now that would be an interesting treatment team meeting!

Sunday, February 06, 2011

Changing the Brain and Having More Fun

What do we know about how to change the brain?
  • •Brains develop and change sequentially. The lower part, which concerns the body, the danger response, and emotional reactions, develops before the higher part which involves words and analytical thinking.
  • Brains develop and change in a use-dependent way. If you use a part more, it gets stronger. If you dn’t use it, it withers away.
  • What fires together wires together. Things that repeatedly happen together get associated in the brain, and the next time one happens it brings up the other.
  • In early years of brain formation, patterns are set in to the brain which determine our assumptions and expectations of life. If a child is hurt by people in the early years, they expect people to hurt them from then on.
  • If you want to change a part of the brain, you have to use it. So, if you are talking, you are not changing the lower part of the brain. You are only affecting the thinking part.
  • Many repeptitions are needed to change a previously learned association or pattern.
 So what is the radical significance of all this for our work?
Our children in residential have almost all been wounded early in life, during the formation of the lower, bodily, emotional and danger response parts of their brains. And, the early patterns that they have established are that people hurt you and leave you. This is what we need to change, before we can work with the thinking, verbal part of the brain. We want to change their expectations of other humans. We want to pair human contact with positive emotions and good results, to undo that old pairing of human contact and pain.

In order to reach the lower part of the brain to change it, we have to engage it. And how do we do that? We involved the child in physical activities with movement and rhythm. These could include music, dance, drumming, rocking, swings, planting a garden, massage, shoveling snow. And, we pair these activities with positive interactions with other people. We make sure they are fun and engaging and done in connection with adults.

Do you see the implications of this? We have always maintained in our training that the daily life in the milieu and the relationships with the mental health workers are powerful forces for change. Now we can see even more clearly that having fun with the kids in physically engaged, active ways, is the very thing we have to do in order to change their brains. And now we can do this more planfully and with targeted goals.

Another implication is this. As we know, our kids are acutely perceptive about other people’s moods and emotions. This also reflects their earliest brain development. They had to develop this perceptivity to stay alive and anticipate the next dangerous event. So they will know if the adult is actually engaged with them, actually having fun and feeling positive and affectionate. If the adult is distant, sarcastic, punishing or distracted and texting on their phone this will not change the brain. In fact, this will confirm and further strengthen the patterns already established. So, in order to be successful in our change process, we need to take good care of our staff, so that they feel energetic, hopeful and available.

Isn’t this amazing? It turns out that having a lot of playful, energetic, engaged fun with the kids is the best thing we could possibly do! Get out that Wii and play Dance, Dance Revolution, and make sure the staff dance too, and laugh a lot…. Do it again and again. And you will be changing brains.

Wednesday, February 02, 2011


Recently our girls have been expressing their intense and unremitting pain. Latasha finds so many creative ways to hurt herself- she eats staples, bangs her head, and hits herself in the face hard enough to make herself bleed. Jessica is so sure that her family is blaming her for revealing her sexual abuse by her uncle that she tried to hang herself. Shahara ran away and tried to pick up some older men. Marguerita takes off her clothes and tries to scratch herself all over, and then she swallowed an open safety pin. We send them to the ER, they come back in a few hours. We surround them with caring, and they feel only despair.

These girls see no hope. They have no one in the world who they are sure loves them. They hate themselves and blame themselves for everything that has happened in their lives. They see no road to any positive future.

The staff and therapists feel a great deal of caring and compassion for these girls. And yet, their behavior is exhausting. It’s hard to believe that Latasha couldn’t just stop it. And we explained to Sharara the dangers in running away, can’t she see them? We are used to getting through crisis’s, but this unremitting repetitive anguish is so draining.

And the problem is that we don’t see any hope either. When Marguerita expresses her certainty that her life will never be better, we wonder if it ever will. And we can’t think of any concrete reassurance to offer her, anyone who loves her, any good thing that is coming soon.

We forget that we are the hope. What the girls need from us is not a specific reassurance that something good is happening. No, what they need is much harder to provide. They need us to be with them in their pain, feel it with them and not turn away. They need us to see their worst and not give up. They need us to care when they are hurting, and keep caring, validate their pain, and not be disgusted. This is the real, substantial gift we can give them. Hope is created when they experience the possibility of true human connection. There are people in the world who accept you as you are, care what has happened to you, and listen. There are people you can trust who do not hurt you. There are people with whom you are safe.

This isn’t the only thing we have to do in treatment. We also have to teach skills, calm biological activation and develop self worth. But it may be the most important.

So, we have to sustain ourselves and each other, because this is hard, much harder than giving advice or administering restrictions. We are doing the most important work in the world, and real engagement will transform both the girls and us. And what could be more hopeful than that?