Sunday, July 31, 2011


Someone I was talking with recently stated that even though he wanted to implement trauma informed care, his agency had to have a points and level system, because otherwise what is going to motivate the children to start doing good behaviors?

That is a good question. What does motivate the children to change?

I would suggest that there are a lot of built in motivations. These include wanting to be normal, not wanting to live in residential treatment, and the natural urge for mastery. Relationships are the most powerful source of motivation. Once a child feels that someone likes him, believes in him, and expects good things from him he develops a need to please that person and to live up to their expectations.

This goes back to the statement: children do well if they can. Children want to do well. Almost any child, if you talk with him when he is calm, will say that he wants to change, stop hitting people, stop cutting himself. It is not that he is not motivated. It is that he doesn’t know how. Our job is to teach him how.

But aren’t there some kids who do not care about relationships and do not want to do better? Don’t these kids need rewards and punishments to get them started towards better behavior? If I were to meet such a kid, I would wonder why. What has happened to this child that he has given up on relationships as the source of anything good? I would see my job as luring this child back into connection with humanity. What can I do to give the child an experience associating good things with other people? How can I change his templates of relationships, that is, what he expects from others? I would concentrate on providing him with as many positive experiences as possible and always have these be shared with adults. What fires together wires together, his brain would gradually, after many repetitions, begin to associate adults with fun.

I have to say I have come to see daily points and daily/weekly levels as completely unhelpful. To me now they seem to be the essence of not accepting where the child is and of being judgmental, rather than helpful. They increase shame, and the pressure to earn points may make cooperation harder.

Imagine you are trying to learn to drive a car. Although you have been around people driving cars all your life, you have never driven one yourself. You have an instructor. He tells you what to do (without many details of how to do it). And he sits there with a point sheet and rates your performance minute by minute by giving or not giving you points. You know that these points will determine what you are allowed to do that evening, whether you can watch TV or have to go to bed early. If you get all your points you will get a special treat but you know that is impossible.

Does this point system increase your learning? No, of course not. It impedes learning. It increases tension.

Instead, imagine the instructor is kind and gets to know you by talking a bit before each lesson. He carefully teaches you the steps in advance, and has you practice before heading out. He praises everything you do right. At the end of the lesson he congratulates you for your progress, goes over any issues that arise, gives you homework to practice and says he will look forward to your next lesson.

You find yourself wanting to please your instructor, and you practice diligently throughout the week. You are eager to show off what you have learned. You progress quickly.

Isn’t the second scenario closer to what we want to set up for our kids? There are so many powerful sources of motivation inside the kids and within the relationships we create with them. We do not have to rely on points and level systems which will in fact undermine learning.

Sunday, July 24, 2011

Self Awareness

Amazing as it is to believe, scientists have identified which regions of the brain are associated with self awareness. Self awareness starts with awareness of bodily sensations, such as hunger, thirst, tiredness, and pain. It includes being able to think about the self, form ideas of the self, notice patterns, and assign attributes. These functions seem to be set in the anterior medial prefrontal cortex. Not surprisingly, self awareness develops through interactions with an attuned other. The caretaker names experiences, assigns words to feelings, connects sensation with action and need with fulfillment. Through these interactions this part of the brain is built, and its connections with other regions developed. Therefore, it is understandable that psychological trauma, including attachment traumas, in the first year of life has been observed to negatively impact on the experience-dependent maturation of the circuits of the anterior cortex.

The children and families we serve who have experienced early trauma have an under-developed ability for self reflection. This means that it is hard to recognize one ’s self. It includes poor awareness of internal stimuli, including the inability to locate the source of internal pain and figure out what to do about it. Imagine that you feel hungry, but you do not recognize the feeling as hunger and therefore eat. You have not been taught by a caring other that this feeling is hunger, and can be satisfied. You are just aware of distress, and become increasingly cranky. In more complex interactions, you cannot identify how your own responses caused reactions from others. Remember, this is an actual inadequacy of one part of the brain. It can be seen in fMRI images and other brain tests. It’s not that you are refusing to understand yourself, its that you can’t, just as a blind person cannot see.

This deficit could be seen in a child not moving away from pain quickly, or appearing not to notice heat or cold. It could result in elimination issues, as the child doesn’t connect his bodily sensations with the need to find a bathroom. It could be a part of eating problems.

It seems to me that understanding this has implications for our constant desire that our children “take responsibility for their actions.” What if the child just does not have the requisite brain structures to be this self aware? Are we insisting he do something he is not capable of?

Luckily, the concept of brain plasticity reassures us that the self reflection part of the brain can be strengthened at any age. How can we help our children in this area? We can do what an earlier caretaker did not do. We can be alert to any signs of need on their part (hunger, pain, toileting, cold) and put it into words and help them immediately satisfy the need. We can avoid being judgmental about this, instead consider teaching much as we would teach them to read if they had never been taught.

An important way of helping is the use of narrative. We can help the children step back and formulate the story of their lives. This can be as simple as a quiet time at night re-telling the story of that day’s activities, or as complicated as a life book. A DBT chain analysis can be a way of creating a narrative of an event. A “Me Book” which illustrates my favorite colors, my favorite games, etc. etc with many facts about me is a way to create a self that can be observed by the self. We can be sure to take pictures, and say “remember when we went to the zoo, and you loved those monkeys?” Any time an adult creates a story about a child’s life she is helping him develop his self-reflective capabilities.

Like every other change we try to make, this change will be slow and involve many, many repetitions. And like every other change we make, it happens only in the context of attuned, engaged, enthusiastic relationships.

Sunday, July 17, 2011

Treatment Planning

I have spent the last week with a JCAHO reviewer who was conducting Klingberg’s Tri-Annual Review. After reading many treatment plans in many of our programs, I have decided to discuss them here.

We all know we have to do treatment planning. Why is this an important part of every program requirement? Treatment planning is designed to make us think about what we are doing in treatment and to proceed in a planful way. It forces us to consider what we are trying to achieve with this client, and how we will know if we are making progress. What will success look like? The planning process leads us to consider what change is necessary for the client to leave this particular level of care. Not be perfect, not have solved all his problems or worked on all his issues, but just to be able to step down to the next lower level. And when done right, the process includes the client and his family. How do they define success? What change are they looking for?

Treatment planning is the expression of a theory. The first part of the theory is: what has happened to this person, and how does that relate to his present problem behaviors? The second part is: what will help heal this person? As you write your treatment plan, you are expressing your theory of how events affect people, and what creates change. Your theory determines what you focus on, how you explain what is wrong, and what you propose to do about it.

For example, consider Jason. Jason was abused in his biological family and was removed from them at age four. He has been is five foster homes. He was removed from the second one because he was found outside at midnight and it was discovered that he was being neglected. In the fourth he was molested by an older foster brother. He presents with extreme angry outbursts whenever he cannot get what he wants right away. He often destroys property and has at times hit people. Afterwards, Jason avoids talking about these incidents and often blames the other person.

Suppose your theory leads you to focus on the fact that Jason has never received reliable rules and structure. He is used to taking care of himself. You learn that in his last foster home the parents often gave in to him to avoid his outbursts. You realize that Jason has never been able to accept adult authority. Therefore, you think that what will be helpful to him is a clear set of rules and guidelines. He needs to learn that you must follow rules and respect authority, or he will never get anywhere in this world. He needs to take responsibility for his actions. Therefore, the plan you create for Jason focuses on establishing strict rules and not backing down due to his tantrums. A behavior system that punishes and rewards will help. After any incident, Jason will be restricted until he acknowledges what he did and apologizes. He will be enrolled in an anger management group. In therapy, you will discuss any recent episodes and encourage him to acknowledge his part in them. Your measure of success will be that Jason can accept no for an answer without acting out.

On the other hand, if you held different theories you might look at Jason’s behavior through a different lense. You would focus on how the repeated trauma in Jason’s life had affected his sense of relationships, his biology, and his feelings management skills. You would assume he did not trust adults because the adults in his life had not been trustworthy. You would assume that he blames himself for everything that has happened to him and thus harbors deep feelings of shame. You relate this to his present response to not getting what he wants through understanding that a no to Jason feels like he will never get what he wants and no one loves him and this is because he is a worthless child. So, your treatment plans would focus on building trusting relationships with adults, learning how to calm his racing mind, and developing self worth through exploring his strengths. You discover that he likes to draw so one part of your treatment plan is art lessons. Your treatment plan also includes individual time with adults to build trusting relationships. In therapy you plan some psychoeducation on trauma, which you expect will lessen Jason’s self-blame. You will work with him to develop some things he can do to calm himself down when something goes wrong. You still measure success by the elimination of outbursts that hurt others, but your theory of what causes these outbursts and what will reduce them is different.

The treatment plan evolves from the formulation. The sequence should be:

Child’s history and experiences
Materials from other treaters and adults
History from family

Combine with

Program assessments
The child’s ideas
The family’s ideas

To create

The formulation, which connects the child’s past with his present behavior through a theoretical model of how inherited tendencies combine with experience to shape the person.

By considering the formulation, the therapist can see what the goals are: what changes will have to happen for the child to move to a lower level of care? What skills need to be learned? How will success look?

This understanding is broken into:

A description of the problem
It’s opposite, the goal
Specific measurable objectives which detail the steps that will lead towards achieving that goal
The interventions which will accomplish those objectives
The person responsible for each intervention

The objectives are another expression of the theory. If (as with Jason) we are working on decreasing shame and increasing self worth, we must consider what do we actually think decreases shame? Objectives could include helping younger kids in an elementary classroom, a leadership role on the unit, taking art classes and holding a show of his work, etc. These would express a conviction that positive accomplishments decrease shame.

It is tempting in our hectic lives to complete treatment plans without any thought, and use the same plan for many kids. Yet if we actually allocate time to think about them and discuss them with our Treatment Team, they can become an excellent tool for sharpening our thinking and our work.

I developed a library of treatment planning goals and objective that come from trauma informed practice. Feel free to email me at if you are interested.

Sunday, July 10, 2011

Ideas from Moving Forward Conference

I have just returned from the Moving Forward in Challenging Times Conference in Austin Texas. This SAMHSA funded conference focused on Domestic Violence and Substance Abuse programs, most specifically how they could work better together so the clients would experience fewer barriers. It was sponsored by Safe Place of Austin, an organization that provides direct service, prevention, and advocacy. The conference was very inspiring, and I wanted to share some ideas I learned there.

I was inspired by the participants at this conference. They approached their work from a mission base, a deep commitment to their clients. And they were working hard to change their programs so that any person would be welcome, there were no barriers to care, no restrictions to participation. This means that however a woman shows up, drunk, using, dirty, belligerent, whatever, she is welcomed with food, sleep and talk. They had carefully redesigned their intake and assessment to be welcoming, and not designed to unearth rule outs, but instead to help them be more skillful and individualized in the help they offer. They have tried to eliminate rules and recognize that their participants are adults. Instead, they have agreements that the clients make with each other. If one is broken, they discuss it. It seemed to me that they were trying to radically work from the premise that the woman is doing the absolute best she can, and their job is to help her do whatever she wants to do next.

Many of these programs use some kind of a crisis management plan, which in my program we call ICPMP. I was impressed with an idea from one presenter, Lourdes Carrillo. Instead of asking what helps you when you are upset and framing the discussion in terms o a crisis, ask questions to get to know the person. Like, “What do you like to do? How do you relax? How do you prepare for difficult situations?” and getting very precise. If the person says she likes music, what kind of music. If she says she relaxes by sitting on the couch, are her feet up or down? Does she like to have something to eat or drink? Water? With ice or without? All these details will be then available when she does get upset- staff can invite her to sit down and bring her some ice water. I think this approach honors the strengths of the person, and acknowledges that she already has many valid strategies for managing difficulties. And, it gives us a lot to work with when life gets hard.

Another interesting point I’d never thought of was in the area of confidentiality. When we say to clients that what happens between us will never be shared with anyone else, this may remind clients of when they were abused. It may sound to them like we are saying that what happens in treatment is a secret. They have already experienced too many secrets and they have usually included danger. Ms. Carillo suggested saying this instead: “This is your story. I am privileged to hear whatever part of it you wish to tell me. It is up to you who knows your story, so I will never tell anyone else whatever you tell me. You, however, are free to talk about what happens here to anyone you want.”

There was a lot of discussion of self care at the conference, including vicarious traumatization and ways organizations traumatize their workers. I was struck by the presentation of Karen Kalergis and Sapana Donde. They spoke of going beyond coping with vicarious traumatization to creating resiliency in our work force. They listed five core elements of resiliency: self knowledge and insight; sense of hope; healthy coping; strong relationships; and personal perspective and meaning. They shared strategies for increasing each of these. I was struck by how well this integrates with both the RICH relationships and our thoughts on addressing and transforming VT.

It is always exciting to meet new people and old friends, and to be re-inspired by the dedication and commitment of others. I could have done without being stuck in Chicago’s Midway airport all night on my way home, but otherwise this conference was a worthwhile experience.

Saturday, July 02, 2011

Basketball and Feelings Skills

Several boys were playing basketball outside their residential dorm. Marcus made a basket despite Jeff’s guarding him. Jeff began to taunt Marcus, saying the basket was luck, he didn’t know how to play, he was too short and too ugly. The insults expanded to include racial slurs and comments about Marcus’ mother. Marcus was flustered and missed his next shot. Jeff started to laugh. Marcus went over and punched him, hard. The staff stopped the game and brought the boys inside. Marcus and Jeff were bother restricted, and Marcus’ punishment was seven days of unit restriction because he had used physical violence.

This incident happened at a place I was training. This provided a great opportunity to put these theories into practice.

There were many men in the training, all shapes, sizes, ages, and races. I asked the men to consider that they were in a pickup basketball game with some friends and someone started insulting them, including using racial slurs. I asked for a show of hands of those who thought they could get through this situation without hitting anyone. All the men raised their hands. I then asked what they would do. Their answers included:

I would just stop the game and walk away.

I would say “hey, man, stop talking like that.” And if that didn’t work I would stop playing.

I would play better and better and wipe the person out in the game.

I would use that event as a reason to practice and make my game better.

I would remind myself that this was not very important; it’s only a game, who cares what he says.

Then I asked: what would you have to know, believe, or be able to do in order to respond like that?

After some discussion these ideas emerged:

You’d have to be confident enough of yourself not to take his words to heart.

You’d have to know you were getting upset and have some ways to calm down.

You’d have to have other good things in your life, other friends, other skills in order to know that this game was not that important and that it did not represent all of who you are.

What we want for these kids, what we are trying to achieve, is that they become these men. The taunts will always be painful. Anyone would be upset. But we want them to have what these men have- the skills that enable them to walk away and not hit someone.

And we also want to think about Jeff- how can he learn to handle someone else’s success or maybe even lose a game without resorting to racial taunting? Both the taunting and the hitting come from the same place: a deep feeling of inadequacy that results in this small game feeling like a measure of total worth.

So what will develop these skills? How can we increase confidence, self awareness, an ability to notice and modulate your own feelings, and the ability to turn bad experiences into motivation? Unit restriction will not accomplish any of those things, in fact may decrease some. Instead, if the boys do something constructive together (maybe raise money for some new sports equipment?) they will discover that relationships can be fixed, and that they have something to contribute to the world- whether or not they can always make a basket.