Tuesday, August 30, 2011

Everyday Life through a Trauma Lens

Jenna’s mentor just called and her therapist, Eileen, is talking to the mentor before transferring the call to Jenna. But she can hardly hear what the mentor is saying because Jenna is banging on her door. “That’s my call!!” Jenna yells. “Stop talking with her!” This feels like the last straw to Eileen. Can’t Jenna just give her a minute? Jenna is always so demanding. Whatever she wants, she wants it now. She asks for the same thing over and over. If there is a delay, she becomes angry and starts calling Eileen belittling names. This makes Eileen less interested in doing whatever Jenna is asking for. Whenever Eileen is involved with one of the other girls, Jenna interferes. She doesn’t have any friends because she is just as demanding and bossy with her peers. Really, Eileen has taken Risking Connection© training and has been inspired to understand her client’s behavior as trauma related. This has helped her respond to Marcelis’s cutting, and Tenisha’s running away. But this constant obnoxious behavior from Jenna is something else.

Eileen has explained to Jenna that her insistence gets in the way of getting her needs met. She has reminded Jenna that she always keeps her promises whenever she can. But Jenna keeps being loud, demanding and rude. She is so self centered, thinks the world revolves around her and she should have everything her way. Maybe they should institute some kind of reward… Jenna could get a prize for polite behavior?

Stop! Just like when we consider the big symptoms (like self harm) let’s try the trauma lens on the everyday behavior that drives us crazy. So, as usual, we start by trying to understand WHY Jenna acts this way.

Every adult in Jenna’s life has let her down. Her mother has been in and out of her life, and in and out of drug involvement and treatment. When she stops using she and Jenna have some wonderful times. But when Jenna least expects it her mother disappears again into the drug world. This has left Jenna caring for her two twin younger brothers, although they are both in foster homes now. Earlier in her life Jenna fed, changed and played with them when her mother was not there. Jenna did her best not to share with anyone at school how bad things were at home, but despite her best efforts DCF became involved after a report from the twins’ doctor. Jenna didn’t fare much better in the four foster homes she has lived in. She experienced one episode of abuse and repeated interpersonal conflict leading to disruption. Jenna’s aunt Mary has been an important person in her life throughout all this. However, Mary too has vacillated about whether Jenna can live with her. Recently after a difficult visit she told Jenna that she cannot live there, and she has started proceedings to get custody of the twins.

Does Jenna act demanding because she thinks she deserves and should get everything she wants? No, she acts demanding because in her life she has never gotten anything she wanted, needed or deserved. Adults have not cared for her the way they should have. She has had to rely entirely on herself. The only way she has survived is through relentless demanding and grasping whenever she could. She does not trust adults, and there is no reason she should. Furthermore, underneath her bluster Jenna is sure that everything that has happened to her is her own fault. It is her fault that her mother went back to drugs, it is her fault that the twins were placed, it is her fault that her aunt doesn’t want her. So she is sure that if adults are talking about her, they are saying something bad. She knows that no one would want to spend time with her, or be nice to her, or take care of her. She will only get what she wrestles from the world.

So now that we understand Jenna’s behavior does that mean we just accept it? No. Jenna will not have a life worth living if she keeps alienating people by being demanding and insulting. So how do we proceed?

One idea would be for Eileen to begin exploring with Jenna how her ability to speak up for what she needs has been and is a strength. But I do not mean saying this perfunctorily and moving on to how she needs to learn to communicate better. I mean discovering times when Jenna saved herself and her twin brothers from death. Were there times when Jenna successfully helped her mother and brothers? Were there times when she got herself what she needed? Stay with exploring the strength Jenna has developed for a LONG time with no hint of wanting her to change. Communicate a genuine appreciation for a little girl who had to find a way to protect herself and her brothers because absolutely no one else was doing it.

Meanwhile, Eileen and all the staff can constantly validate the need beneath Jenna’s demands. Validate without adding “but you shouldn’t talk to me that way ” or “you can’t have everything, you have to think of others.” Instead say, “Jenna it’s hard when you know adults are talking about you, you are sure they are saying something bad. Jenna, you wish Marci could spend all her time with you. Jenna you want Shayna’s book so much you couldn’t wait and you took it.” A constant stream of validating the feelings beneath the words.

And we all should be as completely reliable and trustworthy as we can possibly be. If we have to change something, we should acknowledge it directly. And we should point out when we fulfill our promises, NOT with any implication that Jenna should have known to trust us. Just say: “Jenna, I said I would call your worker today. I did, and here is what she said.”

Is there any possibility that Jenna could use her ability to advocate for the good of others? When she is ready could she call (after rehearsing) a bowling alley and negotiate a discount for the program? Could she collect all the girls’ preferences for activities and present them to staff?

It would be great if Jenna could participate in a social skills training group, such as a DBT skills group. There she will learn interactive skills along with others, without reference to her particular issues.

And most of all, as Jenna feels safer, more appreciated, happier, more included, more trusting and more able to meet her needs she will be able to let her guard down and become more gentle. Then we may reach that miraculous day when Jenna says: “ I tried to talk to my DCF worker about a clothes voucher but it didn’t go too well. Could you help me figure out how to do it better?”

Sunday, August 21, 2011

Trauma Informed Foster Care

Foster parents are a precious resource in our child welfare system. They offer traumatized children what they need most: a loving family. The best thing that could happen to a child who has been wounded is to live with a family that loves him, accepts him, and sticks with him. Foster parents come into their role from all walks of life and for every possible reason. Every family constellation is represented. Some foster parents are relatives of the child, or have known him in some previous capacity. Many have experienced their own traumas and see providing foster care as their way to give back.

Being a foster parent to a trauma surviving child is quite different from being a staff in a treatment facility. You are in your own home, and there is no immediate backup. You may have other members of your immediate family present, such as your biological children. You are trying to integrate the child into your actual life, your extended family, your neighborhood, your favorite activities.

Child care staff in treatment programs are taught a method of interacting with children that is significantly counter intuitive, and is usually completely unlike the way they were raised. But they have a team, other workers, treatment professionals and policies to help them maintain these strange practices. Foster parents do not have any of these readily available. Instead, they have a chorus of extended family members and friends telling them they should be stricter and not let the child get away with so much. It is much harder to change one’s style of parenting in one’s own home where one has successfully raised one’s own children.

The most important gift that a foster family can give a child is permanency. The children are damaged by disrupting and moving over and over again. The education and support we give foster parents should be primarily aimed at giving them the stamina to stick with the child. Keeping these children is very difficult as they put the family through such extreme behaviors, all based on their own assumptions about relationships. Yet the foster parent has the most power to heal this child, but helping the child to experience pleasure and associate it with other people; and by building the child’s brain through rhythmic, repetitive, rewarding activities.

One of the most powerful determinants of how a family responds to behaviors is how they define them. For example, Natalie is a twelve year old girl who has severe difficulties at bedtimes. She was placed with the Bruce family, and they defined her bed time behaviors as defiance. They had told her to turn out her light and go to sleep, and she kept getting up. The Bruce’s case manager asked them to sit in her room, read her a story, and talk with her, and to give her a night light. Mrs. Bruce thought this was just being too indulgent; she would never let one of her own kids get away with this. Did Natalie have no respect for her? Besides, Mrs. Bruce said, she could tell that Natalie was enjoying her presence in her room. This was just rewarding bad behavior. The placement disrupted.

Then Natalie was placed with a single mother, Mrs. Harris. She immediately connected Natalie’s bed time behavior with her having been abused and left alone. She started using music to help Natalie fall asleep, and gave her a night light. They developed a bed time ritual that they both enjoyed which included reading a book and then singing a good night song to each other. These interventions did not make everything perfect and there were still many other behaviors to deal with. Buy Natalie gradually began going to sleep more easily.

When we train foster parents in understanding trauma, how it affects children, how it relates to their current behaviors and how they can heal, we offer them a new framework for understanding their child’s behavior. We help them not to take the behaviors so personally. We must stress that these behaviors are adaptive and reflect what has happened to the child. The child is doing the best he can, and will do better when he is happier, feels seen heard and connected, and when he feels safer. All our training efforts should be directed towards this end.

We are currently creating a training program for trauma informed foster care, and would love to hear from anyone who has any experience with this. Just click on the word “Comment”,

Sunday, August 14, 2011

Change a Brain… Change a Life….

We are beginning to implement some of Bruce Perry's new brain science on one of our units. This is a document I prepared for staff on that unit.

You are the most important source of change for this child. You can create this change through your every day relationships.

Your most essential job is to change that child’s expectations of relationships from:

Relationships bring me pain and can’t be trusted


Relationships bring me pleasure and can help me get what I need.

You do this by providing pleasurable experiences for the child, and participating positively in these activities. Since “what fires together wires together” the child will begin to associate pleasure with adults.

You make it possible for the child to get better at feeling happy, safe, noticed and connected by providing opportunities for him to feel this way, offering him opportunities to practice feeling good.

You have the chance to build the child’s brain and increase his bodily regulation by involving him in rhythmic, repetitive, rewarding activities. By establishing a rhythmic back-and-forth interaction with the child you form a connection and help the child take advantage of your regulation to build his own. In times of stress you can use this attunement and rhythmic interaction to help the child calm down.

Since this work you are doing is the most important work in the world; and since you can only teach the child to feel pleasure if you yourself are genuinely engaged; it is essential that the team take good care of each other and that each of us take good care of ourselves, including being aware of and sharing the pain of vicarious traumatization.

Sunday, August 07, 2011

Connection Post Discharge

I received a call last week from a woman who is a relatively new CEO of one of the agencies we have trained. She had discovered that her agency had a policy that clients once discharged are not allowed to have contact with the agency for two years. She asked if this seemed consistent with trauma informed care.

My answer is no. Why did we all have these policies once? The time frame may have differed… six months, a year… but contact and return visits were forbidden for some period of time. It was explained to me that contact was not allowed in order to help the clients form new relationships. If they had contact with their former treaters this would block the new relationships in their next setting.

We don’t apply these odd ideas to ourselves or our own children. If you start a new job are you forbidden to talk to anyone at your previous job? When your daughter goes to college do you forbid her to talk to any of her childhood friends, or to her family, in order to encourage the formation of relationships at college?

No, because in fact contact with existing relationships actually supports the formation of new ones. We are trying to teach these kids that relationships are worthwhile. How can they be if they must be arbitrarily severed? The old relationships help us feel safe and cherished, and give us the courage to connect with new people. They are there to offer sympathy and advice when things don’t go smoothly, and to encourage trying again.

I believe that kids should be allowed as much contact as they need when they are discharged, and their new placement should support and facilitate such contact. This applies no matter whether it was a positive or a negative discharge. The teams at the two places should work out a plan that they both support. It is especially important when discharging from a higher to a lower level of care. From their many years in the system our kids know how to get themselves back to a higher level of care, and they are very skillful at it. If the only way they can maintain their connections is through dangerous behaviors, they will do so. Instead, let’s set up many opportunities for the child to share with former treaters his success, his life events, and his new relationships.

Occasionally, but not often, an individual child who has been discharged will return to cause havoc. She will tell the current residents bad things about the staff, or offer to help them run away. Then individual plans can be made for that child, such as speaking only with staff. As usual, the team should consider what needs the discharged youth is trying to meet, and whether they can help her meet them in a more positive way.

One other caveat is that individual staff should not have contact with a client outside of the structure of the agency. They should not become mentors, friends or confidants with a child they treated, as this opens all sorts of opportunities for real or alleged boundary violations and moral dilemmas. And they should not friend former clients on Facebook or use any of the many ways technology enables us to keep in touch.

Clients should be redirected to the agency. They can call the unit or programs, come to visit, write letters. As they discover that people still exist and still care, they will have more courage to form new relationships wherever they travel.

How does your agency handle post-discharge contact? PLEASE click on “comment” and tell us all what you do and why, and share any experiences you have in this area. Thank you.