Sunday, November 13, 2011

Connecting Theory to Action

This is a long post that summarizes the way that the Restorative Approach provides a bridge between theory and action in treatment programs.

The Restorative Approach translates what modern science has learned about trauma and how it affects the brain into specific strategies for daily interactions with the children. The following points summarize the connections between theory and daily actions.

The Restorative Approach recognizes that a traumatized child’s brain is different, in that the prefrontal cortex is less developed. Because of that trauma-related difference, the child is easily overwhelmed by emotions. In treatment programs using the Restorative Approach, staff members understand that they will have to act as the child’s prefrontal cortex for awhile, teaching problem-solving rather than punishing a child for seeming to ‘choose’ to act out emotionally when the child is doing the best he can. The staff members’ brain building tasks include helping the child with selective attention, working memory, self-observation, and response inhibition. Further, the staff respond to the child’s emotional dysregulation with calming techniques rather than with thinking interventions.

A traumatized child typically has a strong, even over-developed, response to any situation perceived as dangerous. Using the Restorative Approach, staff members aim to soothe the child whose emotions are blowing up, to reassure him or her rather than get into a power struggle. The last thing a staff member trying to help an emotionally dysregulated child would do is back him or her into a corner. Instead, staff use soothing techniques when the child is upset. They teach uses of emotions and how emotions contain information, and actively teach self soothing. The staff provide and identify safety. One part of this is to talk before doing something, and to provide predictability. The program uses crisis kits and crisis prevention plans. Staff are aware that child will notice everything that they do, how they treat each other, their tone of voice, and their expressions.

Because of their focus on danger, the child may miss a large part of what goes on around them. Staff will have to coax child to have fun and point out joys in life.

Traumatic events that are experienced prior to the acquisition of language may return to the child as flashbacks, as though he were reliving, not remembering, the experience. At times the child may dissociate to manage the pain of his experience. Staff can teach grounding techniques that return the child to the present.

The physical underdevelopment of the child’s brain results in him having more difficulty accessing his verbal memory. Therefore, staff do not rely on verbal planning alone, and whenever possible use multi-model interventions such as charts, pictures, art, dance and music.

The child whose life has been unpredictable has confused, few or no regular bodily rhythms. Staff help develop bodily rhythms by maintaining predictable structures and offering rhythmic activities such as yoga and dance. The child also has an under-developed ability to sort out social cues, so staff are clear in communication and use simple language. They teach social interpretation through movies, books, etc.

Lake of early reliable care combined with trauma and attachment disruptions result in a child whose connection with his own body has not been reliably established. Therefore, he may have difficulty regulating their body functions. Staff can help through offering repetitive, rhythmic, rewarding activities to rebuild the lower brain, the part that controls the body. The child may have difficulty sleeping, so staff will not punish bed time problems, but instead look for ways to help child relax such as night light, reading, or music. Staff will therefore handle hygiene issues with sensitivity and understanding of complexity (symptoms are adaptations), not with consequences, and will find opportunities to teach healthy sexuality.

Because the child has had less attuned interactions, his brain is less integrated and he has more trouble with generalization from one situation to another. Staff therefore make connections explicit and specifically make comparisons between various aspects of life, distinguishing past from present. They give the child opportunities to practice new skills in many arenas and settings.

Children who grow up with neglect and trauma are not taught how to recognize or name emotions, so it is up to treaters to teach them the names of emotions and model healthy emotion. This includes the recognition of bodily sensations of emotions. The child may experience his emotions as moving from extremely aroused to extremely shut down quickly with no apparent rational. Staff can help child develop awareness of his own emotions and their stages, and develop tactics for each stage.

The hallmark of trauma is the victim’s lack of control. He cannot influence what is happening to him, and he is used to fulfill someone else’s needs. He is not treated like a person. After repeated exposure this powerlessness generalizes to all situations. The child learns that no effective action is possible in their life. Therefore it is important that treatment systems do not replicate this experience, and that they allow many opportunities for active participation in decisions involving the youth. They can also respond to problems by guiding the youth to fix damage they have created and repair relationships they have hurt. Because of this previous lack of control, the child may value control above all else. The program can give child control whenever possible, collaborate with him, and focus on him learning to control himself as opposed to staff controlling his behavior. Because control is so important, and lack of control is associated with victimization, the child may cover up vulnerable feelings such as fear and sadness. Staff can create safety to allow the child to share vulnerable feelings, and model having vulnerable feelings in a healthy way.

The child believes that everything that has happened to him is his own fault. To heal he must develop a sense of safety in which he can share what he finds shameful and receive compassion. Staff can also point out his strengths and achievements.

The child’s experiences have taught him not to trust adults. Programs can provide a different experience by being trustworthy, and by emphasizing trustworthy relationships. They can point out how present relationships are different from past relationships. The child expects the worst in relationships, and so may push people away. Staff understand the adaptive aspect of the child pushing the adult away, stay committed, and don’t pull back. They verbalize and validate the child’s fears.

The relationships in the child’s life have often violated his boundaries, involving him in adult problems and activities, requiring him to perform tasks beyond his abilities, causing him to be the caretaker of adults. Therefore the child is uncertain about boundaries and tests them. Staff can maintain firm yet flexible safe boundaries, be aware of the complexity of boundaries in child’s life, discuss boundary issues openly with each other and with children, and also seek supervision around these issues to identify their own reactions so that they don’t interfere with the work.

The child has not been taught how to handle problems in relationships. When he has had relationship difficulties, the other person has often just disappeared. He may have seen adults handle problems with drinking, drug use or violence. Staff has the opportunity to provide relationships that stick with the child. They can model relationship skills, speak from their hearts and share their own modulated emotional reactions. They can always address the relationship aspects of events, provide paths to work through relationship difficulties, and actively teach social skills. Since he does not trust others, the child may have trouble asking directly for what he wants. Staff can encourage direct communication and practice and model skills of making requests. They can say yes when possible.

Similarly, the child has not learned how to handle something going wrong without making it worse. Staff can teach distraction and calming techniques, help the child develop a list of tactics to improve situation, offer child alternatives, not consequences, when he is becoming agitated. and develop with the child a list of many positive coping tactics for handling pain.

Because of both his past and present situations, the child often feels hopeless. Staff can help through pointing out skills and gains. Also, they can teach and support the child in advocating for himself.

Working with children who have survived trauma, neglect and attachment disruptions caused strong reactions in all treaters. The trauma informed program is aware of vicarious traumatization, and imbeds in daily operations opportunities to discuss the effects of the work, care for one’s self and other team members, and encourages practices which promote vicarious transformation.

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