Saturday, February 09, 2013

Evolution in Thinking

Long post- please read and comment.

I would like to write about the way my thinking has changed over time about what we like to call “behavior management”, I am referring to treatment programs in which, in addition to providing treatment, staff have to respond to behavior that hurts others. The idea hopefully is that we respond in a way that helps the youth decrease such behaviors. This applies to any group care program, such as a hospital, a residential, a day program, a special ed school, an after school program…in short, many programs.
First of all, I wonder if we could invent another term. What could we call our attempt to change behavior in the day-to-day setting: behavior support? Learning to be kinder? Any thoughts?

Anyway, once upon a time I worked in a traditional points and levels residential treatment program. In fact, when I first got there it had points, level, phases, and many punishments. The most severe was called “Sub” level because it was below all the other levels. As I recall it involved spending days in a small room without stimulation. The kids were supposed to be thinking about what they did wrong and how they could do better. They weren’t.

I began to have thoughts about this being a bad plan. One of many issues was that when one kid hurt another kid, the victim looked to staff to punish the hurter. No learning what so ever about how to work things out with each other. And we were punishing the kids by ordering them to do things they couldn’t do, like stay in their room quietly for hours. When they popped out trying to re-engage staff, we would order them back in and restart their time. It was the whack-a-mole method of discipline.
We were telling the kids what not to do, but we were not teaching them what to do instead. We struggled to consider things like the function of behavior.

Even in those dark ages, we had wonderful staff who cared about the kids and who formed strong relationships with them. But this was harder when you had to rate their points every half an hour, which took quite a bit of time. And like every place else, we had our own elaborate jargon, which the kids picked up quickly. The behavior management system became the way we talked. Instead of asking “how was your day?” we asked “How many points did you earn today?” When a child became agitated, staff would often react by telling them the consequences that would occur if they kept that up or got worse. They would not ask what was going on. We were embarrassed when we told an outside consultant that our kids earned up to 180 points in school, and he said “You do know that Marcus can only count to 8?” Consistency was highly praised, although rarely achieved. There was no room for individualization.

My colleague Leeora Netter and I, as well as some other Klingberg staff, began to learn about attachment and trauma. We discovered and learned from Daniel Hughes. We knew that what we were doing was not sufficiently healing. And yet everyone was doing some version of the same thing. We had no idea what to do instead.
A neighboring treatment center, Wellspring in Bethlehem CT gave us our first glimpses of alternatives. They gave us ideas as to how to include making amends and learning skills into our responses. They served a different population, so we had to modify their methods, but they were invaluable in getting us started.

So, we began to invent a system that responded to behavior that hurt others in a new way. We wanted to incorporate the concept of making amends from the Restorative Justice movement. We wanted to include skill building, and incorporate an understanding that the kids were doing these things for a reason. In the lives of the clients there had been trauma, attachment disruptions, and neglect and we wanted to understand how that history influenced current actions. We felt our responses had to be individualized. We tried to get away from time-based restrictions and move towards restrictions that ended when a child had made amends and was cooperating with the program. We called our new system the Restorative Approach©.

This was a hard sell. Staff were sure that chaos would break out as soon as we lifted long punishments.
I made a huge book of worksheets and tasks, organized by type and origin of problems. We needed concrete tasks to replace our punishments. This led to kids basically being sent to their rooms to do worksheets. They were allowed to “work off” their earned punishment time by doing tasks. But the tasks had to take as long as the punishment would have. I began to see that the tasks were being used as punishments in disguise. Staff without realizing it believed that the tasks would work by being aversive, the way punishments do. That was not how it is supposed to be.

We were lucky enough to encounter the Risking Connectionâ foundational trauma training. This gave us the language and theory that we needed behind the Restorative Approach. I now believe that it is very hard if not impossible to implement a new way of acting in the day-to-day program without extensive teaching of theory. It is hard enough to make this change. Without changing how you understand the behavior, it is impossible.
Later we became a training center for Risking Connection. Gradually this way of thinking made more and more inroads into our daily life. There were so many ups and downs- but that is another story. But mostly when I heard a kid yelling in the front hall I would NOT hear someone say “you are earning out of bounds time and won’t be able to…” Instead I would hear them say:”What’s wrong?”

So at this point I was advocating that when a youth did something that hurt others, we assign them a restorative task. I suggested that the task contain two elements. One was the learning element. This was supposed to help them explore anything about the behavior, with the idea of helping them learn not to do it again. I had a lot of ideas for this, from research, to role plays, to interviewing others how they handle similar dilemmas, etc. The second part was the making amends part. That involved figuring out whose life they had made more difficult and do something to make their life easier. Here, too, we had a list of suggestions. The underlying idea of making amends was to teach the youth that if they hurt a relationship, it could be mended. They did not have to give up.
It is important that the response should arise from the case formulation. What had happened to this child? How did we understand his current behavior? What did we think was needed in order for him to change? And furthermore, that the response had to be individualized, based on each child’s needs and abilities.

As I trained treatment centers and people began to implement the Restorative Approach, some problems began to emerge. Most people saw the tasks as punishments in disguise. The kids would get task after task, and end up feeling as hopeless as they did with previous punishing systems. People often assigned tasks in a perfunctory way, using standard worksheets that had no relation to the child or her actions, or having everyone make a card for the person they hurt and apologize. The idea of the tasks having meaning was being lost.
Then, in a conference, I experienced an a-ha moment. After I presented on the Restorative Approach, a woman asked for my help. She said: “We have a girl in our program, Andrea, who is incredibly mean to others. She always says just the perfect thing to really hurt someone’s feelings. We don’t know what kind of Restorative Tasks to give her. We assigned her to research Martin Luther King Jr. and do an essay about him, because we thought he would be a good model for her. She did a very nice job on the essay. But she is just as mean as ever.”

That made me stop and think. We have to go back to our theory of behavior and our theory of change. Why do we think that Andrea is being mean to others? I don’t know her, but I will guess that it is because she feels horrible about herself, and wants to share that with others; and that people have always hurt her, she has not had any good friends, and so she has developed a self-protective strategy to strike first.
So what does this essay about Martin Luther King Jr. do for Andrea? This is exactly the sort of intervention I had been recommending, but I now feel that it misses the point. The essay teaches her that there are people who are good to others, and they can have a profound influence. But if Andrea takes this in at all, I doubt that she relates it to herself. If anything, it would probably be: “I wish I were a good person like Martin Luther King, but instead I am a rotten nasty person.”

Now I feel that our intervention has to be more complicated. If we have a theory that Andrea is being mean to others because people have been mean to her; is hurting others because she has been repeatedly hurt; is protecting herself from further pain, and is sure she cannot ever have real friends, what would the antidote be? It would be to be good to Andrea, to help her discover her own worth, to support her in positive friendships, and to give her experiences that show her (with repetition over time) that people can be kind.
What! My audience would say. Respond to her meanness with kindness? How is she ever going to know that you can’t just do this in the real world? She will get beaten up if she continues to act like this. When will she being to take responsibility for her behaviors?

Not only is this new thinking counter-intuitive, it is harder. Andrea would have to learn skills, and we would have to teach them to her. How do you make a friend? What can you say to people that isn’t mean? What is she good at, in which she can lead or teach others?

So am I saying that we ignore her meanness? Sometimes that might be a good idea. But when possible people can also speak from their hearts and say “that hurt my feelings, Andrea. I am much happier when we are having fun together so do you want to go for a walk?” Andrea’s mean comments are a sign that she is dysregulated, that she is scared. If adults can move closer to her at these times, be more affectionate, they will help her learn to regulate her emotions and not spiral far into her fear.
Another evolution in my thinking is coming to see fear everywhere. When our kids attack, insult, damage property, run away, they are afraid. They are confused and overwhelmed. They have no feelings management skills or trusted relationships to help manage their feelings. So they fall into deep pits of hopelessness. These symptoms are their way to climb out.

Another a-ha moment came when I was training at an agency, and during a kids pickup basketball game one boy was taunting another. The victim hit the taunter. (I wrote about this incident on 7/2/11.) The men in my training came up with ways they would handle this without hitting, and all agreed that in order to do so, one would have to have confidence. You would have to be sure that these insults were not necessarily true and didn’t represent the views of the entire world. How do we give our boys (and girls) the confidence these men have? Not by confining them to their rooms, and not, unfortunately, by having them write essays.
I came up with some questions to ask after an incident:

1.       What led up to the incident?
2.       What do we imagine the child was feeling?
3.       What do we want the child to do when he or she is feeling this way?
4.       What skills, knowledge, attitudes, beliefs…would the child have to have to act that way?
5.       How can we assist the child to take one small step towards acquiring what he or she needs?
So I was already getting too radical as I began to see punishment as largely irrelevant. Then I became involved in studying Bruce Perry’s new work on the developmental evolution of the brain. The most important part for me was the idea that for kids with early preverbal trauma, words didn’t reach the problems. Now I was starting to doubt the efficacy of verbal therapy, at least for some of our most damaged kids. Instead, I began advocating positive rhythmic play with an engaged happy adult. The template of relationships is also stored pre-verbally. So, if we engage in rewarding, repetitive play with our kids, we can reach both the reorganization of the body and the reprogramming of the relationship template.

What? These kids are so wild and crazy, so aggressive and destructive, and you want us to have fun with them?
I began to think that the most important job we have is to reprogram the relationship template. I draw on the words of my friend Martha Holden- the child care worker’s most important job is to make sure than child has a wonderful day. If what is practiced grows, should we help our kids to practice being happy? What if we believe that everyone, all of us, act better when we feel better- safer, more connected, more effective? Many agree with that statement but we do not act that way in our programs.

So now I am balancing at the extreme ends of these two continuums:
Do you think that most misbehavior is related to disrespect, disobedience, manipulation, selfishness….. or that it is related to fear, hopelessness, overwhelm and despair?

What do you think will be most likely to reduce hurtful behavior: is it rules, punishments, rewards, lectures…. Or is it love, fun, safety, and belonging?
You might think these answers are obvious, but our day-to-day actions show otherwise. And as my thinking evolves I am worried that people might think I am a bit nuts. Oh well there is no going back now.  I would love to know your thoughts on this journey and where you are. Just click “comments”……. Thank you.


Roia said...

Well, first, I don't think you're nuts, and I agree with you and appreciate your sharing how you're thinking has and continues to evolve.

Now, having said that, I don't have a lot of experience with kids; however, the adults I work with (who have a variety of intellectual and developmental disabilities) who have lived in an institution for the greater part of their lives struggle similarly. Trauma is a serious issue and safe attachments a challenge.

Your first question (way up at the top of your post) invited us to come up with another term to use to describe what has generally been called "behavior management" (which, I agree, is an awful term). How about calling it something along the lines of "listening, paying attention, and trying to understand". It changes the context entirely, and people hopefully no longer have to be talked about in terms of their "behaviors".

I am also in agreement with you that the root of most of our actions that hurt people, insult, disrespect, frighten, push people away and generally freak other people out is fear.

I believe your idea that we need to re-program the relational template is one that exists in the form of object relations therapy (which comes from the psychodynamic areas of thought). I don't know if you've read any of Dan Siegel's work, but he talks about neuroplasticity and helping people change their brains.

I have often said punishment clearly doesn't deter people from acting in unkind/hurtful ways, because if it did we probably wouldn't still need to use this method, because, presumably, if it were effective, we'd all be pleasant to each other.

I think safety is the first task of any form of therapy. If people are frightened (and we all are) then we can't make use of therapy or relationships. Safety comes from being consistent, present and knowing what the boundaries are. It also comes from being able to safely say "no" and having one's personhood respected.

You also mention love, fun and a sense of belonging. I think those are aspects of being part of an inclusive community- one that works to be self-examining and welcoming to all individuals. That, of course, also invites the ability of community members to ask themselves "what's making it hard for me to be welcoming to this person versus another person who I was able to welcome easily?" (and other questions along those lines).

That said, I don't think any of this work is effective unless we, as clinicians/supporters, are willing to do our therapeutic work as well. This type of heavy-duty, relational work affects us deeply, and in order to function most effectively, I think we also need to regularly examine and question our own beliefs, our ways of doing things. I think our willingness to do that and to own when we have made mistakes presents a powerful model for the people we are trying to pay attention to, listen to and understand.

Thanks for a thought-provoking post!

Patricia Wilcox, LCSW said...

Hi Roia,
Thank you for a well written and thoughtful comment Where are you writing from? It is my impression that the world of treating people with developmental disabilities is just beginning to think about the impact of trauma on their clients. Would you agree? Sometimes there can be a conflict between a relational treatment approach and the Behavioral Analysts that work in DD treatment programs. Do you find that? The more sophisticated Behavioral Analysts can incorporate trauma and internal triggers into their formulation. What are your experiences with this?
Thanks again for responding. Pat

Roia said...

Hey, Pat- I live in New Jersey. And your impression regarding the IDD world is correct. Some states/countries are more progressive than others. There are definitely some skilled and sensitive behaviorally-oriented clinicians who do, in fact take the whole person, along with their life history and their physical and mental health as the context within which they create behavior programs, but they tend (in my experience anyway) to not be the norm.

Frustratingly, most of the behavior programs I've read are largely focused on behaviors as being a function of the four basics (the attention seeking, task avoidance, etc. collective). Thanks to the work of people such as Nora Baladerian and Dick Sobsey, though (and I'm sure there are others, I just can't think of their names offhand) there is a lot more awareness these days of the prevalence and impact of trauma on people with disabilities.

As a music therapist (who uses a relationally-based approach) I feel lucky in that I have music to offer as an alternative means for hearing people as well as for expression. As you can imagine, it's particularly helpful in working with people who don't use speech. I often wonder how you verbal psychotherapists manage without music. :- )