Sunday, June 23, 2013

Melissa's Depression

Melissa is depressed. She has begun hurting herself and has made a suicide attempt, for which she was hospitalized. Furthermore, she talks constantly about how unhappy she is. When asked about her day, she says it was horrible. She has difficulty participating in events. She looks sad all the time. Melissa says that her depression is biological and there is nothing that can be done about it. JoAnne, Melissa’s mother, is very concerned about her. When she visits her she asks Melissa constantly abbot her depression and her symptoms, trying to push Melissa to do something about her mood and start functioning again.
Melissa is in a treatment center to which she was admitted following her hospitalization for her suicide attempt. The team is very caring and compassionate, and they feel Melissa’s sadness. They are frustrated because nothing that they are doing seems to be helping. She is not getting better. Another troubling thing is that they do not understand why Melissa is so depressed anyway. Most of the kids they serve have been abused, abandoned, and uncared for. As far as they can tell, Melissa has had a fine life, and no one has reported any trauma. She lives with her two biological parents in the relative affluence of a suburb.

Melissa has described that suburb, Canondale. She says that all the girls in her high school are Canondale clones, with the same hairstyles, the same expensive accessories, and the same ideas. Melissa describes herself as having tried to be like them but failed. Then she realized the because she was depressed she shouldn’t even be trying to keep up. Depression means, she said to her therapist, that you don’t even have the energy to comb your hair.

The team has been doing their best to help Melissa come out of her depression, When she describes her day in negative terms, they ask her to make one positive statement about the day. They have taught her coping skills and encourage her to use them when she is feeling down (but she won’t). They have helped her to start a journal, but they feel impatiend with all the sad things she writes, so they have instructed her to write what is good about her life.

I would suggest that they take a different approach. Instead of fighting against Melissa’s depression, I suggest they help her explore it. Instead of teaching her coping skills I encourage the team to gently lure her back into life by inviting her to do things with them. Instead of family therapy being about reviewing her symptom, it can be about having fun together.

The first step is for the team to talk together about their feelings in this case. It is hard to be treating this girl who is not getting better. It is painful to experience with her the sadness that is getting in the way of her life. It is frustrating not to know a “reason” for the depression and to sometimes feel like she should just snap out of it and realize how good she has it. If the team acknowledges and shares these feelings they will be in a better place to move forward in a different direction.

If you are feeling sad, do you appreciate it if someone says “well tell me the good things about the situation”? No. Well neither does Melissa. As a first step, the team including the therapist should respond to Melissa’s statements of pain with active listening.

“So lunch was particularly hard for you today.”
“During free time you were having sad thoughts.”
“You feel hopeless and wonder if you will ever get better.”
“I feel sad when I hear you describe how hard that was for you.”
Validation. No push for change.

Melissa’s therapist, Tyquanda, can explore her experience with her. “So, what happened exactly? And what was that like for you? What did you do? What happened next?” No symptom or behavior changes by our pushing directly against it. That just solidifies the person in their position.

If Melissa brings up anything that is not specifically about being depressed, such as the statement about the girls being clones, Tyquanda could explore that. She shouldn’t jump all over anything outside herself that Melissa says, because that would frighten Melissa back into her depressive hole. Instead, be gentle. “What is the clone look in Canondale? What are the in brands? Oh really, I never liked Ughs… they don’t like ballet shoes? What are the ways to behave? Are there any other groups a person can belong to if they are not a clone?”

Let’s shift the idea of Melissa’s journal. The therapist or staff could write back and forth with her. If she writes about her pain, respond with validation and exploring. If there is something else you know about her, ask her about that: “Can you tell me more about your dog? What kind is he? How long have you had him?”

It is not important at this time to worry about why Melissa is depressed. It may be that she was feeling lost, unsuccessful and scapegoated in school and found this way out. There may be more to it. There may be biological components. We do know that there is a good reason; in other words, that the depression is solving a problem (or several) for her. And we also observe that the depression has now become her most successful way of connecting with people, including her mother. So, we try to limit pour interaction around either the depression OR ways to change it to brief validation statements. We try to engage with Melissa about anything else. In family therapy we talk about past family memories, present events, the weather. We don’t talk about activities (such as, say, knitting) as coping skills to be used to combat depression. Instead, we invite Melissa to join us in activities- “I’m going for a walk, Melissa, want to come with me?” We start a craft project next to her and invite her in. We invite her to join us in helping others. We especially try to engage with her (but not TOO enthusiastically) if there are any moments she does not seem focused on herself and her depression.

Melissa’s depression while painful for her, is also a friend, a refuge, a protection. She cannot give it up- or even allow it to lessen- until she is sure there is some other way for her to live in the world. Our job is not to teach her coping skills, or insist she make positive statements, or rehash her symptoms. Our job is to gently and compassionately lure Melissa back into the world. We hope to help her experience safety, connection and success.

Let me know you thoughts on this by clicking on “comment” below.






Sunday, June 16, 2013

More Staff Training Modules

Here are a few more training modules to use in staff meetings. These are meant to supplement more formal training, not to introduce new concepts. They are designed to be used in existing forums such as staff meetings or treatment teams.

Adapted from Risking Connection®

Teaching Objectives:
1.    Understand what feeling skills are
2.    Understand that they are learned
3.    Develop strategies to teach them 

Children learn feelings skills through attached relationships with care givers. All the thousands of times things go wrong (a child falls and hurts his knee) and the caretaker intervenes (here, I’ll kiss it and make it better) the caretaker is teaching the child something (love heals). Caretakers teach children to use connections, to feel they are worthwhile, and to identify, use and manage emotions. Our children have had inadequate care taking and multiple caretakers. Often their caretakers have been too absorbed in their own pain to help their children. So the children are not taught the skills they need. Since they don’t know how to rely on adults for help; and they don’t feel they are worthwhile; and the don’t have feelings management skills small setbacks send them into deep wells of intolerable feelings. These feelings are fear and hopelessness. In order to escape these feelings they resort to symptom behaviors, which help in the short term but have long term negative consequences. We cannot just order them to stop these symptoms. We have to teach them the skills to not need these behaviors.

Team discussion: 
What do we do now to increase the children’s ability to use their connection to us for comfort? How could we do this better?
What do we do now to increase the children’s sense of self worth? How could we do this better?
What do we do now to increase the children’s ability to identify and manage their feelings? How could we do this better?

Leader: Emphasize:
Feelings management skills are learned.
Our most powerful strategies for change are to teach feelings management skills within the context of attached relationships.

Teaching Objectives:    

1.    Understand the power of shame and how it influences children’s behavior
2.    Learn how to combat shame 

Shame is a major barrier to relationships. Shame develops because the child blames himself for everything that has happened to him, rather than blame the adults who he loves and upon whom he is dependent. The shame-based child is sure that any one who gets to know his horrible inner core will reject him, and hence relationships will only lead to pain. Shame leads to attack, to move away from others. Taking responsibility for ones actions is not possible when to do so means experiencing ones utter worthlessness.

Shame based children feel it is intolerable to be visible because of the hateful inner core they perceive within them selves. Their anticipation of rejection is so powerful they avoid connection. Any perceived incoming slight is quickly turned around to “kill the messenger” before the powerful shame can be felt. The inner parts of a child that try to protect him refuse contact with others because all contact is painful. He tries to send us away. The impulse of guilt is to reach out and repair…. The impulse of shame is to hide and attack…
The antidote to shame is sharing…To tell the secrets- what is shareable is bearable. These secrets may be specific events, but also may include how sad, confused, hopeless and vulnerable the child feels inside.

Shame Exercise

Team discussion:

What do we do in our programs that adds to shame?
            What can we do to decrease shame?
            How can we talk about problems in non-shaming ways?
            How does shame interfere with “taking responsibility for ones behavior”? 

Leader: Emphasize:
            The power of shame
            The healing power of connection 

Adapted from Risking Connection®

Teaching Objectives:
1.    Our interventions should be guided by our understanding of the client, their history and their current functioning
2.    Restorative tasks can be a way for the client to practice new ways of getting their needs met 


We know that all the behaviors we call symptoms or problems are solutions for the client. The client is escaping intolerable feelings by doing a behavior that helps in the moment, even though it has long term negative consequences.
Give examples, and ask for examples from participants, of things we do that help in the moment and have long term negative consequences. Example: smoking, over eating, shopping. Emphasize the point that they really do help, otherwise they would be easy to give up.
It is important to think about how a given behavior helps a client. That will give us many more creative interventions.

Discuss one or both of these scenarios


Jeffrey is an 11-year-old-boy who has a history of witnessing domestic violence and multiple separations from his grandmother who raised him.  Child protective services finally removed him from his grandmother’s care when they found for the 3rd time that Jeffrey was left alone at home over night.  He was referred to your facility for his explosive anger and defiant behavior.  Staff has noticed that Jeffrey becomes especially defiant during the evening routine – he often refuses to eat his evening snack, will not get into his pajamas, or brush his teeth.   Battles with Jeffrey that often include him pushing staff, spitting at staff, and restraints will often go on for over an hour.  Even when staff allow him to sleep in his clothes, he finds other ways to engage staff like banging his head in his room or playing his radio so loud it is disruptive to other kids.  Staff worked on a sticker chart to motivate Jeffrey to complete his evening routine. It worked briefly, but soon staff were having long arguments with him over the details of the sticker chart. 
            (Leader emphasizes Jeffrey’s fear of being alone and how actions keep staff engaged; mention how in old system we would give Jeffrey and early bed- how would that help?)
Alexandra is a 14-year-old-girl who has a history of trauma and several foster placements.  She has a history of self-injury and suicidality.  Staff has noted that in the last month she’s been opening up to a few of them in a new way that she has not before.  Last week, it was announced that one of the unit therapists (not hers) was being transferred to work in another program.  This morning staff observed that she was wearing long sleeves even though it was 90 degrees out.  When a staff asked why, she told her to “f__off.”  She eventually revealed that she had been scratching herself with a paperclip.
(Leader emphasizes how staff leaving reactivates Alexandra's distrust and fears, she cannot communicate this directly, she feels vulnerable because she had begun to trust.)

Leader: Emphasize:  

Understanding the meaning and function of the symptoms gives you many more options for intervention.

Please comment as to whether you are finding these helpful so I can decide whether or not to post some more. Thanks!











Sunday, June 09, 2013

Training Exercises to Use in Staff Meetings

In any sort of treatment setting, time is impossible to find. In a congregate care or school setting, someone has to watch the kids. In outpatient, there are those ever present billable hours to accumulate. Therefore, bringing staff together for formal training is often very difficult. And there are many demands on what little training time we have. So I developed these short exercises to teach one concept at a time. They are designed to be used in existing meetings such as treatment teams or staff meetings. They are designed to refresh or reinforce the concepts, not to be the main training vehicle. They provide guidelines for short team discussions of the ideas that support trauma informed care.

I thought I’d share a few here and more over the coming weeks. As you can see, the format is that the Leader introduces the topic, there is an exercise with questions, and then there is a summary. Each exercise should take around 10 minutes or so.

If you use any of these exercises in your staff meetings PLEASE comment or write me to let me know how it works out.
What Helps People to Change?

 Teaching Objectives:

  1. Understand the many factors that promote change
  2. Appreciate the role of relationships in facilitating change

Our job is fundamentally to help these children and families to change. Let’s spend some time talking about what we think actually promotes change in people, ourselves included.

Ask participants to think of something they have done (or still do) that has negative consequences that they have NOT changed. Examples would be smoking, drinking, over eating, not exercising, etc. Without asking them what the behavior is, ask what are some of the barriers to change?

Ask participants to think of something they wanted to learn and tried to learn and were UNABLE to master (such as tennis, knitting, anything that they tried but could not become good at). Ask for a couple of examples. What does that feel like? How would it affect them if someone offered to reward them for doing it? Or punish them for not doing it? What role does wanting to do it play? If they could ever imagine getting better at this skill, what would it take?
Ask participants to think of a time in their lives that they did successfully make a change- lose weight, quit smoking, etc. Ask for examples. What made it possible? What started their change effort? What factors made it possible to make the change at that time? What helped? Ask about the role of other people and relationships in making the change. Ask about some examples: if you are on a diet does it help to have another person remind you of it? If you go to a restaurant and bread is placed on the table, what is helpful for your companion to do? If you mess up and over eat, what response to you want from another? Note that different people want different kinds of support. What did you feel about having made this change?

How can you relate these insights to the kids making changes?


  1. Rewards and consequences are not enough, they only increase/decrease motivation- also need skills and support
  2. What part of change is influenced by self-image, hope, feeling a different is possible?
  3. The role of relationships in supporting change

Teaching Objectives:       

1.    Understand how trauma undermines the concept that one can take effective action to resolve problems and achieve one’s goals

2.    Identify opportunities within the program to allow the clients to practice effective action

Traumatic and neglectful experiences are characterized by the impossibility of effective action. There is nothing the child can do to change the situation and make it better. The child gives up on the possibility of effective action. The child does not learn how to solve problems, how to assert his or her own wishes, how to make up for wrong doing, or how say no. Therefore, the child resorts to more extreme measures or gives up. When the child does something wrong he feels that all is lost and often insists on leaving the program. He has no hope.      

Team discussion:

1.    What do we do that discourages or prohibits effective action?

2.    What do we do that allow the child to practice effective action? (Student councils, involving the child in treatment planning, peer mediation, etc.)

3.    How can we give the child practice in effective action, to heal relationships, correct mistakes, and accomplish goals?


1.    Why is it important to believe that effective action is possible?

2.    What would be the consequences of encouraging passivity?

3.    How can a child learn to stand up for herself in positive ways?

 Teaching Objectives:       

1.    Understand the human danger response

2.    Understand that trauma leaves children stuck in this danger response

3.    Identify strategies to help children calm down in times of dysregulation


The human brain responds instantly to danger. We do not choose to do this, it just happens, because when there is danger, we need to act quickly. We become hyper alert and focused on danger and safety. Our brain withdraws blood from non-essential activities such as digestion, and brings all the body’s resources to the muscles necessary for fighting or fleeing. Our hearts beat fast. One of the functions that is shut down is analytical thinking, because in times of danger we don’t need to think, we need to act.
In the normal course of events the danger ends and the person gradually relaxes. However, when a child is repeatedly faced with unpredictable danger beyond her ability to cope she becomes stuck in the danger response, and is always somewhat activated. This results in the child being overly reactive, concentrating only on danger and safety, and being unable to relax. Both sleep and play are difficult. When new things happen, the child often over-reacts.

A sense of safety is necessary before the person is available for connection.

Ask participants to remember a time they were in a near-car accident or otherwise faced sudden danger.

1.    What happened in their bodies?

2.    If they were sleepy, were they still?

3.    If they were admiring the scenery, were they still looking at it? What were they now paying attention to?

4.    If they were chatting with a friend, were they still doing so?

5.    What happened afterwards- how did they return to normal?

6.    How would it feel to be stuck in the danger response?

7.    In what ways do we observe that our children have difficulty with relaxation? 

What are the signals of physical and psychological danger in our treatment programs? What are the signals of safety?

           How can we decrease danger and increase safety?


1.    The human danger response is automatic.

2.    The child experiences more danger than she can handle.

3.    The child gets stuck in the danger response.

4.    The child can learn to recognize this and learn ways to calm herself without help.