Sunday, March 30, 2014

Compassion-Informed Care

One question I get asked a lot when I teach about trauma-informed care is whether this method is appropriate for clients who have not experienced trauma. One reaction I have it that it would be difficult to find anyone, including us, who has not experienced trauma. But putting that aside, I sometimes do regret the term trauma-informed care. Isn't what we are advocating here just good care? Let’s look at the concepts. It is my opinion that they apply to all effective treatment:
  •  A belief that the relationship is the key to healing
  • A conviction that symptoms are adaptive, so that the treater approaches difficult behaviors with respect and looks for how the behavior solves a problem for the client
  • An understanding of the role of the brain and biology and the ways in which development is shaped by experience
  • Empowerment and collaboration
  • Flexibility and individualization
  • A belief that change will come with learning new skills
  • Not relying on punishment and reward as tools of change
  • An understanding that the client is doing the best they can
  • An awareness of the whole body and the importance of non verbal healing activities
  • An understanding that the person will act better when they are safer, happier and more known
  • A deep conviction that the client’s behaviors make sense in view of their experience in the world
So which clients would this approach not be appropriate for? For that matter, wouldn’t it also be the best approach to staff, friends, ourselves?

I wish I could replace the term trauma-informed care with compassion-informed care. After all, compassion is also becoming a buzz word in our world. Would you like to join me in promoting this change? Let’s all begin referring to what we aspire to do as compassion-informed care.

Let me know in comments what you think of this idea.

Sunday, March 16, 2014

Consultation and Training

I am very excited about developing a new division of our training which will offer on line training and consultation. I want this new service to be exactly what you need. To make sure that I understand your struggles and triumphs exactly, would you be willing to take this on line survey? It is called The Joys and Challenges of your job and can be found at:

I would greatly appreciate it. It is short. It is in narrative rather than check boxes because I want to understand you with depth.

I am currently considering a model such as described below. Would you please click on comments and tell me what you think of this- would it be valuable to you? Do you think that you or your agency would purchase it?

An individual or agency subscribes for a specified time period.
During this time, they receive a certain number of training modules.
    Each module consists of a video, transcript, work sheet, and resources
    They are able to download these things and save them
     Topics for modules might include things like:
         How do you know if you are doing trauma informed care?
         A checklist of trauma informed practices
         What can administrators do to promote TIC
         How to formulate and plan treatment
          Maintaining a trauma informed focus in times of stress
          Responding to behaviors that hurt others
During the time period the subscriber has access to once-a week office hours where questions can be discussed.
Furthermore, the subscriber has access to email consultation through which the consultant answers questions and provides additional resources.
For agency subscriptions there are additional elements such as exercises to bring teams together, recognition of accomplishments, notification to administrators when some one completes a module, etc
During this time the subscriber also can join a private FaceBook group consisting of all the subscribers and thus belong to a larger community. This group continues after the time period is over. There is additional less intensive contact and resources after time period is over.   

I am eager to hear your ideas to improve this concept. Thank you for taking the survey and responding to my ideas.

Sunday, March 09, 2014

New Graduates

I am teaching a course at the University of Connecticut School of Social Work. I love it! About two thirds of the members of my class are second year students about to enter the world of job interviewing and jobs. I am interested in preparing them to interview better and enter their jobs with a semi-coherent theoretical framework. In other words, I would like them to be able to demonstrate that they have thought about their work! I often didn't find that when I was interviewing candidates for therapist jobs. When asked about their theoretical framework they all said they were eclectic. So I have developed the following exercise for my students to do to prepare for this question, and then plan to have them practice answering it.

Developing a Theoretical Orientation Statement

Complete these statements:

1.       I believe that people are…
2.       When people experience difficulties it is usually because…
3.       My reading/studying learning of…
has helped me to understand the following about the origins and meaning of problem behaviors:
4.       My reading/studying learning of…
has helped me to understand the following about how to help people change
5.       I believe that the most powerful methods to help people change are:
6.       When doing this work, the helper must:
Compose your answers into a short, coherent statement that summarizes what you believe and know.

What has been your experience with interviewing new graduates? What do you wish they knew or were able to articulate?

You can be sure that the graduates from my class know a lot about trauma, how it affects people, how people can heal, and how the treater needs to care for her or himself to remain alive and hopeful in this work!

Click on comments and let me know your experiences.

Sunday, March 02, 2014

Decreasing Scary Behaviors

Scary days at the Group Home
It is a difficult time in the group home. Sally, a new admission, has been terrorizing the place. She very skillfully causes commotion with all the other girls, making them mad at each other and at her. When they become angry, Sally is astonished and begins to escalate. In her agitation she has left the house in her nightgown and stood in the middle of a busy road, has punched a hole in the wall, hit her favorite staff Tina, cut herself and threatened suicide. The police have already been called three times and she has had one visit to the ER and she has been at the group home less than a month! The other girls are starting to deteriorate, and two of them ran away for a few hours the other night. The staff are very upset. They have begun complaining to each other that the therapist Melissa doesn't seem to know how to handle Sally. Some staff feel the director is being too indulgent with Sally. They say we should impose stricter rules and have stronger consequences for what she does. There is discussion that this is not the right level of care for Sally and the group home should return her to the hospital that she came from.

Sound familiar? What would you and your team do?

Why is Sally acting like this?
Is it because she is unclear about the Group Home expectations? Because she does not know that these kind of behaviors will get her in trouble? Because she does not care about other people? Because she is borderline, manipulative, or bipolar? Because she wants attention?

Sally is acting this way because she is terrified.

She has just moved into this home from a hospital. In many ways she feels more vulnerable. She is right in the town, no campus, no security guards, no gates. She had little control of which group home she moved to, or when, and feels that others are making all the decisions for her. In the past, when adults have made decisions it has not turned out well.

The home reminds her of other homes she has known- both in good and bad ways. She feels much more exposed. She doesn't know these people. She is expected to be more intimate with them than she ever was at the hospital. There is no place to hide. She assumes the girls will hate her and the staff will abuse her and leave her.

When Sally becomes scared, she becomes terrified. She has no one she trusts, so she cannot share her fears with any one. Her already agitated body becomes extremely tense and reactive. She cannot call on any memories of good experiences with relationships to smooth herself. Sally is so sure that she is a horrible person that she knows these new people will not like her and will hurt her. The best defense is a good offense. And Sally does not even recognize what she is feeling, she has no name for it. She does not realize that it is normal to be scared when you move into a new place. She has no ability to calm herself down or use strategies to get through this hard beginning part.

Sally has few skills. She does not know how to make friends. She does not know what to do when her body becomes agitated. She cannot catch herself when she first becomes upset, and she winds up tighter and tighter until she explodes.

When Sally feels hopeless, terrified and overwhelmed she does the best she can to escape these feelings. All the behaviors she displays immediately bring in extra resources and make the situation better. Sally has no idea of any other way to accomplish any relief.

Will consequences and rewards help Sally?
Punishments and rewards effect motivation. Sally wants to to do better. She wants to succeed here and get her own apartment, graduate from college and become a nurse. She just does not know how.

When Sally is emotionally dysregulated, the strength of punishments or rewards is minuscule compared with the mounting pressure of despair and hopelessness. They have no power to influence her behavior.

Punishments and rewards can actually make things worse, by increasing Sally's already strong sense of shame and unworthiness.

If we truly believe that Sally is doing the best she can, why would we punish her?

What will help Sally?
Sally will act better when she feels safer, more noticed and loved, more in control, and when she learns some skills. She will act better when she is happier.

So we can:
Normalize how hard it is to move to a new place
Help her test the safety and security of the Group Home, put her in charge of the locks.
Get to know her.
Do fun things together.
Help her gain control of anything in her life that she can.
Teach her feelings management skills and social skills.
Facilitate relationships with the other girls.

But you say, those are the kind of things we always do. They aren't working fast enough.

These interventions are the fastest and most effective ones there are. Sally won't change quickly. There are no shortcuts.

What can we as a team do to be able to offer the most healing treatment?
Talk to each other. Acknowledge how hard this is. Recognize small progress and special efforts. Plan fun activities together. Talk about vicarious traumatization. Make jokes. Remember other kids who came in snarling and got better. Pay attention when someone gets hurt or has a rough night. Be good to each other. Talk openly about rifts and disagreements that develop. Remind ourselves of Sally's history, and of how hard it has been when we ourselves have tried to change. Have a retreat. Don't work too many hours. Have regular supervision. Take a vacation. Dance together. Have fun with the kids.

There is no magic answer- but there is the possibility of healing
We do not have a system which will immediately result in Sally giving up the strategies that have allowed her to survive her difficult life. However, we have the immense power of love. And again and again we are privileged to create miracles of healing with the young people we serve.