Notes from the Trauma Conference: Emotional Awareness

I have recently returned from Bessel van der Kolk and the Trauma Center at JRI’s (http://www.traumacenter.org/) annual conference (https://www.themeadows.org/events/index.php?rm=event_details&param1=show&param2=27&). It is my second year attending, and again I found it a fascinating and rewarding experience. The overall theme was trauma and the body, with a heavy emphasis on understanding the brain, the roles of various parts, and the impact of trauma. The JRI group are becoming more and more convinced of the importance of including body work in therapy for traumatized patients, and have recently received an NIMH grant to study the use of yoga in trauma treatment. They also recommend EMDR, dance, drama, art and other non-verbal therapies.

One concept stressed by many of the speakers that seemed important to our work is the concept of emotional self-awareness. Regulation of emotions is not possible unless you are aware of emotions.

Trauma causes people to become disconnected from their bodies and numb to their emotions. People keep active, display symptoms, engage in risky behavior, all in the service of not feeling what they are feeling, as they only associate feelings with intolerable pain.

Lane and Schwartz have identified stages of emotional awareness- awareness of:
Physical sensations
Action tendencies
Single emotions
Blends of emotions
Complex emotions

The higher stages recruit higher levels of the brain.

Emotions are felt as bodily sensations. The vagus nerve carries information from the body to the brain, however it is two-way. Therefore you can change how you feel by moving your body. Thus the efficacy of dance and rhythmic movement in helping change our emotions.

How do we become emotionally aware? Through a securely attached relationship with other human beings. Through attuned interactions in which the other person names emotions, recognizes them, expresses them in sync but with a little twist. Through small ruptures in attachment which are soon mended. Through caring others connecting our bodily sensations with the names of emotions and with the suggested action steps. Through people validating our emotions, exploring them, paying attention to them. Through valued others taking our emotions- and theirs- into account when making decisions. Through these complex and oft-repeated processes, we develop the ability to notice our feelings, to name them, to reflect on them, to use our higher brain (pre-frontal cortex) to inhibit our immediate emotional responses when necessary, and to take effective action.

We do incorporate many of these processes in treatment. Most therapists have a feelings chart, for example. But I think we could be much more deliberate and conscious about it. If we understand that one of the basic problems our clients face is the lack of emotional self awareness, we can purposefully incorporate this training into all aspects of our interactions. This can be done through naming emotions we observe, validating, asking for the bodily sensation, teaching Wise Mind (DBT concept), feelings charts and thermometers, and many other ways. Treatment teams could discuss clients in terms of this skill (the first step in the Risking Connection® feelings management skill) and make plans as to specific actions to take for each client.

We cannot teach emotional regulation until the clients can recognize an emotion when they see one.

Feeling Sorry For Her

A central assumption of our approach is that symptoms are adaptations- these kids are doing these crazy things for a reason. The problem behavior is a solution for the child. It is accomplishing something, getting the child’s needs met, in the short term, even though there are longer term negative consequences.

In order to practice this thinking, we give training participants a scenario:

Alexandra is a 14-year-old-girl who has a history of trauma and multiple separations from her mother. She has a history of self-injury and suicidality. She has been placed in this home for six months, and her foster mother has noticed that in the last month she’s been opening up to them in a new way that she has not before. Last week, it was announced that one of the other kids in the home was going to be leaving to go to a group home. This morning her mother observed that she was wearing long sleeves even though it was 90 degrees out. When her mother asked why, she told her to "f__off." She eventually revealed that she had been scratching herself with a paperclip.

We ask people to consider:
What are 2 or 3 hypotheses about how Alexandra’s self injury might be adaptive for Alexandra? What problem (s) might it solve, how might it help in the moment, even though it leads to negative consequences in the longer term?

And then to:
Choose one hypothesis. If this hypothesis was true, what are possible ways the foster mother might help Alexandra to solve that same problem with fewer negative consequences?

In a recent training that I did, people responded (as they often do) "she is doing it for attention". So why does Alexandra need attention? (She may be scared of opening up to the foster mom and then possibly losing her as the other child is going to.) Why doesn’t she ask directly for what she needs, or express her fear directly? (She doesn’t know how, she can’t be that vulnerable especially now when the relationship feels tenuous.)

One participant added: "she just wants the foster mother to feel sorry for her."

Do you agree that the phrase "feel sorry for her" connotes an illegitimate need, something that she shouldn’t want or need? Doesn’t it imply that she is trying to get some kind of unwarranted or excessive response?

Also, this phrase implies that we should resist feeling sorry for her- and by extension resist coddling her, fussing over her, or being sympathetic. Yet some cuddling and caring may be just what Alexandra needs.

Of course, there is every reason to feel sorry for Alexandra, or to feel sorry about what has happened to her. She has had a very difficult life, and terrible things have occurred that were not her fault. Her basic needs have not been met. She has not been safe. These experiences have changed the basic biology of her brain. Her life has not included much relaxation and fun. She has not been taught that she is worthwhile, special, and that people love her. She has not been shown the feelings management skills she needs for life.

Yet when we say "she wants us to feel sorry for her" we are forgetting that Alexandra is doing the best she can, that her fears and needs are legitimate to her, and that she is using the only means she has to meet them. She will only be able to change when she feels safety within a committed relationship, and when she gradually learns new skills.

Although using the phrase "feeling sorry for her" seems like a small thing, it is important to stop and challenge ourselves. This phrase can lead to an entire attitude that will infect our response to the child and interfere with her healing.

Was He In Control?

Luke and Jason ran away last night. But they didn’t go far- they broke into the school and destroyed the kitchen. They broke several appliances, wrote mean things on the walls, and dirtied the place.

As staff discussed this incident one question that came up was: were the boys in control of their actions?

This often seems to be a key question for staff. It has many ramifications as to how they feel the incident should be handled. Although people do not articulate their assumptions, I think that they are:

The more we decide that a kid is "in control" the more we feel we should respond with punishment.

The more we think the kid is not in control, the more we can be understanding and respond in a more "helping" or "treatment" way.

Our sense of how "in control" they are is based on factors like whether they generally are psychotic, whether they appear emotionally dysregulated, whether the act is an impulse or planned, etc.

I think this is a false dichotomy.

First of all, I think we can all identify acts which require planning, but in which the person is not in control- compulsive sexual or other addictive behavior for example.

There is also a moral component here. The "in control" side includes elements of being deliberate, doing this on purpose to hurt others, and slides rapidly into labeling the boy a bad kid.

But most importantly- I don’t think that saying a child is "in control" answers any questions or even changes the questions.

Let’s postulate that those two boys had total control of their actions, planned this event for weeks (although in fact they didn’t), and were not apparently dysregulated at any time.

The question still remains: why?

With all that control, why did they choose this particular action? How was it adaptive to them? What needs was it meeting? What message was it expressing? What kept them from meeting those needs or expressing that message in a more positive way?
I would still assume that their attachment disruptions, lack of consistent positive parenting and early trauma is relevant to the needs they are meeting and to their inability to meet those needs in other ways.

And, I would assert that the response does not change. What would make a child be less likely to consider trashing a kitchen? After all, most kids don’t. Why not?

I think that this behavior would be less likely if the child:

Felt loved
Cared about some people and did not want to disappoint them
Knew that others expected the best from him
Expected that adults would most often meet his needs
Felt hopeful
Cared about the people who would suffer from his actions
Even knew that people would suffer
Had a sense of a future, of goals and a trajectory towards them that seemed possible
Had some skills to manage sad, disappointed, scared and hopeless feelings
Felt that he was a good person who doesn’t do things like this
Had a sense of belonging to a community and being responsible to that community

How can we increase these things? Mostly in day-to-day life, before and after the behavior, through all our treatment strategies which honor and build relationships, help children internalize relationships, increase self worth, and create feelings management skills.

But in response to the behavior? Will punishment increase or decrease these feelings and life assumptions?

Restorative tasks, making amends, working with people to fix the damage, and looking at what was going on will increase the above protective attitudes.

And the question of whether or not the boys were in control will fade into insignificance.

The Brain- Short Version

Brains are formed through interactions with others

The thinking part of the brain is formed through caretakers taking care of baby- organizing, meeting needs, creating a predictable life.

If these things aren’t done reliably, the thinking brain will be under developed, and the child will be more impulsive, less planful, and may have a learning disorder.

Through early attachment experiences the brain develops a template or pattern for how human relationships are going to be throughout life.

Events with a strong emotion attached are most strongly remembered.

The brain and body automatically respond to danger- alertness, focused attention, increased muscle tone, decreased ability to think.

If action is not possible body freezes, withdraws blood from limbs, releases opiods to prepare for injury.

Too much stress- the brain can get stuck in these modes.

When the brain is in survival mode, thinking interventions do not work. Thinking is shut down and not available.

Early positive attachment develops the ability to calm down, self sooth, and regulate response to danger. Inconsistent attachment leaves the person with less of these abilities. They are stuck in survival mode and their thinking brain is not kicking in to send safety messages or to realistically evaluate safety.

The brain can change and grow throughout life. It changes through use and attachments, especially through repetitive, rhythmic experiences.

What We Need to Know About the Brain

In order to offer the most complete healing possible to children with histories of trauma and attachment disruptions, we have to understand something about the brain, how it develops and how trauma effects that development.

Human beings develop through relationships. We have mirror cells in our brains that fire when OTHERS express emotions, creating similar emotions in us. This happens countless times between a mother and a baby. It is the basis of empathy. Human society is built on this interactivity, because relationships necessary for survival.

Infants are born dependent. Luckily, parenting is pleasureful. The infant associates touch with pleasure. She gets her needs met, gets relief from distress, which calms anxiety. Her brain develops a sensory pattern of human interaction associated with pleasure. A template is established. Thus our early experiences contribute the template: our definition of "normal".

Attachment and the Brain
Early attachment relationships sculpt the brain’s survival circuits and make them more or less able to regulate emotion when faced with stress. Secure attachment facilitates thoughtful processing, counters the survival-in-the-moment reactions to stress. We have evidence that loving relationships can help change the brain, regulate the amygdala and the survival-in-moment circuits. The nature of the child’s early attachment is etched in lower levels of the brain. Children respond from that place without awareness.
Although attachment is necessary for safety, humans are also our most dangerous predators. Therefore we are very sensitive to the moods, expressions, and gestures of others. Our stress responses very closely tied to systems that read and respond to social cues.

Principles of Neurodevelopment

The brain grows most rapidly from birth to age four. At 4, its 90 per cent of adult size.
Implication: The greatest opportunity to grow and influence the brain is with the developing child. This period also presents the greatest vulnerability to the destructive impact of threat, neglect, and trauma.

The brain develops from brainstem up to the more complex parts of brain. The primitive parts of brain are the most difficult to change (least plastic).
Implication: Change is possible, but is slow with early trauma. To change, we need repetition, repetition, repetition.

The brain neurons grow in a "use dependent" fashion. The brain sets down a "template" for how life is supposed to be and go. The brain and reacts particularly to any thing out side that template, anything new. To change a muscle through exercise, we must have moderate, repeated, patterned extra stress. Then the brain decides, oh, we are going to be doing this now, better develop some new muscle cells. It is the same with brain cells. The stress is a signal to the cortex- something new is going on here. Moderate stress is good for the brain and the body, it develops our ability to handle stress. However, imagine going to the gym for the first time and trying to lift 200 pounds. It would not build muscle or teach the body anything. You would hurt yourself. This is similar to the stress children receive from trauma.
Implication: Interventions need to be consistent, predictable, patterned, and FREQUENT. Kids with attachment problems need many, many positive nurturing interactions. The number of repetitions needed for change is so high that most adults become discouraged. We have unrealistic expectations about pace of change.

Trauma-related symptoms originate in brainstem and lower parts of the brain.
Implication: When brainstem-driven, the brain processes and functions differently (Perry, 2006). The child’s responses are mostly unconscious, old brain fear responses (not intentional). Cognitive, rational, highly verbal interventions generally don’t work. Conventional therapies will fail if the brainstem poorly regulated. Therapeutic interventions must influence the brainstem and lower parts of the brain.

The brain develops in sequential fashion from brainstem up to cortex. If a sensitive period in brain development is missed, may be hard or impossible to re-create later. For example, if a kitten’s eye is kept closed during a certain period of sight development, may never develop sight even if opened later. So traumas at different ages have differing effects depending on what the brain was working on at the time.
Implications: CBT, insight-oriented will fail if the brainstem is poorly regulated. Once the brainstem is regulated, the child can benefit from more traditional therapies. Just like healthy development, healing from trauma starts from the bottom up. The sequence of interventions matters. We must match interventions to child’s level of neurodevelopment. Examples of interventions to regulate brainstem are music and movement activities like dancing and drumming; EMDR; patterned massage; repetitive, consistent positive interpersonal interactions.

In order to develop, we need repetitive, patterned interactions. Rhythm is very important to human functioning. We need reliable internal cycles to sleep and wake, when to eat, heart rate, etc. The brain changes through repetitive, patterned activity. Rocking is a human comfort response, as exemplified by a person in crisis rocking back and forth or a chair.
Implications: Healing is facilitated by repetitive, rhythmic activities such as drumming, dance and music. Regular structured predictable schedules are also important.

Emotion is the central organizing mechanism of the brain. Humans are hard-wired to pay attention to sex and danger. Advertisers know this!

Although many things are learned through repetition, it is critical to our survival to learn quickly those things that led to negative experiences. We often must remember after ONE bad experience. We don’t have the luxury of taking many repetitions to learn that a snake can be poisonous. Intense negative emotions burn events in to memory.

Humans are programmed to identify danger. Some hard-wired danger cues are: darkness, sudden loud noises, and being alone

Humans are also programmed that comfort and protection is found in: closeness, rocking, and stroking. Note that many of these are found in sexual activity, hence the difficulty at times in differentiating comfort and sexuality.

Trauma sensitizes the nervous system. Extreme, repeated and intermittent stressors are the most likely to result in sensitization (although single stressors may also). When the nervous system is sensitized, relatively small triggers in the present cause extreme survival-in-moment responses. Children "make mountains out of molehills".

Extreme stress without control is the most harmful. This was shown in rat experiments- some rats were shocked when they pressed a lever (had control); some were shocked when the other rat pressed a lever (no control). The experiment found that animals who do have control developed strengths, those who did not developed ulcers, lose weight, had compromised immune systems, become more sensitized to shock, and couldn’t recover. Stress with control leads to habituation (developing new skills and coping mechanisms). Stress with lack of control leads to sensitization (disorganized intensifying response, immobility).

We now know a great deal about the functions of different parts of the brain.
Our brain has three tiers: the Cerebral Cortex (Human Brain); the Limbic System/Diencephalon (Mammalian Brain or Midbrain); and the Brain Stem and Cerebellum (Reptilian Brain). We can refer to them as the Old Brain vs. New Brain. The old brain is the lower order systems, which are responsible for survival. They develop first, and are located in the more primitive parts of brain like the brain stem. The new brain is the higher order systems. It develops last, and gives us our flexible adaptive capacities. It is located in the cerebral cortex.

The pre-frontal cortex is created by a caretaker doing cortex-functions (care taking, safety, meeting needs, figuring out problems). If no one is doing these things, the cortex will be under-developed. The cortex is responsible for complex thinking, analyzing, and using cognition to control emotional impulses.

The amygdala screens for threats, adds emotional valence to events, and activates the danger response when an event is a change from what is expected and appears threatening. It compares in-coming data with laid down patterns- asking one question- does this data suggest danger? It activates an immediate response while sending the information to the higher brain for further refinement. It makes the body become more alert and look for more information. It gets bigger when it is used more.

The hippocampus is involved with retrieval of verbal and emotional memory. It gets smaller as amygdala gets bigger.

The cerebellum is responsible for balance and rhythm.

Low Road vs. High Road of Emotional Processing (Le Doux, 1998, 2002)

"Traumatic stress is about "survival in the moment". The brain processes stimuli that are potentially life threatening and translates this perception into life sustaining responses." (Saxe 2006)

The brain receives sensory input into the sensory thalamus. The brain starts processing the stimulus in two ways, which we can refer to as the "ow road" and the "high road". The low road utilizes the more primitive, older brain; the high road uses the more complex newer brain.

The Low Road

Stimulus/Trigger sent to Sensory Thalamus then to Amygdala yields Response
VERY FAST

The Advantages of the Low Road:
It prepares body for an emergency response, and very quickly gives the organism info about danger. It is reflexive, unconscious, and does not contain contextual info. It sacrifices details for speed

Disadvantages of the Low Road:
It responds rapidly to incomplete bits of information. There is no context to the information. It facilitates memory storage in an incomplete way. This memory may produce flashbacks, which are "flashes of emotionally-laden memory." It leads to misperception of triggers and to overreaction, making mountains out of mole hills.

The High Road

SLOWER
Stimulus/Trigger to Sensory Thalamus to Amygdala and to Prefrontal Cortex to the Medial Temporal Memory System (Hippocampus) to the Sensory Cortex leads to a Response

A "Cognitive Wedge" is inserted between stimulus and response

Advantages of the High Road:
This type of processing leads to the most adaptive response in the moment. The high road pathway can maintain the low road survival-in-moment response if needed. With the help of our cortex (higher brain), we respond at a level appropriate to the level of danger. Determining the level of safety or danger via high road is also often unconscious and rapid. The cortex adds a context to the information, and (if appropriate) sends safety signals to the amygdala. The cortex facilitates memory storage in continuous complete way.

Parts of Cerebral Cortex Used in High Road Processing:
The sensory cortex retrieves and engages information from long term memories that contain experiences with similar stimuli (accurate perception). The medial temporal memory system (which includes the hippocampus) places the stimulus in the proper time and context. The prefrontal cortex puts information into the individual’s direct awareness for considered action to occur. The person inserts a "wedge of cognition" between the stimulus and the response.

What the brain does in danger (hyper arousal):

1. Focuses alertness
2. Shuts down cortex chatter
3. Becomes more vigilant and more concrete
4. Heart rate increases- blood sent to limbs
5. Focuses on social cues- is help available?
6. Muscle tone increases
7. Hunger/digestion disregarded

When unable to fight or flee, a person is left only with the option to freeze. If action does not seem possible, the brain sends a "freeze" response to the body. This response too is self-protective. This response is related to later dissociative responses. It is common in infants and young children. It is more common in females than males. It is driven by the most primitive parts of the old brain. In the freeze response, the brain prepares the body for injury. This response is also graded and occurs on a continuum. The person has a sense that time slows and what’s happening isn’t real.

In the freeze response (dissociation) the person:

1. Curls up
2. Makes her self as small as possible
3. Prepares for injury
4. Blood is shunted away from limbs
5. Heart rate slows to reduce blood loss from wounds
6. Body is flooded with opioids ("brain’s heroin") to protect against pain which produces a feeling of calm and a sense of distance from what is happening (Some times this can help with functioning, such as a soldier functioning without feeling)

Fight/Flight AND Freeze
In both responses, the person has their foot on the gas and the brake at the same time.

Some Clinical Implications
Fight/flight (hyperarousal) often looks like AD/HD, hyperactivity, oppositional defiant disorder. Freeze (dissociation) look like inattention, spaced out, defiance to adults because child literally cannot respond.
Both hyper arousal and dissociation help people survive trauma. Both can be harmful if prolonged and habituated.
Flash backs and re-enactments may be seen as an attempt to have small doses of trauma within one’s control to develop habituation or tolerance. However, if trauma is too much it cannot be mastered this way.

Our brains have two halves. The right hemisphere handles the gestalt, the big picture, and initial impressions. It is responsible for negative emotions such as anger and anxiety. The left hemisphere takes care of details and analysis. It holds positive emotions. Generally the left hemisphere is larger; in children with trauma histories the right is larger. The corpus collosum connects the two, and it is smaller in trauma victims. Therefore, they experience less integration and generalization in learning. For example, a child works on methods for not fighting with his room mate, but he doesn’t think to use these methods to avoid fighting with another person.
Humans are hard-wired to seek attachment, especially when danger is present. The primary goal of attachment for humans is safety. However, we cannot forget that one method of engagement is aggression and provocation.

If there are persistent stressors in the early years of life, neurons do not grow and connect in prefrontal cortex, less inhibition is available.

Less developed pre-frontal cortex leads to:

1. Short attention span
2. Memory problems
3. Distractibility
4. Impulse control difficulty
5. Social and test anxiety
6. Poor judgment
7. Hyperactivity
8. Lying
9. Problems reading social cues
10. Poor organization and time management
    

Terror early in life can shift person to a less thoughtful, more impulsive, more aggressive way of responding to the world. Thinking has been shut down too much just when it was time for it to develop.

The brain develops a template that danger is normal. This could also contribute to under-reaction to danger: since brain is particularly paying attention to what is new, what doesn’t fit the pattern, danger is not new to this brain.

Also, researchers have identified a kindling effect in which a trauma survivor over-screens for danger, over identifies threats. This interferes with reading social cues, distorts his perception of others.

People with "good enough" childhoods have arousal/relaxation cycles and know ways to calm down. Trauma survivors start at a higher base-line arousal, have rapid spikes, and rely on the external environment to help them calm down. This leads them to have to do something to draw in external control (i.e. cutting).

Trauma victims have 40% higher prevalence of learning disabilities especially language: auditory processing and expressive language (Receptive/expressive language disorder). This may be due to under-development of both the cortex and the corpus collosum.

Trauma Damages the Ability to See into the Future
The ability to calculate the potential risks and benefits of an action is a very important human function, and to children growing up in abusive households it is essential and life saving. However, due to the unpredictable nature of events, the over-exposure to danger, and the struggle to survive, this ability will be compromised. The child may both over and under estimate danger, and also may over and underestimate potential pleasure. They may not be able to see any future for themselves.

Healing From Trauma
Moving to high-road processing also depends on environmental interventions to help remove triggers (when possible) and reduce risk of continued exposure to trauma. In addition, the environment must provide the child many "signals of care", which work to counteract the "survival-in-the-moment" crisis mentality.

Selected Resources: Trauma and the Brain
Perry, B. and Szalavitz (2006). The Boy Who Was Raised As a Dog. New York: Basic Books.
Perry, B. (2006). “Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized Children.” In Webb, N.B. Working With Traumatized Youth in Child Welfare. New York: Guilford.
Saxe, G.N., Ellis, H.B., and Kaplow, J.B. (2007). Collaborative Treatment of Traumatized Children and Teens. New York: Guilford.
Vanderkolk, B.A. (1996). “The Body Keeps the Score: Approaches to the Psychobiology of Posttraumatic Stress Disorder.” In Vanderkolk et. al. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society.
www.childtrauma.org

How Will They Learn? What About Punishment?

Staff who are trying to work in this new way often raise this very legitimate question: if we don’t severely punish the kids for things they do wrong, how are they going to learn not to do them? They will be out in the world doing these horrid things and will end up in jail.

How are they going to learn?

Or, to put it another way, what are they going to learn? The idea of punishment is that a person will learn that when they do a certain behavior bad things happen, things they don’t want. So they stop doing that behavior to avoid those bad things.

Alan Kazden states that: "More than 50 years of good science tell us that punishment doesn't do much to improve behavior. Punishment doesn't teach what to do. It rarely succeeds even in teaching what not to do.
The misunderstanding and misuse of punishment go at the top of the list [of parenting misunderstandings]. For too many parents, trying to change behavior mostly means noticing what they don’t want and punishing it. Even if they don’t want to punish their child, they think it’s their duty to do so, but the research tells us that it’s not very effective. That’s because punishment doesn’t teach a child what to do, and it doesn’t reward the desired behavior, the only effective way to get the child to do it. Punishment also has bad side effects, such as increasing a child’s aggressiveness and tendency to avoid you, which can make it harder to improve his behavior. Research shows that even if punishment temporarily stops unwanted behavior, it will return at the same rate, or worse, in the hours or days to come. Your child’s resistance to punishment escalates as fast as the severity of the punishment does, or even faster, so you have to get harsher and harsher to achieve the same result.

Meanwhile, your child is learning all sorts of bad lessons ... Hitting teaches hitting as the way to respond to life’s problems; yelling teaches yelling; becoming angry teaches anger, and so on. Modeling is a very strong way to teach behavior, stronger than punishment, which helps explain why the harm you do with harsh punishments can multiply and last a long time. And, of course, punishing a behavior is still a form of paying attention to it, and any kind of attention can encourage your child to do something again. And yet, in many cases, even the most loving and conscientious parents think that they have to punish and punish to change behavior.

The research shows that punishment can be a small, effective part of a program that also features lots of positive reinforcement of the behaviors you desire. This kind of punishment is mild, brief, and sparingly used, and, if possible, it occurs when the behavior first surfaces, so it can short-circuit an unwanted sequence of actions before that sequence can get fully underway. Sometimes all it takes is a well-timed look or word to stop misbehavior. Technically, that look or word is punishment, or the threat of it. But parents typically wait until the misbehavior has run its course, then punish severely, frequently, and often angrily, and that usually doesn’t work."

(Alan E. Kazdin is John M. Musser professor of psychology and child psychiatry at Yale University and director of Yale's Parenting Center and Child Conduct Clinic. He is also president of the American Psychological Association and author, most recently, of The Kazdin Method for Parenting the Defiant Child.)

Mac Bledsoe, author of Parenting with Dignity lists these reasons punishment doesn't work:
“Buck Minor, the cowboy on our ranch, used to always say, "If you teach an animal a lesson by meanness or cruelty, don't be surprised if the animal remembers the meanness and cruelty and forgets the lesson.
1. Punishment removes the focus of both the "punisher" and "punished" from the behavior in question. When a parent resorts to punishment both the parent and the child begin to pay attention to the punishment, its fairness and its enforcement. This allows the child to stop thinking about the decision process that brought about the negative consequences.
2. Punishment focuses anger on the "punisher." When we resort to punishment it gives children someone else to be mad at or someone else to blame, and when they are mad they do not have to face their own behavior and consequences. The resulting anger interrupts responsible thought for both the child and parent. A child sent to his/her room will seldom or never think about how to behave properly but rather will think about how unfair his/her parents are or some equally negative idea.
3. Punishment induced behavior "extinguishes" rapidly. In the absence of punishment, the negative behavior returns. Behavior that has been shaped by punishment will disappear soon after the punishment has disappeared. It becomes a game of not getting caught.
4. Punishment traps the "punisher" into maintaining the punishment schedule. "You made the rules, now you must enforce them."
5. Punishment does not teach accountability. The "punisher" (parent) is responsible to see that the child's behavior changes. If you use punishment, by your actions you have accepted responsibility for your child's behavior.
6. Most of all, punishment denies a child the right to experience the real consequence of their actions. The reward for good performance is... good performance. Seldom is it necessary for us to provide the reward, and the same is true for poor performance. The punishment for poor performance is poor performance.
7. If you use punishment as a tool it may work to stop a particular action. If you send a fighting kid to his room he may have stopped fighting for the immediate present. Sometimes that is necessary to do. The error comes when we think that the punishment has taught the child what to do in the next situation. It has taught the kid NOT to do something, but it has not taught them what to do!"

Surely our kids have had a lot of experience learning that their bad behavior brings negative consequences. In fact, they blame all the awful things that have happened to them on their own bad behavior. Because of what a terrible kid they are, their mother left them, their father beat them, they were molested, they ended up in residential.

If negative consequences could change them it surely would have happened by now.

Why are they doing these destructive things?

Because they are over whelmed with emotion, over-reactive, and often in the pit of despair. Because they feel lost, alone, and terrified. Because they don’t notice their emotions until they are in the midst of a hurricane. Because they see danger every where. Because they don’t trust others and can’t ask for or accept help. Because they feel worthless, have no hope and nothing to lose. Because they don’t believe any one cares, including themselves.

Does punishment help with all this? In fact it makes every aspect of it worse.

So what will help? What do they need to learn?

That they are safe. That people can be trustworthy. That they are worthwhile and can have a meaningful future. How to identify and manage emotions. Ways to sooth and take care of them selves. That when things go wrong between people, the rift can be mended. And most of all, that there is someone who likes them, sees good in them, and will stick with them as they struggle to heal.

They will learn these things through relationships, not through punishments.

RICH Relationships with Each Other

A central tenet of Risking Connection® trauma training is that trauma survivors are healed through relationships, and that the characteristics of a healing relationships is that it is RICH- containing Respect, Information, Connection and Hope. In my most recent training we began to discuss the idea (which I strongly believe) that we cannot have any better relationships with the children than we have with each other. So we began to consider- what can we do to establish RICH relationships among staff on our teams?

Respect involves (among many other things) treating each other politely, listening, assuming good intentions, not talking behind people’s backs, discussing concerns directly, and not undercutting each others’ decisions.

Information could include sharing events and happenings, communication across shifts and among disciplines, teaching each other, not keeping secrets, sharing schedules, and discussing clinical events and formulations.

Connection can be formed through social and fun events together, pot luck lunches, sharing stories about our lives, discussing common interests, sharing our emotional reaction to the work, and laughing together.

Hope can be created through pointing out small gains and changes, remembering other clients who have succeeded, sharing small victories, and pointing out each others’ strengths.

When we began doing this exercise in the training, we made two columns: one, what can you do to create these things with the clients; two, what can you do to create them within the team. But guess what- the column merged because they turned out to be the same things! What we want and need from each other is exactly what the kids and families want and need from us!

Kevin Creeden at MASOC

As I mentioned, I presented at the Massachusetts Adolescent Sex Offender Coalition Tenth Annual Joint Conference on The Assessment, Treatment and Safe Management of Sexually Abusing Children, Adolescents, and Adults in Marlborough, MA. (http://www.masoc.net/)

I was lucky enough to attend a workshop by Kevin Creeden, M.A., LMHC, LMFT- Director of Assessment and Research at Whitney Academyan East Freetown, MA, an excellent speaker who I have seen several times.

Here are some of the points that Kevin made:

Important facts about the brain:

Children with trauma histories have fewer connections between their limbic system and their pre frontal cortex
The cortex is created by caretaker doing cortex-functions (care taking, safety, meeting needs, figuring out problems)

With psychological arousal the baseline heart rate goes up
There is constant scanning for threat

Cerebellum is responsible for balance, rhythm

Give infant rhythmic activities- rocking, structured activities, schedule
Rocking is a human comfort response (person rocking in crisis)

Amygdala adds emotional valence to events
Screens for threats

Kindling effect- trauma survivor over-screens, over identifies threats
Interferes with reading social cues, distorts

Humans hard-wired to pay attention to sex and danger
Hence use in advertising

Hard to extinguish

Hiking example- you are on a hike in the woods and you see something dark and curvy, it moves- a snake! All danger systems are activated. As you walk on and it slithers away, you see something else dark and curvy- you are on alert again! This time it is only a stick- but for the rest of the hike you over react to every stick.

Movie example- You are alone at home and you put on "Psycho" which you have seen many times before. Still, when he walks towards that shower curtain your heart races. After the movie is over, you have to go down to the basement and get the laundry. Even through you KNOW this was a movie, you put it in yourself, and you have seen it before, you are scared and on alert, and you run back upstairs and close the door. All night you are jittery and over-react to noises- and this after only two hours of something you had total control over and that you knew was not real. (Understanding does not lower arousal!)

Humans programmed to identify danger: darkness, sudden loud noises, being alone
PTSD produces constant danger signals- person may become immune; no longer differentiate real danger, under react (the body that cried wolf)

Humans programmed that comfort and protection is found in: closeness, rocking, stroking
Note similarities to sex
Can’t distinguish nurturing touch from sexual touch

Humans programmed to learn more quickly and more deeply, remember better, those things with strong affect, especially danger- you can’t afford many repetitions to learn that a snake is dangerous

"Normal" people have arousal/relaxation cycles and know ways to calm down-
Trauma survivors start higher, have rapid spikes, and rely on the external environment to help them calm down
Must do something to draw in external control (i.e. cutting)

In normal human relationships, attachment is the road to sexuality- we play monopoly, then we gradually become friends
In trauma survivors, sexuality is a desperate method for attachment- I don’t know how to start, form or maintain relationships so maybe if I have oral sex with you, you will play monopoly with me.

Right hemisphere- gestalt, big picture
Initial impressions
Negative emotions, anger, anxiety
Left hemisphere- details, analysis
Positive emotions
Generally the left hemisphere is larger; in trauma kids the right is larger

Corpus collosum connects the two- smaller in trauma victims
Less integration

Less integration and generalization in learning- child works on methods for not fighting with his room mate, doesn’t think to use these methods to avoid fighting with another person

We must actively teach problem solving, considering alternatives and pros and cons

Amygdala involved with fear conditioning, aggressive behavior, triggers fighting
Gets bigger with increased use

Hippocampus involved with retrieval of verbal and emotional memory
Gets smaller as amygdala gets bigger

When dysregulated, children are helped by slow, rhythmic activities not high energy level activities- yoga, tai chi, brain gym, walking, swinging hands, crawling, rocking, exercise balls, metronomes

Trauma victims have 40% higher prevalence of learning disabilities especially language: auditory processing and expressive language. (Receptive/expressive language disorder)

Often crisis plans and relapse prevention plans are cognitive and language-based, and also are avoidance based- what I am trying NOT to do instead of what I am trying TO do.

Emotion is the central organizing mechanism of the brain

The pre-frontal cortex controls emotional behavior through cognition
If there are persistent stressors in the early years of life, neurons do not grow and connect in prefrontal cortex, less inhibition is available
Less developed pre-frontal cortex leads to:
Short attention span
Memory problems
Distractibility
Impulse control difficulty
Social and test anxiety
Poor judgment
Hyperactivity
Lying
Problems reading social cues
Poor organization and time management

The primary goal of attachment for humans is safety.
One method of engagement is aggression and provocation
(A new way of looking at that awareness we have that for these kids, negative attention is better than no attention)

Sexual offending behavior is about trying to get your needs met in a relationship- otherwise, why not sit home and look at pornography on the Internet?

Healing comes through persistent attention to the daily task of caring

Need whole brain learning, concrete examples, pay attention to generalizing
Understand cannot learn in emotional situations

Incorporate movement

Primary treatment goals:
Establish safety and predictability
Deconditioning and decreasing anxiety and arousal levels
Altering the way victims view themselves and the world
(Van der Kolk, 1996)


Attachment exercises: (do 5X a day, 3-5 minutes at a time)
Mirroring
Reading facial cues- use movies, sop, ask: what was he feeling now? What will he do next?
3 leg races
Jump rope
Reflective listening practice
Passing rhythms around
Taking own pulse, finger monitors
Boundaries- hula hoops

I would highly recommend Kevin Creeden as an excellent speaker and great thinker in our field.

What’s Going on With Michael?

Michael is a fourteen year old boy who is living at a shelter home. He was brought there after his last foster placement, his fifth, disrupted. After nine months Michael had begun to think he might be able to stay with this family. But their bio son started playing with Michael’s game boy, they got into a fight, and somehow Michael found himself hitting the boy over and over. That was the end of that family. They say he can have another family if he learns to control his anger- fat chance that that will ever happen. So here he is at the shelter, and he has to admit it isn’t all that bad here. He has been starting to make a few friends at his new school. He had started to connect with Haley, a girl in his class, even thought they might get something going- how stupid of him. Yesterday she told him she wasn’t interested in him and he was a loser. So he came home in a lousy mood, and got into a fight with a staff member- that nice one, Alicia- over of all things cleaning up some soda he spilled. He refused to do it, it just all seemed too much. Then in home work hour he tried to drown out all of this with his music, but the dumb staff confiscated his radio. Finally he just crashed.

So now it is morning and here’s Alicia again waking him up in her cheery way. And he is still here in the shelter. And he is still himself. And she is reminding him that he has a restoration to clean up the kitchen before he goes to school. What can’t she leave him alone? He doesn’t really mean to start swearing at her.

FREEZE FRAME

We can talk abot how Alicia should talk to Michael, or about what his consequences should be, or about how she cannot let him speak to her this way, or how we have to be consistant and not let these kids get away with this sort of behavior.

But what will actually be healing to Michael?

Now- stop and think about your own life.

Imagine that last night you had a fight with someone you love. You awake today in a very angry and irritable mood. You stub your toe on the way to the bathroom and you can’t find your keys. The shirt you wanted to wear is in the laundry. Nothing is going right- and yet you have to go to work. And if you start swearing at people at work, your job won’t last long. What do you do to get yourself to a place where you can not only go to work, but treat the people there kindly?

Some people might pray, others meditatate. Some listen to music. Some deliberately compartmentalize ("I have to put this aside now; I can deal with it later.") Some talk about their difficulties with a friend before starting the day. Some remind themselves that all is not lost ("I’m sure Chris and I will be able to work this out, and the shirt I picked instead actually looks pretty good.")

What does Michael need in order to be able to survive his very real and serious difficulties with out making them worse?

He needs a sense that he is a worthwhile person who is having some problems, instead of his current certainty that he is a total mess with no redeeming qualities.

He needs to be able to recognize when he is upset, and to put words to it.

He needs some one he trusts with whom he can talk over his thoughts and feelings.

And he needs some strategies he can use to keep functioning when life is hard.

We can help him with this- we can notice the good in him, give him opportunities for competence, be delighted with his progress. We can name and normalize feelings. We can be that trustworthy person by acing in trustworthy ways. And we can deliberately teach him strategies, in part by modeling and naming our own.

So what should Alicia do in the moment of waking Michael? She should ignore his swearing, remain calm and gentle (not too cheery). She should note his mood and mention it gently: "I can see you are feeling a bit low this morning." She should provide any soothing strategy she can think of: "Maybe we can have some music on this morning as you get ready." She should not worry about needing to punish or correct or change him. She can instead concentrate on helping him feel better and calmer, and giving him some emotional supplies to bring to the day.

It is through these processes that Michael can heal and grow. The consequences for swearing are not our most powerful change strategy. Our most powerful change strategy is forming connected, calm relationships.

Thoughts from the MASOC Conference

Last week I presented at the Massachusetts Adolescent Sex Offender Coalition Tenth Annual Joint Conference on The Assessment, Treatment and Safe Management of Sexually Abusing Children, Adolescents, and Adults in Marlborough, MA. (http://www.masoc.net/) I highly recommend this annual conference to anyone with an interest in this subject. You know you are at a good conference when you can’t decide which of several interesting work shops to attend.

In this conference as in others I have attended I was struck by the convergence of thinking in our field. More and more treatment programs are learning about trauma and altering their approach to include that knowledge. There is increasing recognition of the bodily alterations caused by trauma, which can be summarized (and over simplified) by describing the trauma survivor as living in a hyper-aroused state. Programs are increasingly incorporating body-based interventions such as sensory integration, brain gym, bio-feedback and neuro-feedback. We understand we must actively teach the skills that the children have never learned: everything from establishing rhythms in life, to learning about personal space and touch, to self regulation, to social skills and working through relationship difficulties.

Programs are changing- adding body-based adjunct interventions, working more through art, music and drama, and providing skills training. I have come to see the Restorative Approach(tm) as a way of aligning our day-to-day operations with our current understanding of trauma. We understand more now about how trauma survivors live in a danger mode, and how when a person is in danger made they cannot think. Yet we run our programs based largely on cognitive interventions: discussing with the upset child the consequences of his actions; talking about safety plans and relapses prevention plans; explaining to the child how her life will go better if she stops hitting people.

The Restorative Approach(tm) utilizes our understanding of the brain through encouraging staff to simply help the upset child calm down, through listening, physical activity, distraction, sensory interventions, etc. Staff are asked to use their relationships with the kids to demonstrate coping skills, to use attachment to manage distress (as humans do) and to create new templates for the possibility of trustworthy help from adults. The child collaborates in developing a tool kit of strategies to manage their own symptoms. When something serious goes wrong, staff do not focus on punishment and thus increase shame. Instead they focus on the relationship effects and the possibility of redemption through making amends and working it through.

Our day-to-day interactions with the kids we treat provide our most powerful tool for healing. Let’s find more and creative ways to utilize what we are beginning to understand about trauma and the brain. Let our behavior management systems exemplify and make real our basic values. The system can recognize that the children are doing the best they can at any given time. We understand that they have been specifically wounded and have learned how to treat these wounds. Our children need healing through skillful training, interventions and love.

Conference Presentations

Are you attending the CWLA or BACW annual conferences? I’m presenting at both- come by and say hello!

CHILD WELFARE LEAGUE OF AMERICA NATIONAL CONFERENCECHILDREN 2008: A CALL FOR ACTION- LEADING THE NATION FOR CHILDREN &FAMILIES
FEBRUARY 25-27, 2008
MARRIOTT WARDMAN PARK HOTEL
WASHINGTON, DC

B2 Challenges and Rewards of Trauma-Informed Treatment
Room: Washington 5
This presentation explores the joys and struggles of implementing and providing trauma-informed, relationship-based treatment through Risking Connection, training, and the Restorative Approach model. It includes methods, common concerns and responses, indicators of trauma-informed
care, and agency/management strategies. Trauma-informed treatment provides better outcomes for children and better working environments for staff.
Presenter: Patricia Wilcox, Vice President of StrategicDevelopment, Klingberg Family Centers, New Britain, CT


BACW Annual Conference
Listening and Responding to the Voices of Our Youth, Our Legacy
Renaissance Harborplace Hotel
Baltimore, MD 21202
March 2-4, 2008

A-5 The Trials and Tribulations of Trauma-Informed Treatment
This workshop will present compelling evidence that treatment becomes more effective by replacing traditional systems with relationship-based approaches. The workshop will discuss specific training methods to enhance staff understanding of youth and trauma while suggesting solutions.
Moderator: Patricia Simmons, Philadelphia, PA
Presenters: Patricia D. Wilcox, MSW-LCSW, Vice-President Strategic Development, Klingberg Family Center, New Britain, CT; T’Kai Howard, MSW-LCSW; Coordinator Nia
Sage Therapeutic Group Home, Klingberg Family Center, New Britain, CT


See you there!

Inner Connection to Others

In Risking Connection® we teach that a childhood full of attachment disruptions and trauma impairs development of basic self capacities. Self capacities are those core skills that allow us to hold onto who we are no matter what happens, to survive adversity, and to handle what life brings us. Risking Connection® identifies three core self capacities: the ability to form and maintain an inner connection to others; the sense of being worth the air you breathe; and the skills of feelings management. These self capacities develop through connected, attuned relationships with others. When a person does not have a chance to develop these skills, all set backs large or small throw them into extremes of intolerable feelings. They do these things we call "symptoms"- hurt them selves, hurt others, retreat, to escape the intolerable feelings because they know no other options.

The skill of "form and maintain an inner connection to others" is often mistaken for the skill of just making a connection with others. Our kids are not good at making connections: they do not trust, they have been hurt, they protect their hearts. They often do not know social skills of conversation and reaching out to others. They are scared by being close. Just making a connection with them is often hard enough.

But we must go a step farther. In order to survive life, we also have to be able to keep a sense of our connection with others even when they are not physically present. Even when we are alone, we must be able to remember (and actually feel) that someone loves us.

Inner connections with others are formed through repetitive, trustworthy, dependable attuned relationships with loving others. With our own children we work hard to create inner connections. When we will be away from them, whether for a school day or a longer trip, we write notes, call, leave pictures, leave presents, use many rituals to covey: even when I am not with you, you are in my heart and I love you.

The kids we work with have not had this care and constancy. And in fact people have disappeared from their lives unexpectedly. Others have not acted lovingly towards them.

But why is it so important to have inner connections with others?

If not, whenever you are physically alone, you will feel desperately and completely alone. And scared.

When someone leaves work for the weekend you will be certain that you will never see them again.

When something goes wrong, you will not be able to tell yourself: that’s okay, my mother still loves me.

When some one treats you badly you will not be sure that anyone will come to your defense. Or, therefore, that you are worth defending.

We generally think of inner connections as being able to summon the presence of a certain loved one when they are not there, to give ourselves reassurance and courage. And that is a big part of it.

But inner connections also become the voice with which we talk to ourselves, what we say to ourselves ("it’s okay, you’ll get past this" or "you stupid idiot, you messed up again"). And thus they shape our view of ourselves and of the world.

One of our faculty trainers Richard Nicastro (http://www.strengthenyourrelationship.com/) gives this example. A client once described to him the difference between how she imagined the world inside his head and the actuality of how she experienced the world inside her own head:

My client’s description of my internal experience (My room):

Think of a room that you admire, maybe one that you know or visited. Picture the room filled with items you love, items that make you feel warm, bring you comfort, joy, and excitement. People that you love and admire can stay or leave in your room as you see fit. These loving others can sit next to you if you want, they can converse and are responsive to your needs. They can even sit quietly or leave if you need them to. Whenever you’re upset, you have access to these people. Their presence gives you comfort. In this room you’re basically in charge of what happens. You love existing in this place and you know that you belong here.

My client’s description of her internal world (her room):

Now imagine a different sort of room. One of those rooms that exist in the basement of a house that no one wants. It’s cold, dark, and damp in my room. Everything feels unclean in this room. My room is barren and inhospitable. People come and go as they please. People I wish I never knew. They are unpredictable. At times violent and cruel, at other times uncaring—at best, indifferent. They never seem to leave me alone. I hate this room but there is no way out. Sometimes breaking things in my room makes me feel better, but only temporarily. Once in a while someone knocks gently on the door to my room, offering promises of something better. While these people are different from the people who live my room, they never seem to stick around. So I don’t get excited anymore when they knock. Whether I smile and nod or spit and bit, the end is always the same. I end up alone in my room.

This is an extremely evocative description of the inner self that develops when someone does not develop strong inner connections to others.

So, this is the gift we can give the kids and families we work with, by being reliable, trustworthy, by actively thinking about how to create these connections. We do this by mentioning we were thinking of them, by telling them when we will next see them, by giving them a token from our office, by letting them listen to our voice mail, by notes, and many other ways. And gradually they will develop a warm and loving presence to help them through difficult times- and will have less need to resort to crisis behaviors.

Changes from Risking Connection® Training

Recently we have had the pleasure of providing a basic Risking Connection® training and then a Train-the-Trainers training at an agency that is committed to changing its treatment practices. The administration has started this change to a trauma-informed practice, and has demonstrated their commitment in many ways including attending all of the training. These methods represent a significant change for this agency, and in addition the agency is recovering from some significant problems and serious bad events in the past. At the basic Risking Connection® training, we decided that their first initiative was going to be to increase the frequency of trying to understand the adaptive function of a behavior before responding to it.

There was a three and a half month span between the original training and the Train-the-Trainers. We began the TTT by asking what changes people had observed during that time. Within three months they noticed:

There was a boy in the school who consistently went AWOL. When they stopped punishing this behavior and began to investigate it, the boy disclosed that he could not read. When he received targeted help from a staff member he trusted, the AWOL stopped.

A resident was being mean to another. Again, instead of punishing staff explored what was going on. He was finally able to share a humiliating experience he had at school.

They started a Student Advisory Board to give the students more voice.

Staff had been annoyed by a child who always hid under the tables at meals. They then noticed a pattern that he especially did this when others were loud and began fighting. They were able to offer him more reassurance at these times.

They had begun to involve the parents in investigating the meaning of their child’s behavior, and were getting a good response.

They noticed improved student-to-student relationships.

They were individualizing their approaches to the children.

Staff greeted kids returning from a runaway with "we are glad you are back and safe" instead of a lecture or description of their consequences.

Staff were tentatively beginning to discuss their vicarious traumatization reactions with each other.

In meetings more attention was being paid to the child’s history and trying to understand their behavior.

Staff were treating each other with more respect.

It is amazing and moving how profoundly our worlds can change once we begin to understand trauma and also become more self aware.

What to do about Ashley’s Gossiping?

A Residential Treatment Center we have worked with recently sent us the following inquiry:
A school staff member asked for a restorative task for Ashley. She was trying to get some more insight to what would be a good one. Ashley has had several task in the past for gossiping and passing notes and they have not seemed to help any. She wanted to know if contacting the police department and asking what constitutes an assault charge and the legal ramifications would be a good idea. She was also thinking about her past task and what she put on them. One of the task was about what gossiping does for you or makes you feel. Ashley stated that she loved the attention she got, the drama that is created, helped her to get friends, and that she loved talking to others. These behaviors have to deal with all the drama that she has been in this week. One staff member made a suggestion that Ashley should only be able to talk to staff (for like one day) and have no verbal contact with her peers unless it is for a group/activity on the structure. Another liked that idea but we both thought it may be a little on the mean side but may help. We were asked if we had any suggestions.

What would you suggest?

My colleague Steve Brown replied:
Depending on how serious the note passing and gossiping were, I’m not sure this would rise to the level of getting a restorative task at Klingberg. It might be managed in other ways such as: having other kids talk directly with her about how it feels to be gossiped about; having her stay close to adult (sit near teacher in class) so that they can prevent note passing, etc
If she were to get restorative tasks, I would focus on the adaptive function of the behavior- to get desperately need attention, feel power by creating drama, have friends. So tasks such as: Interview 2 adults about how they get attention they need without making others angry; make collage of magazine pictures showing people getting attention in positive ways; interview adults about how they make friends without doing so by gossiping about others; role play getting to know friend in "non-catty" way. For the therapist, I’d be curious about why she likes drama so much- she feels powerful when causing it? If there’s chaos around, it feels like her family. Craziness and chaos distracts her from painful feelings.

Finally, you’ll get lot farther rewarding positive opposites of gossiping rather than punishing -- when you see a shred of positive peer behavior, comment on it, praise it, high-fives etc.

I added that Steve had given them some great ideas. I would agree that this would not be most impacted by a task, and that not talking for a day would probably not accomplish anything. The girl shows considerable insight into her behavior, and I would work from that. My suggestion would be to figure out ways to help her experience the benefits she needs in less destructive ways. Examples of that would be putting her in charge of a project in which she must organize and lead peers, having her lead small groups, having her teach or assist younger kids in academics, having her take a survey of the kids on some important topic, having her write an article for a newsletter that involved talking to various kids about something such as friendship- for example, write an article interviewing kids about the best friend they ever had and what makes a good friend- then publish the article in some agency publication. Any way she can use her leadership and ability to spread information for the good will help her develop functional alternatives.

An example would be: Ashley, we are having an assembly today- can you get the word out- we know you are good at spreading information.

Also, if her gossiping hurt a particular person in some way I would ask her how she could be especially kind to that person today, give Ashley some candy to share with her, have them do a project together, have Ashley help that person with a subject if there is one that Ashley does well. etc.

One other thing I want to say is- having Ashley talk only to staff would further increase her shame, further increasing her need for this behavior. We want to look for things that can make her feel better and more worth while, thus decreasing her need to connect through gossip and hurting others.

And, we might give some thought to how often we see this same behavior in the adult staff, and times we ourselves have done it, to remind ourselves how tempting and engaging it is and how hard it is to eradicate.

Any one out there have any more ideas? Just click on "comment" and add your thoughts.

Time to Think

I am resuming blogging after a hectic pre-holiday and holiday schedule and a nice recovery vacation. I am also trying a new experiment of pictures in the blog. I am recently trying the idea of improving my presentations with pictures so I thought I would try it here as well. As usual, I would love feed back- just click the word "comments" at the end of the entry.

As we do more and more training and consulting I am struck ever more deeply with the importance of one variable: that the line staff have time to think and talk about their work. I am becoming convinced that a congregate care treatment program cannot provide excellent trauma informed care if the line staff are expected to be on the floor for all the time they are at work. It is crucial that staffing schedules be created to allow every full time staff person (and preferably the part time and per deim staff as well) to have time to:

Receive supervision that is scheduled, reliable and actually happens most of the time it is scheduled. This supervision should be more than administrative and correcting mistakes. It should include a focus on the person in the work: how are you doing? Which kids are getting on your nerves? Which do you want to kill? Which do you want to adopt? How are you with VT- how is the job affecting you? And it should have a focus on helping the staff member grow and develop, improve their strengths, learn more, progress on their chosen career path, and explore and utilize their interests.

Learn about the children- and reading the record is not enough. Staff need time to meet with the therapist and come to understand the child’s background and how it is currently influencing the present. Staff need to know the goals and objectives and the proposed discharge path for this child. They need a clear sense of the formulation of the treatment- how do we understand what is going on with this child and what are we focusing on? What problems is this child trying to solve with her symptoms? What self capacities does she need to develop? What social supports does he have? What are his strengths?

Discuss current issues and dilemmas with the team, and develop strategies based on the formulation. What have others found that helps? What can we add to the child’s Individual Crisis Management Plan? What are the early signs of distress that we should watch for- and what helps at those times? Who is doing well with this child and can become more involved? Who is struggling?

And relax- get away from the work for a few minutes, take a break, laugh, eat, talk, share stories of their weekend, form and strengthen relationships with other staff members.

Although it may appear daunting, expensive or even impossible to design staffing schedules that include regular meetings and down time, if fact it is possible. And it is less expensive in the long run because these are the things that result in satisfied staff, people who understand what they are doing, have a road map, and know that their own individual contribution is important and appreciated. Also, staff will have a feeling that they are growing and learning, and that their development is important to the agency. This will result in less staff turnover.

I believe these components are crucial to developing self aware, committed staff who can provide excellent trauma informed treatment for the kids.

The Boy who was Raised as a Dog by Bruce Perry

I highly recommend the book The Boy Who was Raised as a Dog by Bruce Perry (Basic Books, New York, 2006). (http://www.amazon.com/Boy-Who-Was-Raised-Psychiatrists/dp/0465056520/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1195999799&sr=1-1)

Dr. Perry also has a very helpful web site at: http://www.childtrauma.org/default.asp which contains other articles he has written.

Dr. Perry uses the stories of many abused and neglected children to illustrate and develop his points about the effects of trauma. This book is an excellent way of sharing this knowledge as it is quite readable and fascinating.

Here are some notes I took about points I found important. If you want more information or don’t understand a note- read the book! Or, click “comments” and ask questions.

Brain sets down a “template”- how life is supposed to be and go- and reacts particularly to any thing out side that template, anything new

Thus our early experiences contribute the template: our definition of “normal”

Could also contribute to under-reaction to danger: since brain is particularly paying attention to what is new, what doesn’t fit the pattern- danger is not new

Brain changes through repetitive, patterned activity:
Use dependent development of brain

To change muscle (exercise) must have moderate, repeated, patterned extra stress- brain decides, oh, we are going to be doing this now, better develop some new muscle cells
Same with brain cells
Stress is signal to cortex- something new going on here
Moderate stress is good for brain and body, develops ability to handle stress

However, imagine going to gym and trying to lift 200 pounds- would not build muscle or teach body anything
Would hurt yourself
This is similar to stress children receive from trauma

Brain constantly processing info from senses
Becomes habituated to the familiar
Reacts to the new

Critical to survival to remember those things that led to negative experiences
Often must remember after ONE bad experience
Negative emotions burn events in to memory

Lower brain compares in-coming data with laid down patterns- one question- does this data suggest danger?
Makes immediate response while sending to higher brain for further refinement
Become more alert, look for more information

What the brain does in danger:
1. focused alertness
2. shut down cortex chatter
3. more vigilant and more concrete
4. heart rate increase- blood to limbs
5. focus on social cues- is help available?
6. muscle tone increases
7. hunger/digestion disregarded

Dissociation- freeze- response when you cannot flee or fight
1. curl up
2. make yourself as small as possible
3. prepare for injury:
4. blood shunted away from limbs
5. heart rate slows to reduce blood loss from wounds
6. body flooded with opioids to protect against pain
7. produces feeling of calm and a sense of distance from what is happening
8. some times can help with functioning

Both hyper arousal and dissociation help people survive trauma.
Both can be harmful if prolonged and habituated.

Stress without control is most harmful
Rat experiment- some rats were shocked when they pressed a lever (had control); some were shocked when the other rat pressed a lever (no control): animals who do have control develop strengths, those who do not develop ulcers, lose weight, compromised immune systems, become more sensitized to shock, can’t recover

Stress with control leads to habituation (developing new skills and coping mechanisms)
Stress with lack of control leads to sensitization (disorganized intensifying response, immobility)

Flash backs, re-enactments- an attempt to have small doses of trauma within one’s control to develop habituation or tolerance
If trauma is too much cannot be mastered this way

Brain develops sequentially- certain tasks at certain ages
So traumas at different ages have differing effects depending on what the brain was working on at the time

Terror early in life can shift person to a less thoughtful, more impulsive, more aggressive way of responding to the world- thinking has been shut down too much just when it was time for it to develop

Humans develop through relationships
Relationships necessary for survival
Humans are also our most dangerous predators

Stress responses very closely tied to systems that read and respond to social cues
We are very sensitive to moods, expressions, gestures of others

We have mirror cells in our brains that fire when OTHERS express emotions, creating similar emotions in us
Mother-baby
Basis of empathy
Human society built on this interactivity

Infants born dependent
Parenting is pleasureful
Infant associates touch with pleasure- needs met, relief from distress, calming anxiety
Sensory patterns of human interaction associated with pleasure
Template established
Brain develops in use-dependent manner
If sensitive period is missed, may be hard/impossible to do later- if a kitten’s eye is kept closed during a certain period of sight development, may never develop sight even if opened later
Need repetitive, patterned interactions

If touch has not been associated with pleasure this needs to be addressed in systematic, careful way, starting with less scary touch
Touch own hands
Chair massage
Using heart rate monitor to monitor fear

Importance of rhythms
Rhythm is very important to human functioning
Sleep/wake, when to eat, heart rate, cycles
Use music, movement, dance, drumming to re-train

Using psycho-ed with kids, enables them to help each other

Let me know if you read or have read this book and what your reactions are!

Our Presentation at ISTSS

I was extremely proud to be part of a pre-meeting institute at the recently completed Annual Conference of The International Society for Traumatic Stress Studies. Our presentation was entitled:
Preventing Trauma by Applying Theory to Change the World
The premise was that theory based on science provides a road map to guide practice, and theory-based practice leads to effective and lasting change in the world.

The first presenter was Laurie Pearlman, PhD, who discussed the creation of her trauma theory, Constructivist Self Development Theory. (For more information see: McCann, I.L., & Pearlman, L.A. (1990). Psychological trauma & the adult survivor: Theory, therapy, and transformation. New York: Brunner/Mazel and Pearlman, L.A., & Saakvitne, K.W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: W.W. Norton.) Laurie described the need for this theory, the context at the time it was developed, and how it was developed using the Boulder model (theory-research-application). The assumptions of CSDT are Constructivist: trauma effects individuals differently; Developmental: trauma effects the development of self; Relational: relationships are the context for trauma and recovery; and that symptoms are adaptations. CSDT articulates that trauma affects: self capacities (ability to manage the inner world); ego resources (ability to manage the interpersonal world); and psychological needs and cognitive schemas: safety, trust, esteem, intimacy, and control; as well as the frame of reference (big picture) including identity, world view, spirituality; and the body and brain.

Kay Saakvitne, PhD. then spoke of the process of converting this theory into a teaching manual, Risking Connection®. Risking Connection® arose out of a grass roots movement in Maine in which survivors sued the state claiming that mental health services were making them worse. They won, and Risking Connection® was developed to train all mental health workers about trauma. Kay covered the basic outline of Risking Connection® and the collaborative process necessary to make the theory into a teachable curriculum for people at all levels of experience. (Risking Connection: A Training Curriculum for Working With Survivors of Childhood Abuse by Karen W. Saakvitne, Sarah Gamble, Laurie Anne Pearlman, Beth Tabor Lev Sidran Press; Spiral edition January 2000)

Steve Brown, PsyD and I then discussed our work using Risking Connection® to train child serving agencies. We reviewed the reasons agencies feel a need to change from traditional points and levels and rule oriented systems, and how hard that change can be. We described our dual approach of Risking Connection® trauma training combined with the Restorative Approach™ "how-to-do-it" method. Agencies that make these changes are experiencing a drop in restraints and seclusions, better outcomes and better staff job satisfaction.

Esther Giller, MA, described a fascinating project in which Risking Connection® was used to unite faith based and treatment agencies in Baltimore. Risking Connection® training was used to develop a common language and understanding to break through barriers and connect diverse service organizations. Esther described a slow process of forming relationships, developing common terms, and training people separately that was needed before the groups could be brought together. The RICH framework from Risking Connection® provided a structure for respecting each other, sharing information, forming connections and developing trust and hope. The project was evaluated and give high marks for collaboration and sustainability, and remains active today. (DeHart, D. (2006). Collaborative Response to Crime Victims in Urban Areas: Final Evaluation Report. Columbia, SC: Center for Child & Family Studies, University of South Carolina.
Giller, E., Day, J., &Vermilyea, E., (2007). Congregational Clergy Responding to the Spiritual Needs of Trauma Survivors: Risking Connection in Faith Communities. In press, Haworth Press, Journal of Trauma Practice, vol.6.
Full report of findings available at: http://www.sc.edu/ccfs/research/FaithReport.pdf)

Ervin Staub, PhD, then presented his theories of Prevention and reconciliation in mass violence: The theoretical bases for intervention; and the origins and prevention of violence between groups. His theories demonstrate how difficult life conditions and frustration of the fulfillment of basic needs can create a climate in which hatred between groups can grow. He described continuums of conditions which push towards violent or more peaceful solutions of problems (such as devaluation of other vs. humanizing the other; destructive, exclusive ideology vs. Constructive, Inclusive Ideology; Unhealed Wounds vs. Healing of Past Wounds; uncritical respect for authority vs. moderate respect for authority; monolithic society vs. pluralism; unjust societal arrangements vs. just social arrangements; and passive bystanders vs. active bystanders. He described conditions which promote the healing of past wounds. Ervin has also been studying altruism born of suffering: what makes some people who have been hurt turn to helping, instead of hurting, others? Also, what promotes active bystanders who have the courage to object to evil? (Staub, E., Pearlman, L.A., Gubin, A., & Hagengimana, A. (2005). Healing, reconciliation, forgiving, and the prevention of violence after genocide or mass killing: An intervention and its experimental evaluation in Rwanda. Journal of Social and Clinical Psychology, 24(3), 297-334.
Staub, E. (1989). The roots of evil: The origins of genocide and other group violence. New York: Cambridge University Press
Staub, E. (2003). The psychology of good and evil: Why children, adults and groups help and harm others. New York: Cambridge University Press
Staub, E. (2006). Reconciliation after genocide, mass killing or intractable conflict: understanding the roots of violence, psychological recovery and steps toward a general theory. Political Psychology, 27,(6), 867-895.)

Finally, Ervin Staub PhD and Laurie Pearlman PhD presented how Ervin’s theories are combined with CSDT and Risking Connection® to intervene in genocide torn Rwanda to promote reconciliation and healing. They have used the RICH messages to inform a radio drama show which teaches about trauma and healing. Their work has special emphasis on preventing those who have been victimized from vicitimizing others.(For an overview of Staub and Pearlman’s work in Rwanda, see
Staub, E., & Pearlman, L.A. (2006). Advancing healing and reconciliation. In Barbanel, L. & Sternberg, R. (Eds), Psychological interventions in times of crisis. New York: Springer-Verlag.)

For me the most exciting part of this presentation was the connections between the various projects. For example, there were similarities between the careful processes necessary in Baltimore to those needed in Rwanda. And Ervin Staub’s work on promoting healing, and promoting those who have been hurt from hurting others, there lies the blue print for the work we are doing in child serving agencies.

It was an honor to be part of such a distinguished panel; and I think that all such theory-based work in its turn informs and transforms the theory.

Note: descriptions of theories and projects were taken from the words of the authors.

The International Society for Traumatic Stress Studies Presentation

Note: I will be presenting as part of a pre-meeting institute at The International Society for Traumatic Stress Studies’ 23rd Annual Meeting which will be held in Baltimore, Maryland on November 15-17, 2007, with pre-meeting institutes on November 14.Wednesday, November 14.

Half Day
8:30 a.m. – noon
Trauma Prevention as Social Change: From Trauma
Theory to Real Life Practice (Abstract #178942)
Pre-Meeting Institute (commun)
Technical Level: Intermediate
Pearlman, Laurie Anne, PhD1; Saakvitne, Karen, PhD2; Wilcox, Patricia, MSW3; Brown, Steven, PsyD3; Staub, Ervin, PhD4; Giller, Esther, MA5
1Trauma Research and Education Institute, Inc., Holyoke, Massachusetts, USA
2Private Practice, Northampton, Massachusetts, USA
3Klingberg Family Centers, New Britain, Connecticut, USA
4University of Massachusetts Amherst, Amherst, Massachusetts, USA
5Sidran Institute for Traumatic Stress Education and Advocacy, Baltimore, Maryland, USA

In this institute, we present three theory-based initiatives in trauma prevention and treatment. We describe two central theories and three initiatives based on them, highlighting the process, challenges, and benefits of attempts to put theory into actual practice. The theories are constructivist self development theory (McCann, Pearlman, 1990; Pearlman, Saakvitne, 1995), a relational trauma theory which provides a framework for understanding the psychological impact of traumatic life experiences, and Staub´s model for understanding the origins and prevention of group violence (1989, 2003). The three projects all emphasize the importance of theoretical frameworks, the healing powers of RICH relationships (that include respect, nformation, connection, and hope; Saakvitne, 2000), and the ethical imperative to address the experience and needs of the healer in trauma work. Saakvitne will describe the translation of psychological theory into a training curriculum, Risking Connection. Esther Giller will present Baltimore´s Spirituality and Victim Services Initiative using the CSDT-based Risking Connection (Saakvitne 2000) and Risking Connection in Faith Communities (Day 2006) curricula as training and collaboration-building tools to bring together multidisciplinary
community resources to trauma survivors. Wilcox and Brown will describe efforts to create trauma-informed care systems for young adults, adolescents, and children in mental health systems. This initiative has taken place largely in congregate care settings. It combines training and consultation using Risking Connection, and the restorative approach (Wilcox, 2006), a treatment approach emphasizing relational rather than behavioral management techniques. Pearlman and Staub describe a project that combines CSDT with Staub´s Origins and Prevention model to promote healing in Rwanda. Staub´s work identifies the psychological,
social, economic, and historic forces that set the stage for group violence. It emphasizes understanding the sources of violence and the necessary components of reconciliation after mass violence. A controlled evaluation of their approach found decreased trauma symptoms and more positive orientation toward the other group. The approach has been used with groups from community members to national leaders, and is the basis of radio-based public education
in Rwanda, Democratic Republic of Congo and Burundi. Each presentation will discuss research, challenges, and successes.

If you are going to be at ISTSS, stop by and say hello!

Increasing Readiness for Trauma Informed Care

If you work for a treatment agency that is just beginning to think about trauma informed care, there is an important step you can take to increase your readiness to make this change.

This step is: increase the likelihood that staff will consider what is behind a behavior that a kid is displaying before taking action to respond to that behavior.

A key concept of trauma informed care is that symptoms are adaptations: that people do things for a reason. The behaviors the kids do that are problems for us, are solutions for them. Behaviors such as aggression, self harm, destroying property, bullying, screaming, running away, throwing chairs- they all serve an immediate purpose for the child, and what’s more, they work. The purpose is usually to escape some sort of intolerable feeling. Because the child has no reliable attachments to help her calm down, her emotions over whelm her. Because she has a changed biology and a sensitized nervous system, a small problem feels like a catastrophe. And because he doesn’t know any feelings management skills, he does not know how to identify or handle the feelings, does not believe any one cares, and does not think he is worth the trouble any way.

So instead of staying with over whelming feelings of fear and hopelessness, the child does something. And the problem is temporarily solved- even though there are long term negative consequences.

Every behavior is adaptive. And if we understand the benefits a child is getting from a behavior, we open up many more ways to help the child. This is much more powerful than just trying to punish the behavior away.

How can an agency develop a culture in which the adaptive function of a behavior is routinely considered and discussed?

I believe the clinicians should take the lead here. Shortly after a child is admitted (like 2-3 weeks) the team should hold a meeting in which members of all disciplines (teachers, child care workers, nursing, etc) are present. The therapist should convey a beginning formulation of the case- a theory of what happened to the child and why they are acting the way they do. This formulation could be summarized in a treatment theme such as "learning to trust adults" or "learning to manage feelings" that highlights the most important thing the team will work on. The child should also be part of determining the treatment theme when appropriate.

Then for every behavior that occurs the therapist should lead the questions: why is she doing this? Why now? What problem is she trying to solve? What has happened recently? How do we understand this?

After a while this kind of thinking can become so pervasive in the program that everyone thinks this way, and child care workers, teachers, everyone starts asking the same questions.

So if a boy often has a tantrum before bed time, we are wondering what it is about bed time that is hard for him, and thinking more of night lights, staff presence outside his room, soft music- and less of punishing the tantrum.

Start thinking about what meetings, what occasions, what communication channels can be used to communicate ideas about the meaning of behavior.

After a while it will be automatic to ask these questions and use your theories to determine your responses. Then you can start the next steps in implementing trauma informed care.

As always, comments are strongly desired- it’s easy! Just click on the word “comment” below.

Call for Response and the Restorative Approach™ and DBT

First, I would like any one who is reading this to read the previous guest post from Devereaux and respond to the thought-provoking questions they pose through clicking on the "comment" button below.

Last week I attended the first week of intensive training in Dialectical Behavior Therapy (DBT). The State of Connecticut Department of Children and Families is providing this training for 18 agencies chosen through an RFP process. The trainers are from Behavioral Tech, the official training group of Marcia Linehan, who authored DBT. (http://www.behavioraltech.com/)

Several people asked the trainers how DBT fits with a relational model. The trainers stated, and I completely agree, that DBT is a relational model, and pays a lot of attention to the quality of the relationship between the treater and the client. DBT states that the relationship is our main source of power and reward, and our main vehicle for changing behavior.

Many aspects of DBT promote a relationship approach. First of all, the DBT assumption that the client is doing the best they can, and that we must adopt a stance of radical empathy and search for a non-prejorative, phenomenological empathetic interpretation of the clients makes a relationship possible. We are more able to form a relationship with the client if we are not blaming him for his behavior. Secondly, DBT promotes radical genuineness on the part of the therapist. It is okay (inevitable in fact) for the therapist to have personal limits, to be affected by the clients' behavior and to have reactions. These can be shared with the client in a real way. The emphasis on transparency, on teaching the client everything you are doing, on respect for the client's ability to learn and understand, also promotes a strong relationship. The therapists’ ability to respect her own limits decreases her becoming angry with the client.

A critical component of DBT is the consultation team, which supports the treater. The Consultation Team assumptions of fallibility and non-defensiveness, as well as the dialectical method of problem solving, create a strong and healthy team. Therefore, relationships with other providers enable the treater to have strong relationships with the client.

DBT pays very close and careful attention to what the treater does within the relationship. DBT speaks about positive and negative consequences for behavior, and emphasizes contingency management. But most often they are not referring g to 10 minutes more Nintendo time. They are asking us to closely notice what we do within the relationship. When do we spend time with the child? When do we smile, talk in a warm voice, pull back, frown, be closer, be more distant? All of these can reward or punish behaviors. And we need to use these contingencies carefully and planfuly, lest we inadvertently reinforce the very behaviors we are trying to change.

DBT even has a concept of restoring relationships after there has been a problem, and of over correction- doing more than you strictly need to to make sure the breach is healed.

Although there were some parts of the training I need to think more about to integrate with our current approach, over all I think that DBT and the Restorative Approach™ compliment each other.