It Ain't Easy Being RICH- Hope

Anyone who has taken the Risking Connections â training knows that a key element is that the path to healing is through a RICH relationship- one that includes Respect, Information, Connection and Hope. This is such a central point that the publisher, Sidran, has copy write protected the concept independently. In our training we ask participants to share ways in which they are currently demonstrating RICH with the clients, and also with each other in their team. Because amazingly it turns out that what the clients need in a relationship is the same as what we need for ourselves.

For four weeks or so I am going to right about the dark side of RICH- by which I mean the difficult and complex aspects of creating RICH relationships. These are the areas where we struggle, stumble, and sometimes become less than helpful to our clients and each other. Let’s look at each part of RICH and discover what is hard about it and how we can overcome the challenges.

This fourth week I will focus on Hope.

Hope is the foundation on which all the other qualities rest. In the dictionary hope is defined as: “to cherish a desire with anticipation;” “to desire with expectation of obtainment;” and “the feeling that what is wanted can be had or that events will turn out for the best.”

I previously posted on Hope on 4/15/12. The focus of that post was the ways that a RICH relationship in itself creates hope, independently of the external reality.

Not surprisingly, the Risking Connection curriculum (Saakvitne, K., Pearlman, L., Gamble, S., & Lev, B. (2000). Risking connection: A training curriculum for working with survivors of childhood abuse. Lutherville, MD: Sidran) has quite a bit to say on hope. The authors maintain that holding hope is a key responsibility of the therapist. Our clients come to us hopeless, and they often experience setbacks that discourage them further. Meanwhile, we are doing this difficult work in the middle of an ineffective and inadequate child welfare system. So, it is possible for both the treater and the client to become hopeless. It is the treater’s responsibility to take care of him/herself and do whatever is needed to fight vicarious trauma in order to maintain hope. The treater’s job is to “Hold onto vision of the survivor’s potential future self,” and to “serve as trustees for the survivor’s future possibilities.” (RC pp.15-16) The treater is at her best when she can see clearly the client healed, living a productive life. The treater must maintain the tension between seeing that version of the client’s potential and also seeing the current reality of the client. The authors ask us to direct our attention to evidence of hope and resiliency in our client’s stories. When presenting or discussing a case, talk about strengths in a real rather than pro forma way. They also point out that hope is fueled by compassion for our clients. If we understand the adaptive nature of their symptoms, we feel less exasperated and less personally attacked. In other words, having a theory, a road map, that helps you understand the behavior and plan your next treatment intervention creates hope that counteracts the bewilderment and discouragement we usually feel in the face of extreme behaviors.

What is the meaning we ascribe to our client’s behaviors? When Aisha ran away and became involved in dangerous situations, Louis reacted: “How can she be so stupid! We have explained a thousand times that she is putting herself at risk. In fact, I just had a great talk with her last night about this! I told her how worried I was about her when she put herself in such danger. She told me she understood and would not run away again, and she thanked me for spending time with her. I guess she was just manipulating me to be able to stay up longer. She doesn’t care about me or anyone else. She doesn’t even want to get better. She’ll probably end up being kicked out of here just like our last two clients. Sometimes I wonder why we even bother.”

Mario was also affected by Aisha’s running away. He said: “I am so scared for Aisha. She still doesn’t value herself enough to keep herself safe. And we haven’t yet been able to teach her an alternative to running, or to make her safe enough to try it. I wonder if we set up a place on grounds where she could run and stay until she calmed down enough to come back if that would help her. And when I think of it, I realize that Aisha has been forming some close connections with both me and Louis. I wonder if that is scary to her, especially since we are guys? I’m going to talk to Tracy, her therapist, about that, and bring it to team. I don’t  know what we should do differently but maybe there is something. Aisha is so bright and has so much spunk. I know she has a great future if we can just find a way to get her there.”

The enemy of hope is vicarious traumatization (VT). Since it is the treater’s responsibility to maintain hope, it is essential that we combat this aspect of VT specifically. Some strategies, largely taken from the Ricking Connection curriculum, include:

·         Challenging negative thoughts and looking for evidence of resiliency

·         Celebrating all kinds of successes

·         Collaboration with others, within our agency, outside, and even outside our treatment community. For example, when a local business joins us and gives backpacks to all the students returning to school, it helps to know that there are others outside our world who care.

·         Noticing the advances in understanding trauma and in treatment that are being discovered through science and new technology.

·         Appreciating the gifts of the consumer movement.

·         Cultivating our spirituality, whatever that may be

·         Look for meaning and inspiration in everyday events and in natural beauty

·         Seeking and embracing the personal transformation that comes with this work. How has this job, and being involved with these clients, changed you for the better? What have you learned from them? In what ways have you grown?

There are also many ways the agency can help workers fight VT and remain hopeful- another time, another post.

Hope is an essential element of every moment of our work. In fact, our work defines hope- we embody a conviction that people can heal and change. We have seen it happen many times.  As we are presented with each new scared, snarly, obnoxious, difficult client it is our job to shine with the hope of all that they can become.

 

 

It Ain't Easy Being RICH- Part Three: Connection

Any one who has taken the Risking Connections â training knows that a key element is that the path to healing is through a RICH relationship- one that includes Respect, Information, Connection and Hope. This is such a central point that the publisher, Sidran, has copy write protected the concept independently. In our training we ask participants to share ways in which they are currently demonstrating RICH with the clients, and also with each other in their team. Because amazingly it turns out that what the clients need in a relationship is the same as what we need for ourselves.

For four weeks or so I am going to right about the dark side of RICH- by which I mean the difficult and complex aspects of creating RICH relationships. These are the areas where we struggle, stumble, and sometimes become less than helpful to our clients and each other. Let’s look at each part of RICH and discover what is hard about it and how we can overcome the challenges.

This third week I will focus on Connection

Connection is the central concept in a trauma-informed approach. People heal within relationships. Our programs should offer our clients RICH relationships and train staff how to utilize these relationships for the most powerful healing.

Some of the complexities of this approach become clear when we talk about the fact that relationships have two sides- the clients and ours. These relationships affect us too, and all of who we are shapes the relationship.

On April 9, 2009 I wrote about the Restorative Approach and Boundaries. In this post I discussed some of the common complexities that arise from our caring for the children and wanting to help them. People sometimes assume that because the Restorative Approach emphasizes relationships and speaking from the heart, we are throwing out the idea of boundaries. Quite the opposite is true! For relationships to be safe and healing, the boundaries must be clear, reliable and trustworthy.

Because abuse is in its essence a violation of boundaries, it is especially important that we pay attention to boundaries when working with abused clients. Our children have experienced major boundary violations, such as sexual abuse. They have also experienced many other chronic, less obvious boundary problems. Many of our children have had to handle responsibilities far beyond was is reasonable for their age, such as an eight year old being responsible for her two year old sister. They have been way too involved in adult issues, such as being worried about the rent or finding food. They have been exposed to adult sexuality and to relationship worries. They have had to parent their parents- care for a sick mother, listen to parental problems, help ease a parent’s depression.

So many tem[potations can arise for staff. We may want to give the kids gifts; take them to lunch; give things or money to the family; etc. The family may give the therapist a gift. We consider sharing personal information, either because we feel close to the client or we think it would help them. The client may tell us a secret, on the condition that we don’t tell the rest of the team. When the child is leaving, we may consider giving her our email address. We wonder if we should give this boy a hug.

In our training, we emphasize that as a staff you should TALK ABOUT every decision that is outside your job description before saying anything to the child or family. Talk with your supervisor or your team. It may be just the thing to do; it may be dangerous to the child or the group. But it is much easier to make the right choice when you step back, take time to think, and talk with someone else.

That we even have these dilemmas illustrates how much the kids and family matter to each of us. And so, with each of these real connections comes our exposure to the pain the child is feeling.  When a sad thing happens to the child, we feel it too. It is often hard to stay with that pain- we often just wish to fix it. Part of that impulse is to sheil ourselves from really experiencing the painful worlld of the child.

And we experience losses. We don’t talk much about what it is like to take these children into our hearts, and then have to discharge them- often to a less-than-optimal situations. One person in my agency used to say (when we had residential) “You know they are ready when you don’t want them to leave.” But they do leave, and staff are expected to be ready to open their hearts to the newest snarling child. It’s a hard thing to do, and one aspect of Vicarious Traumatization. It’s good to talk about this in our teams, especially every time there is a significant positive or negative discharge.

One more thing about connection and our part of the relationship. We cannot open our hearts to these clients if we are feeling lousy. If we feel hopeless and incompetent; if we feel mistreated by our boss or the agency; if recent encounters with clients have been scary or hurtful. We will not be available for new relationships. A new admission will be greeted with cynicism or distant formal interactions. This is why a trauma-informed relationship based approach cannot work unless we take care of our staff. How do we do that? Imbed discussion of VT. Schedule time to think, reflect and get support. Provide regular supervision for everyone. Utilize a clinical road map to make sense of the behavior. Have retreats, Have many systems for staff recognition. Do fun things together like potluck lunches and sports.  Time spent in these activities will be completely repaid in more effective treatment, less physical interventions, and less turnover.

Connection. It’s been a scary thing in the children’s lives. It has its complications in our own lives. Yet it is what makes us human and what builds our brains. Let’s look at our settings and consider how we are supporting connections in the way we do things.

I’d love to hear your ideas about ties. Just click on “comment.”

 

It Ain't Easy Being RICH 2: Information

Any one who has taken the Risking Connections â training knows that a key element is that the path to healing is through a RICH relationship- one that includes Respect, Information, Connection and Hope. This is such a central point that the publisher, Sidran, has copy write protected the concept independently. In our training we ask participants to share ways in which they are currently demonstrating RICH with the clients, and also with each other in their team. Because amazingly it turns out that what the clients need in a relationship is the same as what we need for ourselves.

For four weeks or so I am going to right about the dark side of RICH- by which I mean the difficult and complex aspects of creating RICH relationships. These are the areas where we struggle, stumble, and sometimes become less than helpful to our clients and each other. Let’s look at each part of RICH and discover what is hard about it and how we can overcome the challenges.

This second week I will focus on Information.

This might seem like the easiest one- just give our clients information. Tell them things. But I would like to explore four areas of complexity: collaborative treatment including the use of medications; sharing information with the team; psycho-education about trauma; and information and heartbreak.

Collaborative Teatment Including the Use of Medications: When working with trauma survivors it is essential to be collaborative. They have had so much experience of things being done to them, and of having no control, and they are exquisitely sensitive to such treatment. Also, trauma survivors have not had a chance to develop a voice, learn to speak up for themselves and advocate effectively. In treatment settings, especially with children, we tend to repeat the same dynamic. We make the decisions and when a child tries to object we call that “resistance” and respond with a punishment or at the least disapproval.

One area in which this happens is in the use of medications. We all (I hope) do discuss with a client why we are suggesting a certain med, what the benefits could be, and what the side effects are. We often give them and their families an information sheet. Yet do we truly respect any hesitation or objection the client has to the medication?

Did you know that even accounting for race, social situation, and other variables foster children receive 2-3 times as many medications as other children? I understand it this way: children handle stress and achieve emotional regulation through strong relationships. Connection is the antidote to stress. If a child does not have the strong connections to help her regulate, medication is used instead.

Back to information. It is important to REALLY be collaborative about medication with the child If the child refuses to take her medications she should NEVER be punished (or consequenced) for this choice. It may be an appropriate decision not to take her on a long trip if staff is concerned about her safety and the safety of those around her. But if a child does not want to take her medication, the therapist will be talking with her trying to understand her reality and what the meds mean to her. Why does she not want to take the red pill when she will take the others? Because it has a bitter taste, because her friend told her it was poison, because ever since that one started she can’t sleep. The therapist will get important information and in working with the psychiatrist perhaps something better can be found. And in collaborating with the child the therapist will be developing self awareness as they together monitor how she feels and acts. So, information about medications is not just giving the client a fact sheet. It is a truly collaborative exploration of the suggested meds and the client’s valid needs and wants.

Sharing Information with the Team: I believe that in a residential treatment center or hospital or any congregate care setting, the line of confidentiality should be around the Team, not just around the individual therapist. Some therapists have difficulty with this belief. In our theory, everyone who interacts with the child and family is a treater and contributes to healing. Therefore, they all have to know what is going on. They need to know the child’s discharge plan and destination and what their goals are. They also need to know what is currently happening in the child’s life. In my consulting I have encountered situations in which the full time child care workers have no idea about either the child’s history or their discharge plan. In some situations, such as when the child is disclosing sexual abuse, she may not want everyone on the team to know about it. Her therapist will create with her a phrase that the therapist can tell the team, such as “Nina is talking about some difficult things from her past right now, so she needs some extra support.” The therapist will help Nina to expand the circle when/if she feels ready. But in general, the team is all there to treat the child, and all need to know what is happening. This policy should be clearly explained to the child and family (and documented) when they are admitted. In order to gather this information and discuss its significance, the child care worker must be able to spend time in Treatment Team to learn about the client and understand their reactions.

Psycho-education about Trauma: How many of you in your programs are teaching the biology and psychology of trauma to the children and their families? Even younger children can learn something about their brain and body and why they act the way they do. This knowledge can be extremely important to our children. It helps them feel less crazy. When they learn that the body reacts a certain way to stress, and the same thing happens to soldiers, and policemen, and the workers in the program, it combats that conviction that their crazy behavior is their own fault. I will never forget Colleen, who when reading The Courage to Heal (Bass and Davis, Morrow, 2008) said: “This is me! In a book!”  For her it was so normalizing to know that others understood her.

Of course, there is my Blub book on “A Kid’s View of Trauma”. This book uses the Risking Connectionâ concepts to explain trauma to kids, including how they can heal. It can be found at www.blurb.com.  Some trauma-specific treatments, like TARGET, also explain the biology of trauma.

Another part of this is the parents. As we know most of them are also trauma survivors, and many have never worked on their issues. When we do psycho-education with them to help them understand their child, many parents immediately relate this information to themselves. Like Mrs. Jennings they say: “I wish I had had this information years ago!”

Information and Heartbreak: When we form caring relationships with children in the child welfare system, we are constantly dealing with heartbreak- the child’s, and hence our own. We often struggle with when to tell the child disturbing information. At what point do we tell Marvin that the foster family he is visiting is beginning to have doubts that they can take him? When does the DCF worker tell Melissa that her mother has dropped out of the drug treatment program? Or does she tell her at all?

I have seen people, especially state social workers, be so reluctant to tell a child bad news (you are not going home) that she hedges and leaves the child with an unwarranted sense of hope. This prevents the child from being able to explore new alternatives.

One are in which we struggle with imparting information is when a beloved staff is leaving. How long in advance should we tell the children? Some feel we should wait until the last minute to tell the kids, as otherwise they will get upset and have melt downs. Yet, if we do not give them time to process this departure, we will be repeating their past trauma in which people came and went without explanation.

In all these situations we have to tell the child in a straight way what is happening, and be prepared for some appropriate emotions of despair and hopelessness. If we can stay with the child through their reactions, and witness and empathize with the painful situation they are in, they will eventually, if reluctantly, be able to move on to the next plan. Their reactions are not inconveniences for us. They are the child’s legitimate protest against an unfair world.

What other dilemmas around Information can you thinkof? I didn’t even get to sharing personal information. Click on “comment” and share your information dilemmas.                                                                                                                                        

It Aint't East Being RICH

Any one who has taken the Risking Connections â training knows that a key element is that the path to healing is through a RICH relationship- one that includes Respect, Information, Connection and Hope. This is such a central point that the publisher, Sidran, has copy write protected the concept independently. In our training we ask participants to share ways in which they are currently demonstrating RICH with the clients, and also with each other in their team. Because amazingly it turns out that what the clients need in a relationship is the same as what we need for ourselves.

For the next four weeks or so I am going to right about the dark side of RICH- by which I mean the difficult and complex aspects of creating RICH relationships. These are the areas where we struggle, stumble, and sometimes become less than helpful to our clients and each other. Let’s look at each part of RICH and discover what is hard about it and how we can overcome the challenges.

The first week I will start with Respect.

The dictionary defines respect as: esteem for or a sense of the worth or excellence of a person, a personal quality or ability and as: deference to a right, privilege, privileged position, or someone or something considered to have certain rights or privileges; proper acceptance or courtesy; acknowledgment. The RC manual states that it is demonstrated through forms of address, respect for confidentiality, punctuality, language used, assuming the client has a valid point of view, and validation of the client’s experience. The therapist believes and believes in the client.

These definitions do not really capture the essence of respect for me. To me it almost carries some aspect of admire. So, if we truly respect our clients we actually, deeply honor the way that they have survived all the pain life has handed them. We look up to them, are in awe of them, for having come through alive and kicking. We actually let ourselves feel how profound the pain was, how deep the losses, how scary the world. And we respect what these kids had to do to survive.

Of course anyone who is caring for someone with problem behaviors (be it one of our kids or your aging mother) knows that it is easier to maintain these lofty attitudes when you are away from the person and their demands. When some kid is yelling at you, or trying to hit you, or refusing to comply with the simplest request, it is hard to see their behavior as an admirable attempt to survive. That is why we all need down time, a time to step back and think about the work, often with the help of a supervisor. We can then let ourselves remember the painful truths of our clients’ histories and respect the creativity of their adaptive behaviors.

Here’s another aspect of the word Respect. Martha, a therapist in our special ed school, tells me that when she asked Tyquan what led up to his throwing several chairs and then leaving the classroom, Tyquan told her that his teacher, Miss Mitchell, was disrespecting him. Miss Mitchell reports that she just asked Tyquan to end his conversation with his friend Marvin and take out his math book. And she probably did so pleasantly. Martha tells me that feeling disrespected is a common complaint of the youth. Now of course our staff may at times speak in a sarcastic or belittling way to the kids. But let’s assume this time Miss Mitchell spoke conversationally. What went wrong here?

Maybe Marvin is the best friend Tyquan has had in years, and having a friend is finally making him feel a little safer. Maybe he is just tired of adults telling him what to do and putting their needs before his. What do you think?

School work is often associated with humiliation for our kids. Tyquan can’t do math. It makes no sense to him. Maybe the fact that when most kids were learning math he was trying to protect his mom, his sister and himself from his step father’s angry rages has something to do with it. It could be that his brain hasn’t developed the ability to think sequentially or use logical problem solving, because no one has ever modeled such a process for him. But anyway, he knows he is in for another period of feeling stupid and hopeless, and that maybe the other kids will see how dumb he is. Marvin’s pretty smart in math- he will probably give up on Tyquan as a friend when he sees how lame Tyquan is.

So, when Miss Mitchell says in her happy voice: “Tyquan, time to end your conversation with Marvin and take out your math book.” Maybe Tyquan hears: “Tyquan, time to stop doing something pleasant that you enjoy and to do something you can’t do, although everyone else can, and to show the world how stupid you are.” This feels deliberate to Tyquan. She is trying to humiliate him. So naturally he feels disrespected.

Does that make sense to you? If anything like that is going on, what does Tyquan need? How can he feel respected in this situation? (I have some ideas, but what are yours?)

One thing we do know is that the more fragile a person’s sense of self is, the more frantically they protect their image from external threat. If you feel fine and happy about yourself, and someone teases you, it’s relatively easy to let it go. If you are already feeling pretty lousy and fairly sure you are doing everything wrong, the teasing arouses such panicky feelings in you that you attack with all the ammunition you can find. And others say you are “over-reacting”.

Which brings me to the final concept of Respect that I would like to explore- and that is its use by staff. Teacher Mr. Hoover says: “I told Luis to stop talking and he went right on talking. He does not respect me!” Crisis worker says: “If I am not very strict with the kids they will lose all respect for me.” Therapist Ron says: “I just will not tolerate the kids swearing at me. It is a sign of disrespect.” Merva, a foster mother, tells her case worker: “We told Natalie to go to bed and she keeps coming out of her room. We can’t read her stories or any of that nonsense. That’s just catering to her. She just has to respect us and do what we say.” Laura, a Child Care Worker says, “I told him he had to go through the front door. He insisted he had to go through the back door. I know it’s trivial, but I will not back down. They need to respect what I tell them to do.”

The first thing that comes across in all this is that the staff seems to feel it is all about them. They want the kind of respect that is evidenced by obediance. Often times a person's position will get them this kind of respect (such as in the military or many offices). But that creates no lasting change. As soon as that person isn't looking, the subordinate does whatever they want, Much more important is to have influence; to be respected for person characteristics and for how you have treated the other.

What the kids are doing is not primarily about the staff. Of course, how a given kid feels about a certain staff does affect their actions. Nothing like relationships to influence behavior. But a lot of times other factors intervene.

Like the youth is dysregulated and no longer even sees the staff for who he is. Or he is caught up in old feelings of mistrust. Or she is testing the staff- will you stay with me even when I show you how bad I am? Or he is desperate for some control in an entirely out-of-control life.

How can we help our staff feel calm and good about themselves so that they do not need the kids to act a certain way in order that they may feel respected?

Wow, a lot for one word- Respect. And we have three more to go. PLEASE share your ideas by clicking “comment.”

 

 

 

Gratitude

Sonia and Ralph were talking on their break.

“These kids.” Sonya says. “They are just not grateful. Here we have done all these extra things for them this summer. And they do not seem to appreciate it at all!”

“I know,” replies Ralph. “Very few of them even say thank you. We have taken them to the beach, to Six Flags, to go-carts and mini-golf. And they are just as obnoxious as ever when we get back!”

“Just yesterday” Sonia chimes in, “I took the girls out for ice cream. I didn’t have to do that. We stayed for quite a while- it was so hot out. And then when we got back, I asked them to go to their rooms and chill out for a while. Several girls had the nerve to talk back to me, and Lisa and Tanika started to get into a fight with each other!”

“You’d think after all we do for them they could at least respond to a simple request. It makes me not want to do any extra activities at all.”

“Yeah. Maybe if they see what it is like to stay on campus all the time they will be a little more grateful for what they do get.”

Ahh yes. Grateful.

How our assumptions do leak through in the most casual of conversations.

What does grateful actually mean? Dictionaries define it as: Warmly or deeply appreciative of kindness or benefits received; thankful. Gratitude is a positive emotional reaction in response to the receipt of a gift or benefit from someone.

Gratitude, thankfulness, gratefulness, and appreciation are feelings, emotions or attitudes in acknowledgment of a benefit that one has received.

And how is one to know whether the other person is experiencing these emotions? Of course one indicator is what the person says. Do they say thank you, do they express how wonderful the experience was, acknowledge the effort of the other person, describe how good it felt to them, etc. And it would be reasonable to expect that the person who was feeling especially grateful or thankful would treat the giver well, want to reciprocate in kindness, and would demonstrate a pleasant attitude. And maybe we could expect…well, hope…that the person would stop some of their most obnoxious behaviors after they have had this fun experience.

Where has this process gone wrong between these staff and these clients?

There are many possibilities. We start with some basic understandings:

Our children’s experiences with relationships have left them with a deep ambivalence about getting close to someone. If a staff member is taking me on a trip, will she meet my needs, stop for a bathroom break, keep me from getting lost? What can I expect at this place where I have never been in the care of these people I don’t really know? A wonderful time together can be scary- can I really trust this person? If I open up to her, will she hurt me?

The brains and biology of our children have been altered by early abuse, neglect and attachment disruption. Sensory data may be difficult to integrate. What seems fun to others may seem overwhelming, confusing and scary. Who knows who could be at this place? Needing to constantly scan for danger can be exhausting.

When the staff take the children on enjoyable activities, they are literally rebuilding their brains. The children have deep seated expectations that interactions with other people will hurt; this is being changed when they experience pleasure associated with other people. New connections are being built between parts of their brains when they successfully master an amusement ride or survive a go cart. Yet, the changes do not happen fast. One pleasant afternoon does not create a pleasant child. Or even ten pleasant afternoons. Many, many repetitions are needed to build a new brain.

Our youth do not know how to modulate and manage their feelings. If they start to feel lost, confused or overwhelmed- or even hot and cranky- they can rapidly spiral into a sensation of complete hopelessness.

When a person does not feel worthy of life, feels like a bad person, she may not feel she deserves pleasurable activities. She may need to sabotage good feelings. She may need to push away any one she has had fun with.

If someone has not developed an inner connection to others, any separation can seem like forever. We just had all this fun together and now you are leaving?!? Who knows if I will ever see you again? I knew I should never have relaxed and enjoyed myself (back to the beginning).

And then there is another, more worrisome over tone in this expectation of gratitude. I will illustrate with an example:

Kayla was 8. She was absolutely adorable with big blue eyes. After early abuse and neglect, she had been recently taken in by Mr. and Mrs. Whitmore. About five months after she was placed, the couple went on a cruise to Alaska, asking DCF to find two weeks respite for Kayla. She stayed with a nice family she had never met before. The parents returned and brought her back a stuffed seal, which she promptly threw away. Mrs. Whitmore complained to her social worker that Kayla did not seem grateful that they had brought her this nice present; in fact she did not seem grateful that they had taken her in. She didn’t seem to understand what a terrible life she would be having if they had not done so!

This is expecting children to be grateful that they are now getting some small part of what they should have had all along; what every child deserves; love and safety. This is seeing the children as less than, as poor unfortunates who should be glad for any scrap. How about the idea that they should be angry about the unfairness of their lives, and protest loudly that they have been wounded through no fault of their own?

Some of this tone can sneak into all our thinking on the hottest days.

As Sonya and Ralph read the above, I can hear them saying: “Oh for heaven’s sake. We know all that. But can’t the kids just say thank you? Can’t they just express some appreciation of the effort we have made, or some happiness in the experiences we have shared?”

Yes. And they will. They will share this with you with they come back and visit in three years, or ten years, or bring their daughter to “see the place that Mommy became a person.” At that time you will be amazed how they remember every detail and say things like: “it was the first time any one celebrated my birthday” or “I was so scared on that roller coaster and I remember that you held my hand.”

And that will give you the stamina to take this present surly group out for one more ice cream cone.

Reactions to My Book

Please pardon the shameless self promotion, but I would love for people to read my new book Trauma Informed Care: The Restorative Approach (www.nearipress.org) and let me know your thoughts.So to inspire you to do so I am sharing some reactions from people I admires and respect:

From Laurie Anne Pearlman, Ph.D. Co-author, Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse:

“Trauma-Informed Care: The Restorative Approach is a solid contribution to clinical work with children and youth in congregate care and their families. Patricia Wilcox offers a smart relational approach grounded in trauma theory and brain-behavior research. She presents the theoretical basis for the restorative approach, describes the approach clearly and succinctly, and illustrates its application lavishly with clinical examples. Her style is conversational and collaborative. Wilcox’s vast experience with this population shines through in both the examples and the comfortable way she raises and addresses potential objections to using the restorative approach. It is a must-read for trainees and workers new to this field and a wonderful resource for administrators, families, policy makers, and staff at all levels of experience. Anyone who works with this population or who is treating or raising kids can benefit from reading this fine volume.”

From Karen W. Saakvitne, PhD

Author Trauma and the Therapist, Transforming the Pain, and Risking Connection
President, TREATI 

“Pat Wilcox conveys the accumulated wisdom of her years working with children too often overlooked by others in this remarkable and inspiring book. The Restorative Approach has the potential to radically change child mental health treatment (and parenting) for children with challenging behaviors and histories of trauma. Integrating current research on trauma and treatment with practicality, compassion, and ethics, Wilcox presents a compelling case for the Restorative Approach as a best practice in trauma-informed child treatment. The book is exceptional in its many detailed clinical examples of effective interventions making it immediately accessible and useful to all staff. Wilcox’s full exploration of all objections to the Restorative Approach convinces the reader of her complete understanding of the real conditions under which most child mental health settings function. Ultimately this book is inspirational; it offers hope for children, their families, and mental health professionals working with them. It should be required reading for all staff working with children in mental health systems.”

And from: Roger D. Fallot, Ph.D.
Director of Research and Evaluation
Community Connections

“Pat Wilcox has written a book full of compassion and common sense.  She integrates the restorative approach with a trauma-informed one, enriching both in the process.  Her vast experience with children, youth, and their families is fully apparent here, as is her creative way of thinking about and working with them.  Pat tells important stories about young people and their traumas, about their responses to being traumatized, and about how a particular kind of setting with a particular set of staff behaviors might be most helpful.  Her bulleted lists of ideas are priceless and the volume’s valuable appendices are an additional highlight.  Pat’s deep caring for children and youth, their families, and the staff who serve them is evident throughout this important, new work.”

With testimonials like that, how can you resist it?

Training for Therapists

 I am thinking of developing a training series for therapists who are working in trauma-informed congregate care programs. This would not be a training to learn about trauma, how it affects people and how they can heal. Risking Connectionâ and other curriculum do that. This is to teach therapists to be the most effective treaters and leaders within a team program that believes that every staff member is actively involved in the treatment process. How can the therapist be the best leader, and be the flag bearer for clinical thinking? Often such programs hire therapists right out of graduate school or with limited experience. And if the therapist has worked mainly in outpatient settings he or she will discover that the congregate care setting is quite a different role. There are many tensions, traps and dilemmas. What do you think a good therapist in congregate care needs to know? What have you wished that people hired into your program had been taught? Click on “comment” and tell me your ideas.

Here are my ideas so far. I envision this to be a four to six week program, 2 hours or so a week.

An Awesome Therapist in a Trauma-Informed Congregate Care Setting

The Role of the Therapist
Take away a screaming child and bring her back calm
Integration- Does not mean running to every restraint or crisis
Characteristics of a good therapist
Role with Family
Role with team
Where is the line of confidentiality?
Interactions with outside system
Need for support and use of supervision

Formulation, Treatment Planning and Treatment Themes
Skill of Formulation
Formulation guides treatment planning
Formulation- current case or examples

Using the Trauma Framework and Brain Science to Know What to Do
Using brain science to decide what stage child is in and vary interventions
Evaluate self capacities
Skill development
Use crisis prevention plans
Constantly re-evaluate

Doing Therapy- Ignoring the Push to Change
How trying to change the client prevents change
Do not talk to child about how his life would be better if he stopped doing these bad things
Relationship
Explore, explore, explore
Using creativity
Walk, move
Involving team members
Family
Group

When Things Go Wrong
Behavior Problems
Lack of progress
Team De-moralized
Cultivating Stamina

Termination
Summary
Strengthening inner connection
Boundary questions

Vicarious Trauma
Staying alive and hopeful in the work

Understanding and recognition

Individual protection
Agency protection
Vicarious transformation

I also hope that such a course for the therapists in an agency would strengthen bonds between them and increase their ability to support each other.

So, what do you think? Would this be helpful in your agency? Anything else you think I should add? I would certainly appreciate your ideas, just click “comment” below.

My Book is Available!

Order from www.nearipress.org. Choose bookstore and then put my name, Wilcox, in the search engine.

I am so delighted to report that my book came out this week. It is entitled: Trauma-Informed Care: The Restorative Approach. This book is a practical guide to implementing trauma-informed care in all sorts of settings. The focus is on making our every day actions in treatment settings match what we know from brain science helps children heal.

Chapter One introduces the trauma framework, a useful road map to understanding both the effects of trauma and how people can heal. Although we have considerable new information about what helps people heal from trauma, many programs serving the children who have experienced the most trauma have not yet incorporated this information into their treatment or their programs’ milieus.

In the following chapters I provide a specific treatment design using this new brain science as the blueprint for treatment programs for children. Chapter Two is an overview of the method, including its theoretical underpinnings, day-to-day operations, how it addresses shame, and answers to common questions and concerns.

Chapters Three, Four, and Five use case examples to convey the specifics of the approach. Chapter Three focuses on demonstrating the daily workings of a trauma-informed treatment program. Chapter Four illustrates the power of how staff define and talk about the children and their behaviors. Chapter Five contains examples of the challenges of caring for traumatized children, and how the method works during hard times.

Chapter Six examines one of the most difficult decisions in implementing trauma-informed care: how to respond when the children hurt others. This chapter asks providers to consider their theory of change, and to operate from a theory of what will actually help the child be less likely to repeat this behavior. It introduces the restorative task, a response that incorporates opportunities for healing and for making amends, and gives examples of such tasks. Suggestions for improving tasks and how to respond if the child refuses the task are included.

Chapter Seven focuses on the role of the clinician in trauma-informed care, the characteristics of a clinician who will succeed in this system, and necessary training. In the Restorative Approach, the clinician and the child-care team work closely together providing individual, group and family therapy as essential parts of the treatment program. Treatment planning reflects the therapist’s theories of what steps help a child heal. As in all best-practice programs, the therapist will need support and supervision in order to lead the team in a clinical approach to behavior.

Chapter Eight covers the importance of providing trauma-informed care for the families. Most of the parents of children in treatment are themselves trauma survivors, which presents unique challenges in parenting. The program helps them by being attentive to their need to feel safe and to build trust. A key component is to recognize and honor their strengths, and to provide opportunities for the family to have fun and joy together. The families can be educated in the restorative approach and experiment with using it themselves when the client is at home.

Chapter Nine extends the restorative approach to foster care, describing how training in understanding trauma can help foster parents not to take behaviors personally and to keep the child despite behavioral problems. Formal training is important, and the support workers use of the theory to understand actual events will solidify the family’s understanding.

Chapter Ten looks at characteristics of the agency-as-a-whole that support trauma-informed care. The role of agency leadership is crucial in implementing this approach. The agency structure makes a big difference in the success of the Restorative Approach. Developing the necessary culture of connection takes time, but enables the approach to endure. The physical plant affects the experiences of both the clients and the staff.

Chapter Eleven, “Cultivating a Trauma-Sensitive Staff,” describes the processes that are essential to develop and maintain a good staff. Many agencies find that staff turnover decreases after the implementation of trauma-informed care. Hiring, training, supervision and promotion are all crucial tools. Certain skills that support a trauma-informed approach can be deliberately taught. Most crucial is attention to vicarious traumatization, the way the work affects staff and how they can take care of themselves and each other to stay alive and hopeful in the work.

Chapter Twelve covers the actual change process, and what steps an agency can take to facilitate the change. A transformation committee is a good mechanism to lead the change. Later steps include changing policies and procedures to solidify the changes. John Kotter’s Stages of Change (1996) form a helpful guide to examine the process.

Chapter Thirteen concentrates on sustaining the change. Unfortunately there are many forces pushing the system back towards a punitive approach. Certain challenges can be predicted and addressed.

Chapter Fourteen emphasizes measuring and celebrating progress. The chapter presents various factors to measure and scales to utilize in measuring them. Results garnered from these data can be shared with funders, the Board of Directors, consumers and other stakeholders. Celebrating success will help sustain the transformation.

The Appendices contain useful tools for agencies to employ.

The books can be ordered from www.nearipress.org. Choose bookstore and then put my name, Wilcox, in the search engine.

If you do read the book, PLEASE email me (patw@klingberg.org ) and let me know what you think of it. I hope you will find it to be a valuable resource to you in implementing and sustaining trauma-informed care.

Two Conference Presentations Next Week

I am presenting at two national conferences next week. If you are attending either, please come up and introduce yourself. I would love to meet you!

The first is the annual NASW conference, Restoring Hope. The conference is in Washington, DC at the Wardman Park Marriott Hotel. My workshop is:

Using the New Brain Science to Create Hope and Healing for Child Survivors of Trauma
Date: Tuesday, July 24
Time: 3:15 pm - 4:15 pm
Room : Wilson B

The second presentation is at the Foster Family Treatment Association 26^th Annual Conference on Treatment Foster Care. The conference will be held July 22-25, in Atlanta, GA. at the Sheraton,Atlanta hotel.

My workshop there is:

Workshop D17 - Using a Trauma Framework to Strengthen Foster Placements.
Wednesday, July 25th
10:30 a.m. - 12:00 p.m.

Seriously I would love to meet you if you will be attending either of these conferences. Please say hello!

Supporting Kinship Care Foster Placements

I have recently become interested in the process of supporting relative foster parents and helping the placements to endure.

In the REPORT TO THE CONGRESS ON KINSHIP FOSTER CARE U.S. Department of Health and Human Services, completed by the Administration on Children, Youth and Families Children’s Bureau, it is stated  that “Because States' data are scarce, it is difficult to estimate how fast public kinship care has increased-but available evidence suggests that it increased substantially during the late 1980s and early 1990s. In the 25 States that do have data, the proportion of children in public kinship care increased from 18 to 31 percent between 1986 and 1990."

I was struck when a foster care leader in our state system described relative foster parents as “the most under-resourced families in the system.” It seems as though there is an un-examined assumption that because relative foster parents are well, relatives, love will carry the day and they will not need help. Foster parenting is a hard job for anyone who does it. And there are some aspects of kinship care that make it uniquely difficult.

Ambiguity of choice presents a significant stressor. Unrelated foster parents choose to be foster parents, decide that this is a good time in their lives, and have to go through an elaborate screening before even hearing the name of a child. Relative foster parents are presented with a child who is a member of their family and who is in distress. They may or may not know this child, and this may or may not be a good time in their lives. But they have to choose between taking the child or having the child go into the child welfare system. Even those who feel deeply that this is more than they can handle also feel a moral obligation to care for the child. The Report to Congress further states that: “Unlike non-kin foster parents, kinship caregivers usually receive little, if any, advance preparation for their role. In all States, non-kin foster parents are required to complete a rigorous training program before the State will license them. Such training helps future foster parents understand the needs of abused or neglected children and emphasizes strategies for meeting these needs effectively. Non-kin foster parents also have time to prepare mentally for their new roles and to adjust their living space to make it appropriate for children of a particular age. In sharp contrast, kinship caregivers often become involved in a crisis situation with little or no notice.”

Accompanying family history and dynamics are always present in the placement. The related child comes with an entire history and many attached feelings. This aspect of relative foster care seems to be rarely discussed in the literature, but is a powerful factor in the outcome of the placement. For example, if a grandmother is caring for a grandchild, that child inevitably connects to a history of pain and distress with this mother’s own child. Perhaps the child’s mother is addicted to drugs. Inevitably her mother, the child’s grandmother, has suffered a lot of pain around this. She may have taken her daughter to treatment progress without success. She has often been deeply hurt by her daughter’s betrayal, such as if her daughter has stolen from her. She has experienced many episodes of hope when her daughter was in rehab or appeared to be turning her life around, followed by despair when the drugs took control again. Furthermore, she may have had experiences with the child’s father, perhaps bad ones. Maybe the child’s father was abusive to her daughter. All of this hurts a mother’s heart and leaves deep impressions. And in fact her daughter is often still in the area, drifting in and out of the family’s life.

How does this all effect the grandmother’s relationship with the child? She loves the child. She wants to do the best for him and raise him right. She wants to protect him from all harm. Yet who does the child look like? How hopeful does she feel towards the child’s future? How resentful does she feel about having this added responsibility in her life at this time?

All these factors are also influenced by the relative caregiver’s health, his/her financial and social situation, and many other aspects of their life.

Often the caregiver has no one to talk to about this, no one to validate their complex feelings and to help them separate the present with the child from the past with the child’s parents. So, the child and the caregiver are both being profoundly influenced by the unexamined past.

Then,  to continue to quote the report, “Unlike trained non-kin foster parents, kinship caregivers often receive little formal training and may have a limited understanding of the child welfare system, what is expected of them, and the resources available to assist them. Kinship caregivers, however, generally have greater knowledge of the family history and dynamics that have created the need for a child to be placed outside the home. Not only are public kinship caregivers less likely than non-kin foster parents to receive services, their needs are more often overlooked. Public kinship caregivers are referred for, offered, and actually receive fewer services for themselves and for the children in their care public kinship caregivers are less likely to request or receive educational or mental health assessments, individual or group counseling, or tutoring for the children in their care.”

Specifically, the kinship care providers often receive little training about trauma, how it affects children, and how they can heal. The main advantage of having such knowledge is that it enables parents to define the child’s behavior differently. When the child won’t eat with them, or refuses to talk, or questions their directives, or has a meltdown in a store, or is aggressive with other children in the home, or won’t go to sleep at night, the parent sees this as rejection, defiance, and a behavior to be eliminated. If the parent is given training that really helps them understand behavior differently, they instead can define the behavior as fear, emotional over load, and problems with trust. This change of definition leads to a complete change of reaction. The kinship care parent is less likely to take the behavior personally, less likely to respond with punishment and more likely to respond with support. This training is essential for kinship care parents. And it must be available in many flexible delivery modes, including a trained person who can offer the parent training in their home individually. Support groups can be both helpful and powerful, but for some parents the thought of having to schedule attendance at a group is such a stressor that any benefit is undermined. A flexible delivery system allows each parent to utilize the help that fits where they are at the moment.

Another essential component of supporting kinship care is to pay attention to the experience of the parent themselves. How is being a kinship caregiver affecting the parent themselves? At a recent training one foster mother stated that she had been a foster mother for sixteen years and no one had ever asked her how the work was affecting her. Caring for children with trauma histories produces vicarious traumatization in foster and kinship care parents as it does in treatment workers. Foster and kinship parents have the additional stress of being largely alone when crisis occur; of possible getting pressure from extended family; of losing friends and family because of being unable to leave the child; of worrying about the effect of the foster child on their biological children; and other issues. For kinship foster parents managing the relationship with the child’s biological parents may be another source of stress.

The kinship care parents need a safe place to discuss all this and to receive validation. This can be individual or in a group. A group, when it is possible for a parent, has the strong benefit of helping the parent that they are not alone. But the parent needs to be educated on the inevitability of vicarious traumatization, how to care for oneself to combat it, and how to maximize the transformative power of providing foster care.

The limited information we have about relative foster care does show that despite the lack of education and support services, relative placements tend to last longer than non-relative placements. We desperately need to create stability for these children that have been hurt through no fault of their own. All the other healing they need and deserve can only take place when they feel safe, cared for and that they belong somewhere. It seems that one way that we could increase that safety would be to provide more and earlier support for kinship care families.

What are your thoughts on this? Have you done any work in this area? Do you know of anything written about supporting kinship care families? Please click on “comment” and let me know. Thank you.

The Real World, Once More

I did a consultation for a treatment team this week. They were a delight to work with. They are very used to looking for the need behind behaviors, and are caring and sympathetic to the youth in their care. Still, they struggled with the same issues everyone else does.

Validating does not mean agreeing.

Tenesha said: “I think this validating can backfire. I mean, When Stacey says she hates this place and everything we do here sucks and the staff are unfair, how can I tell her that she is right? I don’t agree and it would be going against my self and my team.” This reflects a misunderstanding of what validating is. Tenesha does not have to tell Stacey that she agrees with her- she doesn’t. Instead, validating is saying that she hears what Stacey is saying and understands what she is feeling. So, Tenesha does NOT say, “I know, Stacey, this is a lousy place.” Instead she says: “Right now you hate living here, and everything about the place is on your last nerve.” To say this with genuine feeling, Tenesha thinks about how hard it must be to be fifteen and have no family, and to be the only girl in your high school who does not live at home. Then she asks Stacey what in particular is bothering her right now, and tries to help her solve whatever her problem is.

Living in the Real World

Then in the consult Maria said “I still think this validating can go bad. I mean, we validate, validate, validate. What are these kids going to do when they get out in the real world and no one validates them?”

First of all, I think it is interesting that when people make these comments they always portray the real world as so harsh. I live in the real world, and I receive quite a bit of validation- luckily.

Getting What You Want Makes You More Able to Do Without It

But anyway. I would like to talk about the fact that meeting a child’s needs makes them MORE likely to be able to meet the next challenge, not less. When ever teams consider doing something special for a child (sit at her door at night, give him special food, allow him to stay up late) they become concerned that the child will want them to do this forever. Yet, when we feed a baby milk on demand we are not concerned he will want milk forever. We help a toddler learn to walk and to deal with obstacles in full confidence that he will be more independent in a few months.

To further understand this, let’s meet Jose and Richard. They are in fifth grade together, and they both love action figures. Jose has quite a collection, and he brings some to school and the boys stage elaborate battles and adventures. Occasionally, Jose invites Richard over to his house after school. This is very exciting for both boys, because Jose has lots of action figures and their accessories. Now they can really create some stories. However this doesn’t happen too often, because Richard cannot ask Jose to his house, and he feels bad going to Jose’s too often. Richard never knows what his mother will be like in the afternoons, and whether he will have to take care of her. Besides, he shares his room with his brothers, and he only has four action figures and one accessory. He’d be ashamed to have Jose over.

As the boys grow older, which boy do you think most easily got bored with action figures and started to become interested in teenage things? Which boy said to a teacher that he trusted: How am I supposed to start growing up? I haven’t had enough time to play with my action figures!

To belabor the obvious a bit- Jose’s father did not say: “Let’s not give Jose any action figures, because then when he grows up he will always want to play with them.” When you get what you need at the moment, at the right stage of development for you, you take it in, and then you move on when your needs have been met and you are excited by the next phase. If you do not get what you need, your needs are not met, you stay at least partially stuck in that stage, and moving on is more difficult.

So, our kids have never been validated. Nothing in their lives has indicated that anyone was putting their needs first: not when they were neglected, not when they were abused, not when they were moved, and moved again, and again. They have a huge developmental hole where validation should have been. In other words, they have had few experiences in which someone said, I get it, I understand what you are feeling, I see how you could be feeling that way, and maybe even: I have felt that way myself. They have had few experiences of feeling: I am not alone.

So validate all you can- it won’t turn against you. And then when the youth leaves, maybe she will seek out more validating people, because now she knows how good that feels. And if she runs into non-validating people as we all do, she will have inside her a memory of how you understood her, you were on her side, and she will be able to manage that invalidation without disastrous reactions.

And you will have helped her find a life worth living!