Attention

Many times when we start discussing what is going on with a particular child I hear staff say: "she is just doing it for attention". We say this dismissively, as this invalidates the behavior and means we don’t have to take it seriously.
If you go to a play ground where children are playing and adults are near by, what do you hear constantly from the children: "Look, Mommy!" "Daddy, watch this!" "See how high I can go!" The children are clamoring for attention.
In fact, as adults we also demand attention. When you receive a compliment or an honor, do you call someone to tell them about it? Do you get upset if you try to tell your partner something and they are not paying attention?Attention is the food of the soul, the building material of the brain. It is necessary for growth and change. It is through the attuned attention of another that our brain develops and we form a sense of who we are, what the world is like, and what we can expect.
Attention is one crucial part of what was missing in the development of traumatized children. They were not central. Their needs were not put first. Often there was no one to listen to their stories and to take their disappointments seriously. Their needs were problems to be dismissed, not legitimate. Their cries were not answered. They have an attention deficit- not just that they cannot concentrate, but that they have empty spaces that have not been filled through the loving attention of another. No one was watching.
And now they are in treatment programs in groups of 12, 14, 17. Adult attention is in short supply, and is often monopolized by extreme behaviors. It some times seems the only way of being heard is to scream.
Paying attention is the greatest gift you can give another person. So next time you hear the words "he was just doing it for attention" stop. Pay attention. Listen. Express delight. Remember. Comment. Watch. Look, and describe what you see.
Attention is the nourishment you can give that will enable others to grow.

Change Your Conversations, Change Your World

You can further your change towards a trauma informed treatment program by changing the conversations you have as a staff.

Lisa is a sixteen year old girl who has been at this therapeutic group home for almost a year. During that time she has been known to sneak off and be where she is not supposed to be, and to lie to staff. However, recently she has been doing really well and everyone is quite proud of her. Lisa is scheduled to be transferred to a lower level of care shortly- a graduation which makes her staff very proud.

The other night Lisa sat with her favorite staff and said she had some thing to tell her. She then proceeded to confess a series of occasions when she had lied that no one knew about- such as saying she was at her job when she was really with her boyfriend, and sneaking out of the house at night. These things happened weeks and months ago.

What is the FIRST thing that you talk about at a staff meeting?

Is it what is the correct consequence- should she be grounded even though these things happened a while ago? Do staff take sides on yes, ground her, she needs to learn; no don’t ground her after all she told us voluntarily?

If this is your conversation, the fact that you decide not to ground her does NOT prove that you are using a Risking Connection® / Restorative Approach™ approach.

Instead, your first conversation, and ultimately the only interesting one is: what is going on here? Why is Lisa telling us these things? What was happening with her when she was doing them and what is happening now? Of course, her telling this is probably related to her impending discharge. She is probably saying: Look you guys I’m not so sure I am ready for less help. I know you are proud of me and all but I am scared to death. Plus I don’t want to leave you just as I am finally getting used to you. Look what I am capable of- I should stay right here.
And that conversation leads us to lots of possibilities. Is there more we can do to help her get to know the people at her new place? What conversations can we have with Lisa about her fears of going, the difficulties of saying good bye, and what she needs? We do not need to lecture her on the dangers of running away, or how she will never keep a job if she is not reliable. Instead we can talk about what it all feels like to her, the job, the boyfriend, this group home, the place she is going.

And with these interesting conversations going on we never even need to get back to boring subjects like whether or not she should be grounded.

If you want to change your program, after every event ask: what is going on here? What does this behavior mean? How is this action an adaptation for the kid, what problem is it solving for her? How can we help her to meet her needs another way?

These thoughtful conversations among staff and with the kids will strengthen relationships, teach feelings management skills, help the child (and staff) feel sane and worthwhile, and offer the greatest possible power for healing.

Cereal on the Counter

Scenario number one:

It’s a school day and Dahlia is sluggish and half awake. She scatters cereal all over the counter and leaves the milk out when she goes over to the table to eat. "Dahlia!" Mary, a staff member says. "Clean up this mess you made! Put away the milk!"
"No" replies Dahlia. "You do it".
"Dahlia, I have given you a directive. Please get over here and put away this milk and clean up this mess!" Mary insists.
"F you" replies Dahlia.
Eventually Dahlia leaves for school, counter unclean, milk untouched. Mary cleans it up.
Mary is fuming. "These girls" she says to a co worker. "They are so lazy and they have no respect for me or for this house. They are hopeless. How will they ever be able to live on their own?"


Scenario number two:

It’s a school day and Dahlia is sluggish and half awake. She scatters cereal all over the counter and leaves the milk out when she goes over to the table to eat. Mary looks at the counter and says: "Hey, Dahlia, what a mess. How about I’ll put away the milk- will you get the counter after you are done eating?"
"Okay I guess" says Dahlia.
After she is done with her cereal Dahlia cleans off the counter in a half-hearted way, leaving some cereal. Then she goes off to school.
Mary finishes up the cleaning.
"Ahhh, teen agers" she thinks to herself as she goes on with her tasks.

Which was your morning like?

We have all had both types.

Notice the power of how a request is made: a "staff directive" or a request and a mutual effort.

But even more important notice the power of how an event is defined. Is this an obstinate child defying a Staff Directive, a sign of disrespect and a hopeless future? Is it clear evidence that the child has no caring for Mary or for the house? Does it demonstrate beyond doubt that Dahlia will never manage her own life well?

Or is it a teen ager in the morning?

The Real World

I have not written anything in this blog for a while because I have been working on a SAMHSA grant application that has demanded every bit of free time and writing energy I could dredge up.

However, in a Risking Connection® training we were doing recently, a participant made the familiar objection: "we are not preparing these kids for the Real World". I’ve heard this a lot. The idea is that if we do not punish the kids for their behaviors they will never learn that these behaviors are not tolerated in the Real World- we are coddling them, spoiling them, and giving them an unrealistic view of life.

Consider the following analogy:
My 8 year old friend Ryan is in Instructional Little League this year. In this league the kids get five strikes, some times more if the coaches decide that the ball throwing machine isn’t working right. Everyone always says encouraging things to them: "good swing Cameron" (Ryan's team has three kids named Cameron, two girls and a boy) for a strike; "nice try" for a throw to a completely unpredicted part of the field. And the coaches constantly teach the kids skills: move your foot up a little. Keep your eye on the ball. Move your body to catch the ball, don’t just stretch. Every thing the kids do that is even remotely in the direction of what they are supposed to do is highly praised. They can only run two bases (otherwise everyone would get a home run every time, as no one ever catches the ball) and the innings are over when a team gets 5 runs. Obviously, the idea here is to begin teaching the kids the skills, and to limit the humiliation/ disappointment/ frustration they feel so they will want to play again. The game is set up to encourage success and limit damage.

And no one ever says: "we aren’t preparing these kids for the Real World if we give them special treatment like this".

Maybe we can consider our treatment centers to be instructional real life.

In the actual Real World ideas of Restorative Justice are gaining ground, and many more court systems are using them.

I would also hope, however, that the Real World that our kids live in will contain (as mine does) people willing to negotiate, and flexibility, and understanding. I hope that they will not in fact be punished for everything they do wrong (luckily, I am not). When they hurt someone, I hope they will have a chance to make up for it and heal the relationship. I hope that their Real Worlds will not be characterized by unremitting harshness.

In the mean time, maybe we can continue with the Instructional level and teach them skills, encourage them, and limit the damage so they will want to continue to play.

Just Ask What’s the Matter

I want to remind you that there is a major way you can implement trauma informed care without needing any committees, any program change, and without eliminating your points and levels system.

When a kid is upset, ask them what is the matter.

Don’t talk about consequences. Don’t talk about better ways they could be handling it. Don’t try to get them to take responsibility for their actions.

When you ask, be prepared that their response will be about something that someone has done wrong at your "stupid place" (that’s if they are putting it mildly). Don’t argue. Don’t tell them why the person was right to do what they did- even though you know they were.

Paraphrase what the kid said: so you are very angry about being sent up from school? It doesn’t seem fair to you? You can add an element of the possibility of change by introducing such phrases as: "Right now" as in: "right now you don’t like any thing about this place?" or "at the moment it seems impossible that you will ever have any friends?"

Emphasize any feelings they impart, especially any besides anger: you are discouraged, you are sad, you are frustrated, you were hurt.

Ask what else is upsetting them?

Stay for as long as you possibly can at the exploring and paraphrasing stage. No suggestions of how they could have handled it better, no mention of consequences that will happen, no taking responsibility for their action, just explore what are they upset about.

During all this keep your breathing slow, your voice calm, yourself regulated.

And this takes patience. You may have to keep doing this for a long time.

And then when (and only when) you notice some de-escalation on their part, some slowing of breath, and reduction of yelling, willingness to talk, then start considering: so where can we go from here? The kid is upset and wants this, the adults think this is necessary, how can we go forward? Where ever you can compromise, be creative, use unique solutions, do so.

At this point also slip in some discussion of other, non-problem related things: how the room floor is hard, how its cold in here, how you remember they had their basketball game yesterday, how did it go- chit chat. If the child is really much calmer, some humor can often help.

Once the child has regained some sort of regulation, you will often be surprised how easily the next steps can be figured out.

Try this today.

Recent Conference Presentations

I have just returned from presenting at the Black Administrators in Child Welfare Conference in Baltimore and at the Child Welfare League of America Conference in Washington, DC.

At BACW I was struck by the power of inspirational stories and of invoking past heroes and heroines to create courage for the current struggle. Presenters repeatedly told their own and others’ stories of triumph after trauma, prejudice and adversity. Heroes such as Rose Parks, Sojourner Truth, and Martin Luther King were called forth to bring energy to current problems. How can we use these methods more in our own agencies, and in our own change efforts? All of us in this field know inspirational stories of kids and families who have changed, programs that have been transformed, and treatment that has been effective. Many agencies have their own founding heroes and heroines. While we do turn to these rich legacies for help, I felt after attending this conference that we could do so more and with greater emphasis. Also, in this conference I experienced more acknowledgment of the struggle of this work, and the need to comfort and care for each other.

In my presentation I referred to the kids we treat as "damaged". Joanne V. Rhone, Ph.D., Professor at Clark Atlanta University suggested I would be better served by referring to them as "wounded" because as we know, wounds can heal. Damage, she stated, sounds more permanent and unchangeable. I thought this was an excellent point and will adapt my language in the future.

I attended a workshop on "Working Between Circles & Lines: Using the Restorative Circles Process to Create Effective Collaborative-An African Centered Construct for Organizational Prosperity". This workshop includes an introduction to Restorative Justice as a best practice in Child Welfare and how to use it to create paradigm shifts in organizational culture and practice. Restorative Justice is a set of values that guide decisions on policy, programs and practice. The Circles process restores the collaborative effort of agencies working together for the greater good. It was led by Saleem Hylton, CEO, President; K. Ivy Hylton, MSW, LICSW, Youth & Families in Crisis, LLC, Washington, DC They described and demonstrated the power of a Circle to bring people together and hold meaningful discussion. They gave examples of the use of this circle in creating agency collaborations, as well as in offender/victim encounters. I hope to utilize this technique further.

I also purchased two useful small books: The Little Book of Restorative Justice (Little Books of Justice & Peacebuilding Series) by Howard Zehr and The Little Book of Restorative Discipline for Schools: Teaching Responsibility; Creating Caring Climates (Little Books of Justice and Peacebuilding) by Lorraine Stutzman Amstutz and Judy H. Mullet. Both have clear explanations and many practical implementation ideas.

At my presentation at CWLA I had participants from all over the country, and it was very interesting to experience this national change in treatment approach. Many agencies are starting to implement trauma informed treatment and to move away from point and level systems. One agency expressed concern about whether such a change led to longer lengths of stay. Others talked about child care workers indoctrinating each other to "be tough" and not show feelings. It was clearly helpful to connect with others doing this work, and reinforced my hope to start more email net works and communication mechanisms.

Altogether it was a very interesting and inspiring trip.

Upcoming Conference Presentations

Is any one attending either the Black Administrators in Child Welfare (in Baltimore) or the Child Welfare of America (in Washington D.C.) conferences next week? I am presenting at both and would love to see you there. If you read this blog, please introduce yourself to me at the conferences.

My workshops are:

BACW
Friday afternoon
C-4 Creating a Culture of Connection in Residential Treatment

This workshop explores the transformation of a Residential Treatment Center into a trauma-informed, relationship-based treatment program. It explains the Restorative
Approach theory of change, new language used, specific treatment techniques and response to acting-out behaviors. The Risking Connection Curriculum-trauma framework, therapeutic relationships, counter-transference and vicarious
traumatization-will be introduced.
Moderator: Dr. Sharlyn Bobo, Washington, DC
Presenters: Patricia D. Wilcox, Vice President of Strategic Development; T’Kai Howard, Coordinator, Nia Sage House, Klingberg Family Centers, New Britain, CT


CWLA
Tuesday morning
C11 Creating a Culture of Connection in Residential Treatment
This presentation explores the transformation of a residential treatment center into a trauma-informed, relationship-based treatment program. It explains the restorative approach theory of change, the new language used, specific treatment techniques, and the response to acting-out behaviors and it introduces the Risking Connection Curriculum. Presenter: Patricia Wilcox, Vice President of Strategic Development, Klingberg Family Centers, New Britain, CT

Hope to meet you there!

A Wonderful Example of a RICH Interaction

I am in the midst of a Risking Connection training with two co-trainers, Michele May LCSW and Richard Nicastro, Ph.D. Michele is the Clinical Director of Natchaug Hospital’s Journey House Program. Richard is a therapist specializing in trauma with offices in Glastonbury, CT. He is also a life coach, and his blog can be found at http://www.relationshiptuneup.typepad.com/

Richard gave a wonderful example of how even a brief interaction can be RICH.

A few years ago Richard was running an anger management group for boys at a local community center. He noticed that one boy was standing near by imitating his movements and mocking him. After the group, Richard went up to the boy and say: "You know, I am looking for some new members for this group, so if you or any one you know would like to join I’d welcome new people. But you know what, I am looking for someone who is a real wise-ass, because we need some humor in this group. Even though we deal with some serious topics we need some comic relief and I’d like someone like that in the group. So, if you know any one..."

The boy did not join the group, and in fact Richard didn’t see him again for over a year. He learned from others that the boy had been in a lot of trouble and a lot of programs, and that since he was young he had been living with his father’s serious illness and constant near death.

Much later someone called Richard with a referral of an adolescent boy whose father had just died. Richard accepted the referral and was astonished to find the same boy in his waiting room. It seems that when the boy needed to go to therapy he remembered Richard’s name and asked if he could see him.

Think how completely Richard displayed a RICH relationship in those few minutes. He demonstrated Respect for the boy in his approach, and in his assumption that a sense of humor could be an asset. He gave Information: the group is available, you could join, and you could help others. He established Connection (more than he realized) by appreciating the boy and his skills. And he conveyed to the boy the Hope that there is some one out there who wouldn’t judge or dismiss him, who might see the good in him and who maybe could really help.

And look at the power that one moment of RICH interaction can have in someone’s life.

Many thanks to Richard for this excellent example.

Asking Directly for What We Want

Asking directly for what we want is very difficult.

First of all you have to know what you want. That is not always easy. It involves noticing your own distress or need, and correctly diagnosing a possible solution. Many times we feel vaguely unhappy or sad and have no idea what would help.

Then, you have to have in your heart the concept of needs being met, the possibility of improvement. You have to have some experience of feeling bad, then feeling better. When you need help, some times people help you.

And which people would that be? You have to have people you can trust around to receive your requests. You have to experience them being willing, pleasant, and regularly saying yes to you. Your experience must also be that they are gracious and generous about helping you, and do not extract a high price.

Also, to ask for help you have to feel enough okay about your self that you can handle not being perfect. I need help, I cannot manage everything myself, but I am a good enough person over all. I actually deserve help. I help others.

That deserving is a big thing. You have to think there is some reason that some one would actually be willing to do something for you.

Asking for help directly makes you vulnerable. The other person could say no. They could make fun of you. By telling them what you need you are showing how they could hurt you.

I know a lot of very competent people (especially women) who cannot ask for help. I know many professionals that have trouble delegating and work from an "I-can-do-everything-myself" stance. I know women who take on every responsibility in their family, and men who can’t share worries about work. I know a man who overwhelms his friends by doing things for them until they become annoyed, because he can’t imagine they would like him unless he "bought" their friendship. I myself often have difficulty asking for and accepting help.

When we work with treatment systems we try to teach staff willingness to step back from an interaction with a kid and accept help from a peer when you are stuck. People say that this is hard. Harder still is identifying the kid you are struggling with and asking the team members to help you figure out what is going on for you and thus do better treatment with that kid.

So...

When we focus with our kids on "asking appropriately" we are demanding a very high level of functioning, maybe more than we ourselves can do. How many times have I heard a staff saying "you didn’t ask appropriately" or "she is only doing that for attention". Manipulation, as we have seen, is the essence of asking indirectly and dishonestly for what one needs.

If we believe that symptoms are adaptations and solve a problem, we cannot wait until our kids can "ask appropriately" to meet their needs. None of the above conditions have been true in their lives. Instead, we have to guess and use observation and trial and error to figure out what their needs are. Then we have to meet them. We have to volunteer help, give graciously and generously to them as best we can. Then, maybe, after much time, they can relax, trust, and feel safe enough to ask for what they need.

Maybe even appropriately.

And maybe if we also create environments in which we can relax, trust and feel safe, we can also learn to ask for and accept help from each other.

Non Profit Blog Exchange

I am writing as part of the Non-Profit Blog Exchange, a method of connecting the non-profit blogging world and further spreading our work. The blog I am reviewing is Marion Conways’ Consultant to Non Profits Blog, at http://marionconwaynonprofitconsultant.blogspot.com/. This blog covers many aspects of non-profit leadership, including fundraising, finding volunteers, on line donations, promoting your web site, and Board responsibilities. I recommend it because it contains information that is helpful across many types of non-profits. It is very interesting to learn skills from say, museums, and apply them to behavioral health. It helps us identify the commonalities in our struggles. Marion offers very useful help for non-profits of all kinds.

Who Are These Kids?

If I walked up to the first child care worker I saw at your place and asked, "Who are the kids who come here? What are they like?" what response do you think I would receive? Would the person say: "They are kids who have experienced severe difficulties in their lives, who are hurt, who haven’t developed the skills they need to have lives worth living. But they are really great kids"? Or would the response be more like: "they are very difficult, aggressive kids. They have committed crimes or done other bad things. They are wild and out of control. They can’t be trusted, they will hurt you, you need to watch them, you can’t let them get away with a thing"?

Of course the response would vary with the day, with the minute. It might be different from program to program. And most likely the response would contain parts from both responses above.

But who we think the kids really are determines what we think they need. In the first scenario (again, keeping in mind that these are extremes on a continuum) those kids need to heal, to learn to manage their pain and emotions, and they need skills. In the second scenario, those kids need control, punishment, vigilance, to be watched, a tough staff who holds them accountable and doesn’t let them get away with a thing.

And that leads us to who we have to be. Who we think the kids are leads us to our ideal for child care staff. What is the actual ideal that is operating in your culture? Are new child care staff socialized by experienced workers that they should be kind, calm, soothing, and should gently teach the kids new skills? Are they taught and shown that liking, enjoying and appreciating the kids is essential to what we do here? Or are they scared by violent war stories, shamed for being innocent and trusting, or weak, and taught you have to be tough and firm and not let the kids get away with anything? Do staff brag about their moments of connection? Or are they proud of the battles they have endured, the injuries they have received without flinching or showing any response? Is the staff ideal closer to a person or to a rock?

Again, the reality is undoubtedly somewhere in the middle. But let’s have these discussions out loud. Ask staff what they learned from experienced staff when they first came to work here. Talk about what we want the ideal to be and how we can put that into practice. Remember, how we see the kids is undoubtedly how they will act.

Manipulation Part Three- Us

I may seem to be obsessed with the concept of manipulation, as this is my third blog post about it. This concept, for me, represents how hard it is to create an entire world-view change in the treaters who work with our damaged kids. So often we teach the section in Risking Connection on manipulation, only to hear as I did the very next day a child care worked in the training say with indignation something like: "and I couldn’t believe that child was trying to manipulate me to get what he wanted, what did he think I was, an idiot? And by going to that other staff he did get exactly what he wanted!"

First of all, it actually isn’t a crime for a child to get what he wants. And if we would like to encourage direct communication of needs, we have to be prepared to say yes when ever possible.

Secondly, the question of what may have prevented this boy from asking directly for what he wanted was missing. And more and more I become aware that our systems prevent a child from asking directly- for more phone time, for an extra snack, for a later bed- because we are so wedded to our structure that we automatically say no. "He knows the rules. Who does he think he is?"

Yet we ourselves often ask for and get extra, against the rules- an extra cookie from the cafeteria staff, the ability to leave early just because we are tired from our supervisor, some extra telephone time (when we are being paid to be working) because our child is sick.

I have begun wondering why we get so angry about this. We feel angrier than we do for more severe behaviors, such as aggression, at times. One aspect, I think, is that manipulative behavior appears deliberate and calculating, within the child’s control, as opposed to an angry out burst which is clearly emotionally based. We lose sight of the factors beneath the child’s inability to meet his or her needs directly.

What do we feel when we have been tricked or manipulated? When we are vigilant to spot and stop all manipulation what are we guarding so heavily against?Staff comments give us clues: Does he think I am stupid? I felt like a fool. The rest of the staff will not respect me. He thinks he can get over on me. I looked bad in front of every one. I felt like an idiot because I believed him.

So, being tricked makes us feel foolish and stupid. It taps into our fears that we may be incompetent. We feel unsafe, exposed, laughed at. We imagine we look bad in the eyes of our peers and they are judging us as naïve, gullible. In short, we feel a type of shame. We strengthen our resolve never to feel this way again, and become more guarded and distrustful with the kids. We determine to be trickier than they are.

Can we use this experience to develop a new depth of empathy for our kids? After all, they feel this way most of the time. They have been tricked, used, and made to feel foolish. They have trusted and then discovered lies. They have been counting on someone and been left. They, too, have felt unsafe, exposed, judged, laughed at. And just as we do, they develop the protection of being hardened, guarded and distrustful- and indirect.

Humans, adults and kids, are vulnerable. We don’t like to be exposed. We don’t like to be rejected. We don’t like to be taken advantage of, tricked or lied to. If this happens a lot, we close down, form a protective barrier, hide our true hearts, and interact defensively. We try to get what we can through indirect, covert ways. When we feel safe and trusting, we are most likely to ask directly for what we need and want.

When we hear ourselves use the word manipulation, and we feel that familiar indignation, let’s look deeper into our selves. Let’s use what we feel to help us understand in a new way what our kids feel. Let’s use this understanding as a platform to create meaningful, caring discussion about the possibility and benefits of honesty between people.

Dr. Ross Greene

I did attend a training by Ross Greene (http://www.ccps.info/) at the Brattleboro Retreat (http://www.retreathealthcare.org/) Ross Greene does not speak much about trauma. However his approach that children do well if they can, and that defiance and other problems are caused by learning disabilities, are very compatible with our work. He states that rewards and punishments teach that external bad effects rapidly follow bad behavior, when you are caught. This is not always true in the world, and leads mainly to an emphasis on not being caught- a radar detector approach to speeding. Learning how your behavior affects others is a much more powerful force for change.

As I have often stated, it all goes back to your formulation of what you think is going on when that kid is acting up. Why do you think he is not doing well? If you believe it is because he doesn’t want to, then an approach of increasing motivation (rewards and punishments) is appropriate. But if you believe he doesn’t know how, then a skill teaching method is called for.

Ross Greene had some thoughts to add to our investigation of manipulation. He stated as others have that our kids are bad manipulators- their manipulation is too obvious and makes other people feel bad. Good manipulation is more subtle, makes the other person feel they are doing just what they want to do. It involves planning and organization and the other person does not know they are being manipulated, or does not resent it. So- can we start working "being a good manipulator" into our skills classes?

I liked the phrase Dr. Greene used: "decisive not punitive". When we first teach staff about the Restorative Approach some feel that it means that they should ignore kid’ harmful behaviors, not step up to what they are doing that is hurting others. The best Restorative Work requires very active involvement with the kid and lots of feed back on how what they are doing affects others. Decisive but not punitive!

Dr. Greene describes our role as being a "surrogate frontal lobe" for the kids while helping them grow one of their own.

Dr. Greene’s method of collaborative problem solving is certainly an excellent idea. One thing I like was the suggestion to teach kids a few key phrases they can use when they are starting to feel upset. As we know, our kids don’t know what to do when they become over whelmed, don’t know how to ask for help, and resort to old solutions such as throwing chairs. Learning some phrases like: "Gimme a minute"; "I need a break"; "Something is the matter"; "I can’t talk about that now"; and "I don’t know what to do" could be a great help.

Dr. Greene suggested there are really only three basic ways to solve a problem between two people: ask for help, give a little, or do it a different way.

I enjoy the convergence of these various methodologies.

Taking Responsibility Part Two

In treatment programs we talk a lot about kids taking responsibility for their behavior. It seems to be very important to us that the kids acknowledge when they have done something wrong. It is, of course, important to identify when one has done something wrong- how can you fix it if you don’t acknowledge that it ever happened? I have previously written (June 15, 2006) about how shame paralyzes our kids in this area: doing something wrong to them feels like all is lost, all my worst fears about myself are confirmed, no one loves me, everything that has happened is my fault. If admitting you have done something wrong plunges you into total hopelessness, and you have no feelings managements skills, and you have no skills for repairing relationships, your only defense is a complete refusal to own the behavior.

Recently I have been thinking that our indignation that kids "won’t even take responsibility for their own behavior!" might be tempered if we look at ways we find it difficult to take responsibility for our own behavior.

I attend Weight Watchers and that is a wonderful place to learn about adults (including myself) who are trying to make difficult changes- like our kids are. These adults (including myself) by in large have many more assets than our kids do- supporting networks, developed feelings management skills, intellectual abilities. Yet what do we see? People having difficulty taking responsibility for their behavior.

If a person has not been following the eating plan their first impulse is to skip the meeting all together, and to think of a good reason they cannot attend. If they go to the meeting they may want to skip the weigh-in. If they have gained they have many reasons and many extenuating circumstances (in the kids we would call this making excuses, although just as with the kids many of these reasons are completely legitimate). If any one has a bad day of over eating, we often feel that all is lost, that we will never lose weight, and then we keep on over eating more and more. Much in the same way the kids are plunged into hopelessness and despair, these high functioning adults are similarly affected.

We can think of other situations in which we hide our failings, conceal our mistakes, find reasons to excuse our less desirable actions.

I guess it just isn’t that easy for the human being to take responsibility for his or her behavior.

When Programs Have Problems…

Recently we noticed that one of our units, the Acute Unit, was experiencing an increase in the number of restraints and seclusions. This unit provides excellent treatment for extremely damaged children ages five through twelve. The unit has fourteen kids at a time and is co-ed. This was our first unit to transition to the Restorative Approach. The program has a high reputation for attachment focused treatment.

The first step in responding to a problem is to notice it and pay attention. It took us longer than it should have to take the increase in restraints seriously, analyze the data and begin discussions with the staff and with the kids about what was going on. When a program is in crisis mode people’s time is eaten up responding to the demands of the moment. This stepping back and thinking is especially hard. But it is also especially necessary. The staff of the unit described a feeling of relief when the restraint numbers were reported to them- so that is why I am feeling so tired and drained! Finally someone is paying attention!

We analyzed the reports as to time of day, staff involved, reason restraints started, which kids were involved, etc. and then scheduled a meeting with the entire team and administration to discuss the problem. The meeting tone was not "what’s going wrong down here?" but instead "what help do you need?" However, by the time we had the meeting the team had already reduced the restraints and seclusions and changed the unit situation. So, instead we discussed how they did it. These discussions are as important as problem solving. They serve to underline and re-enforce the changes made, give employees recognition, and further unite the team.

So how did they change the unit atmosphere and reduce restraints and seclusions?A therapist from the team led training on "The Attitude" from Daniel Hughes (playful, accepting, curious and empathetic) and everyone committed to using this through out the day.

The difficulties had partly been caused by staff turnover- several people had left at once and the unit had been operating with open positions. So now that the positions were full, they had activities to create the new team, get to know each other, and discover each other’s strengths and interests. That way each staff could lead from their strengths. An example given was staff starting activity groups based on what they liked to do. As one child care worker said: "don’t have the crafty people leading the sports". The retreats and trainings focused on self awareness, understanding one’s emotional responses to the kids, and asking for and receiving help. They spoke proudly of their ability to be honest with each other and share their feelings, let each other know when they are burnt out or depleted.

Analysis of the data revealed some times when restraints were highest, notably after dinner. So the team changed the structure of that time period. They divided the kids into two groups for dinner (instead of all eating together), eliminated "siesta time" when they were supposed to be in their rooms but didn’t want to be, instituted calming and relaxation groups, and decided their would be no gym or active games after 7:00. They also added more structure and planned activities on the weekends, deciding in advance how to split the kids up to break up difficult combinations.

A large turnover in kids had also contributed to the restraints and seclusions. The data showed that only 4 of the 14 kids contributed most of the incidents, and that both the frequency and duration of restraints decreased over time for each of them. So the unit decided to adapt ways of getting to know new kids sooner and better, such as by assigning individual staff to spend time alone with each child. They reported that when they concentrated on this they more quickly learned how to help the child avoid escalation. One example was a kid who could accept a tight hug and avert a restraint.

We also discussed: what are other indicators of how unit life is going, in addition to restraints and seclusions? People identified- there is more laughter. We see the positives in the kids and in each other more clearly. We say more complimentary things to each other. We feel closer to each other. We have more fun with the kids.

The unit management now plans to watch all these indicators, including restraint and seclusion numbers, more closely and report them in staff meetings weekly. There is a tendency that when things get better we drop the practices that made them better, such as carefully planning the activities of each shift. The weekly discussion will guard against this. Also, key times such as a grouping of discharges and new admissions, or several very young kids coming at once, have been identified. When such a time approaches, staff will implement special active plans.

It was so moving to see a team of people realize a problem, take it on, and change it, through using the fundamental building blocks of this approach: relationships, the Attitude, planning, and thoughtful understanding of our traumatized kids.

I Don’t Do Vulnerable

More and more I see a lot of our kids’ behaviors as desperate attempts to avoid being vulnerable.

Priscilla tells me she does not care about her foster parents. Why do I keep asking how she feels about their divorce? Nothing that happens with them affects her, why would I imagine it would? They are just people she happens to live with.

Joey, a boy who is small for his age, enters the unit insulting everyone, making death threats, talking about his gang affiliations and the weapons he claims to have hidden in his room.

Aaron is scheduled for discharge. He becomes aggressive and angrily attacks his favorite child care staff.

Katie is desperately hurting herself, refusing all offers of help, screaming that she needs to go to the hospital shortly after moving to a new group home. She finally says how unsafe she feels the place to be, the locks do not seem secure, it is in the middle of no where, who knows what the neighbors are like, and she’s not all that sure about the staff.

I think we can go far by looking at every episode of aggression we see and think: fear. When we observe unexplained anger, look for anxiety.

The video "Multiple Transitions: A Young Child's Point of View on Foster Care and Adoption" available from The Infant-Parent Institute is a profound and moving story of the child welfare system from the child’s point of view. One part that has always stayed with me is:
"Did I mention how much I am growing to hate smallness, and weakness and defenselessness? It's getting so the only thing I know how to do is to just be as tough as I can, and to try to rub out smallness and weakness wherever I see them:
In the kittens that get hung by the clothesline in the backyard and squished with a tennis racquet.In the babies in my recent foster homes who turned up scratched. In my own Self, which I attack, particularly when I am feeling small or scared, and I need to beat myself into more toughness."

Our kids have seen weakness and where it leads. They have been vulnerable. They have seen their mothers beaten and bleeding. They have been too small to stop the hitting. They have been molested and been unable to protest. They have had it with being too small, too weak, too powerless, too vulnerable. Now they are going for power and protection, whatever the cost.

So what does this mean for us? Try to keep the vision of the hurt little child in your mind’s eye when you relate to the raging teen-ager. Validate the anger and (when you can) identify the fear underneath, and validate that. Understand that the child has real and necessary reasons to hate the softer feelings. Mostly create a caring and respectful environment in which the child can relax and feel safe enough to dare to share how scared she is.

And this will be the priceless gift that you can give these kids.

One of Those Scary Nights

I was expecting eighteen people from the Department of Children and Families Juvenile Justice Division for a presentation on the Restorative ApproachSM. As I was arranging the room, checking on the food and preparing the brochures I began learning about the previous nights’ problems.

It all started with boyfriend issues, and then rapidly escalated from there. One girl pulled the fire alarm, one ended up in the emergency room. The Program Director had to come in to help the girls calm down.

I started to wonder- am I a fraud here? I am teaching all these people about this new approach, and yet we experience a night like this. We have just been enjoying a period of relative peace and calm with the girls- why did this happen? When I do training I teach that staff should not judge their work by whether the kids act up. Judge the night instead by how they, the staff, act, and whether they use the Attitude (courtesy of Daniel Hughes)- playful, accepting, curious and empathetic. Do I actually believe this?

As often happens, I learned from our child care staff. During the presentation the Girls’ Unit Supervisor Karen Pac began to talk about the differences she experiences during a crisis since we began the Restorative Approach. Staff are warmer and more compassionate with the girls. The emphasis is not on the rules, but on helping the girls calm down. If Katie wants to take a shower, although it is not 'shower time'- let her, that is an excellent de-escalation technique. The team of therapists and staff works closely and calmly together. The team concentrates on reaching out to the girls- what is the matter? That approach allows Robin to switch away from anger at her boyfriend and Nicole who has talked to him and the staff that won’t let her beat both of them up. She begins talking about her father, who said he was going to become re-involved in her life and has disappeared. Now she is crying instead of yelling and threatening. Staff are next to her sharing and validating her sadness. The next morning, the conversation centers on what is happening in the girls lives and better ways to help them. Education staff comes to the unit to meet with the girls and gauge their mood, to make plans with them for entering school (where of course the boys are) and becoming students. The girls are calm and able to attend school. Life goes on.

Our Boys Unit presented a skit for our visitors in which they act out 'before' and 'after' we switched to the Restorative Approach. The situation they chose this time was Steve who had not done his homework and was supposed to be in his room completing it. Instead he was sitting in the lounge refusing to move. In the 'before' scenario, staff concentrated on the fact that there was a rule and Steve was not following it. We must be consistent. We must focus on compliance. The therapist stood near by, but she was not relevant when the goal was to get Steve to do as he had been told. This situation rapidly escalated into a restraint. In the 'after' scenario staff asked Steve what was wrong. They noticed that he had been acting differently all afternoon, had been withdrawn and sad. They called in his therapist. They ignored the fact that he was still in the lounge. Soon Steve began talking about what was troubling him, went for a walk with his therapist, and then easily finished his homework.

These kids come to us severely damaged. They have no ability to manage emotions, and every small setback escalates into despair and panic. A problem with a boyfriend evokes all of their many devastating losses. We cannot expect that we will have no crisis’s, no emotionally over-wrought nights. Instead, we can change how we act in those times. We can stay emotionally regulated ourselves so the children have a chance of regaining emotional regulation. We do this by having a plan and through strong teams. We can shift our focus from rules to compassion. We can concentrate on helping kids calm down. And then we will experience crisis that are shorter, less destructive, less frequent, and that provide opportunities for growth for our children.

Yesterday Yet Not Today

One comment we often hear is "She was able to handle this yesterday without acting out so I know she can do it. So why is she so upset today? She must be doing it for attention." The implication behind such comments is that if a child can function without her symptoms on one day, she should be able to do so on all days. Therefore, her symptom today must be somehow contrived, phony or unnecessary. We can become very exasperated with kids who are acting out when we have seen them do much better at other times.

What is going on when a child’s functioning is uneven? When one day the tiniest little setback seems to completely destroy him, yet on another day he can get bad news from his family and react calmly and with understanding? As we consider what may be happening, let’s look at ourselves first.

When I am dieting, some days it seems so easy and so obvious- just make good choices. Why would any one ever do anything else? On other days, however, every minute and every food decision seems like agony. The bread and butter are essential to my survival. I can’t even remember why I ever thought of dieting. Some times I have some ideas why one day is harder- I am tired, or I am in a situation with a lot of food. But sometimes it is inexplicable. I just wake up in an easier place, or a place of struggle. People tell me it is always this way with change, and with improvements we try to make- quitting smoking, doing exercise, changing a behavior towards a person, learning a new athletic skill.

So for the kids, some days are just harder than others.

We can and should learn with them what may contribute to days of greater strength and resiliency. This can include good self care skills, such as getting enough sleep, eating right, and getting exercise. It can include changing the environment- spending time with positive people, finding interesting things to do, being in a safe and nurturing space. It can include setting up supports, be they friends, letters, pictures, sensory distractions, music, art. It can also include predicting times of potential stress (such as phone calls from family) and planning to have support and safe options available if distress occurs.

In the same way, I would do well to employ good self care, not have the most tempting foods in my kitchen, seek out, interesting activities to distract me from food, cultivate supports such as other dieters, and plan for what I’m going to do to manage eating events.

And, we have to understand that for our selves and for our kids, some times all this just doesn’t work and we have inexplicable bad days. And we have to do what we can to limit the damage, and get back on track as soon as possible. And these bad days don’t negate any progress we have made (although it feels like they do). The bad days are real, the difficulty is not "for attention". Change is not linear. We all need relationships, compassion, understanding and connection to just keep going.

Alliance Conference

I have just returned from presenting at the national conference of the Alliance for Children and Families (http://www.alliance1.org/) in St. Louis, Missouri. Many agencies represented there are some where along the path of incorporating trauma understanding into their residential or group care. Many are just at the beginning, and are struggling with similar questions. People are concerned about lack of staff skills, boundaries, time, resistance, and fears that chaos will break out. Several people made the point that in some ways the trauma-informed approach is a return to our roots. Many agencies started as orphanages, and in the early days love was considered the main tool. There were strict rules, but also an emphasis on caring and flexibility. At my agency, people who grew up there in the orphanage years (now in their 80s) come back to visit- and they remember "Miss Mable" who "thought I was special". The relationship is the power!

Mark D. Freado, Director of Re-education and Consultation, and Lisa A.
Shepard, Senior Director of Clinical Services, Pressley Ridge. Presented on "Creating a Trauma Sensitive Culture through Competency Training". They described how Pressley Ridge (http://www.pressleyridge.org/) is using staff training, competency development and evaluation to change the treatment culture.

In addition to implementing trauma informed care, agencies are focusing on more effective, careful management, branding, outcomes, fund development, and Board development. In a keynote presentation Stephen B. Heintz spoke of the power non-profits and their staff have to influence public policy in his address: "Power to the People: The Critical Role of Civic Engagement". Thomas J. Tierney highlighted "The Leadership Deficit" in the non-profit sector, and emphasized the importance of active succession planning at all levels of all our agencies.

It was heartening to see so many agencies beginning to add a trauma framework to their approach. Let’s all work together to figure out how to do this! Please add your experiences through the comments option in this blog- just click on the word "comment".

Siege Mentality

We know that trauma and the resulting fear changes our thinking. Remember that severe trauma produces a constant re-experiencing of the trauma, in the forms of flashbacks. So the trauma survivor is in effect constantly being re-traumatized. He lives in a state of fear.

When a person is living in a state of fear she develops trauma-based thinking. Trauma-based thinking is characterized by a tough, battle mentality. It is a "batten down the hatches, we are in for a storm" way of operating. The person is ready for the worst. She is constantly scanning the environment for sources of threat, and is not noticing much else. She is unable to notice her own inner feelings, and especially must put aside any feelings of vulnerability, weakness, softness of sadness. She develops an "us-vs.-them" mentality. Everything is black or white- war allows no subtlety. You can’t tolerate nuance or ambiguity when your life is on the line. People are either your friends (few) or your enemies (many). Bad things will happen soon, you will soon be attacked- so better to take the offensive now.

If we stop and imagine a situation of real danger, whether it be the proverbial lion attack, a war, or being mugged, we can see how such a method of thought is helpful and in fact necessary.

It is very important that we realize that this is how our kids are thinking, and that only by helping them feel safer and in less danger will they be able to move to any other kind of thought.

In addition, in a parallel process, this can also be how we are thinking.

When programs have become out of control, when there have been numerous staff injuries, when the staffing seems inadequate and the kids unmanageable, when the staff do not feel cherished by the administration and feel blamed by the larger system, we too fall into trauma-based thinking.

We batten down the hatches, and prepare for each day’s storm. We expect the worst from the kids and families. We look at the unit for sources of threat and don’t notice positive events. We turn away from our own feelings of being scared, sad and inadequate. We develop “us-vs.-them” thinking: staff vs. kids; child care workers vs. therapists; line staff vs. administration. Everything becomes black and white for us. The kid in front of us will probably hurt us soon so let’s restrain them now and get it over with.

What is the antidote for trauma based thinking? It is the same for the kids and for us: safety and connection.

Developing connections with each other can start with just talking about what is happening, our feelings, our vicarious traumatization, our exhaustion. Connections and safety can be knit throughout the organization, from the administration to every worker to the kids. Mechanisms can be created for fun, play and relaxation. Patterns and policies can be revised to increase safety and allow for the possibility of heart-to-heart relationships.

If we focus on creating an atmosphere of safety and connection, over time we can all relax. And when we are using less trauma-based thinking, and are more flexible, vulnerable and positive, the kids will be better able to thrive and grow.