Organizational Structure

Using both our own experience here at Klingberg and the experience of other agencies we consult with, we have been thinking about what organizational structure best supports a trauma informed care treatment model. We have come to believe in a structure in which a clinically trained person (a coordinator) is in charge of a treatment unit, the clinicians are assigned to that unit, and both the child care staff and the clinicians report to the coordinator. There may be a child care supervisor who reports directly to the coordinator supervises the child care staff. There is a leadership group consisting of the coordinator, the therapists, and the child care managers that meets regularly to create and implement the treatment vision. 

Recently we were meeting with an agency which was trying to adapt this recommendation to its own needs and personnel. This discussion prompted me to think about why I think this structure is best; or what I am trying to achieve through this structure. 

The ideal treatment team to implement trauma informed care will have these characteristics: (remember- I said the ideal) 

1. Clinical thinking will be integrated into every moment of the work- through every daily activity, every assignment of consequences for actions, every structural decision. What is clinical thinking? It is looking beneath the outward behavior of the child and considering why. How does this behavior relate to his past experiences? What problem is he trying to solve? How is this behavior adaptive for him? What skills does he need in order to behave differently?
   
   
2. Relationships will be emphasized at every level. Staff will be encouraged to form strong relationships with the children, and be given time and mechanisms to do so. There will be close relationships among members of the treatment team, members from all disciplines- child care workers, teachers, therapists, psychiatrists, nurses… These relationships will hold the children in a safe net. They will also provide the humor, sustenance, honesty, caring and support necessary to provide the stamina to do this hard work.
   
   
3. The treatment environment will belong to all, and decisions will be made together by the team: should our bed times be later? How can we get the kids to brush their teeth? What should we do about this recent bunch of run-aways? How do we react to the kids attempts to split us? What should we do about anger developing between the first shift and the second shift? All these questions are everyone’s business and everyone’s responsibility.
   
   
4. The team will develop the ability to discuss hard questions with each other. They will be able to accept help when a team member tags them out. They will ask each other for help. They will be able to discuss whether a given response to a child was too harsh- or too lenient. They will feel safe enough to discuss their individual reactions to certain children- those they want to kill and those they want to adopt. They will talk about how the work is affecting them personally.
   
   
5. The model for the provision of therapy will not be through once-a-week appointments in the clinician’s office. Instead, the therapists will be responsive when the kids need them or are having a crisis. The therapist will be regularly present on the unit and in the kids’ lives, and will take advantage of opportunities when the kid is receptive to connecting. They may also have appointments in their offices for those kids who can accept this, but many discussions will be held on walks, or while playing a game, etc. The therapists will participate when they can in unit fun events like celebrations and some activities. Furthermore, information about the child will be shared within the team, and the child will know this. If the child wants the therapist to not share a certain item, the therapist can honor this while hoping the child will be ready to share with a few soon. Or the therapist can work with the child to create a version to share. For example, the child may not want the staff to know the details of past abuse she is currently discussing in therapy. But she could agree that the therapist tell the staff that she is currently exploring some hard stuff from her past, so they can be prepared to help her with any reactions she may have. This communicates to the child that the entire team is part of her treatment and is there for her.
   
   
6. Every one on the treatment team will have regular opportunities to talk and think about the work, they will not be expected to just be doing it every minute they are at work. This includes individual supervision (weekly for clinicians and full time child care workers), treatment teams, staff meetings, etc. In these forums they will have a chance to learn about the child, his back ground, his issues, his plans, and current happenings in his life. They will have a chance to explore their own reactions to the child. They will share things the have observed, learned, and found helpful. They will participate in setting the course of treatment, as all will understand that every minute of the day is part of the treatment.
   
   
7. The reporting structure will be clear and organized. Every staff member will know who his direct supervisor is, what his job description is, and what his own responsibility is and what the responsibility of other team members is. The direct supervisor is responsible for guiding the professional development of her supervisees- handle performance issues, providing needed training, encouraging and praising, and helping the staff member reach his own goals. 

I’m sure some of these suggestions are controversial- and altogether they may seem impossible. Yet even within all our constraints it is possible to get quite close to this ideal. 

What do you think? Please click on “comments” and tell me your opinion.

 

CWLA Presentation

Our visit to the CWLA annual conference went well. We made some good connections and had some good conversations. After our presentation, we visited our Congressman Chris Murphy. He arranged for his aide to give us a tour of the Capitol, which was delightful.

CWLA

Come and see our poster at the CWLA Annual conference poster session in Washington on February 24th! In addition to our beautiful poster which illustrates the change to trauma-informed care and the results, a client, Ashley will be joining us and sharing her viewpoint about this change. We would love to see you!

Making Connections by Having Problems

We don’t know what to do for Katrina! She keeps cutting herself, putting cords around her neck to hang herself, and recently she has begun using an eraser to create serious burns in her skin. She has given up running away and having sex with strangers, but she keeps up the unremitting self harm. Staff can work with her for hours, and she seems better, but an hour after they leave, she cuts and they feel the whole effort was useless. We are getting so exhausted and depleted. Please help!

Discussion with Katrina, her mother and her treatment team made clear how three facets of the effects of trauma interact to create dilemmas both for the child and the treatment team.

Katrina had a history, as so many of our children do, of repeated moves, changes of caretakers, and of serious abuse in each new home. Following her adoption at age seven she had many treatment episodes such as hospitalizations, emergency shelters, in home interventions and finally residential treatment.

This history had left Katrina with the following three characteristics (as well as others):

A deep sense of shame and self hatred, resulting from blaming herself for all the abuse, the moves, the symptoms and failures she had experienced: Her self hatred combined with a lack of a sense of self- who was she really? She has a tendency to take on the personality of whomever she is with. This lack of self and deep self revulsion results in her conviction that no one could possibly just like her. It also produces the conviction that she does not deserve anything good, or to have any fun, which results in sabotaging whenever something good does happen.

A lack of inner connection to others: for Katrina, when a person is not physically present it is as though they never existed. She cannot keep a representation of them in her mind to encourage her and help her, because she has not had the relationship stability in her life that would be necessary to develop that ability. So when a staff moves away from helping her it is although they disappear completely.

No self soothing skills: Katrina had not been taught how to manage life’s ups and downs. Her models had used drugs and violence to manage emotions. She has not been taught to recognize or name her own emotions, or what to do when she feels them. Through DBT Katrina is learning some of those skills, and she can name and describe them when she is calm. However, due to her over-active nervous system, when something goes wrong she becomes so over whelmed with emotions that her skills desert her.

Like all of us, Katrina needs connection, attention and support. However, both in her homes and in the many treatment programs she has experienced, it has been hard to engage adults by doing well. Early on Katrina learned that the easiest way to draw adult connection was through problems. Although her caretakers were absorbed in their own life pain, when Katrina was suicidal they had to pay attention to her. It is almost as thought she becomes addicted to having problems.

And this becomes harder and harder to change.

Start with Katrina’s conviction that no one would want to be with her just for herself.

Then, something happens, and Katrina becomes upset. Her need for help is intense and unbearable. Life feels hopeless and frightening, and she blames herself. So she does something to hurt or erase herself, which has the added benefit of bringing in the resources she needs.

In an adult’s calming presence, Katrina can some times gradually calm down. And when she does, what happens? The adult leaves. For Katrina, they disappear completely, never to return.

And Katrina does not know how to re-engage them in a positive way. She does not even have any idea this is possible.

So- she tumbles into another problem.

The intervention strategy that will help to change this is to give Katrina a lot of attention whenever she is doing well, and to be less emotional, less intense and less involved when she is doing self-destructive things. But this turns out to be quite difficult. One reason is that Katrina is rarely doing well. When ever she does start having fun or succeeding, she stops herself, because this is not her and she doesn’t deserve happiness. However, staff can still catch the moments in which she is more relaxed or more normal and engage with her then.

And this takes incredible stamina, planning and thoughtfulness of the staff, and demands much reinforcement and praise from those supporting the staff. Because if a child this needy is NOT calling your name, is doing well and enjoying life, who would want to approach her? Better to stay back and enjoy the momentary respite. And yet, this perpetuates the pattern- that she only gets attention and caring by having problems. Staff will have to work hard for quite a while before this pattern changes- but what a gift they will give Katrina! The gift is the repeated experience (more powerful than any words) that she is a normal girl who can be competent and can receive attention, caring and connection through achievement and every day life activities. This is what she needs to experience in order to move towards a life worth living.

 

 

 

 

 

Brain Research and What To Do: Program Questions

I have recently been giving a presentation on brain research and how it can guide us to what to do in our treatment programs. I will be giving this presentation with my colleague Steve Brown at the Healing the Generations conference at Foxwoods in CT. this week. The following is a summary of some of the main points with questions for programs to consider. 

Connections between parts of the brain are necessary for emotional stability and thoughtful decision making. Brains grow and connections are created within relationships that are attuned and emotionally significant.

            What actions between people in our environments create attunement?

            What happens that strengthens relationships and adds to their significance?

            How can we increase this? 

Feelings of danger focus a person only on danger and safety. A person cannot form relationships unless they feel safe.

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

            What are the signals of safety?

            How can we decrease danger and increase safety?

Shame is a major barrier to relationships. The shame-based child is sure that any one who gets to know his horrible inner core will reject him, and hence relationships will only lead to pain. Shame leads to attack, to move away from others. Taking responsibility for ones actions is not possible when to do so means experiencing ones utter worthlessness.

            What do we do in our programs that adds to shame?

            What can we do to decrease shame?

            How can we talk about problems in non-shaming ways?

            The antidote to shame is sharing…To tell the secrets- what is shareable is bearable. 

Traumatic and neglectful experiences are characterized by the impossibility of effective action. There is nothing the child can do to change the situation and make it better. The child gives up on the possibility of effective action.

            What do we do that discourages or prohibits effective action?

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

Feelings management skills are the key to managing life’s ups and downs. They are learned in consistent, attuned care taking relationships which our children did not have.

            What do we do that discourages feeling awareness and communication?

            How can we actively teach and encourage the use of feelings management skills? 

When something bad happens and a child has no reliable attachments internally or externally to turn to for help; when a child is already hyper aroused and feeling in danger; when a child feels worthless, hopeless and scared; and when a child does not know how to recognize or sooth their feelings; a child is left with action. The action makes them feel better in the moment even if it has long term negative consequences. These actions that we call symptoms are adaptive for the child.

            What things that we do make this pattern worse, by leaving the child with less connection, more shame or more fear?

Which of our responses help break this cycle through understanding the symptom and helping the child the skills she needs? 

To do this difficult work and remain hopeful and healthy we need to take care of each other and ourselves.

            What do we do in our programs that decreases the opportunity and encouragement for self care?

            What can we do to take good care of each other and ourselves?          

 

 

Lost at School by Ross Greene

Lost at School: Why Our Kids with Behavioral Challenges are Falling Through the Cracks and How We Can Help Them

by Ross W Greene 

Scribner; 1 edition (October 21, 2008)

  

I have just finished Ross Greene’s new book, Lost at School. This book describes how to implement his Collaborative Problem Solving Method in schools. Although Ross Greene does not focus on trauma, his method overlaps with ours in emphasizing the need to teach specific skills. Ross Greene has done excellent work in delineating and specifying the specific thinking skills that our kids need to learn. He is also clear that points and levels, punishments and rewards are not helpful in changing behavior- that children will show better behavior when they learn the skills which will enable them to do so. 

I would like to highlight Dr. Greene’s differentiating between people who believe that "kids do well if they want to" and those who believe that "kids do well if they can". The former assumption leads adults to employ systems to make kids want to do better- rewards and punishments. The belief that "kids do well if they can" will lead adults to teach kids skills so that they have the ability to do better and assumes that the already want to. When they have the skills, their behavior will improve. 

On pages 12-13 Dr. Greene describes some common things that are said about challenging kids, and why they do not make sense: 

"He just wants attention."

            We all want attention so this explanation isn’t very useful for helping us understand why a kid is struggling. If a kid is seeking attention in a maladaptive way doesn’t that suggest that he lacks the skills to seek attention in an adaptive way? 

"He just wants his own way."

We all want our own way so this explanation doesn’t help us understand a kid’s challenges. Adaptively getting one’s own way requires skills often found lacking in challenging kids. 

"He is manipulating us."

This is a very popular and misguided characterization of kids with behavioral challenges. Competent manipulation requires various skills- forethought, planning, impulse control, and organization among others- typically found lacking in challenging kids. In other words, those who are most often described as manipulative are those least capable of pulling it off. 

"He’s not motivated."

This is another characterization that can be traced back to the “kids do well if they want to” mentality and it can lead us straight to interventions aimed at giving a kid the incentives to do well. But why would a kid not want to do well? Why would he choose not to do well if he had the skills to do well? Isn’t doing well always preferable? 

"He’s making bad choices."

            Are you certain he has the skills and repertoire to make good choices? 

"His parents are incompetent disciplinarians."

This, too, is a popular way of thinking, but it fails to take into account the fact that most challenging kids have well behaved siblings. Blaming parents doesn’t help anyone at school deal effectively with their kid in the six hours a day, five days a week, nine months of the year that he is in the building. 

"He has a bad attitude."

He probably didn’t start out with one. “Bas attitudes” tend to be the by-product of countless years of being misunderstood and over-punished by adults who didn’t recognize that a kid was lacking crucial thinking skills. But kids are resilient, they coming around if we start doing the right thing. 

The book is very well written and contains many examples and stories. I recommend this book for its clear description of the Collaborative Problem Solving Method and how implementing it can revolutionize our schools.

 

Tips for Starting Trauma Informed Care

Here are some tips for beginning the transformation to trauma informed care: 

1. Every time you talk about something a child has done, have someone review the child’s history.
2. Any time some one wants to know what punishment you should apply to a given action, ask: how do we understand why he did that?
3. Clinicians- think of a treatment theme for each child you are working with, a brief statement of the central focus of your work, such as "learning to trust adults" or "learning to handle disappointment without making things worse" or "learning to recognize emotions". Communicate this to the team.
4. Develop an individual crisis management plan with each child, noting what tends to upset them, how they show they are starting to get upset, what helps, what doesn’t help. Make these living documents, available to the whole team, used by all, and constantly revised.
5. Discuss with both staff and kids what about your program makes them feel safe, what about the program makes them feel unsafe. What can you improve?
6. Start some Youth Leadership activities- a student council, a unit group to decide unit activities, youth-to-youth mentoring, older kids teaching younger, etc.
7. Use sensory interventions, such as rocking chairs, weighted garments, blankets and fur, soft music, aroma therapy
8. Add yoga and meditation to your offerings
9. Institute a program where the kids engage in some social action to help others, such as collecting food for a food bank, or volunteering at a Senior Center.
10. Start a discussion among staff about how people are feeling about the job and how the work is affecting them.
11. Buy night lights for all kids who want them.
12. Have a staff retreat including all disciplines during which you have fun and do team building activities.

 Do you see the connection between each of these ideas and healing from trauma? If not, let me know and I will write more about it.

Which of these are you already doing?

Do you have any other ideas?

Eating at the Table

LaTasha came to the group home from a residential treatment facility where she had been for two years. Prior to that placement, she had been hospitalized seven times, was in a shelter for eleven months, had been in nine foster homes, and had suffered early abuse from her biological family. She pushed so hard to get out of the residential and was so eager to be discharged to the group home that both she and her staff were surprised at how hard the transition was for her. When she first came to the group home, she showed all the signs of feeling unsafe. She tested the staff, insulting and mocking them. She asked questions about the locks and security measures of the home. If ever a staff was uncertain about what to do or if the staff changed a rule (“yes, I guess you can go outside and hang out for a while before you do your homework”) LaTasha would say they were stupid, didn’t know what they were doing and were too young to be staff anyway. A couple of times LaTasha had become so escalated she had been taken to the local ER.

When LaTasha first arrived, she completely refused to eat. She said she didn’t like the food, it wasn’t her type of food, staff didn’t know how to cook. The Treatment Team wondered if she had an eating disorder, but there was no mention of it in her records. Then, she began taking food and smuggling it to her room, which of course was against the house rules and could bring bugs and all sorts of complications. She would some times eat snacks or make herself a late night peanut butter sandwich, but she would never sit at the table with the group. Occasionally she tried to eat her sandwich in the living room in front of the TV- another behavior that was against the rules.

Fortunately LaTasha’s group home was using trauma informed treatment and had an excellent treatment team. Led by the clinician they looked at LaTasha’s behavior and asked "why"? What function was LaTasha’s behavior serving for her? What was she expressing to the team? What emotion management capacities did she lack and need help with?

It was clear that LaTasha was scared and didn’t trust them. Being in the house and in a strange community, very different from any she had previously known, made her feel unsafe. She was in danger mode. She didn’t know the staff or the other kids. Many other people, both professional and not, had let her down and rejected her. She had gotten used to a residential setting with its inflexible structure, many staff, and locked doors. This new place seemed very weird to her and she was not sure what to make of it. She was not going to connect with these people, act like they were her family, only to be hurt once again.

The Treatment Team decided that all their efforts should be focused on helping LaTasha feel safe. One key to that would be validation- letting her know that her reaction was completely understandable, given her experiences, and in fact that anyone would feel uneasy in a new place. So, instead of insisting that she eat at the table with the group, staff began trying to support whatever arrangement felt comfortable for her, and expressing their hope that she would join them whenever she felt it was right for her.

So, they let her eat in the living room for a while- and started bringing her a tray of whatever they were eating, so she wouldn’t be stuck with peanut butter sandwiches. After a while, she began eating in the kitchen near where the others were, but not at the table. Then she came to the table, but she was wearing headphones and listening to music. Instead of telling her this was not allowed, staff welcomed her and ignored the headphones. Later, she began to wear the headphones around her neck at the table ("I am in control, I can retreat if I need to"). LaTasha now eats regularly with the group, and her overall agitation has also calmed down.

This is a perfect example of how we can implement trauma informed care in the daily details of life. The first step was for staff to move beyond "rules" and "misbehavior" and "defiance" to the meaning of what this girl was experiencing- and then to take it seriously, really let themselves feel what this move must be like for her. And then the whole team focused on helping her feel safe and welcome. They did not get caught up in worrying what if she always wants to eat in the living room-what if all the girls start doing it- soon no one will be following any rules. Instead they allowed themselves to honor the emotional reality of one particular girl, and had faith that as needs are filled people can move on.

This example is real, and was recounted by a participant in our recent Day of Learning and Sharing.

 

Day of Learning and Sharing Successful

This is a report on an event I helped plan and participated in.

On December 8, 2008 the Trauma Research Education and Training Institute (TREATI) and the Traumatic Stress Institute sponsored the Third Annual Day of Learning of Sharing. This event is provided to Risking Connection® trainers to increase their skills and knowledge in training and helping to implement trauma informed care.

The theme of this years’ event was Visible Mending, a Japanese practice in which broken bowls are mended with gold, making the repaired bowl more beautiful and more valuable than the original, unbroken vessel. The parallels to both our work and our care of ourselves and each other are obvious.

The day was attended by eighteen agencies, including agencies from Connecticut, Massachusetts, Kentucky and New York. In addition to Risking Connection® trainers, agency executives, CEOs and managers were invited to learn more about implementing trauma informed care.

The day started with each agency presenting what they were most proud of regarding training and implementing Risking Connection® concepts. These included reductions in restraints and seclusions, reduction in staff turnover, changes in agency cultures, more emphasis on relationships, implementation of evidence-based trauma treatments, and better outcomes for children. It was very moving to hear the transformation that is taking place in our field resulting in better treatment of our children.

The morning featured a presentation from Roger Fallot, Ph.D.  Dr. Fallot, Director of Research and Evaluation for Community Connections headquartered in Washington, D.C., consults nationally to agencies and mental health systems on the implementation of trauma-informed services.  He is co-editor (with Maxine Harris) of Using Trauma Theory to Design Service Systems. Roger presented on transforming agency cultures to meet the needs of traumatized clients. He emphasized the importance of five core principles: Safety, Trustworthiness, Choice, Collaboration, and Empowerment. Roger then facilitated a discussion on what agencies could do to improve their practice in each of these areas.

After lunch Patricia D. Wilcox, LCSW, Vice President at Klingberg, Risking Connection® Faculty trainer and Executive Director of TREATI, presented on

Healing the Hurt Brain: How we can use our knowledge about trauma and the brain to make our treatment as effective as possible. She connected current knowledge about brain development and plasticity with the implications for effective treatment practices. Pat focused on the role of attuned relationships, safety, understanding shame, and developing emotional skills.

Steve Brown, PsyD. Director of the Traumatic Stress Institute and Risking Connection® Faculty trainer led the group in a wonderful Vicarious Traumatization exercise using the Visible Healing metaphor. Many participants commented that this exercise was helpful to them and would be valuable to bring back to their agencies.

The day ended with a closing ceremony which emphasized our connections to each other and to the web of people trying to implement trauma informed practice and change the world.

 

 

 

 

 

 

Does Our Discipline Threaten Our Relationships?

In a recent training we were talking about relationships, as we often do. A therapist asked the following question:

"I am often called onto the floor to intervene with a kid who is acting up. I take on the role of the child care workers. I end up giving him consequences. When that happens how can I preserve my relationship with him, and not seem to him like just one more person trying to manage his behavior?"

 I was struck by what I see as dangerous assumptions beneath that question, which I will exaggerate for purposes of discussion. I think in fact these assumptions often do underlie our thinking and actions in treatment programs.

This question assumes that the therapist has a special healing relationship with the child, which would be threatened by the therapist addressing the boy’s behavior in the normal way of the program. The child care workers, on the other hand, are expected to address behavior routinely and so whatever relationship they have with the child is expendable. They are those people who are just trying to manage behavior.

I would propose that there should be no people in a treatment program "just trying to manage behavior". The first priority of every person who interacts with the child should be to form, maintain and strengthen their relationship with the child. Every relationship can be healing. Every relationship is important.

I would also suggest that none of us, whatever our role, should ever be just managing behavior. Of course, in a crisis one has to direct traffic to restore safety. But with regard to any individual child, our constant focus should be to understand the meaning and adaptive function of every symptom, and teach the child more positive ways to meet those same needs. Our programs, and all our staff, should in every way promote a sense of safety and caring. We do not ignore behavior or remain paralyzed as the child becomes increasingly upset and out of control. We intervene actively and constantly from our base of relationship to help the child calm down, and, when he is calm, to figure out how to get what he needs. Our goal is not to control his behavior. It is to help him to feel calm and safe enough to try new ways of meeting his needs.

I seriously believe that everyone in the program should be thinking this way- every child care worker, every therapist, and every teacher. Everyone should be engaged with the child from a carefully formed relationship. Naturally, the child may be angry, unappreciative, nasty, upset and uncooperative with any one of the many people on his team. Any one should then acknowledge and validate his feelings, and (when he is calm enough to hear) share their experience of whatever happened from their heart.

When we acknowledge the central importance of all the relationships between the child and the team members; when we truly believe that the child is doing the best he can; when we see symptoms as adaptive; when we react by helping the child to learn better ways to meet his needs: then we can all do all parts of the job of treating and raising these children, and we can all enrich our relationships as we do them.

Meeting Their Needs

In Risking Connection® training we focus a great deal on counter-transference, the helpers’ feelings while doing the work. Our basic point is that any feeling is okay, it is what you do with it that matters. In order to illustrate this, we use scenarios. In each scenario, the questions are: what is the staff member feeling? How could they use their feelings to enhance the treatment? How could their feelings get in the way of the treatment?

Here is one of the scenarios:

"Lucinda, a fourteen-year-old resident, told you that her aunt had called her and told her that her mother was very sick. She seemed quite distraught. You arranged with other staff for her to have an extra long phone call outside of phone time. Later you learn that she actually used that opportunity to call her boyfriend and her mother was never sick."

The usual response is that the staff member is feeling angry, betrayed, used, foolish, and ashamed. And maybe we had better think again about allowing Lucinda this relationship with her boyfriend, since it apparently gets in the way of her treatment. Our reaction is to toughen up, make sure we never believe this child again, that no child can ever trick us again. She has betrayed our trust and we will not trust her again for a long time.

We talk about noticing that this is how the kids we work with always feel. That moment when the staff member, feeling humiliated, decides never to open her heart and let any child trick him again is the place where our kids live.

In a recent training, however, a miraculous thing happened. One staff member said: what if we realized that Lucinda doing this was a sign that she was not able to trust us to meet her needs? What if we assumed that her wish to talk to her boyfriend was legitimate? It is developmentally appropriate, and also part of her understandable need to have connections, someone who cares about her, attachments.

What if we worked hard to assure Lucinda that we would like to meet her needs, and we would like to discuss how we can make sure she has regular access to her boyfriend without the necessity for lying to anyone?

What if we thought that more important than the phone rules was a chance to teach a child that adults care and that you can turn to other people to help you get what you want?

I would love to live in a world in which this kind of thinking was even part of the conversation.

Safety

Let’s consider the topic of safety.

One of the most basic, immediate and continuous distinctions our brains are constantly making is: safe or not safe? Danger or no danger? This decision is made instantaneously in any new situation by the part of the brain known as the amygdala. Any change triggers a reevaluation. In a healthy brain, the amygdala’s instantaneous decision is combined with and moderated by information from other part of the brain, that add information regarding context, past experiences, reasoning, and observations from the sensory system.

If the brain concludes: Danger! Not safe! the body’s protective system is activated. Energy is directed to the parts of the body that will be needed for fight or flight. Non-essential systems, such as digestion and reasoning, are shut down. The activation chemicals in the body/brain are released, and the alertness system turned on. The person is alert, but focused only on signals of danger and safety. The heart is beating fast, the muscles are tense, ready for action.

Think of a time you can remember when you felt seriously unsafe. A near car accident? An encounter with a threatening person? A weather-related event? Even a common example like trying to drive home from work after an ice storm can be illustrative. In fact, an even more appropriate example would be being a passenger in a car when someone you didn’t know very well was driving through an ice storm.

What did you feel like? What did you do? What happened in your body?

If there was someone in the car with you, would you have been able to have a conversation about a movie you had seen, much less about something that was troubling you? If some one told you a joke, would you have laughed? Would you enjoy the songs on the radio? Could you take a nap?

To further elucidate the experience of danger, there is the experiment with the baby mice. (Panksepp, J. (1998) Affective Neuroscience: The Foundations of Human and Animal Emotions. New York, Oxford University Press) Some baby mice had been raised in cages. They had never seen or heard of a cat. Like all baby animals, they engaged in a lot of free play with each other. The experimenters put two cat hairs in the cage. Although the mice had no cat experience, the cat hairs were wired into their brains as signifying danger. Immediately, all free play stopped. And, also significant, when the cat hairs were removed after just a few days the mice play gradually returned, but it never returned to the level it had been before the cat hairs were introduced.

So what does all this have to do with our work? It is helpful to think of the children we work with as being stuck in the danger response. Because of early, overwhelming and unpredictable experiences of trauma, their brain chemistry was modified such that they can not come back to a relaxed state.

But the wonderful news of brain plasticity is that at any age, the brain can be rewired through attached relationships. In order to begin this process, and in fact in order to be available to attached relationships, the brain must sense "I am now safe". Since the brain patterns of danger are so deep, this will not happen quickly, but it can happen.

So it is important that we think closely and observe the ways in which our treatment environments are signaling safety to our clients, and the ways in which they signal danger. As part of this we must consider ways in which we as staff feel safe in our work places.

As you look around your environment, what safety and danger signals do you observe?

Danger signals could include sarcasm, not being allowed to speak ones’ side, restraints, loud noises, disorganization, emotionally dysregulated staff, belittling comments, physically ugly places, lots of damage and disrepair, creaky doors and funny noises at night, messages from other kids, boundary violations, bullying, messages from staff to other staff, blaming and scapegoating- the list could go on.

Safety signal could include warm tones of voice, respect, politeness, promises kept, organized environments, delight, fun, relaxed kids, caring messages when upset, physical protection such as locks, clear and observed boundaries, a sense that we are all in this together, team work, pleasant physical spaces, an appreciation of strengths and competences, a real voice in decision making.

It would be interesting to have a team discussion of this question. How safe does our environment feel to the kids- and to us? It would also be interesting to ask the kids to make lists of "things here that make us feel safe" and "things here that make us feel not safe".

And as we do this, it is important to remember that unless the body begins feeling safe, the person will not be able to begin the work of healing. It’s not that they will be resistant or unwilling- it’s that their brains will not be available for that work.

Thus it is very important that we pay more attention to this subject of safety.

We Have to Hold Her Accountable… or How is She Going to Learn?

At the beginning of Risking Connectionâ training we discuss the differences between a traditional approach and a trauma informed approach. These include: The traditional approach maintains that the treater is the expert, and the client the recipient of this expertise; the main value in the traditional method is control and elimination of symptoms as opposed to collaboration and understanding the adaptive function of symptoms; and the idea that the treater should be unaffected by the work is replaced by understanding that all treaters are emotionally impacted by the work. 

As we finished this exercise in a recent training, one participant said: "I can see that in this method you do not hold the clients accountable. This will not work for me, I work in a juvenile justice facility and we have to hold the clients accountable or how will they ever learn?" Furthermore, she stated that she sees the clients as making choices, and her job to point out that there are consequences to these choices. 

This comment contains several of the most common fallacies or mis-beliefs about the trauma informed approach. We have to take these concerns seriously as they represent one of the largest obstacles to implementing this method. 

First of all there is the idea that we are recommending "not holding the client accountable". 

When you look up the definition of holding accountable you find it is associated with words like blame, find fault with, censure, to place the responsibility for, reproach, reprove, reprehend, criticize, to hold responsible; hold culpable. We don’t seem to speak of holding someone accountable for good things or positive achievements. 

We are as usual stuck in the middle of a dialectic- to use the words of DBT, the client is doing the best she can, and she needs to learn to do better. Our treatment must include both validation and a push for change. 

A child’s past and his current reality influence the choices he makes. If he is presented with the opportunity to steal a car and the urging of peers to do so, many things so influence whether he does or does not:

Does he have any self worth? Does he think there is any one who cares what he does? Has he learned values through loving attachments? Does he have a sense of hope for his life? Does he think he has anything to lose? Is he in the grip of intolerable anger, despair or fear and does he have any skills to manage whatever he is feeling? Is he mired in shame from other events and actions of his life? Does he have attachments with other friends or does he feel he will be alone forever if he alienates these friends? Does his mind have the capacity to think before he acts? 

If he decides to steal the car, gets caught, and is presented (involuntarily) to us for treatment, how can we best help him? What interventions on our part will result in him being more capable of turning away from him next opportunity to break the law? 

It would be neglectful to ignore the fact that he stole the car, to never mention it, or to act as though it was some how all right to have done so because of difficulties he has had in his past. 

It would also be neglectful to ignore the factors that contribute to his vulnerability to such actions. We would be less helpful if we did not offer treatment that increases his self worth, forms strong relationships, emphasizes the relationship consequences of behaviors, build up avenues for achievement and hope, helps him learn both emotion management skills and relationship skills, and teaches him how to calm his biology to increase his ability to think. 

A trauma informed approach confronts the behaviors directly. The treaters bring to the discussion respect, an assumption that every behavior is adaptive and solves a problem, information about change, a strong connection, and hope for a better future. 

In a trauma informed approach we answer the question: "how will he learn not to do this again?"

He will learn by a strong, respectful and straightforward investigation with his treaters of what happened and what contributed to his decisions.

He will learn through developing attached relationships. Within these he will learn values. He will have something to lose that matters. He will learn that he has strengths and talents. He will find hope. He will also learn through specific strategies to teach him emotion management and relationship skills. 

It’s not so much that we do not hold him accountable. It’s that caring and be cared about, skills and achievement offer so much more power for changes than simply explaining that if you steal cars you may go to jail. 

How would you answer this person’s comment? What are your views on this central concern about trauma informed care? We need to do much more thinking and talking about this. Click on “comment” and express your ideas.

 

 

 

 

 

 

 

 

The Role of the Clinician and of Formulation

Trauma informed care depends on clinical thinking. What is clinical thinking? It is looking beneath the behavior of the moment, and asking why? What’s going on? It is understanding that symptoms are adaptations that behavior has reasons, that people are doing the best they can, and that their behavior is solving a problem for them. The job of the clinicians in a treatment program is to be the standard bearers for clinical thinking, to teach and train the team until this sort of inquiry is second nature to all members of the team.

So when a child care worker reports that Monique ran away last night, and wants to know what her consequence should be, the clinician should divert the discussion to the question of “why”. What was going on last night? What was the provoking incident? What is going on in Monique’s life? What are her sources of stress, her worries, her fears? What are her strengths, what good things are happening for her that could be brought into the equation? What internal and external resources does she have?

In a congregate care treatment program there is considerable pressure for a clinician to turn away from clinical thinking and become a “fixer”. Some times it seems that clinicians’ job is to take away a screaming child and bring her back calm. The clinician may be drawn into thinking that what she is supposed to do with the child is talk to him about what he has done wrong and how if he stopped doing it his life would be much better.

The problem with this approach is that it doesn’t work. If it did, the kids would be much better already because this has been done a thousand times before. The job of the clinician is first of all to form a healing relationship with the child, then to use this relationship to help the child learn their own worth, develop connections that can be accessed even when the clinician is not present, and learn emotion management skills.

The clinician should have a complex and ever increasing understanding of the child, what their experiences have been, and how those experiences have shaped them. The clinician should hold in his mind a clear picture of the healed child- of who this child can become. He holds the hope for the child, even when the child can see no hope.

Similarly, in family therapy the clinician can get trapped into endless discussions of behavior and consequences. Instead, she must understand and honor the rich complexities of the family’s life. What is their history, their trauma, their pain, their strengths? What are the dynamics between family members, including extended family? What are their resources? What are their fears, what paralyzes them? The healing relationship, connection, developing self-worth and emotion management skills are equally important with the family.

Clinicians should be taught the art of formulating a case. A formulation makes explicit the clinician’s best understanding of the child’s history, their current circumstances, the effects these have on the child, how we understand their current behavior in light of their situation, and what we think will be the path for growth and change necessary to develop healthier methods for meeting needs.

The formulation should be one to two paragraphs which provide a clear road map for understanding and for treatment. Of course it is ever changing and evolving as we come to understand the child and family better.

In one program I heard described (Germaine Lawrence in Boston, http://www.germainelawrence.org/) they have a practice that every time they talk about a child, they start with a quick repetition of the formulation by the clinician, just to remind them of their road map and where they are on it. I thought this was a great idea.

Here are some examples of formulations:

1. Sarah suffered early neglect and abuse followed by repeated moves. Her siblings were adopted but she failed the placement. She struggles to maintain safety by keeping her fears hidden in oppositionality. She sees danger every where and over reacts with physical and verbal aggression. Her processing difficulties contribute to this misapprehension of events. She responds to care givers with suspicion but does react to limits. She will need to develop safety and trust in order to be able to relax, to explore her past and decrease her conviction that what has happened to her is her fault.

2. Thomas is a young man whose genetic heritage suggests that he might be vulnerable to a mood disorder. Multiple stressors have apparently exacerbated this biological predisposition. These stressors have included inconsistent parenting, being a witness to domestic violence, physical and emotional abuse, emotional, medical and educational neglect, and the death of his mother. Thomas’ most likely felt overwhelmed by these stressors and developed a negative coping style that resulted in his trying to “shut down” or avoid painful thoughts and experiences. When he was forced to be reminded of these painful experiences and when he had to incur more stress during times when adults were not able to limit his exposure to it, Thomas would rapidly become disorganized and resort to primitive defenses as evidenced by his becoming aggressive, suicidal, and even by his reporting psychotic symptoms.

Based upon reports of his progress in previous programs, Thomas seems to be able to utilize the structure of residential treatment to afford him the predictability and safety he needs in order to organize his thoughts and demonstrate his desire to behave in a socially acceptable way. His treatment goals should focus on increasing his ability to identify and practice positive coping skills to manage overwhelming affect, and on developing age-appropriate social skills.

3. Vanessa had early experiences with severe neglect and observing domestic violence because of her mother’s drug addiction. She learned to take care of herself. The loss of several family members combined with mom’s addiction and unavailability sent Vanessa and her sister into a crisis culminating in their removal from the home. The family seems to now be on a positive track as the mother is in recovery and the girl’s have made improvements. However Vanessa understandably still has difficulty trusting her mother and other adults, and does not let adults help or guide her.

4. Latasha’s symptoms and level of functioning seem consistent with her admission diagnosis of Reactive Attachment Disorder, Posttraumatic Stress Disorder, and Oppositional Defiant Disorder. She experiences chronic and pervasive shame as a result of her past abuse, separation from family, disruptions from foster care, and multiple placements. These feelings of shame are overwhelming and cause her to react with a well-established pattern of oppositionality and defiance. In addition, considering that her developmental stages were disrupted by her trauma, she may be struggling with issues of competency and trust leading her question her own safety and sense of belonging as well as her ability and to learn new skills and grow in her functioning.

Latasha will benefit from the routines and structure of daily living in residential treatment. Latasha will benefit from a restorative approach in treatment to help her gain confidence and trust in her caretakers and to allow her to develop her strengths, which include good verbal skills, a sense of humor, and an ability to engage positively others, in the context of healthy relationships.

5. Stephanie is a bright and insightful child who has suffered immense abuse and neglect in her formative years. She was witness to horrendous domestic violence, substance abuse and sexual activity. Stephanie was often the caretaker of her brother and biological mother while her own needs went unmet. As a result, she learned that it was not safe to trust adults to care for her. Upon her adoption to the Anderson family, Stephanie struggled to adjust to this environment. Her adoptive parents appeared to accept her need to be in control and for a while went along with her behavior. However, over the years, Ms. Anderson grew increasingly worried and angry. As she became more vigilant in monitoring her daughter, Stephanie grew increasingly oppositional and detached. Ms. Anderson felt Stephanie was deteriorating and influencing her other children whom she felt were connected and settled. As a result, Ms. Anderson gradually began to disconnect from her daughter. Stephanie impacted by fears of abandonment responded accordingly and became increasingly withdrawn and detached from the family.

Ms. Anderson raises her foster and adoptive children primarily on her own without much spousal support and is looking to meet her needs through her children. Her husband is largely unavailable and detached. She expects her children to “love back” considering how much effort she puts into caring for them. Stephanie’s lack of attachment to her, therefore, is intolerable. It is also complicated by the fact Stephanie is entering adolescence. Ms. Anderson has limited experience with this stage of development and since her own childhood was unremarkable, she expects the same from her children. Ms. Anderson is also angry at Stephanie due to the conflict it has raised with her own parents, who criticize her parenting skills and lack of nurturing with Stephanie. Her perception of their withdrawal of support has been extremely painful, which she blames on her daughter. Ms. Anderson feels that she needs a break from this child and treatment will focus on whether the relationship can be restored in order to support Stephanie’s return home.

The formulation articulates our theories, our understanding of what causes problem behaviors and what helps to heal them. The formulation leads directly to the treatment plan. In the treatment plan we describe the problem behaviors, we describe their positive opposites, the behaviors we would like to see, and we describe the steps to get there. The treatment plan, again, is a theory: it makes concrete our understanding of the steps that would help a child heal. Thus if Latasha is feeling shame, what will help her? Experiences of competency, positive relationships, identifying strengths, developing skills to master her own emotions. These should be clear in her treatment plan.

If Vanessa cannot trust adults and use their help, what will change that? Small experiments in trust. Using her leadership and self care skill to accomplish things. Positive trustworthy relationships. An understanding of her past and it’s effect on her. Developing emotion management skills to withstand the fear she experiences when she beings to trust.

If Stephanie and her foster mother are locked in a painful cycle of unmet needs, what will help? The relationship between the therapist and Ms. Anderson may begin to meet some of her needs, allowing her to relax with Stephanie. Perhaps her mother will be part of the family work. Helping mother and daughter share their experience and listen to each other may be part of the healing. Structuring positive experiences between them may begin to rebuild their connection. These interventions would be clear in the treatment plan.

So the clinician’s job is to gather information respectfully and understand the experience of the child and family, then to use that to develop a formulation. The formulation articulates what has happened, what is going on now, how these factors produce these behaviors, and what steps may help move towards more effective meeting of needs. Then, the clinician must convey this formulation to the entire treatment team, including the child and family (in understandable and respectful language).

Then, and perhaps even harder, the clinician’s job is to keep the formulation alive. Whenever a new behavior happens, or the four hundredth repetition of the old behavior, or an accomplishment, or something bewildering, return to the formulation. Is this still how we understand this child and family? Do we need to adjust our thinking? How do the new events fit into our theories? Where does this understanding lead us- what new interventions are suggested?

For this to be a viable and vibrant process the clinicians need administrative support. They need excellent clinical supervision. They need access to on going training of many sorts. They need opportunities to replenish them selves and their work. They need reasonable caseloads which allow time to think about their kids.

This clinical leadership will gradually develop a more knowledgeable and sophisticated team, in which all the staff will assume the child is doing the best they can, routinely wonder what is behind a behavior, and seek ways to help the child develop new skills. This thinking will produce more creative and caring intervention possibilities. And this will lead to more deep and lasting healing for the children and their families.

Improving Restorative Tasks

Three ideas have recently occurred to me related to making restorative tasks more meaningful to both kids and staff.

1. Mapping the Effects of Behaviors: In a workshop I just attended on Restorative Practices in a school the presenters emphasized that after each incident they meet with the child and create a map of who was affected by the child’s recent actions. Include any one who was affected positively! Then the child has a chance to think about how to make it up to them. Some children would be unable to do this because their shame would produce overwhelming and intolerable emotions. But for those who could, taking this step formally might be a way to underscore the meaning of the restorative tasks.

2. Practicing Positive Ways to Meet Needs: A key tenant of trauma informed care is the belief that symptom are adaptive, that every behavior is a person trying to meet their needs the best way they know how at that moment. The behavior (hurting yourself, running away, throwing a chair) may be an escape from intolerable feelings of despair and hopelessness. It may be a way to draw humans closer and avoid deep aloneness. It may be a mask for desperate fear or unacceptable confusion. But the behavior serves a function, and it helps in the moment. It actually makes things better for a time, even if it also brings long tem negative results.

Led by the clinician, the Treatment Team should try to understand the needs that this child’s behavior is meeting. They can do this by talking with the child, by noticing patterns, by knowing the child and her history, even by guessing. And then their job is to teach the child how to meet these needs in ways with less negative consequences.

So how about using the learning part of restorative tasks as ways to discover and practice these new ways of meeting needs? So Yolanda is angry and destructive many nights before bed, and the team speculates that night time is hard for her and she has trouble falling asleep due to racing unhappy thoughts. What if her restorative task is to read a story to a younger girl on the unit every night? Or (with staff help) to put together a CD of soothing sounds and make copies for some other girls whose lives she disrupted? Or to make a stuffed animal for someone filled with lavender- and make one for her self too?

Get the idea? Yolanda learns some ideas of how to fall asleep, while making amends to others.

What if we postulate that Andre becomes aggressive and assaults staff whenever he feels afraid. What would we like him to do when he becomes afraid? Probably tell some one. So how could he practice that? He could talk with three of the male staff about times they felt afraid, and what they did about it (experience modeling of the desired behavior). Could he read or write a story about a boy who was afraid and handled it well? What else occurs to you?

In treatment team, think about the needs a behavior is meeting and what the desired way of meeting those needs is. Then think of some possible ways the child could experience or practice that more positive alternative.

3. Peace offerings: In a novel I just read when one character hurt a friend, she brought her friend a peace offering when she went to apologize (I think it was cookies). It occurred to me that the concept of peace offering conveys what we want to accomplish in the making amends part of the restorative task. The things we ask the kids to do to make amends can never be as big as the things they have done wrong (at least, not if we want to stay licensed). So using the phrase "peace offering" might help convey the spirit of what we want them to accomplish- a gesture of apology.

Click on the comment button below and let me know your reactions to these ideas.

How Much Restoration is Enough?

In a recent training I did, I was asked a familiar question: how do you know how much restoration is enough? When a child does something that hurts another person or threatens the community, how do you decide how many or how large the tasks assigned for restoration should be? And how do you decide whether the child has completed these tasks with enough sincerity, effort or seriousness?

I think that some of the impetus for this question comes from thinking of restorative tasks as punishments in disguise, and from believing that their effectiveness comes from their being aversive. In other words, that (like punishment) the tasks should not are fun to do, and the child will change his behavior in order to avoid having to do them. In this framework, the tasks should be "as big as" the offense, and take a lot of effort and time, especially if the behavior was very serious or hurtful. The learning or relationship nature of the tasks is secondary. People often speak of staff feeling like the child "got away with" his behavior because what he had to do was not hard enough. The person who was hurt by the child does not feel sufficiently paid back, and thus feels resentful and disrespected.

In order to think further about this, let’s turn to our own lives. We all have had experiences of forgiving people who have hurt us, and continuing the relationship. Imagine that a friend has done something that hurt you. What would that be? Told a secret, let you down, forgotten to meet you for a planned appointment, said something thoughtless or mean to you, cancelled a plan with you at the last minute in order to do something else, borrowed money and not paid it back: what else?

In order to restore this friendship and for you to truly feel better about this friend, what would you want from him? First, I guess, an apology and an acknowledgement of what went wrong and his part in it. You might want him to listen to you speak of how this behavior affected you and to seem to actually care and take in what you said. Then, you would want him to act differently from now on, or try to, or at least start to.

So these are the skills and behaviors we want our kids to learn.

The first thing that gets in the way is shame. In order for a person to deal directly with something they have done wrong, they have to be able to tolerate the bad feelings involved. In order to admit you have hurt some one and to face them, you have to have some inner core of believing you are okay. You have to believe that forgiveness is a possibility.

Stop here for a moment and think of a time when you did something wrong, hurt some one you cared about, or made a mistake you were ashamed of. As you were trying to convince yourself to face up to the mistake and deal with it, what were you feeling? What got in the way of your honestly going to the person you hurt and admitting what you had done? What helped you to do so?

When our kids realize they have made serious mistakes, their sense of hopelessness comes crashing down on them. All is lost. There is no hope of forgiveness or redemption. They remember everything that has gone wrong in their lives, which they believe is totally their fault. When feeling this horrible despair and seeing no way out of it, their impulse is to run away from the events. This running can take many forms: actual running, denying responsibility, blaming or attacking others, aggression, self harm, retreat to bed, and many others. Often it takes the form of the child demanding to get out of this stupid place: send me to detention! Hospitalize me! All of this reflects self loathing, despair and lack of hope.

So- back to the restorative tasks- in treatment we are trying to help the child grow and be able to feel hope, to believe in the possibility of things working out, and to have some skills that will provide steps towards that outcome.

Traditional punishment, such as confinement to your room for a period of time, has exactly the opposite effect- it leaves the child feeling worse and without any adult support or steps to reconnect with others.

The restorative tasks should aim towards helping this particular child, with her particular abilities, needs, and treatment formulation, to become slightly better at:

• Acknowledging what went wrong and her part in it.
• Listening to the hurt other speak of how this behavior affected them, caring and taking in what that person says
• Acting differently from now on

In order to do any of these, the child has to develop some sense of being a worth while person, someone who deserves the air she breathes; some one others could care about and could forgive. Much of our treatment is designed to accomplish this in many different ways.

How do you get better at acknowledging your mistakes, and listening to the other describe the effect on them? Practice, mostly I think, and discovering that the world doesn’t end and in fact you can often repair the relationship. So, for some child the whole making amends could be a short conversation with the person hurt- that could be a huge step for her. Another child can’t do that, the shame is too intense. But he can draw a picture of the steps leading up to the event, and how he was feeling, and give it to the person hurt. Maybe she could respond by drawing a similar picture of the events from her point of view and how she was feeling- and he could further respond with some communication that shows he paid attention to what she said. The goal here would be: what are this kid’s current abilities to face her mistakes, and what action would be one small step further than she usually can go? In the past in this child’s life, making mistakes has led to abuse, and often to the person hurt disappearing all together. Our goal is to make this time different, a restorative relationship experience, to create a new template which includes the possibility of healing.

We’d all like the kids to then act differently. Preferably completely and immediately. In fact, that is one difficulty people report with the Restorative Approach- when you engage in a heart felt exchange with a child and the child still repeats the behavior, it feels worse than when you punish them and they repeat the behavior. We all know it takes a long time for these children to change, to un-learn the lessons of their life times.

But what will it actually take for the child to be able to behave different? Emotion management skills. Developing a sense that there are people who care about him, and that thy still exist when they are not physically present. Developing a sense that he is worth the air he breathes. And developing the ability to recognize, name and manage emotions, including the ability to self-sooth.

Thus, the learning aspect of the restorative tasks. This part is aimed to teach some small part of emotion management skills. This could be describing what I was feeling, or what else I could do, or listing ten good things I have accomplished, of drawing pictures of people who care about me. Again, what are this child’s current emotion skills strengths and deficits? What are the next steps in her treatment, what are we currently trying to teach her? Let’s give her some chance to practice as part of her restoration.

So back to the question we began with- how much is enough? It is enough when the staff feel the child has made any little step on any of these dimensions. They have talked about what happened sincerely. They have actually listening to the person they hurt. They have explored the feelings that led up to their actions. It doesn’t have to be the whole solution- just one tiny step, one new interpersonal experience, one moment of feeling "I am worth worrying about"- one building block in creating a new reality for the child.

Next questions- how do we as a team decide this? How do we teach it to new staff? How do we convey it to the children? Let me know your thoughts.

Article in Children's Voice Magazine

I am very excited to announce that I have an article in the latest issue of Children's Voice magazine, the Child Welfare League magazine. The article is titled: A Restorative Approach to Residential Care. Please check it out and let me know what you think. The magazine is not on line yet, but when it is (later this summer) I will post a link here.

Dare to Transform 2008

I am leaving today to present at the Dare to Transform Conference sponsored by the National center for Trauma Informed Care, a part of the Center for Mental Health Services. I will be presenting with my colleague Dr. Steve Brown, a co-worker Samantha Morris and an adolescent consumer Ashley.

This is the official description of the conference:
Dare to Transform capitalizes on the momentum building since 1994 for trauma informed systems change to bring about a revolution in human services delivery. The Center for Mental Health Services (CMHS) has been sponsoring conferences that have defined the agenda of what needs to be done to recognize, understand, spark, and speed the healing and recovery process from violence and trauma. From Dare to Vision in 1994, to Dare to Act in 2004, and now Dare to Transform in 2008 we are moving closer to real action for positive and lasting change. At the National Center for Trauma-Informed Care (NCTIC).

With the Dare to Transform trauma summit, the stage has been set for a revolutionary learning exchange devoted to trauma-informed innovation and systems transformation. Joining in this experience are consumers and survivors; policy makers; administrators and those providing staff support; service providers; and other advocates who have a stake in this transformation. Dare to Transform is the boldest expression yet of what needs to and can be done to bring about change - and you are a part of it!

Our Goal: Revolutionizing Human Services with Trauma-Informed Care

Find out more about the conference at: http://www.daretotransform.ning.com/

Our workshop:

Friday 1:15 pm to 2:15 pm Workshop Sessions
Georgian Room Creating a TIC Culture of Connection in Child Serving Agencies
Pat Wilcox, Klingberg Family Centers
Steven Brown, Director, Traumatic Stress Institute of Klingberg Family Centers

This presentation explores the joys and struggles of implementing and providing trauma-informed, relationship-based treatment to children and adolescents. This approach utilizes Risking Connection® trauma training and the Restorative Approachtm implementation model. One agency's process will illustrate the reasons change is necessary, how the trauma-informed model compares to a traditional control-oriented model, how to utilize training, how to facilitate the process of changing an agency, barriers to change and how to address them, and long-term benefits of transformation.

Please come by and say hello!

What We Know About Trauma…

The Restorative Approachtm creates a milieu management system that is based on what we know of the effects on a person of early repeated trauma and attachment disruptions. The following makes that connection more explicit.

Biological Disruptions in the Brain and Body

Less developed pre-frontal cortex
More easily over whelmed by emotion
Over developed response to danger
More difficulty accessing verbal memory
Confused, few or no rhythms
Less integrated, has more trouble with generalization
Less connections and conductivity
Lives at a hyper aroused state
Is always very alert
Sees danger every where, therefore misses a large part of what goes on due to focusing on danger

Create the Need To:

Staff has to act as cortex for the time being
Actively teach problem solving rather than punishing
Help the child with selective attention, working memory, self observation, and response inhibition
Don’t respond to dysregulation with thinking interventions- respond instead with calming and soothing
Reassure, don’t get into power struggles, don’t back child into corner
Do not rely on verbal planning
Use multi-model interventions such as art, dance
Maintain predictable structure
Offer rhythmic activities such as yoga
Be clear in communication
Make connections between various aspects of life explicit
Practice new skills in many arenas and settings
Be aware that child will notice everything
Actively stress safety
Look for ways to help child relax such as night light, reading, music

Negative Assumptions about Self and the World

The child has learned that no effective action is possible in his life
Blames self for the events in his life
Feels worthless and less-than others
Feels hopeless

Create the Need To:

Avoid shaming interventions or interventions that dictate passivity
Develop competencies
Build trusting relationships
Develop a sense of safety in which child can share that which he finds shameful
Allow many opportunities for active participation in decisions involving the youth
Respond to problems by guiding the youth to fix damage they have created, repair relationships they have damaged
Point out strengths and achievements, skills and gains

Difficulties with Relationships

Has under-developed ability to sort out social cues
Has difficulty trusting adults
Values control above all else
Expects rejection
Does not know how to handle problems in relationships
Has trouble asking directly for what they want
Is uncertain about boundaries and tests them
Evokes strong feelings in others around him

Create the Need To:

Be reliable and stick around
Be aware that child will notice everything
Be clear in communication
Teach social interpretation through movies, etc.
Emphasize trustworthy relationships
Use the language of the heart and communicate the relationship effects of behavior
Provide relationships that stick with you
Give child control whenever possible
Collaborate
Provide paths to work through relationship difficulties and to restore damage done, to make amends
Staff model relationships skills and actively teach social skills
Practice and model assertiveness
Say yes when possible
Maintain firm and flexible boundaries
Be aware of complexity of boundaries in child’s life
Staff discuss boundary issues openly with each other and with kids
Culture of self awareness and team development

Lack of Learned Emotion Management Skills

Unable to recognize or identify emotions
Does not know how to sooth themselves
Does not know how to handle something going wrong without making it worse
Has many negative coping tactics for handling pain
Moves from extremely aroused to extremely shut down
Covers up vulnerable feelings such as fear and sadness
May experience flashbacks and dissociation

Create the Need To:

Teach names of emotions
Teach recognition of bodily sensations of emotions
Help child develop awareness of own emotions and their stages
Develop tactics for each stage
Actively teach and model self soothing
Teach distraction and calming techniques
Develop a list of distress tolerance tactics
Offer child alternatives not consequences when child is becoming agitated
Look for adaptive function of symptoms
Collaborate with child in developing other strategies to solve problems
Create safety to share vulnerability
Model having vulnerable feelings while remaining strong
Teach grounding techniques