Trauma Conference 2010

I have just returned from the 21st Annual International Trauma Conference in Boston. This conference is directed by Bessel van der Kolk and the staff of the Trauma Center at the Justice Resource Institute (http://www.jri.org/). As usual this conference offered a unique combination of science and practice. In this article I will attempt to extract a few central ideas that I think can immediately add value to our every day work.

The conference focused a great deal on the contributions of neurofeedback, both in understanding the brain and it treatment. In addition, information continues to grow about the parts of the brain, their purposes, and the ways in which a developmental path which includes neglect, trauma and attachment disruption can derail their functioning.

The most emergent theme for me in this conference was the idea of rhythm. All human functioning depends on the establishment of rhythm, and perhaps our basic rhythms start with the mother’s and baby’s heartbeat. When infants are born, they can almost immediately respond to music. Presenters such as Ed Tronick, PhD (Infants’ Reactivity and Coping With Stress: Here Today, Gone Tomorrow?) demonstrated the exquisite musicality of the mother/baby attuned interactions, and how the tune is often led by the baby. Our interactions with babies emphasize rhythm (such as baby songs) and any parent can confirm how important routines and predictability are to the regulation of the infant’s emotions. All this rhythmic interaction has many functions for the growth and development of the baby. One result is becoming socialized to the rhythms of human interaction and social communication.

It is clear that the children we work with did not have either the attuned communication or stable rhythms in their daily lives.

This suggests an area of intervention that we do not utilize enough. Rhythmic interaction between people offers opportunity for attunement without words. This can be done in many ways: bouncing a ball back and forth, dancing, singing together, drumming, listening to music and clapping the beat, swinging, etc. These activities could easily be incorporated more into our daily lives, school and recreational activities.

I attended a workshop on SMART: Sensorimotor Arousal Regulation Treatment for Traumatized Children presented by Anne Westcott, LICSW, Elizabeth Warner, PsyD, Jane Koomar, PhD, OTR/L, FAOTA, and Alex Cook, PhD. This treatment integrates knowledge from child development, occupational therapy sensory regulation, and sensory motor psychotherapy. At their clinic they have outfitted a treatment room with various OT equipment such as cushions, large balls, wedges, etc. They utilize bodily work and rhythmic interactions between the child, the therapist and the care giver to produce regulation and a window of opportunity for connection. With this support the child can often talk about difficult topics in a way they otherwise cannot. They will soon be releasing a manual for this treatment.

Through careful research using fMRIs and Neurofeedback, more evidence has been gathered about the biological result of trauma. One important finding is that the area of the brain that is responsible for self reflection is significantly impaired. Children who have grown up in disruptive situations have less ability to think about themselves. They also have considerably less ability to recognize and interpret their own internal sensations. They cannot identify the sensation, associate it with a specific need, or figure out what to do about it. This includes the sensations of hunger, thirst, satiety, needs to eliminate, pain, and tiredness.

Think how significant this is to understanding the daily struggles we experience. Not being able to observe ones self- that has implications for the ever popular concept of taking responsibility for one’s actions. Not being able to notice and interpret bodily signals- that can be part of the explanation for the constant hygiene and toileting problems these children experience.

Inability to recognize and identify bodily sensations can also lead to serious social problems.

In examining brain waves of traumatized children, researchers discover that some parts of the child’s brain are over active and some are under active- often at the same time. Children especially have difficulty moving between states, such as between sleep and wakeful attention, or excitement and calm.

Researchers have also learned that the sleep problems experienced by children with trauma may be more significant than previously thought. We have all noticed that large numbers of our kids cannot get to sleep, or wake up, or have nightmares. However, it is now known that even when these kids appear to be sleeping they spend much less time in deep sleep than other children- and deep sleep is what is restorative and nourishing.

Understanding the biology behind the behavior we see can be helpful in not taking it personally, having patience, and deliberately designing interventions to target certain kinds of brain changes.

The presenters gave many examples of how neurofeedback had helped children, including for ADHD and even for schizophrenia. Neurofeedback also improved the musical performances of both skilled musicians and novice nine year olds, as reported by John Gruzelier, MD in Neurofeedback and its Benefits for Psychological Integration and Creativity.

Margaret E. Blaustein, PhD earned a standing ovation with her presentation Lessons from Kids and Families on the Treatment of Developmental Trauma. She brought the voices of the children and families into the conference, relating her ten lessons. They included both seeing the oak tree in every acorn (the strengths in the kids and families) and sometimes admitting that life sucks. Her strongest message was that traumatized kids are complex and deserve a thoughtful, complex intervention from us.

And as Ed Tronick, PhD said in his presentation Infants’ Reactivity and Coping With Stress: Here Today, Gone Tomorrow: The best tool is a "polymorphic stress resolver: an adult who unconditionally cares in all ways and at all levels."

That would be us.

I cannot write about this conference without mentioning the campaign led by Bessel van der Kolk to establish a new diagnosis to be included in the DSM V: Developmental Trauma Disorder. With a diagnosis that more completely and accurately captures the reality of children and adults that grow up with neglect, trauma and attachment disruptions, we can have research, medication, and treatments that really make a difference. To learn more about this diagnosis and the criteria for it, visit http://www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf. To contribute badly needed funds to its establishment, see http://www.traumacenter.org/products/DTD_Field_Trial.php.

Every presenter was passionate about the importance of this change in our system.

I am sure I have only scratched the surface of the ideas presented at the conference. If you were there, or have any opinions on these subject, please click on "comment" and add your thoughts.

Children Act Better When They Feel Better

I believe that children act better when they feel better. Do you agree?

What would our worlds look like if we deeply believed this, and put it into practice? Then our mission would become to help the children feel better. How could we do that? Of course, we do that already in many ways- but what if we deliberately made helping the children to feel better our top priority?

It would be essential to define “feeling better” in a complex and multi-faceted way. Each area has many parts and of course they overlap. It could include:

Feeling Better Physically:

• Addressing any health problems
• Establishing good nutrition
• Helping with sleep
• Engaging the kids in exercise, helping them overcome their fears and shame around moving their bodies
• Providing nice, comfortable clothes
• Addressing sensory distress

Feeling Safer:

• Eliminating bullying
• Addressing signs of danger
• Being caring, welcoming, sensitive to their needs

Felling Calmer:

• Teaching self soothing skills
• Teaching yoga, meditation, neuro-feedback
• Help with life problems

Feeling Less Shame:

• Exploring areas of self blame
• Forming relationships
• Experiencing competency

Feeling more competent

• Building on strengths
• Teaching new skills
• Encouraging self expression
• Providing opportunities to help others
• Providing praise and recognition of achievement

Feeling more effective:

• Providing many opportunities to control ones own life
• Teaching and practicing conflict resolution skills
• Providing opportunities to make a difference
• Developing leadership

Feeling more connected:

• Developing strong relationships between ourselves and the kids
• Providing assistance to help them maintain relationships with family and friends outside the agency
• Providing assistance to help maintain connections with communities such as religious organizations, their own school, sports teams, etc.
• Encouraging and facilitating appropriate relationships between the kids
• Encouraging exploration of their own culture and history

Obviously these are the things we do anyway- but does this way of looking at them help understand or organize our work in a new way? If a child acted out, we can wonder in what way they are feeling bad, and how can we help them feel better. Our response should be focused on helping them feel better, not explaining what was wrong with what they did.

I am just beginning to think about this. What is your reaction? Click on comment to respond.

Accommodation

I am in the middle of a six week training of foster parents. The topic is: Trauma Informed Foster Care. The foster parents are teaching me what they need to know in order to stick with these difficult children. The information about trauma and its effects is important; the practical applications are essential.

We were talking about the idea that children are doing the best they can, and how the biological changes they have experienced create real challenges for them. One foster father said to me: "I don’t expect anything different from my foster son as I do from my biological sons. I expect him to do everything they do and if not, have the same consequences they do."

This led me to think about how we readily make accommodations for physical disabilities that we can see. Yet is so much harder to see trauma in the same way. So this led to the creation of the following skit:

I asked two foster care social workers, Jaime and Neftali, to play two brothers. One (Jamie) played the son with a badly broken leg. He had broken it when his friends challenged him to try a jump on his skate board. We wrapped Jaime’s leg with gauze and an ace bandage, and gave him some crutches. The other (Neftali) was fine. But he was angry and resentful that Jaime is getting all the attention and is getting out of doing things.

As the two sons sat in front, I gave volunteer foster parents cards with situations, and asked them how they would handle them. The first was: "Your sons attend the local high school. There are long halls, stairs, and lots of changing classes." The foster father who chose this card, John, said he would go to the school and advocate for his son, ask for a longer time to change classes, a wheelchair, use of the elevators. Immediately both boys began to object. Jaime said that would be embarrassing and he could manage it himself. Neftali said he would NOT be pushing Jaime’s wheelchair. John was sure that he would insist that the accommodations be made even if Jaime objected.

The next scenario was that Jaime’s doctor had recommended PT for his recovery. Jaime did not want to go. PT would hasten his recovery, but it was not life or death. Jaime immediately said it was stupid and he knew he wouldn’t like it and it wouldn’t help. Neftali said he should be forced to go. The foster mom, Rose, who took this card said she would insist that he at least go- he could decide what to do when he got there. Other foster parents disagreed, and said that at least by some unspecified age he should decide for himself once the pros and cons had been explained to him.

The next situation brought us to chores. The boys usually handle the outside, mowing the lawn etc. Naturally Jaime could not do this. This time he was willing to accept his limits and do nothing. Neftali said if he had to do it all he should get Jaime’s allowance. The foster parents all suggested finding other ways Jaime could help such as doing the dishes while sitting in a chair. We had a spirited discussion of allowance, whether it should be used (it is mandated by DCF) and whether it should be contingent. If someone has a physical problem and can’t do the chores should the allowance be withheld?

I thought it would be obvious why I was doing this, but interestingly when I asked the foster parents none of them mentioned the connection between the broken leg and the broken brains our children have. When I pointed this out, the parents wrestled with the implications.

We are used to the idea of being flexible to accommodate visible physical limitations. I wonder if it would help if some how we could see our children’s broken brains?

What are your thoughts? Click on "comment" to respond.

How to Enhance Hope

A central concept in our Risking Connection® teaching is that healing relationships are characterized by Respect, Information, Connection and Hope. In fact, the concept is so integral to Risking Connection that the acronym RICH has been trademarked by Sidran. I would like to look at the concept hope.
I began thinking about this today as I wrote a book review of Trauma Stewardship by Laura van Dermoot Lipski with Connie Burk. This review will be in our May newsletter- be sure you are on our mailing list to get it (www.traumaticstressinstitute.org).

Van Dermoot Lipsky describes organizations as to whether they have a hopeful, energetic feel or a defeated, listless feel. I began thinking how essential hope is to all our endeavors. Do we make enough deliberate efforts to strengthen hope in our organizations, our staff, ourselves and our clients? How can we do this? Here are a few ideas- please add yours in comments.

Organizations
1. Hold regular celebrations
2. Communicate successes
3. Share stories of clients who return to visit and are doing well
4. Reward all sorts of staff efforts
5. Share any honors, recognitions or praise widely
6. Regularly and publicly reflect on where we have been and where we are now and where we are going
7. Articulate a vision of what kind of organization we want to be. Specify values and refer to them often.
8. Organize many child activities such as plays, field days, art shows, science fairs. As many staff as possible attend and applaud.
9. When something goes wrong, pull together and identify the parts that were done well. Praise the staff for those. Be specific about what we have learned from the event.
10. Articulate our pride in our agency and specifically what we are proud of.
11. Have fun, make jokes, do silly things
12. Celebrate staff milestones (new babies, weddings, etc.)

Staff
1. Praise, praise, praise- little and big things
2. Comment on any instance of staff doing their work well.
3. Assist staff in meeting their personal goals through providing training and education reimbursement
4. Provide supervision
5. Share client success stories
6. Promote from within when possible
7. Deliberately groom people for their next job
8. Remark on extra effort
9. Make room for creativity and individual interests, like the child care worker that hooks the kids up with a horseback riding stables through their personal interests
10. Do something different
11. Encourage staff to say yes- and say yes to them
12. Be flexible whenever possible
13. Maintain a clean and beautiful environment, fix damage quickly
14. Create fun events together such as pot luck lunches or volleyball teams
15. See above organizational ideas

Personal
1. Reframe experiences to focus on what you have learned.
2. Maintain balance with work and non-work connections
3. Take breaks and vacations
4. Decorate your space when possible
5. Notice changes in clients even when small
6. Notice changes in yourself such as increasing skill, and point them out in others
7. Notice ways the work has grown you as a person
8. Set goals for areas you would like to learn more about or new things you would like to do
9. Connect with others in the profession
10. Talk about your experiences11. Use supervision and therapy.
12. Laugh.

Clients
1. Point out small changes
2. Set small goals with them, notice when they are met
3. Express delight
4. Celebrate their achievements, attend their plays, admire their art
5. Arrange for them to take extra classes in an area of skill
6. Fantasize the future when they are a famous football player and are returning to your place to speak with the kids who are there then- what will they say?
7. Show that they matter by speaking from your heart.
8. Allow them to take some risks and try something new.
9. Offer new responsibilities
10. Arrange ways they can help others
11. Encourage the older to teach the younger
12. Put them in charge of things
13. Have a Youth Council that has real power
14. Tell stories of other successful kids
15. Have fun together.

What do you think? How can we be more active in cultivating hope, which is the core of everything we do? Click on “comment” and add your ideas.

Safety Empathy Action

I have been thinking that a shorthand guide for what we need to do for kids in treatment would be:
Establish safety
Teach emotional intelligence and empathy
Promote effective action

Now if only I could make it spell a word!

Safety- nothing good can happen when the child does not feel safe. If a person is in danger mode, he cannot learn. She cannot trust enough to form the relationships that will be the vehicles for healing. He cannot sleep- and so life feels so much more difficult. She has trouble relaxing and having fun. He misses much of what is going on because of the necessity to constantly scan for danger. Fear manifests in aggression, self harm, running away, and retreat. Fear without any one to turn to is completely overwhelming and is more powerful than both rationality and reward.

Of course, safety is not an all-or-nothing state. The sense of danger rises and falls. Yet we must pay close attention to the signals of danger and safety in our programs and in our relationships with the children (and families) we serve. If we actively strive to create safety in every aspect of our environments and relationships, we will help the children be more available sooner. And if we look for fear under many problem behaviors, we will discover more powerful intervention options.

Emotional Intelligence and Empathy: We could describe much of what we do in treatment under this category. I have just finished Dr. Bruce Perry’s new book, Born to Love (will review soon). His entire thesis is the necessity for empathy for societies to function at all. And as loyal blog readers will know, I heard a presentation on emotional intelligence at a recent conference. Dr. Hendrie Weisinger listed five key skills in emotional intelligence. They are:

1. Self awareness- processing information about yourself
2. Mood management- how quickly can you change your moods?
3. Self motivation- how can you get yourself to do things you don’t want to do
4. Interpersonal expertise-Build consensus, handle conflict, accept feed back, etc. Effectiveness in interpersonal emotional situations
5. Emotional mentoring

Self awareness is the key skill that is the foundation for all others- how can you be emotionally aware of others unless you are aware of yourself? This of course correlates with the skills of feelings management.

Empathy is a key part of interpersonal expertise. How can we build consensus, handle conflict or even form relationships if we have little ability to see things from another’s perspective?

Can we more deliberately build teaching empathy into our programs? When we use restorative tasks in response to a behavior that hurt others, we could include tasks that encourage the child to see another’s point of view. My friend and Risking Connection® faculty trainer Dr. Bob Davis shared some ideas from Devereaux. These included having the child write a story of the incident (or draw a picture) from the other person’s point of view, exploring what that person was feeling before, during and after the event. To create meaningful making amends tasks, the child should first think about who his behavior hurt and in what way. Then he should consider what could make that person feel better. That in itself is practicing empathy.

Of course the most powerful way we teach empathy is by showing it ourselves. We do this in our attempts to understand what the child was experiencing when she did something, and our working conviction that she was doing the best she could at the time. We model empathy is what we say about other staff, people in the news, people in movies or TV shows.

What else could we do to increase empathy?

Effective Action- Our children come to us believing that it is not possible to influence one’s own life. What happens, happens- and it is usually bad. There is nothing you can do about it- especially because you yourself are bad. We must teach, promote and make space for effective action. Particularly we must teach our children how to fix problems that happen within relationships. We grow as humans through relational attunement, rupture and repair. Our kids have had little of the attunement, a lot of the rupture and almost none of the repair. So again we must model- reach out to reconnect when we know we have missed the mark with a child. We can also demonstrate how we work out differences between ourselves as staff.

With restorative making amends tasks, we teach children what a person does when something goes wrong in a relationship, when you screw up. At first, we make the suggestions and offer the ideas. Later kids will think of ideas themselves. And when they see that genuine attempts to work through problems result in real reconnection, they will feel hope. They will begin to trust that maybe they can count on other people.

And then we have to offer opportunities for effective action in all other aspects of our programs. Examples include a student council, opportunities for volunteering and helping others, student input in activity planning, opportunities to develop special talents, and choice in everything from food to activities.

So- that’s all we have to do- create safety, teach emotional intelligence and empathy, and promote effective action. Not easy- not simple- but very powerful.

What do you think of this formulation?

Musing on a Busy Week

Last week I had a busy and exciting week.
On Tuesday Steve Brown and I presented at the Massachusetts Department of Mental Health Child & Adolescent Restraint/seclusion Prevention Initiative Grand Rounds. Our topic was: Transforming Resistance to Enthusiasm-Implementing Trauma Informed Care. Around 100 people attended, from hospital, residential and school settings. It was great to share ideas with others who are in various stages of implementing trauma informed care. As is often true, people seemed particularly concerned with how to overcome staff resistance to this change. We shared strategies such as: relating this theory to their own lives, celebrating every success, and having those who do it naturally teach others. We received many compliments of our presentation.

On Wednesday I attended a retreat of our Klingberg Therapeutic Foster Care Department. This staff is implementing trauma informed care for the entire department, including providing a six week training for the foster parents and more intensive training for the staff. Another component has been an increased focus of the experiences of the workers. This staff is on call for crisis 24 hours a day. They often have to experience the sadness and disappointments the adolescents endure. However, they also celebrate successes- six adoption this year! Their mission is to promote mutually claiming relationships and prevent disruptions. The trauma framework has helped make sense of some challenging behaviors, and enabled the parents to take them less personally and thus have more patience with the youth.

On Friday Steve Brown and I presented a workshop at the Massachusetts Adolescent Sex Offender Coalition Annual Conference. We spoke on a new topic: He Just Refuses to Take Responsibility!!! -- Implications of Trauma Theory on the Issue of Taking Responsibility. The phrase "taking responsibility" is used in all our programs, and I have written about it here before. However, it is central to sexual abuse treatment programs. We argued that it is helpful to see the word as response ability, and to realize that this is a skill not a characteristic. What can we do to build this capability in clients? This includes creating trustworthy attachments, teaching feelings skills, and most importantly reducing shame. The 70 or so workshop attendees participated in lively discussions of these concepts.

The conference itself was very interesting. The keynote speaker Cordelia Anderson was eloquent on the ways our culture sexualizes children and produces demand for child abuse, and she called us all to action in the prevention area. I attended a workshop by Phil Rich, PhD on ten things we think we know that we don’t, in which he pointed out how contradictory research can actually be on what really helps kids. Another workshop I attended led by Melissa Malter, MSW detailed a CBT approach to decrease shame.

All in all, a very worthwhile day. It was fun to have people coming up to me to say they saw us at the Grand Rounds or attended our conference in Worchester- our community is growing!

A very full week- and I must say I am glad to have less events scheduled this week!

The Process of Change

A cold and rainy weekend in March in New England provides us the opportunity to consider the process of change.
In nature, change never happens in a straight line. The seasons do not move from winter to spring through each day being one degree warmer than the day before. Instead, we have a warm day, and we notice buds on a tree. Then it snows. The crocuses come up, then the temperature drops and we wonder if they will survive. It’s very cold and raw, yet we see some skunk cabbage by the side of a river. We get discouraged, and say things to each other like "I am so done with winter. Is it ever going to warm up?"

Yet if we compare May to February, everything is different.

In February, if it is 45 degrees, we say: "A warm spell!!"

In May, if it is 45 degrees we say: "It is so cold!"

The parallels with our work are obvious. The children don’t get better each day in a clear progression. One day, Juan responds with kindness when another boy is upset. Staff make hopeful remarks to each other. The next day, Juan says something very mean to that same boy. Staff feel hopeless. Marcie has not had a restraint in months- maybe she is changing? Then she does and all feels lost.

Yet often when we compare this month to last year at this time, Marcie is substantially different. She is going to school and doing her work, and has not hit anyone in months.

We loose track of these changes. Now we complain with great intensity that Marcie is using a sarcastic tone when she speaks to us- forgetting that a year ago she would have hit us.

We have to learn to look for the snow drop in the snow, the red buds on the spring trees in the cold. Let’s rejoice in the warm day and point out the yellow willow to each other. When we see the small yet certain signs of change, we will have the strength to hang on through the raw days. Remembering to notice changes over time will help us celebrate the miraculous transformation we help our children achieve.

Emotional Intelligence and Trauma

I have just returned from the National Council annual conference. It was an excellent conference, very large. I enjoyed the keynote speakers especially: Howard Dean, Malcolm Gladwell, Geoffrey Canada, Lee Cokerell from Disney and others.

I attended a workshop given by Dr. Hendrie Weisinger about emotional intelligence at work. He quoted research that shows that emotional intelligence correlates much more highly with having a good life than any other measure, including IQ. He described the problems that bring people to therapy as failures in emotional intelligence. Therefore, we should be more deliberate in teaching EI skills to our clients. So, I wondered how the ideas of emotional intelligence interacted with our ideas about trauma.

Dr. Weisinger listed five key skills in emotional intelligence. They are:
1. Self awareness- processing information about yourself
2. Mood management- how quickly can you change your moods?
3. Self motivation- how can you get yourself to do things you don’t want to do
4. Interpersonal expertise-Build consensus, handle conflict, accept feed back, etc. Effectiveness in interpersonal emotional situations
5. Emotional mentoring

Self awareness is the key skill that is the foundation for all others- how can you be emotionally aware of others unless you are aware of yourself? This of course correlates with the skills of feelings management. I remember at the Bessel van der Kolk conference seeing evidence that the part of the brain that provides self awareness and self reflection is under developed in survivors of trauma.

In Risking Connection® training we read a letter written by a woman who grew up in the child welfare system. She describes eloquently how her repeated moves and continual re-defining by various families resulted in her not developing a sense of who she was and what her characteristics were. In short, she had no continuous self narrative.

So if self awareness is a key skill of a happy life and our clients are impaired in this area, what should we do? We should be consciously creating a narrative with the client. We should teach them self observation, including how to notice emotions in their bodies, patterns about themselves, awareness of their own strengths and weakness, a sense of their own skills and interests.

Mood management is also a key area of difficulty for our clients. Too much of their behavior is mood dependent- the child wants to be a lawyer, but because she discovered a stain on her shirt she is dropping out of school. At first we may have to support, cajole and help the kids in learning how to change their moods and to get through them without derailing. Hopefully they will improve in doing this on their own once they experience that it is possible.

Self motivation is another hard one. How do you get yourself to do things you don’t like to do? I usually promise myself a reward when it’s finished. Also, I picture other people who will be pleased. So I guess inner connection comes in here- being able to hold the awareness of someone who cares what you do, even when they are not physically present to help you complete the task. If we say to a child, let me know how that turns out, I will be waiting to hear from you, we are developing this skill.

Interpersonal expertise- how to defuse situations, handle conflict, work through differences, build consensus, accept feed back- of course this is a focus of much of our efforts. The Dialectical Behavioral Therapy skills manual by Marcia Linehan offers one excellent curriculum for teaching these skills.

Emotional mentoring means teaching others- and actually, we do see these among our clients when one gives another good advice. We can encourage this.

Strategies that Dr. Weisinger gave included:

1. Learn to listen to how you talk to yourself. Five minutes 3X/day listen to what you are saying to yourself- change your self talk
2. Write down three statements on a card that put you in a good mood, keep it handy
3. Use emotional self instruction. Create a learning aid. What would you want “Little You” to be whispering in your ear to help you manage the situation. Remind yourself that you have options.
4. Praise- write down behaviors you want more of in others, then praise when you see them (Imagine if we taught kids to do this with staff?)
5. Physical arousal- learn how to physically relax. Learn to notice when you are tense. Tension and relaxation exercise. Four components of relaxation exercise: Quiet environment; physically comfortable position; key image or phrase; passive attitude. (the quiet environment is hard to come by in some of our programs.)
6. Humor 10-14 good laughs a day- Get staff and kids together and have joke sessions
7. Can change our responses to difficult situations- the real problem is my own response. Then you can do something about it

It would be interesting to incorporate some of these strategies into our work.

Gloves and Lying

An example from a recent Risking Connections® training demonstrates simple, free interventions we can use to implement trauma informed care- and also demonstrates exactly how hard they are to do.
Juan constantly lies, according to the staff of his group home. He lies to avoid consequences or to avoid admitting he has done something wrong. He also tells lies about things that are happening in his life- such as that he has a girl friend in school. He doesn’t have a girlfriend! He makes up whole stories that simply are not true. For example, staff gave him some new gloves the other night to replace the pair he lost. Now tonight he is saying that he doesn’t have any gloves, that no one will ever give him any, and that none of the staff care if his hands are freezing off.

It is such a normal human response to argue with the truth of these assertions. You KNOW you gave him gloves Tuesday night. He has probably just lost them again or left them in school. Juan really has to learn to be more responsible! We don’t have enough money around here for an endless supply of gloves. And what is this story about a girl friend! You know from talking with his teacher that mostly Juan is a loner in school and has few friends. How is he going to manage life if he keeps lying? So it seems important to tell him that you know this is not the truth and how can you trust him if he keeps lying.

What is happening with Juan during these events?

His hands are cold and he cannot believe he cannot find his gloves again. He feels like such an idiot and a loser. No one likes him, no one cares about him, and no one should- who would want to be around such a jerk? He feels stupid and unloved, and plus his hands hurt. Saying no one has taken care of him enough to give him gloves expresses his emotional truth. Certainly he cannot admit to having lost the gloves again, then everyone will be mad at him, as usual.

What if staff IGNORED the truth/falsehood dimension of the situation and just reacted to the emotional and physical reality? What if Mark, Juan’s favorite staff, said- "Hey Juan I see you have no gloves, let’s find some you can wear." And when Juan said "No one ever gives me gloves" Mark could say "You’re feeling right now that no one cares enough about you to help you- so let me see what I can do to help you right this minute."

How hard would that be? Mark might feel that if he doesn’t confront the lie Juan will have put one over on him, or will never learn that it is not okay to lie, or will start telling more lies to get what he wants. He might feel that he needed to defend staff against Juan's charge of neglect, point out that staff have been responsive and would never let Juan go without gloves. But I would suggest that Juan will need to lie less when he develops a new view of the universe- that this world is a place where people will help you, where people care what you are feeling, where they do not shame and blame you. Only then would Juan be able to admit that he left his gloves at school.

And what about the girlfriend? Juan is desperately lonely at school and is sure he will never fit in there. He thinks none of the kids like him or ever could. Especially not the girls. So when he comes home he creates a new reality, life as he wishes it could be.

What if Mark were to reply: "wow it would sure be nice to have a girlfriend at school. What do you like in a girl, any way? What kind of girl would be the perfect girl friend for you?" and start a discussion of girlfriends in general. At some point Mark could ask, "If you wanted to make friends with a girl, what would be the first thing to do?" and start teaching social skills.

Note that Mark just side steps the true/not true question and again, reaches for the emotional reality. He doesn’t believe or challenge Juan’s story. He just turns it into a discussion of an important subject to Juan- girls. He avoids shaming Juan further (“Juan, I talked to your teacher an in fact you do not have a girlfriend”) which would just lead to Juan’s needing to lie even more.

What would it take for us to respond like this much of the time? When we are away from the situation in a training it all sounds like a good idea, yet in the pressure of real life we find ourselves reverting back to arguing about the lie. Time to think and plan, time to consider what needs the child is meeting, and to choose a more thoughtful and healing response are essential.

What do you think about the likelihood of this sort of response in your setting? Click on comment and let me know.

Connection in California

I received the following email on Friday afternoon. What a wonderful way to end a long and successful week!
Pat,

I wrote to you in May of 2009 and shared that I am a therapist in a Level 12 co-ed group home in San Luis Obispo California. We had recently changed our residential treatment program from a CBT based program to a Relationship Based model and we were having some growing pains. Since then we have made some tremendous growth, yet there are just a few things that keep us coming back to the table. Each time it does my thought is "what would Pat do," and more often than not due to the AMAZING blog you share we are able to work through the issue. ...

I have to say that is was an article that you wrote that finally helped change our program. For years I worked as line staff and was pleading to make some changes and then I found Pat and your blog. Thank you doesn't even express how much I appreciate, respect and admire you..you have started a movement toward healing these children. "Change your thoughts, you change your world." ...

And I want to leave you with this quick story...we have a young man who has been in our program almost two years. When he would get upset at times his coping skill would often be breaking the T.V. or other items the other kids enjoyed using. His response when given feedback by the kids or staff was to defend himself and say "I don't care." Within 3 months of us changing our program he sat in a group meeting with the other kids and said, "I know I broke the T.V. and I am working to fix it," he also had the other kids jump in to help him in that process. It was AMAZING!!!

Anna K. Yeackle, LMFT
Program Therapist
Transitions Mental Health Association
The Youth Treatment Program

Thank you Anna... people like you are the reason we continue our efforts to change the world.

Dr. Robert Davis to present on Benefits and Implementation of Trauma Informed Care

Risking Connection® faculty trainer Dr. Robert Davis to present on Benefits and Implementation of Trauma Informed Care at the Doctor Franklin Perkins School in Lancaster, Massachusetts.

This workshop will describe efforts to implement a trauma-informed approach to residential treatment and an on-campus school environment. Over a five-year period, this multifaceted initiative resulted in substantial reductions in both physical management episodes and staff injuries. Research in the area of trauma-informed practices within residential schools is still in its infancy.

Objectives:

1. Participants will learn about the national movement toward use of trauma-informed strategies.

2. Participants will learn about the benefits of training interdisciplinary staff in Risking

Connection®, an established curriculum for working with traumatized youth.

3. Participants will learn about numerous trauma-informed milieu and/or classroom approaches which can be integrated into existing evidence-based models of treatment.

4. Participants will learn about future directions in trauma treatment for youth, including

several body-based interventions.

5. Participants will learn ways to anticipate and overcome many of the institutional challenges of implementing trauma-informed treatment.

Presenter:

Robert Davis, Psy.D. Director of Clinical Services, Devereux Rutland, MA

Dr. Robert Davis has served as the Director of Clinical Services at Devereux as well as the Chief Psychologist of Devereux’s APPIC-approved Predoctoral Clinical Training Program. He also is a Faculty Trainer for the Risking Connection® Training Program for which he has trained multidisciplinary staff from congregate care settings throughout the country.

The workshop will be from 9:00 a.m. to 2:00 p.m. The cost is $45 for Members and $65 for Non-members. (Lunch is Included in registration fee).

To Register: copy this link into your web browser:

http://maaps.org/cde.cfm?event=300568

Deep Listening

One of the more difficult concepts which we teach is the power of listening. Such an old idea, so commonly taught, so rarely applied. In our training we have a section in which participants role play handling a crisis using a trauma informed approach. The most common problem is that people jump too quickly to offer solutions. They do not spend time to explore what the child is experiencing. In practice in our agency I hear the same thing. It is so tempting to offer advice, and so difficult to just stay with and share the other person’s pain.
We do this in spite of the fact that we ourselves do not like it when someone does this to us. What if I were to tell you that I was at my elderly father’s house last night, and I felt so tense about his deteriorating condition and what I should do that I ate two boxes of cookies? How would I feel if you responded: "Pat, there are better coping skills you can use. Next time you go there, bring some carrots." I actually might slap you. I would not even appreciate it if you told me about Visiting Nurse agencies in the area. Instead, what do I need? Some one to just say: "That sounds difficult. That must be very stressful for you."

Since I struggle to teach this is a way that people will remember it, I was struck when I recently read an interview of Thich Nhat Hanh by Oprah featured in O, The Oprah Magazine February 16, 2010. Thich Nhat Hanh has been a Buddhist monk for more than 60 years, as well as a teacher, writer, and vocal opponent of war—a stance that left him exiled from his native Vietnam for four decades. He speaks here of the incredible power of listening and not correcting:

"Oprah: The case is the same for deep listening, which I've heard you refer to.

Nhat Hanh: Deep listening is the kind of listening that can help relieve the suffering of another person. You can call it compassionate listening. You listen with only one purpose: to help him or her to empty his heart. Even if he says things that are full of wrong perceptions, full of bitterness, you are still capable of continuing to listen with compassion. Because you know that listening like that, you give that person a chance to suffer less. If you want to help him to correct his perception, you wait for another time. For now, you don't interrupt. You don't argue. If you do, he loses his chance. You just listen with compassion and help him to suffer less. One hour like that can bring transformation and healing.

Oprah: I love this idea of deep listening, because often when someone comes to you and wants to vent, it's so tempting to start giving advice. But if you allow the person just to let the feelings out, and then at another time come back with advice or comments, that person would experience a deeper healing. That's what you're saying.

Nhat Hanh: Yes. Deep listening helps us to recognize the existence of wrong perceptions in the other person and wrong perceptions in us. The other person has wrong perceptions about himself and about us. And we have wrong perceptions about ourselves and the other person. And that is the foundation for violence and conflict and war. The terrorists, they have the wrong perception. They believe that the other group is trying to destroy them as a religion, as a civilization. So they want to abolish us, to kill us before we can kill them. And the antiterrorist may think very much the same way—that these are terrorists and they are trying to eliminate us, so we have to eliminate them first. Both sides are motivated by fear, by anger, and by wrong perception. But wrong perceptions cannot be removed by guns and bombs. They should be removed by deep listening, compassionate listening, and loving space.

Oprah: The only way to end war is communication between people.

Nhat Hanh: Yes. We should be able to say this: "Dear friends, dear people, I know that you suffer. I have not understood enough of your difficulties and suffering. It's not our intention to make you suffer more. It is the opposite. We don't want you to suffer. But we don't know what to do and we might do the wrong thing if you don't help us to understand. So please tell us about your difficulties. I'm eager to learn, to understand." We have to have loving speech. And if we are honest, if we are true, they will open their hearts. Then we practice compassionate listening, and we can learn so much about our own perception and their perception. Only after that can we help remove wrong perception. That is the best way, the only way, to remove terrorism.

Oprah: But what you're saying also applies to difficulties between yourself and family members or friends. The principle is the same, no matter the conflict.

Nhat Hanh: Right. And peace negotiations should be conducted in that manner. When we come to the table, we shouldn't negotiate right away. We should spend time walking together, eating together, making acquaintance, telling each other about our own suffering, without blame or condemnation. It takes maybe one, two, three weeks to do that. And if communication and understanding are possible, negotiation will be easier. So if I am to organize a peace negotiation, I will organize it in that way.”
(Read the full interview at
http://www.oprah.com/spirit/Oprah-Talks-to-Thich-Nhat-Hanh)

So- Listening may be a path to world peace- and it is definitely the path through which we offer connection to our children and families. It can be painful, because it necessitates opening your heart to the sadness and suffering of the other person. But it is also healing, both to our clients and to our selves.

Transforming Resistance to Enthusiasm in MA

On April 6, 2010 (Tuesday) Steve Brown, PsyD. and Pat Wilcox, LCSW will be presenting at the Massachusetts Department of Mental Health Child & Adolescent Restraint/Seclusion Prevention Initiative Grand Rounds. Our topic will be: Transforming Resistance to Enthusiasm - Implementing Trauma-Informed Care. Trauma-informed care is an important element to the success of preventing restraint and seclusion use. This training will provide and understanding of how to implement trauma-informed care in child & adolescent settings. It will include an overview to the Risking Connections trauma training program, as well as the Restorative Approach which is a trauma- and relationship-based approach to treatment of children. The presentation will focus on the most effective transformation process for overcoming common staff concerns and changing resistance to enthusiasm.


The presentation will be held 9:00 AM – 12:00 PM, (Registration starting at 8:30AM) at the Lazare Auditorium of the UMass Medical School in Worcester, MA. The registration deadline is Monday, March 29th, 2010. To register please contact Annabelle Lim at Email: annabelle.lim@massmail.state.ma.us or Phone: 617.626.8087. An email confirmation with directions will be sent upon registration. CEU applications have been submitted for: Licensed Mental Health Counselors, Psychologists, Nurses, & Social Workers. Hope to see you there!

The Rush to Change

We are in the change business. So when a child comes to us because of difficult behaviors our first thought is what can we do to change him or her? Jeffrey assaults people when he doesn’t get his way. Latasha cuts herself so badly she sometimes needs to go to the ER. How can we stop these things? That’s why people pay us the big bucks after all.

And there is plenty of external pressure for change- at every review someone is asking why that child hasn’t changed yet. Her parents, too, have suffered enough and want to see something different soon.

Then there is the internal pressure. Our lives would be a lot easier if these kids would stop doing these crazy things. And we judge ourselves- do we really know what we are doing? When Jeffrey hit his teacher yesterday is it because I am not a good enough therapist? I feel guilty about the pain the teacher suffered. We can start to blame each other- isn’t it the therapists’ job to take an angry child to her office and bring her back calm and happy?

And when we feel compassion for the child, we start to feel even more urgent about change. Jeffrey’s life would be so much easier if he could control his anger. He is in danger of being kicked out of this place, as he has been out of his last six places. It is so painful to see the blood stream down Latasha’s arm.

In this urgency for change we ourselves feel powerless, vulnerable and incompetent. We feel much like the kids we serve. So like them, we turn to something that we think will give us more power and control. We often think first about punishment. Surely if we restrict Jeffrey long enough he will learn that his life goes better if he does not hit people. Or, being more enlightened, we think about rewards. Maybe if we promise Latasha that we will take her out to lunch if she can go a week without cutting…

It would be actually astonishing if Jeffrey didn’t already know that his life would go better if he controls his anger. Look at all the bad things that have happened to him already- he is on probation, he has been kicked out of six placements, and he is in residential- just to name a few.

When Latasha is calm she fervently wants to stop cutting, and she hates her scars. She does not need more motivation. She needs more skills.

I would suggest that this very urgency we feel to change the kids gets in the way of effective treatment. It makes it harder for us to stop and think about what is going on. How do we understand this behavior? What is actually happening when Jeffrey hits someone? What leads up to Latasha’s cutting? What problem are they trying to solve? How does this behavior help them in the moment?

We need to take time to explore, observe, think and consider. We need time to help the child feel safe enough to share their experience with us. They will be able to do this when they form strong relationships. In collaboration with the child we will discover the meaning and function of the behavior.

Then, we must consider what skills the child would need in order to choose a different behavior, a new way to meet his needs. It will take time for the child to learn these skills.

Jeffrey formed a close relationship with his teammate (primary child care worker). After a while Jeffrey shared how scared he was that he is such a bad kid that no one will ever take care of him or meet his needs. He said has learned that force is the only way you get anything you want. Staff started looking for the first signs that Jeffrey was agitated and asking if he needed anything. In small steps Jeffrey learned to trust them enough to ask for help. It was important that at the same time Jeffrey discovered a skill at cooking, and became the star chef of the school café. He got a lot of praise and recognition for this and was generally feeling better and calmer.

Latasha connected with her therapist slowly. They began looking at the patterns that led up to cutting. After a while, several factors were identified: not getting enough sleep, fighting among the girls on the unit, and not hearing from her mother. They worked out many strategies, including a crisis kit. Medication helped with her disturbed sleep. Latasha found soothing music, a piece of fur to rub, and a honey candy soothing. This did not always work and she continued to cut for a long time, but the self harm decreased in frequency and severity. She started telling staff when she felt vulnerable.

Note that these children did not change quickly. They did not change because of punishment. But with time, safety and relationships they did change.

And then the staff felt the true power of changing the life of a child.

Healing the Generations Conference

I want to highly recommend the second annual Healing the Generations conference at Foxwoods on March 25 and 26th. Last year’s conference was wonderful and this year looks to be even better. I am presenting on Trauma Informed Foster Care, Helping Survivor Parents and What We Know about the Brain and What We Should Do. My colleague Steve Brown is presenting on teaching Healthy Sexuality to High Risk Kids, and on our statewide initiative to use Risking Connection to train the staff of Extended Day Programs. This presentation, in conjunction with Marilyn Cloud from DCF, will include exciting new research demonstrating the effectiveness of the training. I hope to see you at the conference, and be sure and come up and say hello!


The Clifford W. Beers Guidance Clinic, Inc. Presents

Healing the Generations:

Second Annual Family Violence and Child Trauma Conference

Keynote Speaker: Dr. Alicia F. Lieberman, PhD

Dr. Lieberman has spent her career trying to prevent and undo the emotional damage inflicted on people at very young ages. "Young children, even babies, remember traumatic events in their bodies with increases in stress hormones such as cortisol--the event makes a distinct impression on them." Investments made in the first three years of life have the best predictive role in creating positive change in a person's life, so the infancy years are crucial in shaping not only individuals, but society as a whole.
Dr. Lieberman's keynote and workshop will describe the impact of chronic adversity on parents' attitudes and child-rearing practices, illustrating the transmission of emotional difficulties and relational conflicts from one generation to the next. It will also describe how parents can surmount difficult child experiences to transmit a message of love and hope to their children.

Spotlight on Workshop Presenter:

Michael Mack

Haunted by memories of childhood clergy sexual abuse, Michael Mack wondered for decades if one day he might meet his abuser for a conversation. In 2008 he had that chance. Although Mack had anticipated countless scenarios, what happened was beyond anything he had ever imagined. He will deliver a theatrical monologue about the healing power of personal storytelling. He uses monologue "because when we can talk to ourselves consciously, we can experience healing more deeply."

Michael Mack is a poet, playwright, and solo performer best known for his one-man verse play "Hearing Voices (Speaking in Tongues)" about his mother's life with schizophrenia. Mack has performed Off-Off-Broadway, at the US Library of Congress, at Yale University, and for faculty and students of the Harvard Medical School.

For full conference agenda visit:

www.cliffordbeers.org

Up to 12 CEUs will be available through the Women's Consortium for MFT, LPC, LCSW, NASW and CCB.

Contact Info:

Jane Hendrickson at (203) 772-1270 ext 246 or jhendrickson@cliffordbeers.org

Legacy of Caring Conference a Resounding Success

On February 9, 2010 Devereux Mass and Klingberg Family Centers co-sponsored a conference entitled "The Nuts and Bolts of Trauma Informed Care". The conference was attended by over 300 people, from CT. MA, Florida, Kentucky, NY, Missouri and several other states.

The conference began with a welcome by Steve Yerdon, CEO of Devereux. After Dr. Bob Davis set the frame of the day, Dr. Steve Brown asked the audience questions to determine who was attending. Some participants rated their agencies at the beginning of trauma informed care; others had considerable experience. Disciplines such as direct care, therapists, administrators, nurses and teachers were all represented; and settings included residential, schools, hospitals, out patient and foster care.

Dr. Davis led the presentations with a history of the trauma informed care movement, which related to the restraint reduction initiatives. Then Dr. Brown and Dr. Davis described the Risking Connection® foundational trauma training. Dr. Brown included a clip from Star Trek in which the character Data, who has no feelings, wonders whether it is actually advisable to form connections- much as our children do.

Patricia Wilcox, LCSW and Dr. David then described a vision of a trauma informed agency, using a formulation created by Roger Fallot. Ms. Wilcox described how an agency can incorporate safety, trustworthiness, collaboration, choice and empowerment. Dr. Davis followed with sharing agency practices that embody administrative commitment to change, universal screening, staff training and education, hiring practices, and supporting policies/procedures.

At lunch the Legacy of Caring Award was bestowed on Lynn Sanford, LCSW. Lynn made an inspiration and humorous acceptance speech.

After a delicious lunch (the cheesecake got especially good reviews) participants attended workshops on trauma informed care on the units, in education and in clinical practice. The role of administration in creating and sustaining trauma informed care was the subject of one workshop, one covered sensory interventions, and the Restorative Approach was another.

Participant comments included:

"It was relevant to what we are trying to do. The presenters were knowledgeable and helpful."
"I appreciated the honesty about the challenges."
"Different agency perspectives were helpful in comparing/contrasting real life processes and challenges."

Trevor and his Restorative Experience

What we heard on the grapevine Monday morning- a kid trashed Susan’s office! He even broke her computer! Can you believe it?

Trevor worries about everything. He loves his mother, and his worrying may have started very early in life when he observed her being beaten by his biological father. His anxiety continued to mount as his mom’s mental health problems have caused her to have extreme, fluctuating moods, at times feel suicidal and need hospitalization, and often need a lot of help from others. Trevor blames himself whenever his mom is unhappy or having trouble. His stepfather tries to take care of Trevor, but his rigid standards result in him using discipline such as tying Trevor to the bed and stuffing socks in his mouth. Trevor worried when one of his brothers died and worried when another was placed out of the home. Trevor knows this is all just because he is a bad kid.

Trevor wants to be good. He tries to please everyone. Yet he gets so anxious so fast, and at age 14 he becomes completely overwhelmed by sudden changes, uncertainty, unpredictability, and things going wrong. The pressure in his mind is so intense that he resorts to behaviors such as head-banging, self-cutting, screaming and physical agitation.

So when another kid, Marvin, broke off the antenna of Trevor’s new remote control car, the one his mother gave him on her last visit, it was more than Trevor could bear. Aside from being angry that the car wouldn’t work and sure that it could never be fixed, Trevor believed that his mother would blame him for not taking better care of this expensive present. It was her hard earned money and already it was broken! One more example of how he could never do anything right.

Trevor could not stand how horrible he felt, and so he started screaming-- and the staff were just making it worse by talking to him. So Trevor ran off the unit and outside. As he was storming around the yard he noticed an office window that was open right over a porch roof. A refuge! He easily climbed up and got in the window, closed and locked it, and found himself in the secretary’s office-- but staff saw him! They couldn’t get through the now closed window, but they were knocking on the door and trying to unlock it.

Trevor knew that if they got in all sorts of horrible things would happen, people would yell at him, he’d be kicked out, he’d have to go to jail, and he’d never see his family again…so he decided to barricade the door. He began moving furniture frantically towards the door. As he pushed the desk, the computer monitor fell off and broke. A whole lot of plants toppled over. The fax machine fell and shattered. When he moved the bookcase, lots of papers scattered around. But he kept pushing furniture towards the door- he had to make himself safe.

The staff became worried. They could not get the door open. The banging continued. And the sounds Trevor was making made them wonder if he was hurting himself. So, they called the police for help. The staff were able to disable the door, and with the police present opened the door, and Trevor moved some of the furniture so they could get in. The staff and police decided Trevor needed to go to the ER. The policeman told staff that he would call later about whether or not Klingberg wanted to press charges.

So- a kid did major- in fact VERY major- property damage, and destroyed the office of someone we all love. What should we do?

Susan was surprised when her boss, the Vice President of Treatment Programs, met her at the door on Monday when she came in. He wanted to warn her before she opened her office door. And when she did, she was horrified. Who could have done this to her? And why? She was always nice to the kids and in fact she had had some pleasant conversations with THIS kid. Why would he target her? And all the work she was going to have to do to clean this up and restore order!

Susan was a little apprehensive when the team suggested that Trevor would need to work with her when he returned from the hospital. Would she even be safe with someone who could do all this? What on earth could she have him do? What should she say to him? Should she talk about what happened and her reactions, or not? And besides- she was quite angry that he had caused all this devastation and she wasn’t at all sure she wanted to be around him.

Susan talked all this over with the team. They validated her feelings and encouraged her to talk to Trevor about her reactions and listen to his experience of what had happened. She agreed to participate in the restorative process.

Meanwhile, the team discussed whether it would be helpful to have Trevor arrested for the property damages he caused. For some kids, being arrested could provide a deterrent next time. Yet when the team talked it over, this did not seem to be the case for Trevor. His main problem was that he worried too much, and gets over whelmed by anxiety about all the ways he has disappointed everyone and all the bad things he knows will happen. Being on probation would probably make that worse, cause him more panic and make it more necessary for him to do something to escape his horrible feelings. So the team decided not to press charges.

While Trevor was in the hospital he did not really want to come back to Klingberg. He was so ashamed of what he had done, and he did not want to see people who knew about it. He assumed they all hated him now; in fact he was surprised he was even allowed to come back. He was especially worried about seeing Susan and said "I thought she would yell at me."

Trevor was scared when he started working for Susan. She had him carry some heavy boxes of files to the downstairs storage area. He was proud of how much he could carry! He was afraid he would do it wrong but soon saw that he was actually helping her. The next day they started to re-pot all her plants. During this process they talked a little about what had happened. Susan told Trevor how upset she had been walking into that mess. He apologized and said he had just been so scared.

Susan says that the experience of working with Trevor made a difference in how she thinks about this event. "I realized he was not attacking me. I could see he was just so scared. And it meant a lot to see how genuinely sorry he was. He even brought me back pictures from a trip he went on. I am not left with anger or fear. I don’t feel like I am working with a bunch of dangerous kids. I feel sad about how scared Trevor is and I hope we can help him feel better."

Trevor says that he liked working for Susan. In fact, he kept doing things for her and making her things long after the restorative tasks were over. When asked if he thought the fact that he liked doing the tasks would encourage him do something wrong again in order to be assigned new pleasurable tasks, he looked puzzled and couldn’t get that concept. “Maybe it would work that way for some kids” he said "but not for me. Not for me." (Clearly, he’s never taken a course in behavior therapy!) When he imagined just being grounded instead of doing the restorative work, Trevor said "then I would still be worried and nervous and I’d still be feeling so bad about what I did. Now I am friends with Susan."

Trevor is leaving Klingberg soon and going to a therapeutic foster home. When asked if he thinks he has changed, Trevor says, "Oh yes, now I can use some coping skills." What are those? "Art- I really like art. And music. I have a guitar now. And drama- did you see me in the last school play? And I am going to be Jack in the next one." What helped him most were "the staff- not the kids so much-although some kids helped me." He thinks that the kind of staff that help kids are the kind that "listen and don’t get an attitude," although he does feel they should be "strict." And Trevor says that it has helped him that staff have been his friends- especially Susan.

The Devil is in You

I met a gentleman named Ernie this week who was talking about his life. He is French Canadian, and grew up speaking French in his home. He attended Catholic school. When ever he answered a question in French, the nun would hit him with a ruler. He was not taught to read English, but was punished for not being able to do so. The nuns told him that his problem was that he had the Devil in him, and that their job was to drive the Devil out- mostly through punishment.

Ernie dropped out of school before graduating, and got a job working hard as a carpenter- skills he learned from family members who were also carpenters. He never learned to read or write.

I think we would all disagree with this form of education and we would not be surprised that it was not successful.

Yet, how different is this (except in degree) from our traditional ways? We see what the child has learned from their family. We do not like it, and we try to drive it out with punishment. Luckily, there is not so much hitting with rulers- more confinement to small rooms.

In various ways we convey to the kid that he has the Devil in him, and we are trying to drive that Devil out with our strictness.

And often the kid drops out of treatment, and remains emotionally illiterate. They can sometimes till be successful as Ernie is, if they find people to teach and mentor them. But they are left with a bad feeling of being a Devil-person.

There must be a better way.

From Strategy to Reality: The ‘Nuts and Bolts’ of Implementing Trauma-Informed Care in Child and Adolescent Settings

I want to make sure that you all know about our conference in Worchester MA on Feb. 9. We are delighted that both people we have worked with and people who may want to work with us are coming in from other states for the conference. We hope to see you there!

Devereux presents:

The 2010 Legacy of Caring Conference
(in conjunction with Klingberg Family Centers)

From Strategy to Reality: The Nuts and Bolts of Implementing Trauma-Informed Care in Child and Adolescent Settings

Date: February 9, 2010
Time: 9:00 am - 4:30 pm
Location: Crowne Plaza Hotel
10 Lincoln Square
Worcester, MA 01606

Overview:

Successful restraint and seclusion reduction happens within a trauma-informed setting. But, implementing trauma-informed care (TIC) requires system-wide culture change - - no easy task, especially with ever-more challenging clients and settings that historically have placed a premium on controlling children’s behavior. Centered on the Risking Connection® treatment philosophy, this nuts and bolts conference will help your school or agency translate broad stroke strategies about trauma-informed care to real life solutions.

Conference Objectives:

• Participants will be able to describe the daily operations and practice of a trauma informed agency and relate these to restraint reduction.
• Participants will identify training strategies that promote trauma-informed care,
Including Risking Connection®, an established curriculum for working with traumatized youth.
• Participants will learn trauma-informed behavior management, administration, milieu and classroom treatment techniques, which can be integrated into existing evidence-based models of treatment.
• Participants will learn ways to anticipate and overcome many of the institutional challenges of implementing trauma-informed treatment.

Schedule:
8:00-9:00 AM Registration and Check-In
9:00-9:30 AM Welcome and Introductions
9:30-9:45 AM Trauma-Informed Care: Its History and Relationship to Restraint Reduction
9:45-10:45 AM Risking Connection®: An Integrative Pathway Toward Trauma-Informed Care

10:45-11:00 AM BREAK

11:00 AM-12:00 A Vision of a Trauma-Informed Agency

12:00-1:00 PM LUNCH (provided)
Presentation of the Annual Legacy of Caring Award

1:00-2:30 PM Workshop One (please choose one of the following)
A. If You Don’t Feed the Staff, They’ll Eat the Children: Leadership’s Role in Trauma-Informed Change
B. Relationships, Structure & Individualized Care: All This and Paperwork Too? Running a Trauma-Informed Care Unit
C. From Chill Rooms to Calm Down Kits: Sensory Interventions to Prevent Crisis
D. Healing the Heart of the Helper: Helping Staff Manage Vicarious Trauma

2:30-2:45 PM BREAK

2:45-4:15 PM Workshop Two (please choose one of the following)
A. Relationships, Structure & Individualized Care: All This and Paperwork Too? Running a Trauma-Informed Care Unit (Workshop 1 repeated)
B. The Restorative Approach: A Relationship-Based Alternative to Points and Level Systems
C. How Can I Be Trauma-Informed and Still Get Through My Lesson Plan? Trauma-Informed Care in Educational Settings
D. Why Are These Kids Doing These Crazy Things? The Role of the Clinician and Clinical Supervision

You may register on line: http://events.devereuxma.org

Or call 508-886-4746, ext. 314. Fax 508-886-4473

See you Feb. 9th!

A Warning Sign

"It’s the tasks" your program manager says to you. "We just cannot seem to think of enough tasks to assign to the kids in my unit. And those we can think of they don’t take seriously, they are done quickly, and I just don’t think they are significant enough to deter the behavior."

What would be your response to this plea? Would you start researching tasks that the unit could use?

I think this is a sign that more training is needed. In my experience, this focus shows that staff are still considering the tasks as punishments, and thinking that their power for change is found in their deterrent function. That is, the kids won’t want to do the tasks so they will avoid that behavior. If you are thinking that way, you start to wonder if the tasks are hard enough, significant enough for the bad behaviors. You become concerned if the kids seem to enjoy the tasks. You hear statements like "they did ... and THAT is all they have to do?"

Let’s step back a few steps. Our basic premise is that symptoms are adaptations- that the kids are doing the best they can, and they are doing these behaviors because they do not know any other way to handle their intolerable feelings. Therefore, in the Restorative Approach we respond to behavioral problems with tasks that are designed to help the child learn new skills and to repair damaged relationships.

So- Kayla has a difficult call with her mother. (A small (or large) set back happens in the present.) Kayla does not trust relationships and cannot ask for help. She is already over activated and is now completely lost in her stress response. She has no sense that there is any one who loves her and will care how this turns out. She feels pretty worthless anyway, and knows that this latest event is just one more sign of what a lousy person she is and how her mother gave her up because she is such an awful girl. And she does not know how to notice, identify or sooth her feelings. So, Kayla is plunged into the depths of fear and hopelessness. Who wants to feel that way? So she does something, anything, to escape these feelings. She cuts herself. She throws a chair. She runs away. She hits a staff.


So what Kayla needs to be able to handle a setback in a better way is:

Relationships she can trust
A calmer body
A sense that people care about her, and the ability to remember them when they are not present
The knowledge that she is worth the air she breathes
and
Skills to identify and soothe her feelings

And hopefully we know Kayla. We know the neglect, sexual abuse, and multiple placements she has experienced. We know her strengths in drama and her ability to teach younger children, and we know how mornings are hardest for her. And we have a formulation, a theory about what is going on with her and that our primary theme in working with her is learning to trust others and ask for help.

So this is where the tasks come in. The tasks are a chance to practice some part of what she needs. To put one building block in her wall of creating a competent self.

Kayla will act better when she feels better. After her blow up she is feeling worse, more shame, more self hatred. And that can send her into another acting out episode.

So- the tasks.
Making amends helps strengthen relationships and teaches how to fix problems in relationships.
Doing a task with a staff member is practicing trust and accepting help.
It is also practicing effective action- when something goes wrong, Kayla can do something about it. She does not have to freeze.
Practicing what to do when upset (a feelings chart, a poster to illustrate what Kayla was feeling or six steps I can take when she is angry, interviewing others, making a plan for her next contact with her mother, etc) help to develop feeling skills, and include methods to create a calmer body.
Doing something to make things better (chores, create a bulletin board, make brownies, helping a younger child with her homework) increase self worth.

The idea is to use the opportunity that an episode provides to help give Kayla what she needs to handle life better.

Kayla doesn’t have to hate the tasks. She has to take them seriously and do them well. Then its over, and we go on, hopefully just that little bit closer to what she needs.

This is where I would focus with the unit that needs more tasks.