Crew Rowing and Repairing the Brain

I have just returned from Sacramento, California where I did a recertification for the Associate Trainers of Victor Services. It was very moving to reconnect with these skillful practitioners and experience how they had made Risking Connection their own and used it to transform their treatment programs.
While I was there I visited a local lake and saw some teenagers practicing crew racing, the sport with those long thin boats and many people rowing together. And it occurred to me that this might provide a useful metaphor for the task of healing the lower brain.

Imagine that you have been asked to coach a crew team. Although you have not done so before, you have seen the lovely boats slipping across the water as the coordinated rowers respond to the call of the leader. How hard could it be? So you agree.

Alas, when you first meet your team in action you find them to be much different from what you had envisioned. There they are, a bunch of rowers in a lovely boat on the water, with a separate boat calling out instructions. But, the leader sitting in the front is terrified, and keeps yelling: “Careful!!! We are going to drown! Oh no we are tipping over! Hold on!” and other such things. This constant stream of fear has all the rowers upset and disabled. Several are rowing frantically, but in different directions. Two have dropped their oars into the water and are sitting with their arms crossed. One is crying. The boat is turning in circles, lurching from side to side. The noise is so loud; no one can hear the instructions coming from the other boat.

(This is the disorganized brain. It results from early trauma and lack of attunement. No parts are working smoothly together, and the fear system is in full alert, drowning out all other input. Movement forward is impossible.)

As the new coach, what do you do? Do you tell them you will give them each $5 if they can do a better job and row from one end of the lake to the other? Or do you tell them that unless they row that distance successfully they will be on restriction for two weeks and not able to see their friends? Do you give them a lecture on how much better everything would be if they would just get it together and row smoothly?

(Our normal approaches to our children.)

I would suggest that the best coach would not start with rowing at all. He would start by doing lots of exercises on land. First, there would be activities to help the team members get to know each other and trust each other. These would start with easy things and gradually increase in difficulty. (Relationship forming) Then, he would begin having them experience physical challenges together. He would use all sort of rhythmic activities such as drumming together, dancing, playing ball to help them experience the feeling of being in sync and interacting smoothly with each other. Other games would increase their strength and confidence. Every activity would include elements of relying on each other, interacting with each other, helping each other to achieve success. When things didn’t go well they would develop a method for working them out. They would practice team coordination through carrying the boat together, lifting it up and putting it down, making turns on land while carrying it.

He would make sure they all knew how to swim.

The team would adopt a name, and begin a narrative of its journey from the beginnings to success. The team members would retell the story, always adding the day’s events, each night around a campfire.

Then, gradually, the team would return to the water. The challenges would be small at first. They would try regular rowboats in pairs. When they started the crew boats again they would be in shallow water. Each of them would practice leading the beat, the rhythm that coordinates them all, until they could feel it deep in their bodies and respond almost automatically. They would try rolling the boat and falling out until they felt confident they could handle any eventuality. This phase would take a long time.

(All the treatment activities of healing the brain.)

And then, the magical day would come when the team would get into the boat, row through the water together in a smooth and effective way. The youth in front would carry the beat. The team would respond in rhythm. The ideas from the second boat would be easily heard across the silent water. When a wave came, or it started to rain, or they had to make a turn, the team would laugh and solve the problem together.

(And thus the brain would become as powerful and skillful as it had always been meant to be.)

My Recent Travels

I have had the honor and privilege of participating in two special events over the last two weeks. The first was the Vermont Foster/Adoptive Family Association 24th Annual Spring Conference: Hope and Healing. At that conference I attended a one day workshop by Dr. Bruce Perry. I was so delighted to finally have a chance to hear Dr. Perry in person, after having read all his work and listened to him on video tape. When I remarked to the conference organizer that he reminded me of Seinfeld she told me I wasn’t the first person to notice that. As I have written in this blog, his ideas are opening new avenues of learning and teaching for me, and I hope to write more about them here in the future. Dr. Perry expanded on the idea that rhythmic, repetitive, rewarding physical activities with another engaged person are necessary to rebuild the brain stem of children hurt in early life.

The next day of the conference I delivered a keynote address and then led two workshops. The subject of my keynote was: What is Trauma Informed Care and What Does It Mean for Foster Care? The workshops were: The Trauma Survivor as Parent and Maintaining your Sanity While Walking in The Minefield: Helping Youth With Challenging Behaviors. I received much positive feedback for all of them.

Vermont has prioritized supporting and training foster parents. They offer this conference to foster parents and those who work with them every year, and it combines education with a break, recreation and connection. They also raise money at the conference through a silent auction and fifty/fifty raffle for a fund that provides extras for foster children. I found the foster parents to be very knowledgeable and thoughtful, tuned in to the adaptive nature of their youth’s behavior, and extremely caring and committed. I was also impressed with the professionals I met such as the conference organizer Karen L. Crowley, System of Care Manager, Family Services Division, Department for Children and Families. Vermont’s governor Peter Shumlin was present, as was the new DCF Commissioner Dave Yacovone. Their presence also spoke to Vermont’s commitment to foster parents. Vermont is emphasizing the concept of co-parenting between the foster parents and the bio parents, which made my “trauma survivor as parent” workshop especially relevant to the foster parents.

One foster parent asked me a question which we agreed we must defer to Bruce Perry. She has a teenage foster son who is very sexually active. She said that it occurred to her that he was engaging in an activity that is rhythmic, repetitive, rewarding and physical with another engaged person. Is he building his brain stem?

On the third day of the conference we watched a movie entitled “Ask Us Who We Are ~. From the program description of the film: “Directed and produced by Bess O’Brien. This documentary film focused on the challenges and extraordinary lives of youth in foster care. The film is a reflection on loss and the search for belonging and fining family. Although the film highlights the heartbreak that many foster care youth carry with them as they move through their lives, the documentary also reveals the tremendous strength and perseverance that grows out of their determination to survive and thrive. The documentary also focuses on the lives of foster care parents and kinship families that open their homes to children. Through small and large acts of kindness these adults can change the course of children’s lives and give them a sense of place. In addition, the film highlights two parents who lose their children.” It was very moving and I look forward to the time that it will be released for greater distribution outside of Vermont.

The following week I travelled to the Change Academy Lake of the Ozarks (CALO), a specialized therapeutic school that I have described previously in this blog. This school was founded specifically to utilize attachment principles to help children heal. They specialize in children who have been adopted. Their canine program allows each child to adopt and learn to care for a golden retriever, and take the dog with them when they leave. This is one of the powerful elements of the healing process.

I am honored to have been asked to be on the Board of Advisors of CALO. On this visit I got to know the program and people even more, and attended a conference CALO hosted. On the Board also are a parent advocate (who is also an adoptive parent), a lawyer who advocates for children and who is an adoptive parent herself, and an attachment specialist in private practice in the Washington DC area. For me it was a great treat to be among people who are so immersed in this trauma informed, relationship based way of thinking. I was soaking it in, being reaffirmed and recommitted to the importance of what we are doing. I learned some new ideas as well. And all this in the midst of the beauty of the Ozarks in the Spring, with many lovely flowering trees.

I feel very lucky to have been able to participate in these events.

Ten Essential Elements of a Successful Transformation to Trauma Informed Care

1. Administrative buy in: The top administration, including the Board, must understand the change and see compelling reasons to make it. They will need to support the change through their actions, financially, by presenting it to the outside world, and by demonstrating patience and hope through the inevitable roller coaster implementation process.

2. An Implementation Committee: A group of people dedicated to keeping the process moving, deciding next steps, and checking to make sure there is follow through.

3. Trainers and Champions: A group of dedicated trainers and champions who are enthusiastic and eager to see change.

4. A training role out plan. This should include who will do the training, what will the schedule be, who will attend and how many trainings will be done.

5. A new behavioral management approach: a plan for moving away from a consequence based approach to behavioral issues which includes what the agency will do instead.

6. Communication: Mechanisms to communicate to the whole agency what the change is that is being made, how is going to happen, why are you doing it, and how will you measure success. Communicate with the families and involve them in the process. Also communicate to the outside world (funders, licensing, donors, the public)the changes you are making and your hopes for improvement.

7. Celebrations of success: Share and applaud ways to share particular interventions that have made a difference, good outcomes, positive feedback, and particular staff who have done a great job.

8. Attention to vicarious traumatization: Time and space for staff to talk with each other about the ways the work is affected them.

9. Measurement: Set some goals that you hope to reach by implementing trauma informed care, such as: reduced restraint and seclusions; less staff turnover; less negative discharges; and more positive outcomes. Measure these and report the findings to the agency.

10. Fun: Make the training g fun. Invent rituals, sayings and games around implementation on the units. Give little gifts and certificates to staff who interact flexibly and warmly. Play more with the kids! Add more fun interactive activities to your daily milieu life, and make sure the staff and kids play together. Make joy your primary daily goal!

The Primacy of Safety

Feeling safe is necessary for relationships, for fun, for relaxation, for sleep, for concentration, for verbal learning, in fact for daily living. I have quoted before the experiment in which baby rats in a cage were playing, and the experimenters introduced three cat hairs for ten minutes. All play stopped. When the cat hairs were removed, it was weeks before the play started again and it never resumed its previous levels.

The kids we work with feel so unsafe. They are constantly on the lookout for the danger that has permeated every part of their lives. A central fact of their existence is that any small indication of danger sends them into full life-or-death alert mode. And the world is full of indications of danger.

So how do we recognize this, make sense of it and work with it? How do we help our kids to feel safer?

Allison talks often about feeling unsafe. And, in fact the other girls do pick on her and at times assault her. Allison comes out of her room and stands in the lounge swearing at the girls, calling them names and insulting their families. She is smart and knows exactly what to say to each individual girl to totally infuriate her, and she constantly does so.

Malcolm runs away two or three times a week. Anything at all that upsets him can trigger him to run away. Often it doesn’t seem that anything has upset him, and the run aways seem planned. He often persuades other boys to go with him. When he runs he puts himself in very unsafe situations. He also does self destructive things, including jumping into the street and using his belt to threaten to hang himself in the middle of a town park.

Both Allison and Malcolm have had very unsafe lives, and now seem to be deliberately courting danger with every ability that they have. How do we understand this?

Maybe it feels safer for Allison to bring the danger and abuse on herself; at least she has some control. It may feel to her like she has the upper hand over others for once, even when it results in her being hurt. Maybe when the unit is calm and quiet Allison feels foreboding, like something terrible is about to happen. So she precipitates it and no longer has to wait for it.

Maybe Malcolm is so used to a life of danger that it feels familiar to him. Maybe the danger of relationships, letting people down, failing, being disappointing others, is so acute that the danger on the streets pales in comparison. Maybe (using a reenactment approach) he relishes leading others into danger instead of being led.

We can look at the patterns, explore with the kids how they feel and what they think just before they do something, and gradually come to an understanding of the adaptive function of these behaviors for these particular kids.

So what can we do to help these children and all the others in our care?

First, of course, we should try to achieve as much actual safety as we possibly can. With staff supervision, schedules, routines, checks, the physical environment, and planning we should create as safe a world as we can.

Then let’s talk about safety in our community. In unit groups let’s discuss what kind of community we want to live in. It is important to acknowledge that everyone there has experienced an unsafe childhood, and has not been protected as they should have been. We can use a psycho-ed approach to teach the youth about how early exposure to danger changes the bio-chemistry of the brain and body, and hence every youth there reacts easily to any sign of danger. We can teach them to observe this in themselves and others, and hopefully over time to feel some compassion for themselves and each other. And we can collaboratively develop some plans for our community by which we will increase everyone’s safety.

And let’s actively address the issue of safety with each individual child. This could include (depending on what fits with the individual) looking at and mourning the ways the child was not kept safe when she was young. We could talk about what makes him feel safe and unsafe. How do you make others feel safe or unsafe? We could be clear that we are trying to be different than adults in their past: we are trying to keep them safe. We can use multi media: drawing, collages, music, movies, all exploring safety and lack of safety. We must surround this investigation with as many experiences as possible in which the youth is engaged in positive, active, physical fun interactions with caring adults. All members of the team should know that the treatment theme is safety, and inquire and comment regularly on their own feelings of safety in a given situation.

Our days in residential are precarious. We are always trying to keep groups of deeply suffering children safe. The more we are aware of this, articulate it, and address it collaboratively with our kids, the better chance we have at succeeding.

What Administration Can Do to Support Trauma Informed Care

The actions of the agency administration will determine the success of a transformation to trauma informed care. The administration must truly understand and support this approach, or it will not have a chance. Staff are keenly attuned to what is actually expected and rewarded within an agency. Mere lip service will not convince them to make this difficult change.

How can administrators demonstrate their support? First, they can arrange financing for training for all staff on trauma, how it affects people, and how they can heal through attuned relationships. Key members of the administration should attend at least a portion of trauma training themselves (vs. sending designees in their places). The agency must make provisions for the staff to attend the training and be released from their regular duties.

Expectations are conveyed in many ways throughout an agency. Does the administration value control and lack of disruption more than anything else? Can the administration tolerate certain level of organizational chaos in making the transition, including such things as staff confusion, conflict within treatment team, resistance to change, and increased property destruction? Trauma informed practice encourages staff to be flexible and to offer choices to the clients, even when the result is that the client is not immediately brought under control. Can the administrators support this?

In one residential agency trauma informed care champions had been working with the staff to be more flexible. They were teaching staff to ask upset clients what is wrong and to listen and to validate their feelings before discussing consequences or solutions. Maggie, a sixteen year old, had just learned that her mother had relapsed. She was screaming in the main hall on the afternoon of the Board Meeting. The CEO was wondering what Board members would think if they walked in the door and heard a girl yelling about killing herself and running away, and heard staff empathizing with how bad she was feeling. So he went out and said he knew she was upset but could staff please get her to go back to the unit or at least into one of the meeting rooms?

What messages are sent in this two minute interaction? That not upsetting the Board is more important than what is happening to Maggie; that in fact what Maggie is feeling and saying is unacceptable and shameful and should be hidden; and that the job of staff is to get Maggie to quiet down and stop bothering people. Those two minutes can undermine months of training.

Administration should look for every opportunity to praise staff members for their patience and kindness. They should express their sadness about what the children are going through, and acknowledge how real and important the stressors on these children are. A response of compassion to both the child’s and the staff’s experience in an incident will have a very powerful effect in reinforcing the staff’s flexibility with the child.

This example also points out that it is important to share the principles of trauma informed care with the Board of Directors. They need to know why the agency is making this change, and how it will affect agency functioning. Both possible positive and possible negative ramifications must be shared with the Board. If possible, Board members can be invited to attended some portion of the trauma training, or even participate in the over site committee.

Staff members want to do a good job. They want to be seen as competent and successful. If administration makes them feel bad about the children’s emotional outbursts, they will try to stop these outbursts. It administration helps them feel proud of their kindness and flexibility with the children, these behaviors will increase.

Fundraising is a key function of the CEO of any agency. Implementing trauma informed care can help with fund raising. The agency can become a leader in a cutting age treatment modality. Developing sophisticated treatment skills will help the agency survive current economic stressors. Emphasizing the trauma histories of the clients served helps donors understand why they need assistance. Also, using research such as the ACES study will demonstrate the economic benefit of helping people heal from trauma.

Administrative leaders can further set the tone for trauma informed care by celebrating both staff and client achievements. Their concern, kindness and compassion towards issues affecting both staff and clients model the response needed from staff. Their heartfelt joy when a client wins and award or a staff member gets their professional license reminds everyone of the purpose of this difficult work.

A transformation to trauma informed care is not possible without this strong administrative support.

It’s All for You, Mallory

Picture Mallory sitting in the Main Lounge. She is a large sixteen year old girl in tight garish clothes. Next to her is an over turned couch. She is surrounded by glass from the window she just broke. Her legs are swathed in gauze bandages covering the cuts she just inflicted on them, and there is blood on the carpet. The wail of the fire alarm she pulled is giving voice to her pain. Her face is frozen.

Everything we are doing is for you, Mallory. For you, who was abused by a relative repeatedly over five years. Your mother struggled with her own abuse history and depression, and has made several suicide attempts. She is not able to endure your pain, but she cares about you. She has advocated for you as you have travelled between treatment programs and hospitals.

Because of the transformation we have made at our treatment center, someone is holding your hand. No one is talking to you about consequences. There is compassion and caring in the eyes of the staff who look at you.

When you have left for the hospital, the staff discussion will center on your pain, not that you were difficult or annoying. Your team knows that you read an article in the paper today about your molester. They understand how this would be unbearable. They are shaken and disturbed, and they are feeling with you, not feeling angry at you.

Because of the changes we have made, everyone appreciates how hard this incident was on Mallory’s team, and immediately people rush to comfort her therapist, the people who saw her cut, all those who helped. We are aware of how this difficult work takes its toll on us all as we stay present with Mallory’s sadness.

We know we have work left to do when the policemen says sarcastically to Mallory “well, I guess someone’s angry” and the EMT threatens to drag her to the ambulance. And we are working on it through a grant to train the police force and have regular fun activities shared by the police and the kids. This has made great improvements in our cooperation as agencies- but today wasn’t our best day. Still more to do.

Nothing that happened to you was your fault, Mallory. You are not being manipulative and just wanting attention. You are unbearably unhappy, and you have every right to be. We are honored to be by your side, even when it doesn’t go well, even when you are not cute, even when we are exhausted and far from perfect, even when the system lets all of us down.

When Mallory is in the ambulance ready to go to the ER she asks her special staff member Rebecca if she can have a hug. Mallory is covered in blood and Rebecca hesitates. “Here, I’ll put on my coat” Mallory says. They hug.

We are trying to change the world for you, Mallory.

Becoming Naked

Today I would like to ask for a consultation on a certain behavior- namely, taking off all one’s clothes.

Davonte is 12 years old, and is small for his age. He has a history of extreme abuse, and has lived in 19 places. He exhibits many problem behaviors, such as aggression and threatening. However, one of the most common is taking off all his clothes and coming out of his room. He often makes statements about how great his body is and how he will someday be on magazine covers. Sometimes he will respond to and matter of fact directive to get dressed, other times that will lead to a full fledged meltdown.

What is the adaptive function of this behavior? What does it communicate and/or accomplish? What needs does it meet?

We see this behavior quite regularly, in boys and girls, in younger children and in adolescents. Often children take off all their clothes within a crisis, but other do so in every day times and when it is unexpected.

Obviously this same behavior means different things to different youth, but what are some of the possibilities, just to start us thinking?

Some possibilities that occur to me are:

1. To shock and get a reaction

2. To keep people away

3. To test whether someone is going to molest them or use them sexually

4. To determine whether people will accept their real, true self

5. To replicate what they saw in their family

6. Because a child is uneasy about his or her body, they want to see if people are revolted

There must be many other thoughts.

I am sure that Davonte does not disrobe because he is happy about his body and wants to show off how wonderful it is. Instead I feel certain his behavior comes from a place of fear and shame, in which he fears that there is something inadequate, awful and disgusting about his body.

Have you had experience with this behavior in your settings? How have you come to understand it? How have you and your team responded?

Please click on comment and share your experiences so we can all learn from each other.

Responding to Martin’s Threats

In his fifteen years before his admission to residential, Martin has been repeatedly abused by multiple people, including horrifying sexual abuse. When first admitted he was primitive and reactive, unable to trust anyone, easily panicked and always alert for danger. Whenever he felt threatened he lashed out, often physically. Gradually however Martin began to feel safe and was able to form some relationships with staff. His outbursts became less frequent and less severe, and he was more often able to participate in fun activities. He demonstrated an ability to draw and created some amazing cartoons. Both he and the staff are beginning to feel some hope for his future. He and his therapist are talking about a possible move to a group home or a foster family.
It was very discouraging then when the report came from school that Martin was suspended for threatening his teacher. He became extremely agitated, would not go to his next class, threw some books, and told the teacher that he was going to kill her with a knife. He was so intense that the teacher was frightened, and a restraint resulted.

What happened here? How do we understand this behavior? What should our response be?

Martin will not have a life worth living if he often becomes so agitated that he threatens to kill people, destroys property and disrupts whatever is going on. There is no doubt that we need to help him change this behavior. What is our most powerful strategy to achieve that change?

Punishment is the first idea that occurs to everyone. Martin needs to learn that he cannot treat people this way. He should be suspended from school for three days, and not have any activities or fun events during that period. Then maybe next time he will think twice before threatening someone.

But will he? In fact, the problem is that Martin cannot think once when he is agitated, much less twice. The punishment will confirm Martin’s world view: that he is a horrible kid who continually does bad things, and that the world is a place where he has no role, where people do not like or accept him.

Because Martin has formed relationships with his treatment team he was able to tell them several days later what had happened in this incident from his point of view. First, Martin is feeling anxious because discharge is being discussed. He is facing leaving the first place he has experienced any success and formed connections. That day, Martin was scheduled to go to art class. He had been dreading art since the last class earlier in the week. Martin has decided that the art teacher, Mr. Howard, is a homosexual. Mr. Howard has been very nice to him and encouraged his drawing skills. Martin has started to like Mr. Howard. Last class, while helping him with a project, Mr. Howard put his hand on Martin’s shoulder. Martin knows this is the first step towards Mr. Howard molesting him. He is terrified. The only way he can protect himself is to avoid art. But Miss Lesley, his home room teacher, didn’t understand this (nor did he tell her). She kept insisting he had to go to art. Martin was terrified and flooded with feelings of being small, vulnerable and powerless to prevent abuse. So he tried to save his life by threatening people and getting them away from him. He did not have to go to art or see Mr. Howard.

It is quite likely that throughout his life Martin will encounter situations that evoke his previous abuse and make him feel desperately afraid for his life. What do we hope that he will be able to do when this happens?

We hope that Martin will feel safe enough and trust someone enough to turn to them for help. We hope he will have one moment of realizing what is happening to him, one moment of considering that it may not be the truth that the art teacher is going to molest him, it may be related to his past. In that moment, he could say to someone: can I talk to you? I need help.

What would Martin need in order to do this? He would need to trust people. He would need to experience that the world has safety in it, that there are people who will not hurt you, that in fact people may care and want to help. And he would need to develop some self awareness so that he can recognize when he is having feelings related to his past and be able to stop for a moment and consider whether in this case the present is different from the past. This is a very hard thing to do.

When Martin is in the grip of panic related to his past abuse, the thought that he will be grounded if he threatens this person is of no use at all. His cortex (analytical thinking) is not available to him. Even if he could remember that he will be grounded (and he can’t) being grounded would be infinitely preferable to being molested by the art teacher, an event he sees as a complete certainty if he does not get out of going to art.

So what can we do to help Martin?

When he is not upset, his therapist and others close to him can talk to him about these things, teach him about trauma, and help him understand the connection between past events and current behavior. Together with him, they can mourn and deplore the horrible things that happened to him. And they can begin to identify the situations that are most difficult and most likely to bring up feelings of the past. Martin can begin to observe what the first signs in his body are that he is becoming upset. Staff can also learn with him what are the early signs of anxiety, and can identify them to him.

In the crisis, it would be helpful if someone noticed when Martin was beginning to be agitated. There are many more options if we catch this event when it starts and before it has escalated into a full meltdown. In either case, it is helpful if staff approaches Martin asking what’s wrong, what’s bothering you, rather than by telling him what to do. Martin will not be able to tell anyone what is really bothering him when he is agitated. Their faces (even those he likes best) will be the faces of his past abusers. So staff should employ any calming techniques they know. Can Martin go for a walk? Can he draw? Can he play basketball? Does he need to be alone, be with someone? There should be no focus at all on making him do the next thing he is supposed to do. All the focus should be on helping him feel soothed, accepted, and calm.

What if this doesn’t work, and Martin threatens or hurts someone? What can we do afterwards? Remember that once Martin regains his sense of being in the present he feels very remorseful that he hurt someone. He also feels more shameful than ever. So what can he do to make amends to that person? He can talk with Miss Lesley. She can speak from her heart, in a modulated way, and tell him how scared she felt. She can relate that to how scared he must have felt as a little boy when people threatened and hurt him. Together they can plan some strategies for the next time Martin feels scared. Maybe Martin can also do something to make Miss Lesley’s life easier, like clean up the classroom or do some other chore for her. And what about learning? Could Martin draw a cartoon illustrating how the world looked to him right before this happened? Can he start a comic strip about a boy who is learning that the present is different from the past, and make different episodes as the boy learns new things?

The theme here is that Martin will not be less likely to threaten people if we make him feel worse. He already feels about as bad about himself and his life as a person can feel. He will be less likely to threaten people if we help him feel better. He will be less likely to threaten people when he trusts them, feels safe, and is relaxed.

There is a particular opportunity in this situation. If Martin feels up to it when he is calm, it would be great for him to meet with Mr. Howard in the presence of someone he trusts. He could plan this in advance. And of course Mr. Howard would have to be comfortable and at ease in this discussion. Mr. Howard could assure Martin that he will never in any way molest him. He could apologize for putting his hand on Martin’s shoulder, and say that he did not realize how scary that would be for Martin but he can completely understand how it would be given Martin’s experience. He could say that he hopes he and Martin can continue to work together as he sees that Martin has a lot of art talent. But he understands that might be scary for Martin, so could they set up any plan for when Martin gets nervous? Maybe he can leave the art room and go back to home room. Or is there anything else that could help that Martin can think of? This conversation and their subsequent work together can become an extremely important corrective experience for Martin. Maybe there are people in the world that are friendly and want to help you and will not hurt you. This is what we hope Martin can come to believe.

It’s not that we are letting Martin “get away with” threatening the teacher. Punishment is irrelevant here. What we are trying to do instead is to use our most powerful relationship tools to help Martin learn how to identify and cope with his understandable panic responses so he will not feel his life is in danger and thus will not need to threaten others in order to save his own life. It is a long process, requiring many repetitions. We have already seen progress in Martin and with this awareness we feel hope for his happiness.

Revolutionary Ideas about Treatment

In my last two blog posts I have written about incorporating the ideas of Bruce Perry and those of Risking Connection to create a new approach to congregate care treatment.

Let’s see if I can put this all together.

Foundational ideas:

1. Our children were injured early in their lives, therefore their lower brains have been damaged. This part of the brain is involved with bodily regulation, the calmness/alertness cycle, the danger response and the regulation of emotion. It has tendrils into all parts of the brain.

2. Early experiences create templates or patterns of relationships deep in the lower brain. These templates are what the person expects from relationships, their deepest assumptions about what kind of world this is and how people treat you.

3. Brains can change and be healed at any age, and it takes a lot of repetition.

4. Parts of the brain change only while you are using them.

5. Whatever you use in the brain gets stronger; you get better at whatever you do most.

6. Things that happen together repeatedly become wired together, associated with each other and thus in the future the presence of one evokes the other.

7. Human connection is in itself reinforcing because it stimulates our reinforcing brain chemicals. If a person gets inadequate supplies of the reinforcement of connection they are more vulnerable to other activities that stimulate these same chemicals, such as self harm, drugs and risky behaviors.

8. Because of early trauma, neglect and attachment disruptions the biochemistry and brain structures of our clients have been changed. They have become caught in the human danger response, which leaves them hyper-aroused, over responsive, and with difficulty regulating and relaxing. They may also have developed a dissociative, freeze response to stress.

9. Because of early unresponsive and/or abusive caretaking, the children have developed templates or expectations that people are not trustworthy, will hurt you, and do not care about your needs.

10. Change is possible through repetitive healing experiences.

11. People act better when they feel calmer: safer, welcome, accepted, competent and at ease.

What does this mean about what we should do in treatment programs?

Every person in the treatment program must understand that their first and primary job is to help the client feel better. What can I do today to help this child feel safer, more appreciated, welcome, noticed, connected? Feeling better, less afraid, less hopeless will free the child to take the risk of acting better.

Especially at the beginning of treatment, we must deliberately fill the child’s day with activities that are physical, rhythmic, and regulating. This would include rocking, music, drumming, dance, Wii games, throwing and catching a ball, etc. The non-verbal connection with animals is also healing. As the child participates in rhythmic activities his own bodily rhythms and cycles will become more regular.

These activities must be done with active, engaged, hopeful adults. Using the body activates the lower brain. Pairing lower brain activity with positive relationships will gradually change the template the child has about relationships.

Since whatever a person does, they will get better at, we should make sure our children spend their time being successful, having fun, and enjoying positive interactions.

We should make sure every child experiences many positive human connections throughout their day.

What are the program implications of this way of thinking?

We can be much more deliberate and planful about our use of recreation- both recreation therapy and all the recreation/ down time in the day in our milieus. We can make sure the activities are tailored to develop the brains of the children we have, at whatever stage they currently are, and are fun and interpersonally rewarding.

What about therapy? Do we no longer need it? Nothing could be further from the truth. In the early stages of treatment, the therapist can e primary source of reparative connection. He or she can incorporate these principles by having a rocking chair in their office, using art and music, walking while talking, and making sure the appointments are positive and fun. As the child feels safer and calmer, he or she will be more available for cognitive approaches. The cognitive part of the brain inhibits immediate action on impulses, and needs increased strength to successful do so. Any discussion, reading, talking (about anything, like sports or the weather) builds this brain skill. Therapy interventions such as TF CBT or Target are still very helpful, especially after the child has made some progress. Therapists can also incorporate these principles into group and family work. They can assist the family and child in engaging in joyful games that may heal the brains of both. Groups that cook, read and discuss books, do crafts, take walks can build all parts of the brain. And with the team the therapist has an essential role in leading staff to think beneath the behavior, consider how it is adaptive and plan how we can help the child meet his or her needs in a less destructive way.

And perhaps most importantly this theory demonstrates in a new, more urgent way the importance of taking good care of our staff. If a child is playing Dance, Dance Revolution and the staff is at the side of the room texting his friends on his cell phone, the child may be having fun but her templates about human relationships are not being changed. The template that people really don’t notice or care is being strengthened. As an agency we must prioritize keeping our staff happy, hopeful, engaged and energetic. The staff’s ability to offer warm, rewarding, joyful connections to the clients is ultimately the only tool we have to use.

What is your reaction to these ideas? Please click “comment” and share your thoughts.

These Kids Will Act Better When They Feel Better

In May I wrote about what it would mean if we really believed that children will act better when they feel better, and discussed what "feel better" would really mean. Feeling better includes:

• Feeling safer

• Felling calmer

• Feeling more connected:

• Feeling better physically

• Feeling less shame

• Feeling more competent

• Feeling more effective

I am struck with the connection between this way of thinking and our understanding about how the brain changes. The brain changes in a use dependent way: what happens often is strengthened; what is not used withers away. What happens together is associated, which means that one thing evokes the other. Many repetitions are needed to change something previously learned or associated. We also know that human interaction is intrinsically rewarding, and that if humans do not have enough of this reward they are more vulnerable to seeking other rewards such as those available from cutting, drugs, aggression, etc.

We want our children to associate human contact with pleasure and help. We want them to experience that life can be a fun, positive rewarding experience. We want them to know that when difficult things happen, you can turn to others for help and use your own skills to surmount them.

It is true, then, that our main function in treatment should be to help each kid have a great day. (Idea courtesy of Martha Holden, CARE project, Cornell). Because having a great day will establish new patterns and templates in their brains. Having fun with staff, repeated many many times, will begin to change their expectations of interactions with others.

I was talking this over with a friend, and he asked: does this mean we should just let the kids do whatever they want, and sit around and eat candy all day? No, it does not. For one thing, feeling better is a complicated phenomenon, and includes all the aspects above- so it demands many activities and challenges. Felling better necessitates lots of the delicious rewards available through social connectedness. For another thing, we have to consider the group. Each person has to have a great day in a way that does not impede the other people having a great day. And thirdly, there is the staff. In order for the child’s template of relationships to change, there must be a genuine, positive engagement with adults. To do this, staff must be feeling hopeful and caring. So promoting anything that hurts or pushes away the staff does not achieve our brain-changing goal.

Therefore, we should be discussing how to create a milieu containing the most possible highly engaged, physical, rhythmic fun for the staff and the kids. Now that would be an interesting treatment team meeting!

Changing the Brain and Having More Fun

What do we know about how to change the brain?

• •Brains develop and change sequentially. The lower part, which concerns the body, the danger response, and emotional reactions, develops before the higher part which involves words and analytical thinking.
• Brains develop and change in a use-dependent way. If you use a part more, it gets stronger. If you dn’t use it, it withers away.
• What fires together wires together. Things that repeatedly happen together get associated in the brain, and the next time one happens it brings up the other.
• In early years of brain formation, patterns are set in to the brain which determine our assumptions and expectations of life. If a child is hurt by people in the early years, they expect people to hurt them from then on.
• If you want to change a part of the brain, you have to use it. So, if you are talking, you are not changing the lower part of the brain. You are only affecting the thinking part.
• Many repeptitions are needed to change a previously learned association or pattern.

 So what is the radical significance of all this for our work?

Our children in residential have almost all been wounded early in life, during the formation of the lower, bodily, emotional and danger response parts of their brains. And, the early patterns that they have established are that people hurt you and leave you. This is what we need to change, before we can work with the thinking, verbal part of the brain. We want to change their expectations of other humans. We want to pair human contact with positive emotions and good results, to undo that old pairing of human contact and pain.

In order to reach the lower part of the brain to change it, we have to engage it. And how do we do that? We involved the child in physical activities with movement and rhythm. These could include music, dance, drumming, rocking, swings, planting a garden, massage, shoveling snow. And, we pair these activities with positive interactions with other people. We make sure they are fun and engaging and done in connection with adults.

Do you see the implications of this? We have always maintained in our training that the daily life in the milieu and the relationships with the mental health workers are powerful forces for change. Now we can see even more clearly that having fun with the kids in physically engaged, active ways, is the very thing we have to do in order to change their brains. And now we can do this more planfully and with targeted goals.

Another implication is this. As we know, our kids are acutely perceptive about other people’s moods and emotions. This also reflects their earliest brain development. They had to develop this perceptivity to stay alive and anticipate the next dangerous event. So they will know if the adult is actually engaged with them, actually having fun and feeling positive and affectionate. If the adult is distant, sarcastic, punishing or distracted and texting on their phone this will not change the brain. In fact, this will confirm and further strengthen the patterns already established. So, in order to be successful in our change process, we need to take good care of our staff, so that they feel energetic, hopeful and available.

Isn’t this amazing? It turns out that having a lot of playful, energetic, engaged fun with the kids is the best thing we could possibly do! Get out that Wii and play Dance, Dance Revolution, and make sure the staff dance too, and laugh a lot…. Do it again and again. And you will be changing brains.

Hope

Recently our girls have been expressing their intense and unremitting pain. Latasha finds so many creative ways to hurt herself- she eats staples, bangs her head, and hits herself in the face hard enough to make herself bleed. Jessica is so sure that her family is blaming her for revealing her sexual abuse by her uncle that she tried to hang herself. Shahara ran away and tried to pick up some older men. Marguerita takes off her clothes and tries to scratch herself all over, and then she swallowed an open safety pin. We send them to the ER, they come back in a few hours. We surround them with caring, and they feel only despair.

These girls see no hope. They have no one in the world who they are sure loves them. They hate themselves and blame themselves for everything that has happened in their lives. They see no road to any positive future.

The staff and therapists feel a great deal of caring and compassion for these girls. And yet, their behavior is exhausting. It’s hard to believe that Latasha couldn’t just stop it. And we explained to Sharara the dangers in running away, can’t she see them? We are used to getting through crisis’s, but this unremitting repetitive anguish is so draining.

And the problem is that we don’t see any hope either. When Marguerita expresses her certainty that her life will never be better, we wonder if it ever will. And we can’t think of any concrete reassurance to offer her, anyone who loves her, any good thing that is coming soon.

We forget that we are the hope. What the girls need from us is not a specific reassurance that something good is happening. No, what they need is much harder to provide. They need us to be with them in their pain, feel it with them and not turn away. They need us to see their worst and not give up. They need us to care when they are hurting, and keep caring, validate their pain, and not be disgusted. This is the real, substantial gift we can give them. Hope is created when they experience the possibility of true human connection. There are people in the world who accept you as you are, care what has happened to you, and listen. There are people you can trust who do not hurt you. There are people with whom you are safe.

This isn’t the only thing we have to do in treatment. We also have to teach skills, calm biological activation and develop self worth. But it may be the most important.

So, we have to sustain ourselves and each other, because this is hard, much harder than giving advice or administering restrictions. We are doing the most important work in the world, and real engagement will transform both the girls and us. And what could be more hopeful than that?

2011 NATSAP Annual Conference

I have just returned from presenting at the 2011 National Association of Therapeutic Schools and Programs (NATSAP) Annual Conference in Tucson, Arizona. NATSAP was created in January of 1999 to serve as a national resource for programs and professionals assisting young people beleaguered by emotional and behavioral difficulties. Their members include therapeutic schools, residential treatment programs, wilderness programs, outdoor therapeutic programs, young adult programs and home-based residential programs. For me, this is somewhat of a new world. Instead of the child welfare/ mental health world, this is the private school, wilderness program, self pay plus insurance pay world. Yet the children we all treat have remarkably similar symptoms and behaviors, despite some differences in socio-economic backgrounds. Like child welfare programs, the schools and programs within this organization are learning about trauma and adapting their treatment accordingly. And they face familiar difficulties in doing so.

I met many interesting people in the course of these two days, and hope to develop training relationships with some. I also spent time with my friends from Change Academy Lake of the Ozarks (CALO) and enhanced my ongoing respect for what they are doing. Take this opportunity to check out their program at http://caloteens.com and learn about their unique animal assisted attachment based program. They also have an excellent blog, found at http://caloteens.com/blog .

One workshop I attended was The New Brain Science: Can it Make Treatment More Effective? Presented by Linda Zimmerman CEO/President and Kurt Wulfekuhler, Clinical Director Sandhill Child Development Center Los Lunas, New Mexico. The Sandhill program has adopted the teachings of Bruce Perry, and uses The Neurosequential Model to direct their treatment. The presenters reviewed Bruce Perry’s six core principles:

1. The brain is hierarchical.

2. Neurons and neural systems change in a use dependent fashion.

3. Brains develop in sequential fashion.

4. Brains develop most rapidly in early life.

5. Neural systems can be changed, and the more complex (higher) are more easily changed than the lower.

6. The human brain is designed for a different world than the one we now inhabit.

The presenters showed examples of how mapping a child’s experiences and competencies can pinpoint the areas of his brain that most need to grow, and thus suggest therapeutic interventions. A central tenant is that if the lower parts of the brain are damaged, they must heal before the upper parts can change.

Interventions that help the lower parts of the brain heal are sensory motor, not verbal. Examples would be touch, swinging, rocking, swimming, drumming, neurofeedback and music. The presenters also emphasized the importance of intensive aerobic physical exercise as well as good nutrition in promoting brain growth.

Extensive repetition is necessary to change the lower parts of the brain. But the presenters showed brain maps that demonstrated the change that is possible. This was very interesting to me as I would like to incorporate more of the sensory motor learning into our programs. Are any of you using this approach? Please share your experiences by clicking “comment”.

Brittany in Transition

Brittany has been part of our agency for many years. She started on the Junior Unit, graduated to the Girls Unit, and then transferred to one of our Group Homes. She has had many ups and downs. But right now she is driving the staff crazy.
Brittany has been completely defiant. She will use the phone whenever she wants to for as long as she wants to. Whenever anyone asks her to do anything she swears at them and tells them she doesn’t need them, they cannot tell her what to do. She is nasty, calls staff names, and is threatening. She led several peers on an AWOL a few nights ago. The other girls are complaining- how come Brittany is getting away with this behavior? Maybe they should begin to act like she does.

Leah, the supervisor, talked with Brittany. Brittany maintained that she does not want anything from the house or anyone in it. She said: “You cannot change me. This is who I am.”

The staff is frustrated. Brittany is making them feel disrespected, ineffectual and useless. They are worried about the stability of the house. They are tired of all this nastiness. Brittany is restricted, and they cannot see any way she will be able to get off restriction. In fact, they are considering whether her visits to her foster home should be contingent on better behavior. Especially because Brittany taunts them with the fact that she can act however she wants and still go on visits. The situation is particularily frustrating because staff members have a connection with Brittany and care about her, and it feels like she is rejecting that connection and pushing them away.

The first question is always: how do we understand this behavior? What is happening in Brittany’s life? What might she be feeling? What needs is she trying to meet?

Brittany has started a transition to a foster home, the Thompsons. She has lived with the Thompsons in the past, but had to leave their home due to her behavior. However, they retained a connection with her and are now willing to try again. They have been through a lot of major episodes with Brittany and have not given up. But the Thompsons are not yet completely sure that Brittany can live with them. They are having her for weekend visits, which are going well, and are exploring their options in therapy. No date for discharge has been set. Brittany has been doing well in her public school, and it is also unclear whether Brittany will be able to stay in that school if she does go to the Thompsons, since they live in a different town.

Brittany has made many statements about being eager to go to the Thompsons and leave this stupid group home behind. At times she has also expressed doubts about the Mrs. Thompson. She is not sure she likes her or can trust her. Recently when Brittany was going through a medical problem she asked staff not to tell Mrs. Thompson because she was sure it would make Mrs. Thompson hate her.

It is so hard, in the midst of Brittany’s defiance, to see how scared she is. This is the most difficult situation in the world for her. She is attempting to take a leap of faith and trust her fate to an adult and a family. This has not worked out in her past. Many people have not been able to stick with Brittany. And in fact she has a previous disruption from this very family, although they retained their connection. Brittany is preparing to leave the agency that has raised her and has been her home for years. She is leaving the group home that has been her base and her success. She knows all too well how much more precarious a foster home is than an agency. And furthermore, the time frame is indefinite, the arrangements are unclear, and it is not even certain that she is going.

Brittany is trying to make it work. She is behaving well at the Thompson’s and also at school. But when she is back in the safety of her group home, all her tension comes out. The message is her defiance is: “I don’t need you! I won’t miss you! It is perfectly fine that you all are pushing me out the door into an unknown and unreliable future because I never liked you in the first place!” Her unwillingness to accept direction and help is her extreme method of convincing herself that she can depend on herself and she will be fine whatever happens. Her heightened agitation, constant drama and behavioral episodes are her way of escaping the tension she feels so acutely right now. She is sure that this placement with the Thompsons will not work out. She knows that she is an awful girl that no one could ever want or love. She cannot bear to trust again and risk being disappointed. She daily expects the news that the placement plans are cancelled. She hates to say goodbye to the staff she depends on. Yet, part of her longs for the love of a family, for normal life, for a future.

And, she has no idea when she will go. This is in part a feeling of safety- she doesn’t have to leave yet. In part it is frustrating- I want to move on! And in part it is just tense.

So if this is our working hypothesis, what should staff do? What they should do is the hardest thing possible- look past the defiance and the obnoxious behavior, see the frightened little girl inside, and move closer to comfort her. First of all, they should talk about all this: “It is often hard for kids to leave, no matter how much they want to. It still feels scary.” Or: “I’m sure you feel worried about whether it will work out with the Thompsons, and part of you really wants it to, and part of you is afraid it won’t. Sometimes that is so hard that you try to believe you don’t even like the Thompsons.” Validate that these feelings are natural and to be expected. Brittany will reject these interpretations, and insist that no, she is eager to go and that the staff is just stupid. But somewhere inside she will hear what is being said and be comforted. Talk with the group as a whole about how hard transitions are, and if possible encourage all of them to share feelings they have had in making changes (like what about when they came to the group home?) and how they have managed them, Anything that is possible to make the transition process as clear and transparent as possible will also help Brittany.

Find ways to remind each other as staff of Brittany’s history and what a difficult leap of faith she is trying to make. And remind each other that even as she feels safe enough to rant and rave, you are playing a priceless and important role in Brittany’s life.

Administrative Support for Trauma Informed Care

A crucial factor in the success of any transformation to trauma informed care is the support of the leadership. There are many ways this support much be demonstrated, including financial support for training. One important way is the administration’s response to behavioral incidents.
Expectations are conveyed in many ways throughout an agency. Does the administration value control and lack of disruption more than anything else? Can the administration tolerate certain level of organizational disruption in making the transition, including such things as staff confusion, conflict within treatment team, resistance to change, and increased property destruction? Trauma informed practice encourages staff to be flexible and to offer choices to the clients, even when the result is that the client is not immediately brought under control. Can the administrators support this?

In one residential agency trauma informed care champions had been working with the staff to be more flexible and to ask the clients what is wrong, to listen and to validate their feelings before discussing consequences or solutions. Maggie, a sixteen year old, had just learned that her mother had relapsed. She was screaming in the main hall on the afternoon of the Board Meeting. The CEO was wondering what Board members would think if they walked in the door and heard a girl yelling about killing herself and running away, and heard staff empathizing with how bad she was feeling. So he went out and said he knew she was upset but could staff please get her to go back to the unit or at least into one of the meeting rooms?

What messages are sent in this two minute interaction? That not upsetting the Board in more important than what is happening to Maggie; that in fact what Maggie is feeling and saying is unacceptable and shameful and should be hidden; and that the job of staff is to get Maggie to quiet down and stop bothering people. These two minutes can undermine months of training. If staff are blamed for not quieting disruptive behavior, they will blame the children for their dysregulation.

Administration should look for every opportunity to praise staff members for their patience and kindness. They should express their sadness about what the children are going through, and acknowledge how real and important the stressors on these children are. A response of compassion to both the child’s and the staff’s experience in this incident will have a very powerful effect in reinforcing the staff’s compassion towards the child.

This example also points out that it is important to share the principles of trauma informed care with the Board of Directors. They need to know why the agency is making this change, and how it will affect agency functioning. Both possible positive and possible negative ramifications must be shared with the Board.

Staff members want to do a good job. They want to be seen as competent and successful. If administration makes them feel bad about the children’s emotional outbursts, they will try to stop these outbursts. It administration helps them feel proud of their kindness and flexibility with the children, these behaviors will increase.

The Holiday Monster

Everyone who works in a congregate care program knows that there are more behavioral problems during the holidays. The escalation usually starts around Thanksgiving. We explain it to each other: “you know, it’s the holidays.” Yet have we taken the time to look at the components of the holiday experiences of our children, and from that understanding plan how to best support them during this time?

Memories are a central part of the holidays. For our children, both good and bad memories can hurt. If they have warm and caring memories, they feel sad and angry that they are no longer with their families. Many children also have painful holiday memories of fights, alcohol, abandonment and other types of pain. These become vivid as the holiday season approaches.

We are all surrounded with media images of what the holiday season is supposed to be. On Christmas or Hanukah you should be surrounded by loving family and friends, eating huge piles of delicious foods, and opening wonderful gifts that change your life forever. It’s not just that our children’s holidays do not fit this picture. It is the meaning they ascribe to that difference. What does it mean about me that I have no family, no feast, such a different holiday? There is an underlying message in the media that suggests that if you do not have these things you are a loser and it is somehow your own fault. Our kids are prone to thinking everything is their own fault anyway. So holidays are not just disappointing, they are one more source of shame: I must have done something terrible because I am the only child in America that is not having a happy day.

Then there are the gifts. Many places like ours are inundated with generous donations during the holiday season. We receive more presents than our children can possibly use, and we save some for distribution throughout the year. The kids get to ask for specific presents, and then get many more they do not choose. So they should be happy they are getting all this very nice stuff, right?

But what is this gift receiving experience like for our children? They know the gifts were not chosen by someone who knows and loves them. They know that people give gifts out of sorrow and caring about their plight. They may receive gifts from family; they may not. Often the donated gifts are more than their family could afford. What does all this feel like? It is wonderful that people donate gifts and it means a lot to the child that receives them. Yet, there is a hollowness, a disappointment, because the gifts are not the same as love.

A child may build up expectations around the holidays. Maybe my mother will finally come and visit. My father said he would send me a video game. Often, these are disappointed. Luckily, some children are able to spend time at home. In fact, we facilitate them going home if it is at all possible. Sometimes our wish that the child be at home for this one important day may even overcome our common sense. So a child who has not gone home in a long time does, and may or may not have a good visit. Either way, it evokes a lot of complex emotion.

Then there is the inevitable let-down. The holidays are over. Nothing has changed. My life is still the same and I still have no plans for my future.

So what can we do to help our kids with this holiday season? The most important thing is to validate, rather than try to cheer them up. It might be helpful to share that there are many people who do not have a picture perfect holiday. And to acknowledge that gifts from strangers feel different from gifts from families; and that it sucks to be stuck in a residential at Christmas or Hanukah. Give them an opportunity to talk about their memories of past holidays, good and bad. Talk about their feelings about their families, any contact they are going to have, anything they are going through. Don’t try to point out the good things- at least not at first.

Another thing to watch out for is over-stimulation. In our efforts to offer many treats to our kids we can ignore the fact that too much good stimulation can be overwhelming to them. Getting over tired reduces their already limited coping ability. Lots of noise and activity can wind them up and they do not know how to calm down. For some kids, a low key mellow celebration might be best. If there are parties, make sure to alternate them with down time, time to relax, talk about what you are feeling, and to engage in quiet activities with people you know. Remember that strangers are scary to some of our kids. It is easy to underestimate how stressful it may be for certain kids when members of the public attend agency events. Will my abuser be one of them?

Schedules and predicting what is going to happen, where it will be, who will be there, how long it will last is helpful. Also predict any stressors or issues that might come up. The child may dismiss what you say, but it can still be helpful when the event happens. Involve the child in planning for success. Is there a signal he can give you if he has had enough at a party? Will it help if he sits next to you, or brings his stuffed animal, or takes a nap before the party? Remember in doing this you are not only helping the child with this particular event, you are teaching him a method to anticipate and conquer stress which he can use throughout his life.

The adults caring for the children are also often stressed out by the special demands of the season and the pressure to do more, plan more, accomplish more. They may be experiencing their own holiday stress outside of work. And on the actual holidays themselves, the children may be cared for by part time staff they don’t know as well. Furthermore, we experience vicarious traumatization from participating in the childrens’ pain. It can feel especially sad to see children managing without their families through the holidays. Anything we can do to support each other and acknowledge the pain to each other will help us offer regulation to the kids.

Most importantly, watch and listen. Pick up early signs of stress. Give the child plenty of time close to regulated adults, when he can talk, be validated, and just be connected with someone who cares. After all, isn’t this really what we are all looking for during the holidays?

Working with Regulatory Agencies

Providing treatment for children in a congregate care setting is a complex job. There are so many parts to what we do, and we are constantly on the edge of disaster. Thank heavens most of the things that could go wrong don’t. But the behaviors are so dramatic and life threatening, the staffing so stretched, the tasks so many, and the stakes are so high. Every day includes many many interactions with the children, designed to help them get through the day, change and improve, have fun and relax, or just manage life. In addition we have all the physical care of our living spaces. We provide everything necessary to raise the children, from food, clothes, supplies and living space to medical care and education. We must document everything we do following regulations of various agencies and accreditation bodies. There is so much to do on a given shift!
Sometimes things do go wrong. These can range from egregious, deliberate wrong doing, to mistakes of omission by a harried staff, to errors in judgment, to just plain accidents. When something goes wrong, we are often visited by representatives of regulatory agencies. It is their job to investigate what happened, make sure that the care being provided meets acceptable standards, and make suggestions for improvement. It is essential that such agencies exist and that we maintain oversight of the care that is being provided to children.

However, I wonder if it would ever be possible to apply what we know about how people change to the relationship between regulators and service providers. I believe that care would be improved by maintaining a RICH© relationship between the regulators and the agency staff. RICH means treating each other with respect, sharing information, establishing and maintaining connection, and creating hope.

In the situation in which a basically sound agency did something wrong such as inadequate documentation or imperfect handling of an incident, and therefore needs to improve in some way, what actions on the part of the regulators would make improvement most likely to happen? I think that if the agency felt understood and respected, had information about better ways to do things, had a relationship with the regulators and felt hopeful about the possibility of change they would be most motivated to strive for excellence.

Both the treatment agency and the regulating agency have a common goal: providing excellent treatment and care for children. One essential component of the agency’s ability to do this is retaining committed, enthusiastic, hopeful staff. The work itself makes this difficult, as staff working with these children and families experience significant vicarious traumatization from the pain they share with the clients. If the staff feels constantly criticized; if they feel that nothing they do is ever good enough; if their good work is not noticed or appreciated; if they have to spend large parts of their time in meetings explaining what they have done; and if they feel that there is no way to win this vicarious traumatization is compounded.

In our training we stress that there are two sides to a relationship. If we feel that the relationship is our main tool of healing, we must pay attention to both sides. The staff cannot offer a caring relationship to the children if they themselves do not feel cared about and well treated. Just as it is crucial how agencies treat their staff, it is equally important how the staff is treated by the surrounding community. If the staff begin to feel that there is no way they can succeed within the child welfare system; if they experience constant criticism and no recognition, they will feel hopeless. And hope is a crucial component of our work with the children, who are often hopeless themselves.

So how could this be different? First, it would help if outside agencies instituted a method of praising and recognizing the hard work of treatment staff, and called meetings to convey positive impressions at the least often as those for negative issues. Another important factor is the attitude of inspectors when they are in the agency. They, too can mention good things they see and want to encourages, as well as acknowledging the hard work of individuals. They can express appreciation for extraordinary efforts, and display understanding of the complexity of the work.

Agency staff expects correction and suggestion, and is usually eager to improve. This can be offered in a spirit of respect and mutual desire to improve the lives of the children. And when changes are made, they can be acknowledged and celebrated by both agency and regulatory staff.

In short, it would be great if we adults treated each other in the way that we are advocating treating the clients.

What are your experiences with regulatory agencies? Has anyone had good, mutually respectful relationships you can share? Click “comment”.

Thoughts on Developing Resiliency

As I begin to write about resiliency, I have to mention what Geoffrey Canada said when I heard him speak at a National Council conference. He said he was not that interesting in studying what helped people succeed despite bad situations; he was interested in creating fewer bad situations.

Still, when I heard Mark Katz, PhD speak at the Joint Commission Behavioral Management Conference I was struck by the overlap between his presentation and our training. Dr. Katz is the Director of Learning Development Services, a Clinical and Consulting Psychologist in San Diego, California, and author of the book On Playing a Poor Hand Well, published by W.W. Norton and Company (1997). In the book, Mark explores the lessons learned from those who've overcome adverse childhood experiences, and discusses ways of incorporating these lessons into our existing system of care. http://www.learningdevelopmentservices.com/

In his presentation, Dr. Katz emphasized that the meaning people attribute to misfortune is a key factor in their ability to overcome it. He stated that: “The meaning we attach to adverse experiences can determine whether we view ourselves as resilient and courageous, or helpless and hopeless.”

Dr. Katz reported on a study that identified beliefs that interfere with the ability to overcome adversity. These are perceiving adversities to be permanent, pervasive and personal. (Seligman, 1992)

• Permanent – the perception that things will never change
• Pervasive – problems are evident not just in one life area, they’re pervasive
• Personal – It’s all your fault.

Seeing our adversities in these ways increases the likelihood of psychological problems; it may also weaken our immune system. Developing these beliefs when young may be especially impairing.

On the other hand, perceptions that foster resilience (Seligman, 1998; 1992) are that:

• Adversities are temporary – the perception that things will get better
• Adversities are limited – Things may not be going well in one area but they are going well in others areas
• Not personal – The person sees that he is doing the best he can under the circumstances and that it is not all his fault.

Dr. Katz identifies a key factor is resilience is fostering a sense of mastery. This includes highlighting, nurturing and expressing strengths and talents, and things you feel passionate about, feeling you’re making a contribution, and the belief that our actions can alter our destiny. So, people are able to rebound from a difficult past by learning to attach new meaning to adversities past and present, aided in large part by their ability to:

• Re-shape personal identities around longstanding strengths and talents,
• Re-frame personal limitations and vulnerabilities within the context of these strengths and talents, and
• Find or create social contexts where they felt valued for their contribution.

It is interesting to note that the three attitudes that Dr. Katz identifies as particularly harmful are exactly those that are created through trauma. His work highlights the importance of treatment programs deliberately organizing interventions to change these beliefs. The child who is experiencing abuse from his or her family does not see any hope, and thinks that their current situation is permanent. Because the neglect and abuse is so pervasive and repetitive, it affects every aspect of the child’s existence. And in our training we emphasize the role of shame. This child feels that the abuse is his fault, partly because that gives him some possibility of control, as well as to preserve his connection to his parents, and because he is told it is his fault.

What can we do in our programs to convey hope and to show the child that adversity is temporary? First and foremost we must create experiences in which the child is successful, is happy, and experiences joy. We must offer opportunities for the child to explore his strengths. We must coax the child to play. And then we must take care of ourselves and each other so that we can maintain our hope, and thus be able to show hope to the child.

If the child has these experiences of play and success, she can gradually experience that while some areas of her life may be troubled, other parts are not. The pain can be compartmentalized in an adaptive way.

Help a child to emerge from shame is a slow and meticulous process. We must be careful not to rush to reassure the child that whatever happened was not his fault. Instead, we must provide space for him to explore his thoughts and feelings, and share his secret fears and concerns. The antidote to shame is sharing and receiving and empathetic response.

It is important to note that Dr. Katz emphasized a sense of mastery as a key to resiliency. In our training we explore the concept of effective action. The essence of trauma is not being able to change it, control it, or have any power to influence what happens. In our treatment programs we must make sure we do not replicate a sense of powerlessness. Instead, we must offer children lots of ways to take effective action in their own lives. These can include having choices in activities, food and unit functioning; being involved in planning meetings for their lives and advocating for their own wishes; and participating in helping others, volunteer work, helping causes they care about, etc.

The overlap between the literature about beliefs that support resiliency and the evidence about healing from trauma strengthens our understanding of the importance of addressing these areas directly and planfully.

Update on My Travels

In October, my colleague Steve Brown and I taught both Risking Connection© and the Restorative Approach© to Child and Family Service of Hawaii. This excellent agency is especially interested in improving the services in their group homes for girls. They also have an array of other programs which will benefit from being trauma informed, such as domestic violence shelters and in home services. The staff was eager to learn and felt that this approach was exactly what they had been looking for. And this was the first training in which I was given two leis, one at the beginning and one at the end of the training.

I also did a Risking Connection© training with Dr. Kay Saakvitne in at Elmcrest Children’s Center in Syracuse, New York. I appreciated the staff there who had the courage to embrace change in their methods and appreciate the possibilities within trauma informed care. It was also a treat to teach with Kay, one of the original authors of Risking Connection©. I always learn a lot from her. One highlight of this training was the flock of wild turkeys outside the window of the room in which we were teaching. I guess they were also seeking some knowledge!

Two weeks ago I was an invited speaker at the Joint Commission and Joint Commission Resources Annual Behavioral Health Care Conference in Chicago. I was proud to share the stage with such notables as Pamela S. Hyde, JD, Administrator, Substance Abuse and Mental Health Services Administration; Amy Dworsky, PhD, Senior Researcher, Chapin Hall – University of Chicago; Paul Schyve, MD, Senior Vice President, The Joint Commission; David A. Litts, OD, Director, Science and Policy, Suicide Prevention Resource Center; Mark Katz, PhD, Director, Learning Development Services, Clinical and Consulting Psychologist; Kim Masters, MD, Medical Director, Three Rivers Midlands Campus Residential Treatment Center and Mary Cesare-Murphy, PhD, Executive Director, Behavioral Health Care, The Joint Commission. There was some very interesting information about the future directions of SAMHSA, the ramifications of health care reform for mental health. It was fascinating to hear the latest research and prevention efforts regarding suicide. The discussion of resiliency had some intriguing ramifications for treating trauma- the subject of another blog post.

I received many compliments on my presentation and had some good conversations with folks about what they are doing. And, the Joint Commission staff treated me so well!

Then last week Steve Brown and I travelled to Whitehorse, Yukon Territory, Canada. We taught both Risking Connection© and the Restorative Approach© to the Child Assessment and Treatment Services of the Yukon government. Included in this group were staff from Residential Youth Treatment Services and Child Abuse Treatment Services (C.A.T.S.). Also participating were staff from Alcohol and Drug Services. First let me say that it is a long way from Connecticut to the Yukon Territory. And lost bags, delayed flights and phones that stop working do not help. But it was most certainly worth it all to work with these excellent treaters. Providers working in the Yukon deal with situations of multi-generational abuse, extreme poverty, long standing drug and alcohol use, and lack of resources. I was extremely impressed with their compassion for and commitment to their clients. Two social workers we have come to know each spent over a year living in (different) remote First Nation communities for over a year to get to know the people and their culture. In the residential programs, they never eject a child. If the child runs away, gets drunk, does anything, they are still welcome back. No one was focused on consequences and they did not use points and levels. All staff seemed immersed in understanding the adaptive nature of the behaviors, and could see clearly the pain beneath the behavior. We had many wonderful discussions within the training, and the staff eagerly soaked up our framework and methods as a way to organize their thinking and their work. Through the kindness of everyone towards us, we were able to explore some of the beautiful area surrounding the town, and even go cross country skiing. I look forward to our return in April for the Train the Trainer.

I am extremely fortunate that my work brings me to such diverse and beautiful places and introduces me to so many committed, caring and intelligent people.

Explanation of the Restorative Approach for Parents

I am trying to create an explanation of the Restorative Approach for parents, to be given to them at admission. This is what I have so far. Any suggestions?

Welcome to Klingberg Family Centers! We appreciate the opportunity to work with you and your child. We hope the following explanation of our approach will be helpful to you in understanding how we do things at Klingberg.

We believe that all healing takes place within relationships. We will do anything we can to create a strong relationship with your child and with you.

We understand that children and adults do things to try to meet their needs in the best way they know how at the time.

Many of the children and families that we work with have experienced bad things in the past. These difficulties have changed them.

If people have been hurt by other people, they stop trusting. They do not believe that relationships can be a source of help and can be counted on. Instead they have come to see relationships as unreliable and painful. So, it is important that we try to show the children and families we treat that relationships can be trusted and that other people can help.

When bad things happen to people, they start seeing the world as a dangerous place. It feels important to always be alert and looking out for danger. This makes it hard to relax, have fun and sleep. We hope to offer our children and families as safe place where they can learn to relax and learn ways to stay calm.

Many of the youth we treat have not learned the feelings skills that we all need to get through the hard things in life. It is very important that we teach them these skills. Often, the children cannot remember that anyone loves them or is on their side. They have a hard time thinking about people who care when those people are not near them. So we hope to strengthen their relationships with people who care (especially you and your family) and teach them ways to keep those people with them in their hearts.

The children we work with have often come to believe that they are no good and that everything that has happened to them is their fault. We work with them in many ways to develop a strong and healthy sense of their strengths and abilities.

A lot of the children in our programs do not know how to deal with their feelings. They cannot notice their feelings when they are small, name them, or get through them without making things worse. We will ask you to join us in teaching the child how to understand and react to feelings, including teaching them some skills to calm down and get through bad times.

When something goes wrong for one of our youth, they do not trust that others can help them with it. They are already feeling hyped up and anxious. They do not know what to do with all the feelings they are having. So they start to feel very bad, hopeless, and scared. They do something that makes them feel better in the moment, like yell, hit someone, hurt themselves or run away. They feel better at the time but then they have made things worse.

We have to help the child learn better ways to meet their needs, ways that do not hurt them and others.

When one of our children does something that hurts others, we try to figure out why they did it. What need were they trying to meet? Then we think about what they would have to know in order to handle this situation differently next time.

We give them a restorative task that offers them a chance to learn or practice a skill that will help them next time.

Also, we believe that the children need to learn how to make up for damage that you cause. So, when a child hurts others we expect them to make amends, to do something good for the person or people they hurt. So the child will receive or create a restorative task to make life better for the people they hurt. We will help you use this approach within your family if you would like.

Sometimes it may seem that the learning and making amends tasks are not enough when the child does something hurtful. You may wonder if the child should also have a punishment or a restriction. We believe that punishments do not help the child change very much. Instead, what will help them change is to learn skills so that they can meet their needs in a better way.

We urge you to talk these ideas over with your therapist, and let them know any concerns that you have.

We look forward to being part of the healing journey for your child and you.