Yesterday Yet Not Today

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

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

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

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

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

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

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

Alliance Conference

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

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

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

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

Siege Mentality

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

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

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

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

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

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

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

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

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

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

Alliance for Children and Families

I am presenting at a national conference this coming Friday- the Alliance for Children and Families. (http://www.alliance1.org/conferences/national2006/) If you are there, please come by and say hello!

Alliance for Children and Families 2006 Annual Conference
Building Community Voices: Creating a Healthy Society and Strong
Communities for All Children and Families
St. Louis, Missouri, October 18 – 20, 2006

Session E
Friday, October 20
8:30 – 10 a.m.
Creating A Culture of Connection: The Transformation of a Therapeutic Program
This presentation will describe the process of changing a residential treatment program from a traditional approach to a trauma-informed relationship model. The presenters will cover the challenges and issues that motivated the change, the theoretical underpinnings of the model and how it operates, the change process, outcomes, next steps, and lessons learned. Participants will
learn about the human trauma-informed relationship approach and how it works, and also about managing a major change in system.
Presenter: Patricia D. Wilcox, LCSW Vice President Strategic Development, Klingberg Family Centers

The Restorative Approach and the Collaborative Problem Solving Model

I have been reading Ross Greene’s new book: Treating Explosive Kids: The Collaborative Problem-Solving Approach (Ross W. Greene and J. Stuart Ablon; the Guilford Press, 2006). I am struck by how much overlap there is between his methods and the Restorative Approach.

Ross Greene reminds us of the important truth: children do well if they can. He emphasizes the connection between one’s understanding of the causes of children’s explosive behavior and ones’ intervention. If you see the cause as inept parenting and lack of motivation by the child, strict consistent parenting responses and systems to increase motivation might be helpful. However, if you see the cause as more related to cognitive inadequacy (as he describes) and/or biological changes and skills deficits created by trauma (as we emphasize) then your response would center on opportunities to learn new skills and improve cognitive and emotional functioning.

Greene and Ablon describe four key cognitive skills that are often impaired in our children: language processing, emotion regulation, cognitive flexibility, and social skills. They advocate for the importance of careful observation and tracking to clarify which skills the child particularly lacks, and what triggers explosive episodes. They make an excellent point that a situation or condition does not have to always produce an outburst to be a trigger- it just has to increase the likelihood of one.

Greene and Ablon also emphasize the importance of the relationship, stating on page 91 that “The single greatest predictor of therapeutic change…is the degree to which a therapeutic alliance is formed between clinicians and patients.”

The collaborative Problem Solving Method involves working with the child to find a solution to the problem that satisfies the needs and desires of both parties. In the course of this process, skills of flexibility, emotion regulation, and social skills can be modeled and taught. This process overlaps with the Restorative Model response to serious behavioral issues, in which the child participates in figuring out a way to overcome the problems his behavior has caused.

Both models advocate for a treatment setting that relies on respectful treatment relationships, on listening to and learning from/about the child, and on skills teaching and practice.

Greene and Ablon even use the same example I always use in my training, about making basketball shots! (see page 217)

I will be attending a training with Ross Greene at the Brattleboro Retreat (http://www.retreathealthcare.com/) in December, and I look forward to learning more about his ideas.

©2006 The Restorative Approach is a servicemark of the Klingberg Family Centers, Inc.