What Should Be Earned?

In creating our traditional behavior management systems, we operated from the premise that earning rewards and privileges would be the principle motivator for the children in treatment to change. We expected the children to change their behaviors so that they could earn more points and go up in the levels. In order to interest them in doing this, we had to have as many aspects of daily living as possible be contingent. Because we couldn’t actually neglect or abuse the children, we were already limited in what parts of life we could make the children earn. We were not allowed to use food, for example. So, we looked through the day and considered what could be part of the level system. We asked the children. And each system ended up with lots of things that the children could not have unless they were on a certain level. These ranged from extra TV and Nintendo time, to later bedtimes, to posters on their walls, to trips and special events, to lining up first in lines, to contact and visits with their families. The theory was that the more important the privilege was to the child, the harder he or she would try to control their behaviors and earn the higher level.

However, we have now learned that this formulation ignores many aspects of what we know about trauma, how it affects people and how they heal. Points and levels approaches assume that the main problem for these children is motivation. Rewards and punishments increase motivation to do well. But these children are already motivated to do better, they just can’t. They do not have the skills. When you do not have skills, increasing rewards and punishments actually makes behavior worse, as you feel pressure and resentment at being rewarded and punished for something you cannot control. Imagine if some part of your paycheck was based on your flying from office to office. You might make a few tries, but quickly you would give up and be angry and resentful.

Another factors ignored by level systems is the role of shame. If a person has experienced significant trauma, they are often shame based, which means that they feel that they are no good, different and worse from others, and totally unlovable. Being on a low level reinforces this familiar shame, especially when the levels are posted on a public board. Since success seems so impossible, why even try.

What if we actually believe that children act better when they feel better? If children are safe, happy, enjoying life, feel cared about, and are surrounded by trustworthy relationships, they will in time be able to be kinder, calmer and more trustworthy themselves. This assumption would lead us to give the children everything we could as soon as they were admitted. We would make their rooms warm and welcoming and allow them to personalize them. We would offer them many fun activities and warm relationships. We would give them support so they can experience success. Our goal would be to make our units places where the child learns that life can be good, safe, warm, and happy.

More specifically:

Children’s contact with their families should never have to be earned. The greatest predictor of success after residential treatment is how often the child connects with his family during treatment. There are already so many barriers, both practical and psychological, between the child and his family. Our job should be to facilitate as much contact as possible. We should not have visiting hours, the families should be welcome at any time. We must try to provide whatever practical help we can in areas such as transportation and child care. And we must make sure the family feels welcomed and not shamed when they visit. If the child or family is unsafe, we can provide visits at our facilities, supervised if necessary. But contact should be a right, not an earned privilege.

Also, we must keep in mind that children need fun, leisure activities, and play for many reasons. It is through play that children learn and grow, experience success, develop friendships, and experience joy. Many activities such as music, electronic games, dance, art and crafts can also be ways to self soothe and to get through difficult periods without making things worse. How are children going to learn to use coping skills if we tell them that they can’t have coping activities until they show us through their behaviors that they have already mastered coping?

The only time it makes sense to have a privilege be earned is when a child needs skills to be able to use that privilege safely. For example, a child who is repeatedly running away should not be given the privilege of going on walks alone. More autonomy and less supervision should be a result of responsible behavior. As children achieve their treatment goals, and as they show increasing ability to let adults know when something goes wrong or is bothering them, they can be supervised at increased distances. If a program wants a formal system for this kind of earning, it is best handled through a long term phase system linked to treatment goals. Advancement through the phases should be a team and child decision reached after discussion, and not based on point totals. Children should not go down in these phases.

It is certainly a good idea to suspend a given activity in response to a child’s behavior. For example, a child just hit a staff, then wants to go to the mall. The staff should reply: “Of course we are not taking you to the mall today. I do not trust that you will be responsive and not have a meltdown like just happened. However, work on your restorative tasks, let’s figure out together what just happened, and I’m sure we will go to the mall together in the future.” How long this suspension lasts should not be based on a pre-set time period. It should be determined by the child completing his restorative tasks and his attitude.

People worry that without many things to be earned the child will have no incentive to get through the day. Why should he finish his dinner, do his chores, go to bed if there are no points to be earned by doing so? Well, he should finish his dinner because it tastes good and he is hungry, or, it should be fine that he does not finish his dinner. He should do his chores and go to bed because he is asked to and is part of the community, because he gets help and encouragement from those around him and because he will not be able to do the next fun thing until he does so.

Look over your own system. What is currently earned? Do those things need to be earned? What do you think would happen if we gave the children every joy we possibly could for free just because they are alive?

Click comment to let me know your reactions to these thoughts.

The Characteristics of a Good Trauma Informed Residential Therapist

The most essential characteristic of a therapist that will succeed in a trauma informed congregate care treatment program is that he or she likes the children and their families. This probably cannot be taught. These children can be difficult, demanding, and try anyone’s patience. If the therapist does not find them delightful, cannot see their goodness, does not look forward to being with them, she will have nothing to help her get through the bad parts. The children generally feel hopeless. They do not see their own worth and cannot imagine a positive future for themselves. If the therapist cannot do that, who will? And at times the therapist holds the hope for the whole team. One role of the therapist is to see a picture of how this particular child would be if he were at his best, even while remaining aware of the child’s current reality. The therapist who genuinely cares about and appreciates the children and their families can do this.

A therapist in a congregate care setting must be flexible. The day never turns out as one expects. Things rarely go as planned. It is time for an important family meeting and the child is at the park. An individual session is scheduled but another child is threatening suicide. The therapist is going to do her paperwork and the licensing inspector drops in for an unscheduled visit. Roles shift between people. The child needs to talk with her now. A person who needs a predictable day would not be happy in this setting.

Working with a therapeutic team is a particular experience. For some, it feels wonderful to have so much help and support. For others, it is difficult to have to share everything, discuss everything and make decisions within a group. The therapist who enjoys teamwork will be the most successful in congregate care. Often the teamwork is frustrating. There are factions, problems, disagreements. The therapist tells twenty six people about something and the twenty seventh complains that she wasn’t told. Decisions are made and then not carried out. Interpersonal issues between team members can be intense. Yet the treatment team can be the most powerful intervention possible in helping a child to change. And as the therapist struggles with the pain and difficulty with the work, it can be sustaining to have a team to share with. The team can laugh together, cry together and care together about the clients. The therapist that flourishes working in this complex environment will have the ability to form relationships with other staff, will assume good intensions in fellow workers, will give and accept feedback, will handle disputes openly, and will notice and praise the positive efforts of others.

At this level of care, a therapist must be able to tolerate chaos and intensity. The symptoms that the children display are frightening and are often life-threatening. There is usually more than one child in crisis at once. The families too can be angry, demanding, sad and scary. The systems around the child are often inadequate and frustrating. The therapist must know how to stay calm herself in the face of the agitation of others. She must prioritize and respond to the problems step by step. She must also be able to tolerate strong emotions in the clients, and stay with the client as they experience their pain, longing, anger and sadness.

In order to do this the therapist must have or develop good self care skills. All therapists will experience vicarious traumatization. The therapist must use their team to help them through difficult times. Outside of work the therapist needs strong supports and connections in order to maintain a work/ life balance.

A sense of humor is crucial for surviving and thriving in these jobs. Self awareness is also essential. The therapist needs to notice her responses to individual children and families, and use these responses to deepen her work. She should accept seek out and accept help in this area from her supervisor and her team. She should monitor her vicarious traumatization and know when she needs a break.

There are many skills and much knowledge that a therapist should have, but these can be taught in supervision or through workshops and training. If the therapist is eager to learn and grow, the agency must only provide the opportunity. In addition, the therapist must know or learn writing skills and have the ability to document and do treatment planning. Of course, the therapist must be responsible, come in on time, and be self motivated in completing her job requirements. Often, some on call duties will be part of the job.

It would be wonderful if agencies had the ability to pay this paragon what she is worth!

Recent Travels

On the first of October I presented a Keynote speech and a workshop to the Midwest Regional Conference of the National Association of Therapeutic Schools and Programs. It has been interesting and rewarding to get to know these programs, which include both therapeutic residential school and Wilderness Adventure programs. They are beginning to utilize trauma informed care in their treatment approaches in unique ways.

I then travelled to Hawaii with my colleague Steve Brown to provide Risking Connection and Restorative Approach training to an agency there, Child and Family Service. It was a wonderful experience. It is certainly the only training at which I have been presented with two leis, one at the beginning and one at the end. I loved the Aloha spirit of the people in our training- they were so welcoming and helpful. The emphasis on multi cultural awareness was very moving. We can all learn from the way Hawaii incorporates all cultures into daily life. We had both agency personnel and representatives of the State Department of Mental Health in attendance. With four separate trauma related national grants, Hawaii is working hard to change their practice and offer more trauma informed services. We look forward to our ongoing work there. And of course exploring the island was wonderful- those beaches, turquoise water and waves! I snorkeled with bright colored fish and sea turtles.

This week I will be presenting two guest lectures: one at Hampshire College in Amherst, MA and one at St. Joseph’s College in West Hartford, CT. I am looking forward to the interaction with the students. It is encouraging to see information about trauma being included in college curricula.

Then I move on to upcoming trips to Chicago, Syracuse and the Yukon territory of Canada.

It’s a busy fall!