Insights from Dr. Kenneth Hardy

I had the privilege of listening to Ken Hardy as he presented at the NASW CT specialty conference on social justice. He focuses on oppression, which of course has a lot of overlap with trauma.

Dr. Hardy is a Professor of Family Therapy at Drexel University and the Director of the Eikenberg Institute for Relationships in NYC. He has written several books including Teens Who Hurt: Clinical Interventions to break the Cycle of Adolescent Violence (Guilford Press, 2005) and, with Monica McGoldrick, ReVisioning Family Therapy: Race, Culture and Gender in Clinical Practice (Guilford Press, 2008).

Dr. Hardy described people as divided into three groups: jailers, helper, and healer. Jailers value correction over connection. They protect the prevailing order even at the cost of crushing the human spirit. Their primary goal is to keep order, and they use the tactics of demanding obedience or ejection. Their words are: Not here! Out of here! Dr. Hardy pointed out that there is a lot of recruitment and rewards pushing people to become jailers in our current society.

The helper is well intentioned, and tries to intervene in the face of injustice and harm. They try to restore order, but do not focus on preventing injustice from happening. Many of us in the social services world find ourselves in this position.

The healer is a visionary who tries to challenge the established order and to rejuvenate the human spirit. He values connection over discipline. He establishes mutuality. His work is not just a job, it is a passion. He works on behalf of the human condition, to make a better planet. He is in the business of manufacturing hope.

Dr. Hardy suggested that the way to become a healer is by embracing one’s own suffering, turning towards one’s own pain instead of denying it. We have all been oppressed in some way. Look at your own invisible wounds, find and speak your own authentic voice.

In our programs, is there pressure to become jailers? Are we encouraged to become healers?

Shame was a central topic for Dr. Hardy. He spoke that we are even ashamed to admit we feel shame. Shame is a powerful force that cannot be named or spoken about, because it is associated with weakness. Shame arises from the devaluation of human dignity. The more a person’s basic dignity has been eroded and assaulted, the more that person will demand respect, and will be aggressive rather than suffer further degradation.

Further, Dr. Hardy described “learned voicelessness”. This is what happens to a person whose dignity has been degraded, and who has been unable to speak. Of course this applies to children who cannot speak of their abuse. The more a person has been silenced, the stronger their rage. The role of the healer is to help the person find and speak their voice, and transform their rage into outrage that is channeled into action to change the world.

I felt this description illuminated my thinking about effective action: that trauma with its inherent helplessness over time convinces the victim of the impossibility of effective action in their own life. Our job is to re-teach that effective action is possible. Add to that, trauma and its secrecy silencing the voice, and our job is also to help the person regain their voice. We have to be careful that our treatment programs do not themselves demand silence from the clients.

I was very moved by Dr. Hardy’s presentations, and I look forward to reading his books. Stay tuned for book reviews!

What if... A Post-Penn State Fantasy About the Prevention of Child Sexual Abuse

Here is the second article written by Dr. Steve Brown

by Steve Brown, Traumatic Stress Institute

Roxanne is a fictitious 27-year-old mother of six-year-old Sarah. A single mom since Sarah’s birth, Roxanne has finally found the “love of her life”-– 35-year-old Justin. He’s got a steady job, only drinks on weekends, and seems to just adore Sarah. He loves playing with her and even has been willing to babysit whenever Roxanne needs a girls’ night out. Quite frankly, Justin almost seems too good to be true.

Six months ago, Roxanne and Justin were ready to take their relationship to the next level so they moved in together. Justin pays most of the rent and gas so things are looking up financially for Roxanne. They have even talked about marriage, prompting lots of chatter between Roxanne and her girlfriends about when Justin was going to “pop the question.”

Sarah was SO happy when Justin moved in. She’s never really known her father and always felt jealous seeing her best friend playing with her dad in their front yard. She secretly hoped her mom and Justin would get married.

Three weeks ago, Roxanne grew concerned when Sarah started to wet her bed, something she had not done for years. Sarah also seemed especially clingy at bedtime, not wanting to say goodnight or to go into her bedroom alone. Roxanne needed to lay down with her at night in order to get her to go to sleep.

Once, when Roxanne went to lay down with Sarah, Sarah’s bed smelled like cigarette smoke. She didn’t smoke, only Justin did. In the morning she asked Justin if he had been in Sarah’s room and he shook his head, looking at her as if she was crazy. Another night, Justin came home late and Roxanne happened to wake up and hear the door to Sarah’s room creak. She thought it was strange because Sarah almost never gets up to go to the bathroom in the middle of the night. A third time, Roxanne found Justin’s shoes underneath Sarah’s bed -- “That’s strange," Roxanne thought, “well, maybe Sarah was just playing her make-believe games and used Justin’s shoes.”

In a post-Penn State sex scandal world, maybe, just maybe, the following would transpire.

Like millions of other Americans, Roxanne has been riveted by the news about the alleged sex abuse by Jerry Sandusky at Penn State. On CNN’s Late Night with Anderson Cooper, she sees an expert talk about how most people think of sex abusers as creepy perverts, lurking around playgrounds, but in fact over 70 percent of sexual abusers are known, and often loved, by the children they abuse. They point out that true prevention of sex abuse will only happen when mothers, grandmothers, neighbors are alert to the possible signs of troubling behavior by their boyfriends, uncles, the next door neighbors. They need to pay attention to their gut feelings when they think something isn’t right about the sexual behavior of the person they know. It’s hard to face the possibility that someone you’ve trusted may be hurting a child, even harder to speak up.

Suddenly, Roxanne flashed to the smell of cigarette smoke in Sarah’s bed – “why on earth would Justin be in Sarah’s bedroom without me knowing about it. There must be an explanation. Maybe he was just tucking her in that night and I didn’t know about it. Maybe I’ll ask Sarah.”

When Roxanne asks Sarah, Sarah looks away and doesn’t say anything. When Roxanne asks her again, “Has Justin ever come into your room at night?” she quietly says, “no.”

“This isn’t possible,” Roxanne thinks, “Justin is SO good with Sarah. He adores her and she seems to like spending time with him. There’s no way. Finally, I’ve found the man of my dreams. Everything is working out. I might even get married. I love Justin. But, I can’t stop thinking about this.”

The next night Anderson Cooper reports:

“One of the most disturbing parts of the Penn State sex abuse scandal is how many people likely either had direct information or suspected Mr. Sandusky of abuse and failed to come forward and speak up on behalf of the victims. They were passive bystanders, not active ones. Think how many victims could have been spared if JUST one of those adults had come forward and had the courage to not let it rest.”

Roxanne suddenly feels like she’s been kicked in the stomach. “How many times now have I had this yucky feeling about Justin. I keep wanting to put it out of my mind. WHY does it keep nagging at me? All those people at Penn State, they looked the other way. Am I looking the other way? It CAN’T be possible, but maybe…I have to talk with someone.”

The next day Roxanne has lunch with her girlfriend. “Can I talk to you about something? This is going to sound so strange, but I just can’t get it out of my head…” and she goes on to tell her friend about what she has observed ending with “I’m sure it’s nothing, right?” Her friend looks stunned, “I CAN’T believe you’re saying this. Justin has always struck me as a little creepy. I never told you this, but I saw him sort of hitting on a 13 year-old girl. I didn’t think anything of it, but it was WEIRD. Once, when I was at your house, I heard him tell Sarah that her butt was cute in her tight jeans. I didn’t think it was anything so I didn’t tell you. But, it did seem really inappropriate. ”

Two days later, Justin came home again in the middle of the night. Roxanne stayed awake this time. Again, that creak of Sarah’s door. When Roxanne burst into the room, she saw Justin lying next to Sarah on her bed. He immediately stood up and yelled, “What the hell are you doing here? I was just tucking Sarah in.” Justin had clearly been drinking. Roxanne threatened to call the police unless Justin left immediately.

When she talked to Sarah about what had happened, Sarah said that Justin had been coming into her room numerous days in the past month. He always woke her up, lay down next to her, and talked about how she was so special. He always had alcohol on his breathe. He’d kiss her face and rub her back. When Roxanne asked if he had touched her on her private parts, she said “no”, but she hated when he came in. She couldn’t fall asleep at night thinking it might happen again. Roxanne said, “Sweetie, I’m so sorry this happened. He will never do that again to you. I promise. I swear.”

As Roxanne sat awake in bed that night, she could barely contain her rage. "But, at least I caught it before anything really bad happened. It could have been like those boys at Penn State. Thank God I trusted my gut. Thank God I talked with someone. Thank God I spoke up!!!”

Now THEN we’d be making progress on preventing sexual abuse of children.

Preventing and Reporting Child Abuse: The Questions Raised by the Penn State Scandal

This excellent article was written by my colleague Steve Brown, PsyD.

Last week, a Pennsylvania Grand Jury indicted former Penn State defensive coordinator Jerry Sandusky for sexually abusing eight boys over the course of a 15-year period. The indictment also charged two top university officials with perjury and failure to report what they knew about the allegations. The indictment has kicked off a firestorm of media attention both in the sports world and the US at large. On November 9th, the Penn State Board of Trustees fired legendary football coach Joe Paterno and Penn State President Graham Spanier. Allegedly, a graduate assistant told Paterno that he observed Sandusky abusing one of the boys. Paterno reported this to Athletic Director Tim Curley although did not follow up later on the matter or alert legal authorities himself. The indictment stated that President Spanier was made aware of the incident reported to Paterno as well.

In any particular abuse situation there is an abuser, a victim, and (almost always) bystanders. This is true in bullying, street violence, as well as child sexual abuse. One of the most important questions that the Penn State situation, and cases like it, raise is -- what is it about the nature of intimate sexual violence that stops so many bystanders from taking action when they either have direct information that abuse has occurred or, more commonly, just an inkling that something might not be right.

It is true that men like Mr. Sandusky can often be well-regarded, upstanding citizens, involved in the community, even loved as a role-model by many. However, it is ALSO true, as has come out in the press, that numerous people had direct knowledge of, and even directly witnessed, Mr. Sandusky sexually abusing boys. Despite this knowledge, they were passive bystanders, not active ones. If any one of these adults took appropriate action to report this to the proper legal authorities, maybe the abuse would have ended with one or two boys rather than eight. Maybe the victims would have been given help and protection.

While some adults in this situation had direct knowledge of the abuse, I'm guessing there are likely many others who had troubling gut feelings about Mr. Sandusky --family, neighbors, players, coaches, etc. Many such people are now wracking their brains about what signs they might have missed, why didn’t they trust their gut, and, most importantly, what prevented them from coming forward. These are good and important questions. Even Joe Paterno, whose Penn State football team proudly extolled a reputation for being “squeaky clean” and whose motto was “success with honor,” could not see clear to act on his moral responsibility to protect current and future victims. It is especially disturbing that those with direct knowledge could not muster the resolve to actively speak out.

However, for all of us, there is this critical question -- WHAT prevents us from speaking out, not ignoring what we see, paying attention to these gut feelings, checking them out, talking with a friend or colleague about them, and ultimately taking action to alert the proper authorities?

I think there are complicated answers to this question.

Much of it relates to our societal denial about the reality of child sexual abuse. We SO want sex abuse to be about the creepy pervert, the stranger who abducts and molests our kids. Let’s just put them all on sex offender registries, attach GPS devices to their ankles and we’ll be okay. We DON’T want to admit that 90 percent of sex abuse is committed by people known by the victim and the family – our brothers, uncles, fathers, stepdads, and…yes…coaches.

If we do speak up, we are intruding on the privacy of the hallowed family --whether it be a family unit or the Penn State family. Sometimes, we don't know what signs to pay attention to in these men. Even if we do, we don't want to get involved: “I told my supervisor. If they don’t act, it must not be that big a deal. Anyway, if anything happens, it’s on them, not me.”

We especially don't want to get involved when there are powerful people and institutions involved. When those institutions have “squeaky clean” images to uphold, we don’t want to be responsible for tarnishing that image. If we do raise our concerns, we risk social rejection. We also need to have some comfort with our feelings related to the shrouded area of sexuality and the language of sex to get involved and speak up. If we speak up (as an adult bystander or a victim), it is HIGHLY likely that things will get worse in the short term although hopefully better in the long term.

Many people, playing Monday morning quarterback, are outraged about the fact that bystanders didn't speak up (and we should be outraged by this case), but this does NOT recognize the reality of the barriers listed above. Until we grapple as a society with these many barriers, we will make limited progress on prevention.

Child sexual abuse prevention, led by organizations such as Stop It Now!, seeks to answer exactly these questions – how do we help adult bystanders recognize the signs of sexual abuse, talk with others about what they are seeing, and find the courage and words to speak up. Unlike Penn State, most often it is a wife speaking up about (or to) her husband whom she sees repeatedly coming out of their daughters’ bedroom in the middle of the night; a neighbor speaking up about (or to) a beloved neighbor who frequently has boys coming in and out of his house; an adult niece speaking up about (or to) a great uncle who always wants to play video games in the basement alone with a 10 year-old relative.

This is not an easy subject to raise when the abuser is the primary earner for the family; when he is well-loved, even by the son or daughter he is abusing; when he is the founder of organizations for vulnerable kids which do a lot of good; when speaking up means a crisis will ensue.

To prevent sexual abuse, we must ALL struggle with these questions. Perhaps the Penn State situation will move us a little closer to speaking up as ACTIVE bystanders, not passive ones, looking out for the well-being of our children and those who cannot speak for themselves

Connecting Theory to Action

This is a long post that summarizes the way that the Restorative Approach provides a bridge between theory and action in treatment programs.

The Restorative Approach translates what modern science has learned about trauma and how it affects the brain into specific strategies for daily interactions with the children. The following points summarize the connections between theory and daily actions.

The Restorative Approach recognizes that a traumatized child’s brain is different, in that the prefrontal cortex is less developed. Because of that trauma-related difference, the child is easily overwhelmed by emotions. In treatment programs using the Restorative Approach, staff members understand that they will have to act as the child’s prefrontal cortex for awhile, teaching problem-solving rather than punishing a child for seeming to ‘choose’ to act out emotionally when the child is doing the best he can. The staff members’ brain building tasks include helping the child with selective attention, working memory, self-observation, and response inhibition. Further, the staff respond to the child’s emotional dysregulation with calming techniques rather than with thinking interventions.

A traumatized child typically has a strong, even over-developed, response to any situation perceived as dangerous. Using the Restorative Approach, staff members aim to soothe the child whose emotions are blowing up, to reassure him or her rather than get into a power struggle. The last thing a staff member trying to help an emotionally dysregulated child would do is back him or her into a corner. Instead, staff use soothing techniques when the child is upset. They teach uses of emotions and how emotions contain information, and actively teach self soothing. The staff provide and identify safety. One part of this is to talk before doing something, and to provide predictability. The program uses crisis kits and crisis prevention plans. Staff are aware that child will notice everything that they do, how they treat each other, their tone of voice, and their expressions.

Because of their focus on danger, the child may miss a large part of what goes on around them. Staff will have to coax child to have fun and point out joys in life.

Traumatic events that are experienced prior to the acquisition of language may return to the child as flashbacks, as though he were reliving, not remembering, the experience. At times the child may dissociate to manage the pain of his experience. Staff can teach grounding techniques that return the child to the present.

The physical underdevelopment of the child’s brain results in him having more difficulty accessing his verbal memory. Therefore, staff do not rely on verbal planning alone, and whenever possible use multi-model interventions such as charts, pictures, art, dance and music.

The child whose life has been unpredictable has confused, few or no regular bodily rhythms. Staff help develop bodily rhythms by maintaining predictable structures and offering rhythmic activities such as yoga and dance. The child also has an under-developed ability to sort out social cues, so staff are clear in communication and use simple language. They teach social interpretation through movies, books, etc.

Lake of early reliable care combined with trauma and attachment disruptions result in a child whose connection with his own body has not been reliably established. Therefore, he may have difficulty regulating their body functions. Staff can help through offering repetitive, rhythmic, rewarding activities to rebuild the lower brain, the part that controls the body. The child may have difficulty sleeping, so staff will not punish bed time problems, but instead look for ways to help child relax such as night light, reading, or music. Staff will therefore handle hygiene issues with sensitivity and understanding of complexity (symptoms are adaptations), not with consequences, and will find opportunities to teach healthy sexuality.

Because the child has had less attuned interactions, his brain is less integrated and he has more trouble with generalization from one situation to another. Staff therefore make connections explicit and specifically make comparisons between various aspects of life, distinguishing past from present. They give the child opportunities to practice new skills in many arenas and settings.

Children who grow up with neglect and trauma are not taught how to recognize or name emotions, so it is up to treaters to teach them the names of emotions and model healthy emotion. This includes the recognition of bodily sensations of emotions. The child may experience his emotions as moving from extremely aroused to extremely shut down quickly with no apparent rational. Staff can help child develop awareness of his own emotions and their stages, and develop tactics for each stage.

The hallmark of trauma is the victim’s lack of control. He cannot influence what is happening to him, and he is used to fulfill someone else’s needs. He is not treated like a person. After repeated exposure this powerlessness generalizes to all situations. The child learns that no effective action is possible in their life. Therefore it is important that treatment systems do not replicate this experience, and that they allow many opportunities for active participation in decisions involving the youth. They can also respond to problems by guiding the youth to fix damage they have created and repair relationships they have hurt. Because of this previous lack of control, the child may value control above all else. The program can give child control whenever possible, collaborate with him, and focus on him learning to control himself as opposed to staff controlling his behavior. Because control is so important, and lack of control is associated with victimization, the child may cover up vulnerable feelings such as fear and sadness. Staff can create safety to allow the child to share vulnerable feelings, and model having vulnerable feelings in a healthy way.

The child believes that everything that has happened to him is his own fault. To heal he must develop a sense of safety in which he can share what he finds shameful and receive compassion. Staff can also point out his strengths and achievements.

The child’s experiences have taught him not to trust adults. Programs can provide a different experience by being trustworthy, and by emphasizing trustworthy relationships. They can point out how present relationships are different from past relationships. The child expects the worst in relationships, and so may push people away. Staff understand the adaptive aspect of the child pushing the adult away, stay committed, and don’t pull back. They verbalize and validate the child’s fears.

The relationships in the child’s life have often violated his boundaries, involving him in adult problems and activities, requiring him to perform tasks beyond his abilities, causing him to be the caretaker of adults. Therefore the child is uncertain about boundaries and tests them. Staff can maintain firm yet flexible safe boundaries, be aware of the complexity of boundaries in child’s life, discuss boundary issues openly with each other and with children, and also seek supervision around these issues to identify their own reactions so that they don’t interfere with the work.

The child has not been taught how to handle problems in relationships. When he has had relationship difficulties, the other person has often just disappeared. He may have seen adults handle problems with drinking, drug use or violence. Staff has the opportunity to provide relationships that stick with the child. They can model relationship skills, speak from their hearts and share their own modulated emotional reactions. They can always address the relationship aspects of events, provide paths to work through relationship difficulties, and actively teach social skills. Since he does not trust others, the child may have trouble asking directly for what he wants. Staff can encourage direct communication and practice and model skills of making requests. They can say yes when possible.

Similarly, the child has not learned how to handle something going wrong without making it worse. Staff can teach distraction and calming techniques, help the child develop a list of tactics to improve situation, offer child alternatives, not consequences, when he is becoming agitated. and develop with the child a list of many positive coping tactics for handling pain.

Because of both his past and present situations, the child often feels hopeless. Staff can help through pointing out skills and gains. Also, they can teach and support the child in advocating for himself.

Working with children who have survived trauma, neglect and attachment disruptions caused strong reactions in all treaters. The trauma informed program is aware of vicarious traumatization, and imbeds in daily operations opportunities to discuss the effects of the work, care for one’s self and other team members, and encourages practices which promote vicarious transformation.

Carter Symposium on Mental Health Policy

I had a wonderful time attending the Carter Symposium. For me, the experience was composed of many parts. These included the inspiration of Mrs. Carter herself; the many interesting and intelligent people I met; some inspiring people I already knew and heard again; and the facility itself and the professional and efficient way the conference was run. My most overwhelming impression was that so many people in so many widely differing areas of the helping professions are transforming how they provide services based on our increasing knowledge about trauma. It may turn out that research about trauma, its effects and how healing takes place will be the revolution of our century!

The first keynote conversations were about the National Child Traumatic Stress Network (www.nctsn.org) In addition to all the wonderful treatment and service provision projects NCSTN has facilitated, they are collecting significant data about all the clients served and all the outcomes of various forms of treatment. This rich national data set gives us all sorts of opportunities to learn about the experiences and symptoms of the children seeking help, and most importantly, what helps them and their families.

Following the speakers was a Poster Session. I had the Traumatic Stress Institute poster on display and enjoyed many conversations with my fellow participants. Next to me was a friend from Connecticut, Jason Lang from the Center for Effective Practice, whose poster describes the Connecticut implementation of TF CBT.

After the delicious dinner, Christine James-Brown, the CEO of the CWLA spoke.

On the second day, the first speaker and panel addressed the increasing awareness of trauma in the child welfare system. The plenary speaker was Brian Samuels, M.P.P. Commissioner, Administration on Children, Youth and Families, US Department of Health and Human Services. He emphasized that the goal of his department was well being, not just permanency. He presented interesting statistics that showed that children who achieve permanency or are adopted do not in fact get better afterwards. Their symptoms continue to get worse. This speaks to the need for specialized treatment services for older adoptive children, and those adopted out of foster care. Speakers then presented several specific interventions for the child welfare population.

Particularly interesting was Dr. Sandra Bloom who presented her theories of how organizations themselves are living organisms, and as such experience trauma and exhibit all the trauma symptoms. She described the Sanctuary Model as a way to heal from this trauma.

The next set of speakers addressed the increasing awareness of the role of trauma in the Juvenile Justice System. The plenary speaker was another Connecticut representative, Julian Ford, PhD. He described his intervention, TARGET. The moderator and the following speakers acknowledged that the Juvenile Justice system is just beginning to implement any trauma informed practices, and that there is resistance. Judge Steven Teske, JD was especially articulate on the importance of educating judges and involving them in the solutions.

This was followed by concurrent sessions. I attended the session about Care Giving and Parenting. I heard two excellent presentations. Patricia Barron, M.A. spoke about helping military families who have a parent deployed away from home, and included excellent resources for agencies wanting to help. Jeanne Miranda, M.P.A. described a specialized intervention she and her team were developing at UCLA to treat children who have been adopted from the foster care system. Both speakers combined personal experience with professional knowledge: Ms. Barron herself is in a military family, and Ms. Miranda is an adopted mother of children from the foster care system.

I have to report that on the way back from these sessions I personally met and spoke to Mrs. Carter, and followed up by giving her my TSI materials. That was so moving! She is a true heroine. She is 84 and had just returned from observing an election in Tunisia (I think that was where it was).

The summation focused on what we can personally do with the material we learned, how we can bring it back to our own practice. It was very inspiring, especially the concluding remarks by Mrs. Carter.

This was all held in a beautiful location, which is also the home of the Carter museum. The staff and volunteers were so helpful, the food was delicious and the conference was very well organized. All in all, an excellent experience.

Patricia Wilcox to Attend Carter Symposium on Mental Health

This year’s 27th Rosalynn Carter Symposium will focus trauma and its long-term effect on children. It will be webcast live.

The National Association of Children's Behavioral Health (NACBH) will be ably represented by Beth Chadwick, President and Pat Wilcox, Klingberg Family Centers Traumatic Stress Institute who will be joining an illustrious gathering of national leaders, advocates, policy makers, practitioners and researchers as they meet to bring this most pressing issue into greater focus and resolution.

27TH ANNUAL ROSALYNN CARTER SYMPOSIUM ON MENTAL HEALTH POLICY TO COVER TRAUMA’S LONG-TERM IMPACT ON CHILDREN EXPOSED TO JUVENILE JUSTICE, WELFARE, AND DOMESTIC VIOLENCE

Estimates suggest that millions of American children and adolescents experience trauma each year, through exposure to physical or sexual abuse, a life-threatening illness, natural disaster, or the loss of a loved one. Although effective treatments are available to prevent the long-term impacts of trauma on a child’s intellectual development and physical well-being, most traumatized children do not have access to these services.

On Oct. 26-27, the invitation-only, 27th annual Rosalynn Carter Symposium on Mental Health Policy will bring together more than 200 health advocates, policy-makers, practitioners, educators and researchers from across the country to discuss ways to remove barriers to providing mental health services for children at greatest risk for trauma—especially those exposed to domestic violence, child welfare, and the juvenile justice system.

The event is open to the media and will be webcast live on www.cartercenter.org on Oct. 26 starting at 1:00 p.m. (EDT) and on Oct. 27 starting at 8:30 a.m.

Oct. 26 Agenda Highlights:

For a full schedule: http://cartercenter.org/resources/pdfs/health/mental_health/2011-mental-health-symposium-agenda.pdf

• 1:00 – 1:05 p.m., Welcome: Thomas Bornemann, Ed.D., director, Carter Center Mental Health Program
• 1:05 – 1:15 p.m., Opening remarks: former U.S. First Lady Rosalynn Carter

• 1:15 – 2:15 p.m., Keynote: “Childhood Trauma in America: Findings from the National Child Traumatic Stress Network”

o John Fairbank, Ph.D., co-director, National Center for Child Traumatic Stress, Duke University Medical Center; and

o Ernestine Briggs-King, Ph.D., director, Data and Evaluation Program, National Center for Child Traumatic Stress, Duke University Medical Center

Background on the Rosalynn Carter Symposium on Mental Health Policy:

The Rosalynn Carter Symposium on Mental Health Policy is part of the Carter Center’s Mental Health Program, which works to decrease stigma and discrimination against people with mental illnesses as well as promote positive policy change on mental health issues.

Visit www.cartercenter.org to learn more about the Carter Center’s Mental Health Program, access resource material such as reports, the Center’s mental health journalism archive, and expert Q&As.

"Waging Peace. Fighting Disease. Building Hope."

A not-for-profit, nongovernmental organization, The Carter Center has helped to improve life for people in more than 70 countries by resolving conflicts; advancing democracy, human rights, and economic opportunity; preventing diseases; improving mental health care; and teaching farmers in developing nations to increase crop production. The Carter Center was founded in 1982 by former U.S. President Jimmy Carter and his wife, Rosalynn, in partnership with Emory University, to advance peace and health worldwide. Please visit www.cartercenter.org to learn more about The Carter Center

Where are My Glasses?!?

Carlos storms into the nurse’s office. “Are my glasses here yet?” He demands in a loud voice.
“No” Amy, the nurse, says. “I haven’t heard from them. I’ll call you when I get them.”

“Well did you call them?” Carlos asks.

“No, they will call us when they come in, Carlos.” Amy replies.

“You should call them! I’ll bet they have them already!” Carlos is becoming more agitated.

“Carlos I’ll let you know if I hear from them.”

“No! Call them now! Give me the number! I’ll call them! Why can’t I call them? Give me the number!” Carlos was becoming angrier. His staff starts to move in. As the staff starts to encourage his return to the unit Carlos yells “I’ll bet they are already made! Give me the number! No one understands that I need those glasses! I can’t see! Doesn’t anyone care?”

After Carlos leaves, Amy can be heard saying “that child is so demanding! He thinks the world revolves around him and no one has anything else to do besides call about his glasses. He has to learn to be more patient and respectful.”

The problem is that Amy and Carlos live in different worlds, and hence have developed different world views.

Amy’s world is orderly. If you send a prescription to a glasses company they make the glasses. As soon as they are done they call you. You pick up the glasses right away and deliver them to the child.

Carlos’ world is quite different. In his world, what he needs is no one’s priority. If he needs new glasses, no one will pay attention. If by some chance the prescription makes it to the company and the glasses are made, they will languish in some back room for months. If they get to the doctor, no one will call for weeks; when they call, no one will pick them up. The only way that the glasses will get to him is if he takes it on himself to call and remind them, and calls often.

Carlos does not think that the world revolves around him. He in fact thinks that the world does not notice or care about him at all, unless (maybe) he yells loudly.

Understanding this will help us reassure Carlos, tell him how long it takes to make glasses, exactly when we will call, and keep him updated often about progress.

Maybe we can be the adults that teach Carlos that some adults can be trusted and do care.

Vicarious Transformation

I have had the privilege of hearing Dr. Laurie Pearlman speak twice in the last month. The first time was at the ATTACh conference, where she was a keynote speaker. The second was in a distance learning training that the Traumatic Stress Institute did for its trainers. This was an interview with Dr. Pearlman by Dr. Steve Brown of TSI.

Laurie is developing the concept of “vicarious transformation”. We always discuss vicarious traumatization (a term she also invented) which refers to the negative effects on helpers of working with trauma survivors. Vicarious transformation refers to the positive changes in the helper which come about through empathetic engagement with traumatized people and active engagement with the changes in ourselves.

In Risking Connection© training we do an exercise which draws from participants both the negative and the positive ways that their work has affected them. In the positive section, people often say that they have grown as a person, become more patient, more tolerant, a better listener, a better parent. They also report that they are more grateful for what they have been given, and that they are inspired by the courage and resilience of the people they work with.

It is these effects which Laurie is naming vicarious transformation. She says: “through opening ourselves to the darker parts of the human experience, we may grow. When our hearts and minds are open to whatever we encounter, our humanity is enhanced.”

Dr. Pearlman stresses that in order to experience this growth, it is necessary that we turn towards the suffering we see. We of course want to deny it, to diminish it, to turn away, We convince ourselves that this could never happen to us. But when we are receptive, it is easier to care, and to enter into a genuine reciprocal relationship with our clients. Just as we feel their pain more acutely, we appreciate their strengths more directly. We experience the human potential in a deeply heartfelt way.

Dr. Pearlman recommends some techniques that can help us maximize the potential for vicarious transformation. These include receiving psychotherapy, journaling, yoga, meditating, praying, symbolizing our experiences creatively, and befriending emotion.

This exciting new concept helps us articulate why we stay in these difficult jobs. I look forward to further exploration by Dr. Pearlman, and by all of us in the treatment community.

The Adult Attachment Interview

As part of the same ATTACh Conference workshop with Michael Trout, Karen Buckwalter, LCSW from Chaddock presented the Adult Attachment Scale. The Adult Attachment Interviewis a twenty question guided clinical interview with a specific scoring protocol. It was developed by Mary Main and her colleagues, and has extensive research validation to support it. A parent’s score on the Adult Attachment Interview is highly correlated with the attachmenmt reaction of their child in the strange person test.

The questions themselves can be the beginning of thoughtful discussions. They include questions such as:

• Choose five adjectives or words that reflect your relationship with your mother starting from as far back as you can remember in early childhood.

• To which parent did you feel the closest, and why?

• When you were upset as a child, what would you do?

• Did you ever feel rejected as a young child?

• What is your relationship with your parents (or remaining parent) like for you now as an adult?

The carefully trained administrator who understands the scoring system can group the adult into one of five categories:

• Autonomous: They value attachment relationships, describe them in a balanced way and as influential.

• Earned autonomous: Someone whose childhood does not contain good relationship experiences, but who has nevertheless achieved some autonomy, probably through other non-family caring relationships.

• Dismissing: They show memory lapses, minimize negative aspects of their childhoods and deny personal impact on relationships. Their positive descriptions are often contradicted or unsupported. This Karen called act and don’t feel

• Preoccupied: Experience continuing preoccupation with their own parents, have angry or ambivalent representations of the past. This would be feel and don’t act

• Unresolved/Disorganized: Show trauma resulting from unresolved loss or abuse.

Karen was careful to point out that people’s scores and types can evolve through positive adult relationships.

Karen presented several possible uses for this interview. Testing therapists and staff who work with traumatized children helps them become more self aware of their own backgrounds and styles. This will help them understand some of their reactions to individual children and families. Testing foster parents has the same benefits. Some audience members have been using the interview with some foster parents, and reported that others are very resistant to doing it.

This interview offers fascinating ways to develop the self-reflection that is so essential in our work.

Michael Trout at the ATTACh Conference

I have just returned from a wonderful week immersed in learning about new treatment ideas and meeting marvelous people. I have a lot to share. This week I am going to focus on Michael Trout, who I had the honor of meeting at the ATTTACh conference (http://www.attach.org/). Michael is the author of the Multiple Transitions video that we include in our Risking Connection training. This video, which our participants always find so moving, can be purchased at the Infant Parent Institute store (http://infant-parent.com/). Many organizations have begun to use it to train new staff, and I highly recommend it.

Michael Trout is the Director of the Infant Parent Institute which engages in research, clinical practice and clinical training related to problems of attachment. He was the founding president of the International Association for Infant Mental Health; was on the charter Editorial Board of the Infant Mental Health Journal; served as regional vice-president for the United States for the World Association for Infant Mental Health; and currently serves on the board of directors (and as editor of the newsletter) for APPPAH — the Association for Pre- & Perinatal Psychology and Health. In 1984 he won the Selma Fraiberg Award for “ . . . significant contributions to the needs of infants and their families.” Mr. Trout has produced 14 clinical training videos that are used by universities and clinics around the world, including the six-hour video training series, The Awakening and Growth of the Human: Studies in Infant Mental Health. He has also written and produced four videos focusing on the unique perspective of babies on divorce, adoption, loss and domestic violence. The most important part of Mr. Trout’s work continues to be in his quiet private practice where he sees individuals and families of all ages on a daily basis.

I attended a work shop by Mr. Trout on the topic of the therapist as a secure base for their clients. He showed videos and led the audience in an experiential exercise to demonstrate attunement. Mr. Trout shared three actions that are essential for the therapist to create a secure base.

Wonder: The therapist must approach the patient with genuine curiosity and awe. He must remain interested in this person’s story, this person’s experience. This wonder can be side tracked by theories. If the therapist thinks he already has the situation figured out, his mind will only go down one path and he will close his eyes to contrary evidence. Hearing others describe the patient, or reading their record, can also interfere with wonder. Hurrying, or having a pre determined agenda, are also problems. When the therapist keeps his mind open in wonder and curiosity, he will deeply hear the patient, and that person will know they have truly been seen.

Following: The therapist must be in pursuit of the patient. The therapist does not come in with a pre-decided agenda. He follows where the client wants to go and what the client wants to talk about.

Holding: This takes many forms. Its opposite is dropping. It means creating a feeling for the client that the therapist has his back. You won’t starve, I won’t leave, we will work this out together. It may require active advocating for the client.

These are the elements of creating a secure bases for the client.

Mr. Trout ended his workshop with a meditation from a CD that can also be purchased at the Infant-Patent Institute store. I plan to add it to my training. It comes from this CD (I include the description from their web site).

The Hope-Filled Parent

What could meditation mean to a foster mother who has learned to arise at 5:15 each day, in order to have 10 minutes of quiet before she begins the careful morning ritual needed for awakening her deeply troubled child without a meltdown? What could meditation mean to an adoptive father sitting alone at midnight, pondering what was happening to the peace of his home, the safety of his other children, and the intimacy he used to share with his wife? Could meditation make a difference to those foster or adoptive families who are on the brink of placement disruption, who are about to conclude they can simply not make it through another day?

Use these meditations in any way that suits you. There is no right or wrong way. If you find one that particularly speaks to you, you may find yourself listening to it every day, at about the same time. Maybe you will invite your spouse to join you, on the screened-in porch. Maybe you will listen to the entire CD on certain nights of despair, or listen to a funny one in the kitchen, while whistling. But it is my hope that you will find something herein that restores hope, that challenges your feelings of impotence that reminds you why your efforts are far from being in vain.

A Week of Travels

I am leaving today for a week of travels. I will go first to Detroit, where I will present at the 2011 National Health Care for the Homeless Regional Training. I will be speaking about Vicarious Traumatization. I also look forward to attending the conference, and hearing a presentation about Trauma-Informed Care by Scott Petersen, LCSW, and CADC; Laurie Hardin, MSSW.

On Tuesday I will travel on to Omaha, Nebraska, where I will attend the ATTACh Annual Conference, Attachment and Trauma Through the Eyes of a Child. I will have the opportunity to hear Edward Tronick, PhD speak about Peek-a-boo, Culture and Social Development: How Infant Meaning-Making Processes Are a Central Mechanism in Governing both Typical and Pathological Child Outcomes. I have heard Dr. Tronick at the Boston trauma conference, and I always learn a lot from him. I am also looking forward to hearing my dear friend and author of Risking Connection (among many other achievements and books) Laurie Anne Pearlman, PhD, Laurie will speak about Vicarious and Secondary Trauma: The Costs of Caring. I am also planning to learn about Integrative Treatment for Complex Trauma in Adolescents (ITCT-A) from John Briere, PhD. Karen Buckwalter, LCSW & Michael Trout, MA are presenting The Therapist as a Secure Base. It will be interesting to meet Michael Trout and tell him how much his video Multiple Transitions has meant to our Risking Connection learners.

There are also many other great leaders in our field at this conference. I will be discussing The Restorative Approach on Friday afternoon. I also look forward to seeing my friends from CALO. CALO is a sponsor of the conference.

If you are attending either of these conferences, please come up and say hello. I would love to meet you.

Trauma Informed Care and Homeless Services

Since to day is that last day of my vacation, I thought instead of writing a new post I would share this artcile from SAMSHA. It is about trauma informed services for the homeless, but is applicable to all services.

Trauma-Informed Care 101

http://homeless.samhsa.gov/Resource/Trauma-Informed-Care-101-46857.aspx

Author(s): Guarino, Kathleen

Description: How can providers help care for people who have experienced trauma? People who are experiencing traumatic stress do not relate to the world in the same way as others. They require special care. In this article, the HRC shares best practices for trauma-informed care. These include understanding trauma and its effects, creating safe physical and emotional space, supporting consumer choice and control, and integrating trauma-informed care across service systems.

Some people experience very few traumatic events in their lives. For others, experiences of traumatic stress are chronic. Research and experience tell us that for people experiencing homelessness, rates of trauma are extraordinarily high. Many who enter the homeless service system have experienced violence, loss, and disruptions to important relationships from an early age.
Additionally, people who are homeless experience the loss of place, safety, stability, and community. These losses are also traumatic. They have a major impact on how people understand themselves, the world, and others. People who have experienced multiple traumas do not relate to the world in the same way as those who have not. They require services and responses that are uniquely sensitive to their needs.

What makes an experience traumatic?

•The experience involves a threat to one’s physical or emotional well-being.
•It is overwhelming.
•It results in intense feelings of fear and lack of control.
•It leaves people feeling helpless.
•It changes the way a person understands themselves, the world and others.

Becoming Trauma-Informed

We know people can and do recover from trauma, and we want to provide services and environments that support healing. To be a “trauma-informed” provider is to root your care in an understanding of the impact of trauma and the specific needs of trauma survivors. We want to avoid causing additional harm to those we serve.

What does this mean in practical terms? How is this different than business as usual? Here are some concrete practices of trauma-informed care.

Understanding Trauma and its Impact


Educating providers on traumatic stress and its impact is essential. Trauma survivors, particularly those who have experienced multiple traumas, have developed a set of survival skills that helped them to manage past trauma. These survival strategies (like substance abuse, withdrawal, aggression, self-harm, etc.) make sense given what people have experienced. But they can be confusing and frustrating to others and often get in the way of current goals.

Without an understanding of trauma, providers may view those they serve in negative ways. Providers might describe behaviors as “manipulative,” “oppositional,” or “lazy.” Yet these behaviors may be better understood as strategies to manage overwhelming feelings and situations. Trauma-informed training can help providers understand these responses and offer trauma-sensitive care.

Promoting Physical and Emotional Safety

Traumatic experiences often leave people feeling unsafe and distrustful of others. Creating a sense of physical and emotional safety is an essential first step to building effective helping relationships.

Safe physical environments may include:

•Well-lit spaces
•Security systems
•The ability for consumers to lock doors
•Visible posting of consumer rights
•Culturally familiar decorations
•Child-friendly spaces

Practices that help to create a safe emotional environment include:

•Providing consistent, predictable, and respectful responses to consumers across an agency
•Asking consumers what does and does not work for them
•Being clear about how consumer information is used
•Providing opportunities for consumers to engage in their own cultural and spiritual rituals

Supporting Consumer Control and Choice Situations that leave people feeling helpless, fearful, or out of control remind them of their past traumatic experiences and leave them feeling re-traumatized. Ways to help consumers regain a sense of control over their daily lives include:

•Keeping consumers well informed about all aspects of their care
•Providing opportunities for consumers to give input into decisions about how a program is run
•Allowing for consumer control over their own spaces and physical belongings
•Having clear boundaries around and giving advanced notice for room or apartment checks
•Ensuring that consumers have input into their service goals
•Using interventions respectful of and specific to cultural backgrounds
•Maintaining an overall awareness of and respect for basic human rights and freedoms regardless of housing status.

Integrating Care Across Service Systems


Becoming trauma-informed means adopting a holistic view of care and recognizing the connections between housing, employment, mental and physical health, substance abuse, and trauma histories. Providing trauma-informed care means working with community partners in housing, education, child welfare, early intervention, and mental health. Partnerships enhance communication among providers, and help minimize consumers’ experiences of conflicting goals and requirements, duplicated efforts, and or of feeling overwhelmed by systems of care. It helps build relationships and resources to provide the best quality of care possible.

Becoming trauma-informed means a transformation in the way that providers meet the needs of those they serve. The ideas above are only a beginning. Change happens as organizations and providers take these ideas, as well as their own, and use them to evaluate and adapt their approaches to care.

Hiring for Trauma Informed Care and a Prize

Agencies have discovered ways to determine whether a candidate is comfortable working in a relationship-based approach.  In some cases agencies have developed a statement that describes their treatment approach and asked candidates to read and decide if they can work that way, and return it signed if they want to proceed with the hiring process. It is useful to ask candidates how they deal with stress and what self care practices they find helpful. Another way is through the use of scenarios.Other options include:

• Ask a candidate about a time when he or she was successful in making a change and what helped him or her
• Ask a candidate with prior work experience to describe a client that they felt especially connected to, and one they found it difficult to connect with, and why. This question looks for self awareness of differing response to different clients
• Ask a candidate about a time when someone helped him or her, a teacher or a mentor or anyone significant in their life. What did that person do that was helpful?
• Ask what do you think might be the most difficult time of day for clients
• Ask what can staff do to make clients feel safer/ more comfortable around bedtime and/or shower

Offering the candidate an opportunity to observe in the milieu can clarify both for the candidate and for the employer whether or not there is a fit.

What have you discovered that is helpful? Press comment and enter questions and scenarios you use. I will offer a free copy of my book "A Child's View of Trauma" to one of the entries that includes their email (so I can contact you). This book is for clinicians to teach kids about trauma. Please join in- I will share the ideas in this blog. Click COMMENT.

Everyday Life through a Trauma Lens

Jenna’s mentor just called and her therapist, Eileen, is talking to the mentor before transferring the call to Jenna. But she can hardly hear what the mentor is saying because Jenna is banging on her door. “That’s my call!!” Jenna yells. “Stop talking with her!” This feels like the last straw to Eileen. Can’t Jenna just give her a minute? Jenna is always so demanding. Whatever she wants, she wants it now. She asks for the same thing over and over. If there is a delay, she becomes angry and starts calling Eileen belittling names. This makes Eileen less interested in doing whatever Jenna is asking for. Whenever Eileen is involved with one of the other girls, Jenna interferes. She doesn’t have any friends because she is just as demanding and bossy with her peers. Really, Eileen has taken Risking Connection© training and has been inspired to understand her client’s behavior as trauma related. This has helped her respond to Marcelis’s cutting, and Tenisha’s running away. But this constant obnoxious behavior from Jenna is something else.

Eileen has explained to Jenna that her insistence gets in the way of getting her needs met. She has reminded Jenna that she always keeps her promises whenever she can. But Jenna keeps being loud, demanding and rude. She is so self centered, thinks the world revolves around her and she should have everything her way. Maybe they should institute some kind of reward… Jenna could get a prize for polite behavior?

Stop! Just like when we consider the big symptoms (like self harm) let’s try the trauma lens on the everyday behavior that drives us crazy. So, as usual, we start by trying to understand WHY Jenna acts this way.

Every adult in Jenna’s life has let her down. Her mother has been in and out of her life, and in and out of drug involvement and treatment. When she stops using she and Jenna have some wonderful times. But when Jenna least expects it her mother disappears again into the drug world. This has left Jenna caring for her two twin younger brothers, although they are both in foster homes now. Earlier in her life Jenna fed, changed and played with them when her mother was not there. Jenna did her best not to share with anyone at school how bad things were at home, but despite her best efforts DCF became involved after a report from the twins’ doctor. Jenna didn’t fare much better in the four foster homes she has lived in. She experienced one episode of abuse and repeated interpersonal conflict leading to disruption. Jenna’s aunt Mary has been an important person in her life throughout all this. However, Mary too has vacillated about whether Jenna can live with her. Recently after a difficult visit she told Jenna that she cannot live there, and she has started proceedings to get custody of the twins.

Does Jenna act demanding because she thinks she deserves and should get everything she wants? No, she acts demanding because in her life she has never gotten anything she wanted, needed or deserved. Adults have not cared for her the way they should have. She has had to rely entirely on herself. The only way she has survived is through relentless demanding and grasping whenever she could. She does not trust adults, and there is no reason she should. Furthermore, underneath her bluster Jenna is sure that everything that has happened to her is her own fault. It is her fault that her mother went back to drugs, it is her fault that the twins were placed, it is her fault that her aunt doesn’t want her. So she is sure that if adults are talking about her, they are saying something bad. She knows that no one would want to spend time with her, or be nice to her, or take care of her. She will only get what she wrestles from the world.

So now that we understand Jenna’s behavior does that mean we just accept it? No. Jenna will not have a life worth living if she keeps alienating people by being demanding and insulting. So how do we proceed?

One idea would be for Eileen to begin exploring with Jenna how her ability to speak up for what she needs has been and is a strength. But I do not mean saying this perfunctorily and moving on to how she needs to learn to communicate better. I mean discovering times when Jenna saved herself and her twin brothers from death. Were there times when Jenna successfully helped her mother and brothers? Were there times when she got herself what she needed? Stay with exploring the strength Jenna has developed for a LONG time with no hint of wanting her to change. Communicate a genuine appreciation for a little girl who had to find a way to protect herself and her brothers because absolutely no one else was doing it.

Meanwhile, Eileen and all the staff can constantly validate the need beneath Jenna’s demands. Validate without adding “but you shouldn’t talk to me that way ” or “you can’t have everything, you have to think of others.” Instead say, “Jenna it’s hard when you know adults are talking about you, you are sure they are saying something bad. Jenna, you wish Marci could spend all her time with you. Jenna you want Shayna’s book so much you couldn’t wait and you took it.” A constant stream of validating the feelings beneath the words.

And we all should be as completely reliable and trustworthy as we can possibly be. If we have to change something, we should acknowledge it directly. And we should point out when we fulfill our promises, NOT with any implication that Jenna should have known to trust us. Just say: “Jenna, I said I would call your worker today. I did, and here is what she said.”

Is there any possibility that Jenna could use her ability to advocate for the good of others? When she is ready could she call (after rehearsing) a bowling alley and negotiate a discount for the program? Could she collect all the girls’ preferences for activities and present them to staff?

It would be great if Jenna could participate in a social skills training group, such as a DBT skills group. There she will learn interactive skills along with others, without reference to her particular issues.

And most of all, as Jenna feels safer, more appreciated, happier, more included, more trusting and more able to meet her needs she will be able to let her guard down and become more gentle. Then we may reach that miraculous day when Jenna says: “ I tried to talk to my DCF worker about a clothes voucher but it didn’t go too well. Could you help me figure out how to do it better?”

Trauma Informed Foster Care

Foster parents are a precious resource in our child welfare system. They offer traumatized children what they need most: a loving family. The best thing that could happen to a child who has been wounded is to live with a family that loves him, accepts him, and sticks with him. Foster parents come into their role from all walks of life and for every possible reason. Every family constellation is represented. Some foster parents are relatives of the child, or have known him in some previous capacity. Many have experienced their own traumas and see providing foster care as their way to give back.

Being a foster parent to a trauma surviving child is quite different from being a staff in a treatment facility. You are in your own home, and there is no immediate backup. You may have other members of your immediate family present, such as your biological children. You are trying to integrate the child into your actual life, your extended family, your neighborhood, your favorite activities.

Child care staff in treatment programs are taught a method of interacting with children that is significantly counter intuitive, and is usually completely unlike the way they were raised. But they have a team, other workers, treatment professionals and policies to help them maintain these strange practices. Foster parents do not have any of these readily available. Instead, they have a chorus of extended family members and friends telling them they should be stricter and not let the child get away with so much. It is much harder to change one’s style of parenting in one’s own home where one has successfully raised one’s own children.

The most important gift that a foster family can give a child is permanency. The children are damaged by disrupting and moving over and over again. The education and support we give foster parents should be primarily aimed at giving them the stamina to stick with the child. Keeping these children is very difficult as they put the family through such extreme behaviors, all based on their own assumptions about relationships. Yet the foster parent has the most power to heal this child, but helping the child to experience pleasure and associate it with other people; and by building the child’s brain through rhythmic, repetitive, rewarding activities.

One of the most powerful determinants of how a family responds to behaviors is how they define them. For example, Natalie is a twelve year old girl who has severe difficulties at bedtimes. She was placed with the Bruce family, and they defined her bed time behaviors as defiance. They had told her to turn out her light and go to sleep, and she kept getting up. The Bruce’s case manager asked them to sit in her room, read her a story, and talk with her, and to give her a night light. Mrs. Bruce thought this was just being too indulgent; she would never let one of her own kids get away with this. Did Natalie have no respect for her? Besides, Mrs. Bruce said, she could tell that Natalie was enjoying her presence in her room. This was just rewarding bad behavior. The placement disrupted.

Then Natalie was placed with a single mother, Mrs. Harris. She immediately connected Natalie’s bed time behavior with her having been abused and left alone. She started using music to help Natalie fall asleep, and gave her a night light. They developed a bed time ritual that they both enjoyed which included reading a book and then singing a good night song to each other. These interventions did not make everything perfect and there were still many other behaviors to deal with. Buy Natalie gradually began going to sleep more easily.

When we train foster parents in understanding trauma, how it affects children, how it relates to their current behaviors and how they can heal, we offer them a new framework for understanding their child’s behavior. We help them not to take the behaviors so personally. We must stress that these behaviors are adaptive and reflect what has happened to the child. The child is doing the best he can, and will do better when he is happier, feels seen heard and connected, and when he feels safer. All our training efforts should be directed towards this end.

We are currently creating a training program for trauma informed foster care, and would love to hear from anyone who has any experience with this. Just click on the word “Comment”,

Change a Brain… Change a Life….

We are beginning to implement some of Bruce Perry's new brain science on one of our units. This is a document I prepared for staff on that unit.

You are the most important source of change for this child. You can create this change through your every day relationships.

Your most essential job is to change that child’s expectations of relationships from:

Relationships bring me pain and can’t be trusted

to:

Relationships bring me pleasure and can help me get what I need.

You do this by providing pleasurable experiences for the child, and participating positively in these activities. Since “what fires together wires together” the child will begin to associate pleasure with adults.

You make it possible for the child to get better at feeling happy, safe, noticed and connected by providing opportunities for him to feel this way, offering him opportunities to practice feeling good.

You have the chance to build the child’s brain and increase his bodily regulation by involving him in rhythmic, repetitive, rewarding activities. By establishing a rhythmic back-and-forth interaction with the child you form a connection and help the child take advantage of your regulation to build his own. In times of stress you can use this attunement and rhythmic interaction to help the child calm down.

Since this work you are doing is the most important work in the world; and since you can only teach the child to feel pleasure if you yourself are genuinely engaged; it is essential that the team take good care of each other and that each of us take good care of ourselves, including being aware of and sharing the pain of vicarious traumatization.

Connection Post Discharge

I received a call last week from a woman who is a relatively new CEO of one of the agencies we have trained. She had discovered that her agency had a policy that clients once discharged are not allowed to have contact with the agency for two years. She asked if this seemed consistent with trauma informed care.

My answer is no. Why did we all have these policies once? The time frame may have differed… six months, a year… but contact and return visits were forbidden for some period of time. It was explained to me that contact was not allowed in order to help the clients form new relationships. If they had contact with their former treaters this would block the new relationships in their next setting.

We don’t apply these odd ideas to ourselves or our own children. If you start a new job are you forbidden to talk to anyone at your previous job? When your daughter goes to college do you forbid her to talk to any of her childhood friends, or to her family, in order to encourage the formation of relationships at college?

No, because in fact contact with existing relationships actually supports the formation of new ones. We are trying to teach these kids that relationships are worthwhile. How can they be if they must be arbitrarily severed? The old relationships help us feel safe and cherished, and give us the courage to connect with new people. They are there to offer sympathy and advice when things don’t go smoothly, and to encourage trying again.

I believe that kids should be allowed as much contact as they need when they are discharged, and their new placement should support and facilitate such contact. This applies no matter whether it was a positive or a negative discharge. The teams at the two places should work out a plan that they both support. It is especially important when discharging from a higher to a lower level of care. From their many years in the system our kids know how to get themselves back to a higher level of care, and they are very skillful at it. If the only way they can maintain their connections is through dangerous behaviors, they will do so. Instead, let’s set up many opportunities for the child to share with former treaters his success, his life events, and his new relationships.

Occasionally, but not often, an individual child who has been discharged will return to cause havoc. She will tell the current residents bad things about the staff, or offer to help them run away. Then individual plans can be made for that child, such as speaking only with staff. As usual, the team should consider what needs the discharged youth is trying to meet, and whether they can help her meet them in a more positive way.

One other caveat is that individual staff should not have contact with a client outside of the structure of the agency. They should not become mentors, friends or confidants with a child they treated, as this opens all sorts of opportunities for real or alleged boundary violations and moral dilemmas. And they should not friend former clients on Facebook or use any of the many ways technology enables us to keep in touch.

Clients should be redirected to the agency. They can call the unit or programs, come to visit, write letters. As they discover that people still exist and still care, they will have more courage to form new relationships wherever they travel.

How does your agency handle post-discharge contact? PLEASE click on “comment” and tell us all what you do and why, and share any experiences you have in this area. Thank you.

Motivation

Someone I was talking with recently stated that even though he wanted to implement trauma informed care, his agency had to have a points and level system, because otherwise what is going to motivate the children to start doing good behaviors?

That is a good question. What does motivate the children to change?

I would suggest that there are a lot of built in motivations. These include wanting to be normal, not wanting to live in residential treatment, and the natural urge for mastery. Relationships are the most powerful source of motivation. Once a child feels that someone likes him, believes in him, and expects good things from him he develops a need to please that person and to live up to their expectations.

This goes back to the statement: children do well if they can. Children want to do well. Almost any child, if you talk with him when he is calm, will say that he wants to change, stop hitting people, stop cutting himself. It is not that he is not motivated. It is that he doesn’t know how. Our job is to teach him how.

But aren’t there some kids who do not care about relationships and do not want to do better? Don’t these kids need rewards and punishments to get them started towards better behavior? If I were to meet such a kid, I would wonder why. What has happened to this child that he has given up on relationships as the source of anything good? I would see my job as luring this child back into connection with humanity. What can I do to give the child an experience associating good things with other people? How can I change his templates of relationships, that is, what he expects from others? I would concentrate on providing him with as many positive experiences as possible and always have these be shared with adults. What fires together wires together, his brain would gradually, after many repetitions, begin to associate adults with fun.

I have to say I have come to see daily points and daily/weekly levels as completely unhelpful. To me now they seem to be the essence of not accepting where the child is and of being judgmental, rather than helpful. They increase shame, and the pressure to earn points may make cooperation harder.

Imagine you are trying to learn to drive a car. Although you have been around people driving cars all your life, you have never driven one yourself. You have an instructor. He tells you what to do (without many details of how to do it). And he sits there with a point sheet and rates your performance minute by minute by giving or not giving you points. You know that these points will determine what you are allowed to do that evening, whether you can watch TV or have to go to bed early. If you get all your points you will get a special treat but you know that is impossible.

Does this point system increase your learning? No, of course not. It impedes learning. It increases tension.

Instead, imagine the instructor is kind and gets to know you by talking a bit before each lesson. He carefully teaches you the steps in advance, and has you practice before heading out. He praises everything you do right. At the end of the lesson he congratulates you for your progress, goes over any issues that arise, gives you homework to practice and says he will look forward to your next lesson.

You find yourself wanting to please your instructor, and you practice diligently throughout the week. You are eager to show off what you have learned. You progress quickly.

Isn’t the second scenario closer to what we want to set up for our kids? There are so many powerful sources of motivation inside the kids and within the relationships we create with them. We do not have to rely on points and level systems which will in fact undermine learning.

Self Awareness

Amazing as it is to believe, scientists have identified which regions of the brain are associated with self awareness. Self awareness starts with awareness of bodily sensations, such as hunger, thirst, tiredness, and pain. It includes being able to think about the self, form ideas of the self, notice patterns, and assign attributes. These functions seem to be set in the anterior medial prefrontal cortex. Not surprisingly, self awareness develops through interactions with an attuned other. The caretaker names experiences, assigns words to feelings, connects sensation with action and need with fulfillment. Through these interactions this part of the brain is built, and its connections with other regions developed. Therefore, it is understandable that psychological trauma, including attachment traumas, in the first year of life has been observed to negatively impact on the experience-dependent maturation of the circuits of the anterior cortex.

The children and families we serve who have experienced early trauma have an under-developed ability for self reflection. This means that it is hard to recognize one ’s self. It includes poor awareness of internal stimuli, including the inability to locate the source of internal pain and figure out what to do about it. Imagine that you feel hungry, but you do not recognize the feeling as hunger and therefore eat. You have not been taught by a caring other that this feeling is hunger, and can be satisfied. You are just aware of distress, and become increasingly cranky. In more complex interactions, you cannot identify how your own responses caused reactions from others. Remember, this is an actual inadequacy of one part of the brain. It can be seen in fMRI images and other brain tests. It’s not that you are refusing to understand yourself, its that you can’t, just as a blind person cannot see.

This deficit could be seen in a child not moving away from pain quickly, or appearing not to notice heat or cold. It could result in elimination issues, as the child doesn’t connect his bodily sensations with the need to find a bathroom. It could be a part of eating problems.

It seems to me that understanding this has implications for our constant desire that our children “take responsibility for their actions.” What if the child just does not have the requisite brain structures to be this self aware? Are we insisting he do something he is not capable of?

Luckily, the concept of brain plasticity reassures us that the self reflection part of the brain can be strengthened at any age. How can we help our children in this area? We can do what an earlier caretaker did not do. We can be alert to any signs of need on their part (hunger, pain, toileting, cold) and put it into words and help them immediately satisfy the need. We can avoid being judgmental about this, instead consider teaching much as we would teach them to read if they had never been taught.

An important way of helping is the use of narrative. We can help the children step back and formulate the story of their lives. This can be as simple as a quiet time at night re-telling the story of that day’s activities, or as complicated as a life book. A DBT chain analysis can be a way of creating a narrative of an event. A “Me Book” which illustrates my favorite colors, my favorite games, etc. etc with many facts about me is a way to create a self that can be observed by the self. We can be sure to take pictures, and say “remember when we went to the zoo, and you loved those monkeys?” Any time an adult creates a story about a child’s life she is helping him develop his self-reflective capabilities.

Like every other change we try to make, this change will be slow and involve many, many repetitions. And like every other change we make, it happens only in the context of attuned, engaged, enthusiastic relationships.

Treatment Planning

I have spent the last week with a JCAHO reviewer who was conducting Klingberg’s Tri-Annual Review. After reading many treatment plans in many of our programs, I have decided to discuss them here.

We all know we have to do treatment planning. Why is this an important part of every program requirement? Treatment planning is designed to make us think about what we are doing in treatment and to proceed in a planful way. It forces us to consider what we are trying to achieve with this client, and how we will know if we are making progress. What will success look like? The planning process leads us to consider what change is necessary for the client to leave this particular level of care. Not be perfect, not have solved all his problems or worked on all his issues, but just to be able to step down to the next lower level. And when done right, the process includes the client and his family. How do they define success? What change are they looking for?

Treatment planning is the expression of a theory. The first part of the theory is: what has happened to this person, and how does that relate to his present problem behaviors? The second part is: what will help heal this person? As you write your treatment plan, you are expressing your theory of how events affect people, and what creates change. Your theory determines what you focus on, how you explain what is wrong, and what you propose to do about it.

For example, consider Jason. Jason was abused in his biological family and was removed from them at age four. He has been is five foster homes. He was removed from the second one because he was found outside at midnight and it was discovered that he was being neglected. In the fourth he was molested by an older foster brother. He presents with extreme angry outbursts whenever he cannot get what he wants right away. He often destroys property and has at times hit people. Afterwards, Jason avoids talking about these incidents and often blames the other person.

Suppose your theory leads you to focus on the fact that Jason has never received reliable rules and structure. He is used to taking care of himself. You learn that in his last foster home the parents often gave in to him to avoid his outbursts. You realize that Jason has never been able to accept adult authority. Therefore, you think that what will be helpful to him is a clear set of rules and guidelines. He needs to learn that you must follow rules and respect authority, or he will never get anywhere in this world. He needs to take responsibility for his actions. Therefore, the plan you create for Jason focuses on establishing strict rules and not backing down due to his tantrums. A behavior system that punishes and rewards will help. After any incident, Jason will be restricted until he acknowledges what he did and apologizes. He will be enrolled in an anger management group. In therapy, you will discuss any recent episodes and encourage him to acknowledge his part in them. Your measure of success will be that Jason can accept no for an answer without acting out.

On the other hand, if you held different theories you might look at Jason’s behavior through a different lense. You would focus on how the repeated trauma in Jason’s life had affected his sense of relationships, his biology, and his feelings management skills. You would assume he did not trust adults because the adults in his life had not been trustworthy. You would assume that he blames himself for everything that has happened to him and thus harbors deep feelings of shame. You relate this to his present response to not getting what he wants through understanding that a no to Jason feels like he will never get what he wants and no one loves him and this is because he is a worthless child. So, your treatment plans would focus on building trusting relationships with adults, learning how to calm his racing mind, and developing self worth through exploring his strengths. You discover that he likes to draw so one part of your treatment plan is art lessons. Your treatment plan also includes individual time with adults to build trusting relationships. In therapy you plan some psychoeducation on trauma, which you expect will lessen Jason’s self-blame. You will work with him to develop some things he can do to calm himself down when something goes wrong. You still measure success by the elimination of outbursts that hurt others, but your theory of what causes these outbursts and what will reduce them is different.

The treatment plan evolves from the formulation. The sequence should be:

Child’s history and experiences
Materials from other treaters and adults
History from family

Combine with

Program assessments
The child’s ideas
The family’s ideas

To create

The formulation, which connects the child’s past with his present behavior through a theoretical model of how inherited tendencies combine with experience to shape the person.

By considering the formulation, the therapist can see what the goals are: what changes will have to happen for the child to move to a lower level of care? What skills need to be learned? How will success look?

This understanding is broken into:

A description of the problem
It’s opposite, the goal
Specific measurable objectives which detail the steps that will lead towards achieving that goal
The interventions which will accomplish those objectives
The person responsible for each intervention

The objectives are another expression of the theory. If (as with Jason) we are working on decreasing shame and increasing self worth, we must consider what do we actually think decreases shame? Objectives could include helping younger kids in an elementary classroom, a leadership role on the unit, taking art classes and holding a show of his work, etc. These would express a conviction that positive accomplishments decrease shame.

It is tempting in our hectic lives to complete treatment plans without any thought, and use the same plan for many kids. Yet if we actually allocate time to think about them and discuss them with our Treatment Team, they can become an excellent tool for sharpening our thinking and our work.

I developed a library of treatment planning goals and objective that come from trauma informed practice. Feel free to email me at patw@klingberg.com if you are interested.

Ideas from Moving Forward Conference

I have just returned from the Moving Forward in Challenging Times Conference in Austin Texas. This SAMHSA funded conference focused on Domestic Violence and Substance Abuse programs, most specifically how they could work better together so the clients would experience fewer barriers. It was sponsored by Safe Place of Austin, an organization that provides direct service, prevention, and advocacy. The conference was very inspiring, and I wanted to share some ideas I learned there.

I was inspired by the participants at this conference. They approached their work from a mission base, a deep commitment to their clients. And they were working hard to change their programs so that any person would be welcome, there were no barriers to care, no restrictions to participation. This means that however a woman shows up, drunk, using, dirty, belligerent, whatever, she is welcomed with food, sleep and talk. They had carefully redesigned their intake and assessment to be welcoming, and not designed to unearth rule outs, but instead to help them be more skillful and individualized in the help they offer. They have tried to eliminate rules and recognize that their participants are adults. Instead, they have agreements that the clients make with each other. If one is broken, they discuss it. It seemed to me that they were trying to radically work from the premise that the woman is doing the absolute best she can, and their job is to help her do whatever she wants to do next.

Many of these programs use some kind of a crisis management plan, which in my program we call ICPMP. I was impressed with an idea from one presenter, Lourdes Carrillo. Instead of asking what helps you when you are upset and framing the discussion in terms o a crisis, ask questions to get to know the person. Like, “What do you like to do? How do you relax? How do you prepare for difficult situations?” and getting very precise. If the person says she likes music, what kind of music. If she says she relaxes by sitting on the couch, are her feet up or down? Does she like to have something to eat or drink? Water? With ice or without? All these details will be then available when she does get upset- staff can invite her to sit down and bring her some ice water. I think this approach honors the strengths of the person, and acknowledges that she already has many valid strategies for managing difficulties. And, it gives us a lot to work with when life gets hard.

Another interesting point I’d never thought of was in the area of confidentiality. When we say to clients that what happens between us will never be shared with anyone else, this may remind clients of when they were abused. It may sound to them like we are saying that what happens in treatment is a secret. They have already experienced too many secrets and they have usually included danger. Ms. Carillo suggested saying this instead: “This is your story. I am privileged to hear whatever part of it you wish to tell me. It is up to you who knows your story, so I will never tell anyone else whatever you tell me. You, however, are free to talk about what happens here to anyone you want.”

There was a lot of discussion of self care at the conference, including vicarious traumatization and ways organizations traumatize their workers. I was struck by the presentation of Karen Kalergis and Sapana Donde. They spoke of going beyond coping with vicarious traumatization to creating resiliency in our work force. They listed five core elements of resiliency: self knowledge and insight; sense of hope; healthy coping; strong relationships; and personal perspective and meaning. They shared strategies for increasing each of these. I was struck by how well this integrates with both the RICH relationships and our thoughts on addressing and transforming VT.

It is always exciting to meet new people and old friends, and to be re-inspired by the dedication and commitment of others. I could have done without being stuck in Chicago’s Midway airport all night on my way home, but otherwise this conference was a worthwhile experience.