2011 NATSAP Annual Conference

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

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

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

1. The brain is hierarchical.

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

3. Brains develop in sequential fashion.

4. Brains develop most rapidly in early life.

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

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

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

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

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

Brittany in Transition

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

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

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

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

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

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

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

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

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

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

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

Administrative Support for Trauma Informed Care

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

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

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

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

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

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