The Primacy of Safety

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What Administration Can Do to Support Trauma Informed Care

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

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

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

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

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

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

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

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

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

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

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

It’s All for You, Mallory

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

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

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

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

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

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

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

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

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

Becoming Naked

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

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

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

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

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

Some possibilities that occur to me are:

1. To shock and get a reaction

2. To keep people away

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

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

5. To replicate what they saw in their family

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

There must be many other thoughts.

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

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

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