Deep Listening

One of the more difficult concepts which we teach is the power of listening. Such an old idea, so commonly taught, so rarely applied. In our training we have a section in which participants role play handling a crisis using a trauma informed approach. The most common problem is that people jump too quickly to offer solutions. They do not spend time to explore what the child is experiencing. In practice in our agency I hear the same thing. It is so tempting to offer advice, and so difficult to just stay with and share the other person’s pain.
We do this in spite of the fact that we ourselves do not like it when someone does this to us. What if I were to tell you that I was at my elderly father’s house last night, and I felt so tense about his deteriorating condition and what I should do that I ate two boxes of cookies? How would I feel if you responded: "Pat, there are better coping skills you can use. Next time you go there, bring some carrots." I actually might slap you. I would not even appreciate it if you told me about Visiting Nurse agencies in the area. Instead, what do I need? Some one to just say: "That sounds difficult. That must be very stressful for you."

Since I struggle to teach this is a way that people will remember it, I was struck when I recently read an interview of Thich Nhat Hanh by Oprah featured in O, The Oprah Magazine February 16, 2010. Thich Nhat Hanh has been a Buddhist monk for more than 60 years, as well as a teacher, writer, and vocal opponent of war—a stance that left him exiled from his native Vietnam for four decades. He speaks here of the incredible power of listening and not correcting:

"Oprah: The case is the same for deep listening, which I've heard you refer to.

Nhat Hanh: Deep listening is the kind of listening that can help relieve the suffering of another person. You can call it compassionate listening. You listen with only one purpose: to help him or her to empty his heart. Even if he says things that are full of wrong perceptions, full of bitterness, you are still capable of continuing to listen with compassion. Because you know that listening like that, you give that person a chance to suffer less. If you want to help him to correct his perception, you wait for another time. For now, you don't interrupt. You don't argue. If you do, he loses his chance. You just listen with compassion and help him to suffer less. One hour like that can bring transformation and healing.

Oprah: I love this idea of deep listening, because often when someone comes to you and wants to vent, it's so tempting to start giving advice. But if you allow the person just to let the feelings out, and then at another time come back with advice or comments, that person would experience a deeper healing. That's what you're saying.

Nhat Hanh: Yes. Deep listening helps us to recognize the existence of wrong perceptions in the other person and wrong perceptions in us. The other person has wrong perceptions about himself and about us. And we have wrong perceptions about ourselves and the other person. And that is the foundation for violence and conflict and war. The terrorists, they have the wrong perception. They believe that the other group is trying to destroy them as a religion, as a civilization. So they want to abolish us, to kill us before we can kill them. And the antiterrorist may think very much the same way—that these are terrorists and they are trying to eliminate us, so we have to eliminate them first. Both sides are motivated by fear, by anger, and by wrong perception. But wrong perceptions cannot be removed by guns and bombs. They should be removed by deep listening, compassionate listening, and loving space.

Oprah: The only way to end war is communication between people.

Nhat Hanh: Yes. We should be able to say this: "Dear friends, dear people, I know that you suffer. I have not understood enough of your difficulties and suffering. It's not our intention to make you suffer more. It is the opposite. We don't want you to suffer. But we don't know what to do and we might do the wrong thing if you don't help us to understand. So please tell us about your difficulties. I'm eager to learn, to understand." We have to have loving speech. And if we are honest, if we are true, they will open their hearts. Then we practice compassionate listening, and we can learn so much about our own perception and their perception. Only after that can we help remove wrong perception. That is the best way, the only way, to remove terrorism.

Oprah: But what you're saying also applies to difficulties between yourself and family members or friends. The principle is the same, no matter the conflict.

Nhat Hanh: Right. And peace negotiations should be conducted in that manner. When we come to the table, we shouldn't negotiate right away. We should spend time walking together, eating together, making acquaintance, telling each other about our own suffering, without blame or condemnation. It takes maybe one, two, three weeks to do that. And if communication and understanding are possible, negotiation will be easier. So if I am to organize a peace negotiation, I will organize it in that way.”
(Read the full interview at
http://www.oprah.com/spirit/Oprah-Talks-to-Thich-Nhat-Hanh)

So- Listening may be a path to world peace- and it is definitely the path through which we offer connection to our children and families. It can be painful, because it necessitates opening your heart to the sadness and suffering of the other person. But it is also healing, both to our clients and to our selves.

Transforming Resistance to Enthusiasm in MA

On April 6, 2010 (Tuesday) Steve Brown, PsyD. and Pat Wilcox, LCSW will be presenting at the Massachusetts Department of Mental Health Child & Adolescent Restraint/Seclusion Prevention Initiative Grand Rounds. Our topic will be: Transforming Resistance to Enthusiasm - Implementing Trauma-Informed Care. Trauma-informed care is an important element to the success of preventing restraint and seclusion use. This training will provide and understanding of how to implement trauma-informed care in child & adolescent settings. It will include an overview to the Risking Connections trauma training program, as well as the Restorative Approach which is a trauma- and relationship-based approach to treatment of children. The presentation will focus on the most effective transformation process for overcoming common staff concerns and changing resistance to enthusiasm.


The presentation will be held 9:00 AM – 12:00 PM, (Registration starting at 8:30AM) at the Lazare Auditorium of the UMass Medical School in Worcester, MA. The registration deadline is Monday, March 29th, 2010. To register please contact Annabelle Lim at Email: annabelle.lim@massmail.state.ma.us or Phone: 617.626.8087. An email confirmation with directions will be sent upon registration. CEU applications have been submitted for: Licensed Mental Health Counselors, Psychologists, Nurses, & Social Workers. Hope to see you there!

The Rush to Change

We are in the change business. So when a child comes to us because of difficult behaviors our first thought is what can we do to change him or her? Jeffrey assaults people when he doesn’t get his way. Latasha cuts herself so badly she sometimes needs to go to the ER. How can we stop these things? That’s why people pay us the big bucks after all.

And there is plenty of external pressure for change- at every review someone is asking why that child hasn’t changed yet. Her parents, too, have suffered enough and want to see something different soon.

Then there is the internal pressure. Our lives would be a lot easier if these kids would stop doing these crazy things. And we judge ourselves- do we really know what we are doing? When Jeffrey hit his teacher yesterday is it because I am not a good enough therapist? I feel guilty about the pain the teacher suffered. We can start to blame each other- isn’t it the therapists’ job to take an angry child to her office and bring her back calm and happy?

And when we feel compassion for the child, we start to feel even more urgent about change. Jeffrey’s life would be so much easier if he could control his anger. He is in danger of being kicked out of this place, as he has been out of his last six places. It is so painful to see the blood stream down Latasha’s arm.

In this urgency for change we ourselves feel powerless, vulnerable and incompetent. We feel much like the kids we serve. So like them, we turn to something that we think will give us more power and control. We often think first about punishment. Surely if we restrict Jeffrey long enough he will learn that his life goes better if he does not hit people. Or, being more enlightened, we think about rewards. Maybe if we promise Latasha that we will take her out to lunch if she can go a week without cutting…

It would be actually astonishing if Jeffrey didn’t already know that his life would go better if he controls his anger. Look at all the bad things that have happened to him already- he is on probation, he has been kicked out of six placements, and he is in residential- just to name a few.

When Latasha is calm she fervently wants to stop cutting, and she hates her scars. She does not need more motivation. She needs more skills.

I would suggest that this very urgency we feel to change the kids gets in the way of effective treatment. It makes it harder for us to stop and think about what is going on. How do we understand this behavior? What is actually happening when Jeffrey hits someone? What leads up to Latasha’s cutting? What problem are they trying to solve? How does this behavior help them in the moment?

We need to take time to explore, observe, think and consider. We need time to help the child feel safe enough to share their experience with us. They will be able to do this when they form strong relationships. In collaboration with the child we will discover the meaning and function of the behavior.

Then, we must consider what skills the child would need in order to choose a different behavior, a new way to meet his needs. It will take time for the child to learn these skills.

Jeffrey formed a close relationship with his teammate (primary child care worker). After a while Jeffrey shared how scared he was that he is such a bad kid that no one will ever take care of him or meet his needs. He said has learned that force is the only way you get anything you want. Staff started looking for the first signs that Jeffrey was agitated and asking if he needed anything. In small steps Jeffrey learned to trust them enough to ask for help. It was important that at the same time Jeffrey discovered a skill at cooking, and became the star chef of the school café. He got a lot of praise and recognition for this and was generally feeling better and calmer.

Latasha connected with her therapist slowly. They began looking at the patterns that led up to cutting. After a while, several factors were identified: not getting enough sleep, fighting among the girls on the unit, and not hearing from her mother. They worked out many strategies, including a crisis kit. Medication helped with her disturbed sleep. Latasha found soothing music, a piece of fur to rub, and a honey candy soothing. This did not always work and she continued to cut for a long time, but the self harm decreased in frequency and severity. She started telling staff when she felt vulnerable.

Note that these children did not change quickly. They did not change because of punishment. But with time, safety and relationships they did change.

And then the staff felt the true power of changing the life of a child.

Healing the Generations Conference

I want to highly recommend the second annual Healing the Generations conference at Foxwoods on March 25 and 26th. Last year’s conference was wonderful and this year looks to be even better. I am presenting on Trauma Informed Foster Care, Helping Survivor Parents and What We Know about the Brain and What We Should Do. My colleague Steve Brown is presenting on teaching Healthy Sexuality to High Risk Kids, and on our statewide initiative to use Risking Connection to train the staff of Extended Day Programs. This presentation, in conjunction with Marilyn Cloud from DCF, will include exciting new research demonstrating the effectiveness of the training. I hope to see you at the conference, and be sure and come up and say hello!


The Clifford W. Beers Guidance Clinic, Inc. Presents

Healing the Generations:

Second Annual Family Violence and Child Trauma Conference

Keynote Speaker: Dr. Alicia F. Lieberman, PhD

Dr. Lieberman has spent her career trying to prevent and undo the emotional damage inflicted on people at very young ages. "Young children, even babies, remember traumatic events in their bodies with increases in stress hormones such as cortisol--the event makes a distinct impression on them." Investments made in the first three years of life have the best predictive role in creating positive change in a person's life, so the infancy years are crucial in shaping not only individuals, but society as a whole.
Dr. Lieberman's keynote and workshop will describe the impact of chronic adversity on parents' attitudes and child-rearing practices, illustrating the transmission of emotional difficulties and relational conflicts from one generation to the next. It will also describe how parents can surmount difficult child experiences to transmit a message of love and hope to their children.

Spotlight on Workshop Presenter:

Michael Mack

Haunted by memories of childhood clergy sexual abuse, Michael Mack wondered for decades if one day he might meet his abuser for a conversation. In 2008 he had that chance. Although Mack had anticipated countless scenarios, what happened was beyond anything he had ever imagined. He will deliver a theatrical monologue about the healing power of personal storytelling. He uses monologue "because when we can talk to ourselves consciously, we can experience healing more deeply."

Michael Mack is a poet, playwright, and solo performer best known for his one-man verse play "Hearing Voices (Speaking in Tongues)" about his mother's life with schizophrenia. Mack has performed Off-Off-Broadway, at the US Library of Congress, at Yale University, and for faculty and students of the Harvard Medical School.

For full conference agenda visit:

www.cliffordbeers.org

Up to 12 CEUs will be available through the Women's Consortium for MFT, LPC, LCSW, NASW and CCB.

Contact Info:

Jane Hendrickson at (203) 772-1270 ext 246 or jhendrickson@cliffordbeers.org

Legacy of Caring Conference a Resounding Success

On February 9, 2010 Devereux Mass and Klingberg Family Centers co-sponsored a conference entitled "The Nuts and Bolts of Trauma Informed Care". The conference was attended by over 300 people, from CT. MA, Florida, Kentucky, NY, Missouri and several other states.

The conference began with a welcome by Steve Yerdon, CEO of Devereux. After Dr. Bob Davis set the frame of the day, Dr. Steve Brown asked the audience questions to determine who was attending. Some participants rated their agencies at the beginning of trauma informed care; others had considerable experience. Disciplines such as direct care, therapists, administrators, nurses and teachers were all represented; and settings included residential, schools, hospitals, out patient and foster care.

Dr. Davis led the presentations with a history of the trauma informed care movement, which related to the restraint reduction initiatives. Then Dr. Brown and Dr. Davis described the Risking Connection® foundational trauma training. Dr. Brown included a clip from Star Trek in which the character Data, who has no feelings, wonders whether it is actually advisable to form connections- much as our children do.

Patricia Wilcox, LCSW and Dr. David then described a vision of a trauma informed agency, using a formulation created by Roger Fallot. Ms. Wilcox described how an agency can incorporate safety, trustworthiness, collaboration, choice and empowerment. Dr. Davis followed with sharing agency practices that embody administrative commitment to change, universal screening, staff training and education, hiring practices, and supporting policies/procedures.

At lunch the Legacy of Caring Award was bestowed on Lynn Sanford, LCSW. Lynn made an inspiration and humorous acceptance speech.

After a delicious lunch (the cheesecake got especially good reviews) participants attended workshops on trauma informed care on the units, in education and in clinical practice. The role of administration in creating and sustaining trauma informed care was the subject of one workshop, one covered sensory interventions, and the Restorative Approach was another.

Participant comments included:

"It was relevant to what we are trying to do. The presenters were knowledgeable and helpful."
"I appreciated the honesty about the challenges."
"Different agency perspectives were helpful in comparing/contrasting real life processes and challenges."

Trevor and his Restorative Experience

What we heard on the grapevine Monday morning- a kid trashed Susan’s office! He even broke her computer! Can you believe it?

Trevor worries about everything. He loves his mother, and his worrying may have started very early in life when he observed her being beaten by his biological father. His anxiety continued to mount as his mom’s mental health problems have caused her to have extreme, fluctuating moods, at times feel suicidal and need hospitalization, and often need a lot of help from others. Trevor blames himself whenever his mom is unhappy or having trouble. His stepfather tries to take care of Trevor, but his rigid standards result in him using discipline such as tying Trevor to the bed and stuffing socks in his mouth. Trevor worried when one of his brothers died and worried when another was placed out of the home. Trevor knows this is all just because he is a bad kid.

Trevor wants to be good. He tries to please everyone. Yet he gets so anxious so fast, and at age 14 he becomes completely overwhelmed by sudden changes, uncertainty, unpredictability, and things going wrong. The pressure in his mind is so intense that he resorts to behaviors such as head-banging, self-cutting, screaming and physical agitation.

So when another kid, Marvin, broke off the antenna of Trevor’s new remote control car, the one his mother gave him on her last visit, it was more than Trevor could bear. Aside from being angry that the car wouldn’t work and sure that it could never be fixed, Trevor believed that his mother would blame him for not taking better care of this expensive present. It was her hard earned money and already it was broken! One more example of how he could never do anything right.

Trevor could not stand how horrible he felt, and so he started screaming-- and the staff were just making it worse by talking to him. So Trevor ran off the unit and outside. As he was storming around the yard he noticed an office window that was open right over a porch roof. A refuge! He easily climbed up and got in the window, closed and locked it, and found himself in the secretary’s office-- but staff saw him! They couldn’t get through the now closed window, but they were knocking on the door and trying to unlock it.

Trevor knew that if they got in all sorts of horrible things would happen, people would yell at him, he’d be kicked out, he’d have to go to jail, and he’d never see his family again…so he decided to barricade the door. He began moving furniture frantically towards the door. As he pushed the desk, the computer monitor fell off and broke. A whole lot of plants toppled over. The fax machine fell and shattered. When he moved the bookcase, lots of papers scattered around. But he kept pushing furniture towards the door- he had to make himself safe.

The staff became worried. They could not get the door open. The banging continued. And the sounds Trevor was making made them wonder if he was hurting himself. So, they called the police for help. The staff were able to disable the door, and with the police present opened the door, and Trevor moved some of the furniture so they could get in. The staff and police decided Trevor needed to go to the ER. The policeman told staff that he would call later about whether or not Klingberg wanted to press charges.

So- a kid did major- in fact VERY major- property damage, and destroyed the office of someone we all love. What should we do?

Susan was surprised when her boss, the Vice President of Treatment Programs, met her at the door on Monday when she came in. He wanted to warn her before she opened her office door. And when she did, she was horrified. Who could have done this to her? And why? She was always nice to the kids and in fact she had had some pleasant conversations with THIS kid. Why would he target her? And all the work she was going to have to do to clean this up and restore order!

Susan was a little apprehensive when the team suggested that Trevor would need to work with her when he returned from the hospital. Would she even be safe with someone who could do all this? What on earth could she have him do? What should she say to him? Should she talk about what happened and her reactions, or not? And besides- she was quite angry that he had caused all this devastation and she wasn’t at all sure she wanted to be around him.

Susan talked all this over with the team. They validated her feelings and encouraged her to talk to Trevor about her reactions and listen to his experience of what had happened. She agreed to participate in the restorative process.

Meanwhile, the team discussed whether it would be helpful to have Trevor arrested for the property damages he caused. For some kids, being arrested could provide a deterrent next time. Yet when the team talked it over, this did not seem to be the case for Trevor. His main problem was that he worried too much, and gets over whelmed by anxiety about all the ways he has disappointed everyone and all the bad things he knows will happen. Being on probation would probably make that worse, cause him more panic and make it more necessary for him to do something to escape his horrible feelings. So the team decided not to press charges.

While Trevor was in the hospital he did not really want to come back to Klingberg. He was so ashamed of what he had done, and he did not want to see people who knew about it. He assumed they all hated him now; in fact he was surprised he was even allowed to come back. He was especially worried about seeing Susan and said "I thought she would yell at me."

Trevor was scared when he started working for Susan. She had him carry some heavy boxes of files to the downstairs storage area. He was proud of how much he could carry! He was afraid he would do it wrong but soon saw that he was actually helping her. The next day they started to re-pot all her plants. During this process they talked a little about what had happened. Susan told Trevor how upset she had been walking into that mess. He apologized and said he had just been so scared.

Susan says that the experience of working with Trevor made a difference in how she thinks about this event. "I realized he was not attacking me. I could see he was just so scared. And it meant a lot to see how genuinely sorry he was. He even brought me back pictures from a trip he went on. I am not left with anger or fear. I don’t feel like I am working with a bunch of dangerous kids. I feel sad about how scared Trevor is and I hope we can help him feel better."

Trevor says that he liked working for Susan. In fact, he kept doing things for her and making her things long after the restorative tasks were over. When asked if he thought the fact that he liked doing the tasks would encourage him do something wrong again in order to be assigned new pleasurable tasks, he looked puzzled and couldn’t get that concept. “Maybe it would work that way for some kids” he said "but not for me. Not for me." (Clearly, he’s never taken a course in behavior therapy!) When he imagined just being grounded instead of doing the restorative work, Trevor said "then I would still be worried and nervous and I’d still be feeling so bad about what I did. Now I am friends with Susan."

Trevor is leaving Klingberg soon and going to a therapeutic foster home. When asked if he thinks he has changed, Trevor says, "Oh yes, now I can use some coping skills." What are those? "Art- I really like art. And music. I have a guitar now. And drama- did you see me in the last school play? And I am going to be Jack in the next one." What helped him most were "the staff- not the kids so much-although some kids helped me." He thinks that the kind of staff that help kids are the kind that "listen and don’t get an attitude," although he does feel they should be "strict." And Trevor says that it has helped him that staff have been his friends- especially Susan.

The Devil is in You

I met a gentleman named Ernie this week who was talking about his life. He is French Canadian, and grew up speaking French in his home. He attended Catholic school. When ever he answered a question in French, the nun would hit him with a ruler. He was not taught to read English, but was punished for not being able to do so. The nuns told him that his problem was that he had the Devil in him, and that their job was to drive the Devil out- mostly through punishment.

Ernie dropped out of school before graduating, and got a job working hard as a carpenter- skills he learned from family members who were also carpenters. He never learned to read or write.

I think we would all disagree with this form of education and we would not be surprised that it was not successful.

Yet, how different is this (except in degree) from our traditional ways? We see what the child has learned from their family. We do not like it, and we try to drive it out with punishment. Luckily, there is not so much hitting with rulers- more confinement to small rooms.

In various ways we convey to the kid that he has the Devil in him, and we are trying to drive that Devil out with our strictness.

And often the kid drops out of treatment, and remains emotionally illiterate. They can sometimes till be successful as Ernie is, if they find people to teach and mentor them. But they are left with a bad feeling of being a Devil-person.

There must be a better way.

From Strategy to Reality: The ‘Nuts and Bolts’ of Implementing Trauma-Informed Care in Child and Adolescent Settings

I want to make sure that you all know about our conference in Worchester MA on Feb. 9. We are delighted that both people we have worked with and people who may want to work with us are coming in from other states for the conference. We hope to see you there!

Devereux presents:

The 2010 Legacy of Caring Conference
(in conjunction with Klingberg Family Centers)

From Strategy to Reality: The Nuts and Bolts of Implementing Trauma-Informed Care in Child and Adolescent Settings

Date: February 9, 2010
Time: 9:00 am - 4:30 pm
Location: Crowne Plaza Hotel
10 Lincoln Square
Worcester, MA 01606

Overview:

Successful restraint and seclusion reduction happens within a trauma-informed setting. But, implementing trauma-informed care (TIC) requires system-wide culture change - - no easy task, especially with ever-more challenging clients and settings that historically have placed a premium on controlling children’s behavior. Centered on the Risking Connection® treatment philosophy, this nuts and bolts conference will help your school or agency translate broad stroke strategies about trauma-informed care to real life solutions.

Conference Objectives:

• Participants will be able to describe the daily operations and practice of a trauma informed agency and relate these to restraint reduction.
• Participants will identify training strategies that promote trauma-informed care,
Including Risking Connection®, an established curriculum for working with traumatized youth.
• Participants will learn trauma-informed behavior management, administration, milieu and classroom treatment techniques, which can be integrated into existing evidence-based models of treatment.
• Participants will learn ways to anticipate and overcome many of the institutional challenges of implementing trauma-informed treatment.

Schedule:
8:00-9:00 AM Registration and Check-In
9:00-9:30 AM Welcome and Introductions
9:30-9:45 AM Trauma-Informed Care: Its History and Relationship to Restraint Reduction
9:45-10:45 AM Risking Connection®: An Integrative Pathway Toward Trauma-Informed Care

10:45-11:00 AM BREAK

11:00 AM-12:00 A Vision of a Trauma-Informed Agency

12:00-1:00 PM LUNCH (provided)
Presentation of the Annual Legacy of Caring Award

1:00-2:30 PM Workshop One (please choose one of the following)
A. If You Don’t Feed the Staff, They’ll Eat the Children: Leadership’s Role in Trauma-Informed Change
B. Relationships, Structure & Individualized Care: All This and Paperwork Too? Running a Trauma-Informed Care Unit
C. From Chill Rooms to Calm Down Kits: Sensory Interventions to Prevent Crisis
D. Healing the Heart of the Helper: Helping Staff Manage Vicarious Trauma

2:30-2:45 PM BREAK

2:45-4:15 PM Workshop Two (please choose one of the following)
A. Relationships, Structure & Individualized Care: All This and Paperwork Too? Running a Trauma-Informed Care Unit (Workshop 1 repeated)
B. The Restorative Approach: A Relationship-Based Alternative to Points and Level Systems
C. How Can I Be Trauma-Informed and Still Get Through My Lesson Plan? Trauma-Informed Care in Educational Settings
D. Why Are These Kids Doing These Crazy Things? The Role of the Clinician and Clinical Supervision

You may register on line: http://events.devereuxma.org

Or call 508-886-4746, ext. 314. Fax 508-886-4473

See you Feb. 9th!

A Warning Sign

"It’s the tasks" your program manager says to you. "We just cannot seem to think of enough tasks to assign to the kids in my unit. And those we can think of they don’t take seriously, they are done quickly, and I just don’t think they are significant enough to deter the behavior."

What would be your response to this plea? Would you start researching tasks that the unit could use?

I think this is a sign that more training is needed. In my experience, this focus shows that staff are still considering the tasks as punishments, and thinking that their power for change is found in their deterrent function. That is, the kids won’t want to do the tasks so they will avoid that behavior. If you are thinking that way, you start to wonder if the tasks are hard enough, significant enough for the bad behaviors. You become concerned if the kids seem to enjoy the tasks. You hear statements like "they did ... and THAT is all they have to do?"

Let’s step back a few steps. Our basic premise is that symptoms are adaptations- that the kids are doing the best they can, and they are doing these behaviors because they do not know any other way to handle their intolerable feelings. Therefore, in the Restorative Approach we respond to behavioral problems with tasks that are designed to help the child learn new skills and to repair damaged relationships.

So- Kayla has a difficult call with her mother. (A small (or large) set back happens in the present.) Kayla does not trust relationships and cannot ask for help. She is already over activated and is now completely lost in her stress response. She has no sense that there is any one who loves her and will care how this turns out. She feels pretty worthless anyway, and knows that this latest event is just one more sign of what a lousy person she is and how her mother gave her up because she is such an awful girl. And she does not know how to notice, identify or sooth her feelings. So, Kayla is plunged into the depths of fear and hopelessness. Who wants to feel that way? So she does something, anything, to escape these feelings. She cuts herself. She throws a chair. She runs away. She hits a staff.


So what Kayla needs to be able to handle a setback in a better way is:

Relationships she can trust
A calmer body
A sense that people care about her, and the ability to remember them when they are not present
The knowledge that she is worth the air she breathes
and
Skills to identify and soothe her feelings

And hopefully we know Kayla. We know the neglect, sexual abuse, and multiple placements she has experienced. We know her strengths in drama and her ability to teach younger children, and we know how mornings are hardest for her. And we have a formulation, a theory about what is going on with her and that our primary theme in working with her is learning to trust others and ask for help.

So this is where the tasks come in. The tasks are a chance to practice some part of what she needs. To put one building block in her wall of creating a competent self.

Kayla will act better when she feels better. After her blow up she is feeling worse, more shame, more self hatred. And that can send her into another acting out episode.

So- the tasks.
Making amends helps strengthen relationships and teaches how to fix problems in relationships.
Doing a task with a staff member is practicing trust and accepting help.
It is also practicing effective action- when something goes wrong, Kayla can do something about it. She does not have to freeze.
Practicing what to do when upset (a feelings chart, a poster to illustrate what Kayla was feeling or six steps I can take when she is angry, interviewing others, making a plan for her next contact with her mother, etc) help to develop feeling skills, and include methods to create a calmer body.
Doing something to make things better (chores, create a bulletin board, make brownies, helping a younger child with her homework) increase self worth.

The idea is to use the opportunity that an episode provides to help give Kayla what she needs to handle life better.

Kayla doesn’t have to hate the tasks. She has to take them seriously and do them well. Then its over, and we go on, hopefully just that little bit closer to what she needs.

This is where I would focus with the unit that needs more tasks.

New Resources

My Australian friend Laurel Downey has created a wonderful new resource: From Isolation To Connection: A Guide To Understanding And Working With Traumatized Children And Young People. It is available at: http://www.ocsc.vic.gov.au/

Published by the Child Safety Commissioner, Melbourne, Victoria, Australia, November 2009

© Copyright State of Victoria, Child Safety Commissioner, 2009
This resource was commissioned by the Child Safety Commissioner and written by Laurel Downey, previously Manager of Practice Development and Training for Take Two, Berry Street Victoria. Laurel is currently consultant to the learning and development strategy for non-government child protection placement services for Far Northern and Northern Queensland and based at James Cook University, Cairns.
(laurel.downey@jcu.edu.au)

At the same site is her previous work: Calmer Classrooms: A Guide To Working With Traumatized Children
This resource was commissioned by the Child Safety Commissioner. It was written by Laurel Downey, Manager, Practice Development and Training, Take Two, Berry Street Victoria. Laurel would like to acknowledge her Take Two colleagues, Annette Jackson and Lisa McClung for their contribution to her work. Published by the Child Safety Commissioner, Melbourne, Victoria, Australia June 2007 © Copyright State of Victoria, Child Safety Commissioner, 2007

Please check these out and let me know what you think!

I just finished an interesting new book: Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others (Paperback) by Laura Van Dernoot Lipsky, Connie Burk, Berrett-Koehler Publishers (May 1, 2009) which is available at:
http://www.amazon.com/Trauma-Stewardship-Everyday-Caring-Others/dp/157675944X/ref=sr_1_1?ie=UTF8&s=books&qid=1263142968&sr=1-1

It is interesting that Van Dernoot Lipsky extends her audience to include those who work caring for animals and in ecological preservation. Witnessing the harm done to animals or to our world can also have profound effects on the helper. This book explains in detail sixteen common components of what she calls a "trauma exposure response" The author then adapts a Native American custom to explore five directions to maintain ones self within this work. A daily centering practice is essential to her approach.

The cartoons added a nice touch!

Another book I am reading is Pain, Normality and the Struggle for Congruence: Reinterpreting Residential Care for Children and Youth James P Anglin Routledge; 1 edition (August 22, 2003).
It can be found at: http://www.amazon.com/Pain-Normality-Struggle-Congruence-Reinterpreting/dp/0789021404/ref=sr_1_1?ie=UTF8&s=books&qid=1263144143&sr=1-1#noop
This book was recommended to me by Martha Holden, the Director of the Cornell CARE Project. It is an important influence on their work. This author studied many group homes in Canada in an attempt to discover what makes a good group home for children. It is very interesting. He is clear about the tensions between best practices and the many pressures and constraints on programs. He gives specific ideas for creating a healing environment, all of which fit completely our work and message.

All comments are welcome.

Happy New Year- New at TSI for 2010

Happy New Year to all readers! Let’s make 2010 a banner year in changing the world- in making sure that the children and families we serve get the best, most effective, caring and meaningful treatment possible.

Here at the Traumatic Stress Institute we have been doing some planning and thinking as to how we can become even more effective in spreading the word about trauma informed treatment for children and adolescents.

We have been working with consultants to develop a new logo and a new look- soon you will be seeing our butterfly on all our materials. Along with that we hope to expand out use of social media. We already have a Facebook page (http://www.facebook.com/home.php?#/pages/Traumatic-Stress-Institute-of-Klingberg-Family-Centers/178395157455 ), but want to learn how to use this and other avenues to better stay in touch with all of you who are also doing this hard work.

To that end we plan to begin a newsletter. Send us your email if you want access to news of what we are doing, information and articles about developments in our field, and other updates. Send your email to megana@klingberg.com with a note that you would like to be on our mailing list.

An exciting change is that we will be occupying a new space in Hartford. Klingberg Family Centers is moving its Hartford office, and as part of that move the Traumatic Stress Institute will have a new space. It will be located at the Rudder Building at 157 Charter Oak Avenue. This is near the new Convention Center and Science Center. Stay tuned for details on our Ribbon Cutting event early this year.

We have been working on a project for Trauma Informed Foster Care that we will have ready this year. It will include Trauma Informed Behavior Management Guidelines for Foster Parents and a six session training manual entitled: Trauma Informed Foster Care- Why are These Kids Doing These Crazy Things and How Can I Help Them while Preserving My Sanity?. Let us know if you would like to find out more.

Our Director of Training, Steve Brown PsyD. has been working hard putting together research that we and other agencies we have trained have conducted on this method. We hope to have those results available soon.

Of course you will not want to miss our conference in Worchester MA. The title is: From Strategy to Reality: The ‘Nuts and Bolts’ of Implementing Trauma-Informed Care in Child and Adolescent Settings. The date is February 9, 2010 from 9:00 am to 4:30 pm. We are co-sponsoring this conference with Devereux, MA. You may also register on line: http://events.devereuxma.org or call 508-886-4746, ext. 314.

We are working on several Risking Connection® trainings. Our next open training is on January 27-29 at Klingberg. (To register contact megana@klingberg.com 860-832-5514.) Steve Brown continues to teach on Healthy Sexuality for High Risk Kids. He will be traveling to the Yukon Territory, Canada to do this training in the spring.

We will continue to support our excellent Associate Trainers though consultation groups, the Day of Learning and Sharing, and other activities. One upcoming event for Associate Trainers is a half-day training by Kathy MacAfee, America’s Marketing Motivator, entitled: Telling Stories and Other Strategies for Presentation Success. This should be a valuable resource for our trainers.

We will present at the MASOC/MATSA conference from Wednesday April 7 through Friday April 9, 2010.conference on He Just Refuses To Take Responsibility!!! -- Implications Of Trauma Theory On Th Issue Of Taking Responsibility. Look for the conference brochure in early January or visit one of our websites in early January at www.mascoc.net and www.matsa.org. And if you have any questions please don't hesitate to contact Diane Langelier at (413) 540-0712 x14.

These are just a few of the exciting events we expect in 2010. We look forward to joining with you in changing the world through improving treatment for children and adolescents.

Holiday Greetings from the Traumatic Stress Institute of Klingberg Family Centers!

We wish you a joyful holiday season rich with connections!

2009 was a very full year for the staff of the Traumatic Stress Institute. We wanted to share some of our 2009 highlights and look forward to working with you in 2010.

Through our sister organization the Trauma Education Research and Training Institute (TREATI) we completedseven Risking Connection® trainings, including teaching in Kentucky, Pennsylvania, Connecticut and California, and five Train the Trainer trainings, as well as two Restorative Approach trainings. We added over a hundred new RC Associate Trainers. Over thirty Risking Connection® trainers were recertified after having been trainers for two years.

A major project was training staff from all Extended Day Treatment programs in Connecticut, as well as training many Extended Day RC Trainers. Our thanks go out to Marilyn Cloud of DCF for all her hard work and excellent coordination for this effort.

We did numerous presentations at conferences including: Healing the Generations Trauma Conference (CT), Child Welfare League of America (Washington DC), Association for the Treatment of Sexual Abusers (TX), Third Annual Peace It Up Violence Prevention and Intervention Conference (CT); Massachusetts Adolescent Sex Offender Conference (MASOC); and Massachusetts Association for Private (MAPPS). Pat Wilcox taught two courses at the University of Connecticut School of Social Work in their continuing education department.

The Klingberg Traumatic Stress Institute and the Foster Care Department launched an exciting new training initiative entitled: Trauma Informed Foster Care- Why are These Kids Doing These Crazy Things and How Can I Help Them while Preserving My Sanity? This is a six session monthly training program based on ideas from the Risking Connection® curriculum and the Restorative Approach®.

We especially enjoy the events where (through TREATI) we can gather our Risking Connection community together. At this year’s Fourth Annual Day of Learning and Sharing, keynote speaker Lynn Sanford, LCSW, spoke in depth about shame. Lynn is a marvelous speaker, warm and human, very knowledgeable about residential populations, and so respectful of both the clients and treaters.

Looking ahead, The Traumatic Stress Institute is co-sponsoring a conference with Devereux MA in February in Worchester MA called From Strategy to Reality: The ‘Nuts and Bolts’ of Implementing Trauma-Informed Care in Child and Adolescent Settings. The date is February 9, 2010 from 9:00 am to 4:30 pm.

We wish everyone a healthy and happy New Year, and look forward to working with you in 2010. As Margaret Mead famously said. "Never underestimate the power of a small group of committed people to change the world. In fact, it is the only thing that ever has."

Happy holidays,
Pat, Steve and Megan

Validation

Why is validation so hard?

Corey was screaming in the main hall. It was hard to even understand why he was so upset, but it seemed to have something to do with not being allowed to call his mentor, Bob. Laura, a unit staff, was with him and was speaking in a calm and soothing voice. But what was she saying? "Corey you have already left him 13 messages and you have called him many times. I’m sure he will call you when he can."

What was she not saying? "Corey it must be so upsetting when Bob doesn’t call. I know you are very worried because you haven’t heard from him in a while. I know it is hard for you."
We do understand how painful and scary it is for Corey when his only human contact outside this agency seems to have disappeared. It’s even frustrating for us when someone doesn’t respond to our calls, and we have much less at stake than Corey does.

Yet what makes it hard for us to make validating statements to kids? Why do we move so quickly to rational explaining and giving advice?

1. Laura knows that Corey may be driving Bob further away with his many frantic calls and messages. She feels desperate to preserve this relationship for Corey and wants to change his behavior before Bob gives up.

2. When we validate kids’ complaints we think we are agreeing with them and strengthening their beliefs. Suppose a kid says: "I hate all the staff. They are so unfair." If a staff responds: "right now you hate all the staff here and think they are all unfair" is that person saying that they themselves think the staff are unfair? No. They are saying that they understand how the child is feeling at this time.

3.We think that if we do not explain away the problem and offer fixes the child will feel worse... and act worse. We are frightened by that possibility.

This, I think, is the most important:

4. Giving advice, fixing the problem, feels better to us. To validate you have to feel the child’s pain. And stay with it. And the pain is so intense. We feel so helpless. We under-estimate the value and efficacy of the gift we give through listening and understanding.

So if Laura says "Corey that must be so hard" she has to stop for a moment and feel Corey’s life. What will it be like if in fact he has lost his only outside contact? What does it feel like to be thirteen years old and have no reliable adults in your life? He blames himself. He has no one. That is so sad- and we feel a strong urge to fix it or lessen the impact for him.

Yet time and time again we have seen the power of validation to soothe, to de-escalate, to strengthen relationships, and to promote healing. By validating we are lessening the impact- because we offer Corey the experience of an adult who understands, a new version of the possibilities of relationship.

And we have only to consider times we ourselves have shared a painful experience with a friend to remember what helped us. Did we want our friend to tell us this wasn’t such a big deal? Did we want her to immediately give us advice? Or did we want her to simply acknowledge how bad we were feeling and to understand?

So let’s pass a law saying you must make five validating statements before you give advice to children.

And I know a lot of wives who would like the law to also apply to their husbands.

How to Help Malina

I was doing a recent training when Martha, a therapist asked me: "Pat, I know you say not to blame the kids for their behaviors. However I am a firm believer in the kids needing to take responsibility for what they do. So what do you do when a kid just will not take responsibility for what she did and keeps blaming others?"

When I asked her for further clarification, the situation got worse, in my mind. Martha told me that a fifteen year old girl named Malina was on a plan that she had to earn her weekend pass with her mother by maintaining good behavior in school. Last week, Malina had a major outburst in school, tipping over tables and completely disrupting the classroom. So, she lost her pass. When Martha attempted to talk with her about this incident, Malina would not admit that it was her own behavior that caused the pass to be withdrawn. She blamed her therapist, her teachers, everyone else.

What’s wrong with this (very common) picture?

1. I don’t think I said that "we should not blame the kids for their behaviors." I actually do not think that blame is a useful concept here. I think we should help the kids understand their behaviors, and teach them the skills they need to act in new, more helpful ways.

2. I do not believe that children should have to earn their home passes. If the home situation and the child are safe, they should go. The ties between the child and her family are essential for both recovery and the child’s future. We should do everything possible to enhance them, and nothing to interfere. If the child is actually unsafe (such as suicidal) the family should be welcome at the agency and, when possible, transportation provided for them. Home passes should not be part of a reward system.

3. Okay, so Malina was on this plan, and she blew it. What are we asking of her when we ask her to "take responsibility for her behavior"? We are asking her to admit that she did the one thing she did not want to do, and in the process disappointed herself and her family once again. We are in her mind asking her to admit she is a no good, worthless person who will never change. How can she possibly be able to do this?

4. Why do we even think that "taking responsibility" is such a good idea? I guess it is because we feel a person needs to admit something before they can change it and as long as they are blaming others they will not try to change themselves. There is of course some truth to this. Yet, there are many gentle, face saving ways to discuss an incident and the factors that contributed to it.
Most importantly- what will help Malina to stop turning tables over when she gets upset? Not mere increases in motivation. The "earn your home pass" plan is designed to make Malina want to behave better. And I’m sure it did, I’m sure she wanted to earn the pass. But the problem is, she does not know how. She is not able to be different yet.

5. So what can we do? We can look carefully at the incident in school, with Malina in any way she can participate. Not in a blaming way- let’s discuss this and get you to admit you were wrong. Instead, to understand what happened. What upset Malina? Where did the incident start? What did she first feel? What were the warning signs that she was getting upset? What alternatives did she have then? What help could we have given her at that point? This discussion is a search for better understanding, looking for patterns. It is a path to interventions both we and Malina can do to avert a meltdown next time. Was Malina frustrated by work she didn’t understand? Did another girl make fun of her? Was she agitated because she hadn’t heard from her mother in several days? No- these are not excuses for her behavior. They help us understand the skills she needs to handle such events in the future without making things worse. What can we do to make it easier for Malina to ask the teacher when she needs help? What skills and sense of self worth does Malina need to withstand peer teasing, and how can we help her build them? How can we teach Malina techniques (such as the ones we know and use daily) to get through anxious situations? These are things she has never learned in her disrupted upbringing, and we are here to teach them to her.

This thinking will actually bring us forward in our treatment. Making her earn her home pass undermines the only fragile support she has and increases her anxiety. Forcing Malina to admit that what she did was wrong will leave her feeling more shamed, more stupid, and in fact more likely to do the same thing again. Working with her to determine why she acted this way, and to teach her other alternatives, will (after many repetitions) create real and lasting change.

A Parable: Symptoms are Adaptations

Once upon a time a man named John decided to go for a kayak ride in a near by river. Unfortunately, he greatly underestimated the strength of the current, and shortly after he set out he capsized, He was tumbling down the river, being injured as he banged into rocks, when he spotted a large log near him. With considerable effort, John was able to grab the log, and he held on to it for dear life. Clinging to the log, John continued to be swept down the river. He still crashed against things but with the log he was able to keep his head above water and survive. Finally, the current ejected John and the log into the middle of a large, tranquil pond. The log got caught on a rock in the middle of the pond.

There were some people on the beach at the edge of the pond, and they saw John out in the middle. The called out to him: "Hello! You are safe now! It is not very far to shore! Just swim over here- the water is calm, it’s not that deep, you will be fine!"
But John could not let go of the log.


**********************************************************************************

Why is John clinging to the log when he is so close to safety?

What will the people have to do if they truly want to help John?

**********************************************************************************


They will have to swim out to him, and they will have to give him something like a life preserver to replace his log.

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In what ways are you swimming out to your clients?

What life preservers are you giving them?

Playing the Victim

Overheard at a Risking Connection® training: "Well, you know Jeff. He just likes to play the victim."

Questions:
What is wrong with talking this way?
How do we understand this behavior?
What can we do about it?

What is wrong with talking this way? Why did I cringe when I heard it? It is because of the blaming quality- the statement that Jeff likes to play the victim, as though it is a deliberate choice he makes every day among the many delightful possibilities open to him. Although minor in itself, it leads to an annoyance with the boy, a frustration that he doesn’t see how much better his life would be if he would just stop this.

How do we understand this behavior? When asked to describe Jeff further, the staff member said that he constantly uses his past abuse as an excuse for not trying or for failing. He also picks on other kids (instigates, to use a residential favorite word) and then blames them for whatever fight begins. So why would a kid do that? It is because he sees absolutely no possibility of success through competence. In other words, he has no confidence at all that he could succeed on the basis of his talents and natural skills. He has had no experience of being loved or appreciated for who he is. All the goodies of life and of relationships have come to him in the context of his problems, of reparations for his abuse, of sympathy for being picked on. That is the only way he knows to engage others.

So, what can we do about it? The road to change is through helping Jeff experience other types of competence and success. And this will be difficult, as he will be afraid to try things and will quickly revert to his old standby methods that have worked so well. But with patience staff can support him into positive experiences, achievements, maybe even triumphs. These must include positive interactions with peers, fun, play, every day social back and forth. He doesn’t know how to do this, staff must teach and model. It will take many repetitions for Jeff to believe that people like him for other reasons than his problems.

When Jeff experiences the possibility of competence and fun, we will notice that he "likes" to play the victim much less.

Victor and Vicarious Traumatization

Victor is eight years old and in residential treatment. He was born to a teen aged mother with a severe trauma history. He has moved around a lot, several foster homes, treatment programs, back and forth to his mother. One difficulty has been that his mother always distrusts his caretakers and forms combative relationships with them. So it is hard for Victor to trust, because he loves his mother deeply. He has a low IQ and sensory issues. He cannot read.

Victor has developed one solid coping mechanism. When ever he is confused, ashamed, sad, upset or fearful, he becomes aggressive. He curses, attacks, spits, etc. He has got this down to a science- because he feels confused, afraid and ashamed often.

Luckily Victor also has a lovable side. Staff care about him a lot. They speak of him with affection and amusement. They go far out of their way to help him feel safe and comfortable.

Victor’s mother has moved to Mississippi, where she has relatives. The long inter-state compact process has been completed, and a plan arranged in which Victor will go to a foster home in Mississippi. In fact, one was located for him. The plan was that he would go there with his state worker for a long weekend, return and say his good byes, and go there to live. Victor was scared, and very excited about being closer to his mother.

Victor was going to be picked up at 5:00 a.m. At 10:00 p.m. the night before, the foster mother called the unit and cancelled the visit, mentioning a "family emergency". Later it turned out that she had not been told any information about the severity of Victor’s problems, and now that she knew more, she was not prepared to take him.

Since then, Victor has fallen apart, and the frequency and intensity of his aggression has increased.

This is why we get vicarious traumatization. Its not just that we read or hear the children’s histories, or that we sit with them and feel their pain from the past- although that would certainly be enough. It is also that we go through with them the terrible things that continue to happen in the present- the many ways the adults (including, at times, ourselves) are not able to provide safe, long lasting homes.

And we have to acknowledge that much as they love Victor, staff were in some ways looking forward to his discharge. It would be a relief not to be spit on, hit or bitten as often. Treaters totally understand why he is falling apart. And, it can be exhausting to deal with the depths of his despair. Especially when we do not ourselves see where there is hope for his future. Not to mention that it can be tiring just to hold a strong wiry little boy over and over again.

But here he still is. And there is as yet no alternative plan. And to give this boy safety, to stick with him, to be there as he survives all this, is certainly the most important thing we could be doing in the world.

So how can we bear it? The most important thing is to talk about it. We have to share all our complex feelings with each other. We have to be free to say that at times we get tired of him, just as we are free to say that our hearts hurt with his pain. Staff have to be commended over and over again for the difficult, repetitive, unending acts of caring they provide. Of course, we continue to advocate that the system give Victor what every child should have.

And we turn to each other with tears in our eyes, make a joke, take a break, have a meal, and return to Victor, and continue the heartbreaking work that will save his life.

Marcus, Take Two

Thank you to everyone who participated- and please, continue to add your thoughts!

If we keep in the front of our minds the idea that symptoms are adaptations, we must wonder what doing the drawings and sharing them with his peers is accomplishing for Marcus. I can think of several possible theories, such as giving him power, expressing his pain, giving him one area in which he is in control and can have an effect on others.

Also, the drawings express a part of Marcus, however disturbing they are. If we just try to ban them, we are giving Marcus a message that we are turning away from his pain, and that we do not want to see, share or accept all of who he is and what he has experienced.

I do not feel that taking drawing supplies away from Marcus will help at all. For one thing, we won’t win on this one. There are many more pencils and pieces of paper in the world than we can ever confiscate. But more importantly, that is a response that tries to eliminate his behavior and not to understand it.

We need to take seriously the effect the drawings have on the other kids, the staff and especially the therapist. This is something we have to discuss as a team and make deliberate plans to give ourselves the stamina to take this on. For example, the therapist may wish to include a male staff at first when she talks with Marcus about the drawings.

Then, as noted by one of the comments, I think we should explore the pictures with Marcus, and not in a judgmental way. What is happening? What are the characters thinking and feeling? What is likely to happen next? The therapist can express her thoughts: "Really? I think the woman might be scared and angry." But all discussion should be from a very centered, calm place- tell me more. Explain how it feels. What does it remind you of?

These discussions should include NO MENTION OF THE NEED TO CHANGE. They are entirely exploratory.

Meanwhile, staff can talk with the other kids about how sometimes when people have had painful lives they draw painful drawings. Encourage the kids not to react, but just bring staff into the conversation if Marcus shows them a picture. Of course, Marcus’ showing them around would decrease if he got less reaction. Then staff would handle it matter-of-factly: you know, Marcus, better to save these for therapy- I’ll give this one to your therapist and you can talk it over with her.

Another area of treatment could be to offer Marcus other opportunities to have power and control, using his drawing. Could he draw some posters for an upcoming agency event (subject to review of course). Can he draw a picture for the unit illustrating some positive message, and can staff get it framed and hang it up? You get the idea.

Marcus has been hurt repeatedly over his life time. He has found a way to both express his pain and get strong reactions from others. His behavior will not change quickly. We must understand that the way that we feel in looking at these pictures is the way that he often feels in his life. And we must support each other in doing the long hard work it will take for Marcus to develop a new, kinder view of life’s possibilities.

Let’s continue this discussion- click on "leave a comment" to share your thoughts.

PLEASE Participate

Please please please participate in our discussion of how to react to the boy with the cruel pictures. Remember to first answer the question: how is this behavior adaptive for Marcus? What is it accomplishing for him- what problem does it solve? Then give your opinion about what the best treatment approach is that will help Marcus change and heal. I REALLY want the opinions of everyone who is reading this. Just click "post a comment". Thank you.

Marcus and the Scary Pictures-What Would Your Team Do?

Marcus came into residential after having been ejected from a previous residential. He is adopted, and his current adoption is actually his second as he was removed from his first home because of abuse. He is small for his age and a bit strange looking. In the month he has been here he has not made any friends, in fact the other kids seem to pick on him. Several times he has said inappropriate sexual things to female clients and to female staff, which does not increase his popularity. Generally he is the kid who is always doing what you just told him not to do, then accusing you of only talking to him when he does something wrong. Staff is finding it hard to engage with Marcus.

However recently a more upsetting issue has emerged. Tony and Jarell, two of the other boys, and Amber, one of the girls, separately came to staff to complain that Marcus has been showing them some very disturbing pictures that he drew. A search of his room in fact produced many of these pictures, which are very graphic (and skillfully drawn) renditions of men torturing naked women, complete with blood and gore. Amber said to her staff that she thinks Marcus is going to grow up to be a murderer and the staff who have seen the pictures tend to be worried about the same thing.

At first when this was discovered, staff gave Marcus a sketch book and said he could draw the pictures in there, but not show them to anyone. However yesterday his roommate Tim told staff that Marcus had been showing him his latest creation. It is one of the bloodiest yet. Lisa, Marcus’s therapist, finds that the pictures make her very uneasy and she does not know what to do to help Marcus. In fact lately she has been avoiding meeting with him. In the staff meeting the most popular suggestion is that Marcus be forbidden any access to paper and writing or drawing materials in an attempt to prevent him from making these drawings.

Do you think this is the best approach? Why or why not?

How do you understand Marcus’ behavior? In what way are these pictures adaptive for him- what positive results is he getting from drawing and sharing them?

What does Marcus need? What approach would you recommend?

What should be done to support Lisa and the staff in helping Marcus to heal?

Share your answers by clicking on "post a comment" below. I strongly encourage you to participate in this discussion. Let’s generate a robust list of possible answers. I will write more about this in my next post.

The Persistence of Punishment

Why is it that no matter how much we know, when we are concerned about a behavior our first thought about how to change it seems to always be punishment? Is it our Puritan heritage? Our religious backgrounds that emphasize Heaven and Hell? Is it that our parents used to ground us when we did something bad? Maybe our entire culture reinforces the idea that punishment solves problems. After all, we do keep building all these jails.

If you are interested in learning more about exactly how to use both reinforcement and punishment, I recommend a book called Don't Shoot the Dog! The New Art of Teaching and Training by Karen Pryor Ringpress Books Ltd; 3rd edition (March 2002). This was recommended to us in our DBT intensive training. The author states that punishment is not as powerful as reinforcement, and must be used precisely- for example, it must happen immediately after the undesirable behavior.

Let’s go back to our own upbringings. I certainly did not like it when my parents grounded me for sneaking out to see my boyfriend. However, much MUCH more difficult was when they sat me down for a talk that began: "Young lady, your mother and I are deeply disappointed in you." In other words, it was the relationship. That they loved me, and I had let them down. That is what I really wanted to avoid.

In out programs we could be much more deliberate about relational rewards and punishments, making sure to convey both our delight and our sadness about the events that take place.

But let’s remember that no matter how well done, rewards and punishments affect motivation. They make some one want to do something more, or want to stop doing it to avoid the punishment.

But if you do not know how to do anything different, it does not matter how much you want to. You need to learn the skills.

In my training I ask participants to think of a time they have tried to do something they really wanted to do, but they were not able to. The examples have included playing tennis, rollerblading, knitting, learning a language. People readily see that more punishment for not playing tennis well would not have helped- in fact it might have made the situation worse, and/or contributed to the learner giving up. If someone wants to learn to play tennis, they need lessons from a kind and patient teacher, who will teach them the many small skills that go into the game.

In some ways our punishments render our children LESS likely to achieve better behavior. They often contribute to shame and hopelessness, thus increasing the intolerable negative emotions that currently overwhelm the child’s ability to think. They accentuate passivity- I have messed up and there is nothing I can do about it. They undermine self worth.

But if not punishments, then what? We often turn to punishment when we ourselves are feeling overwhelmed and helpless.

Increase the child’s sense of safety
Build strong relationships that the child can trust so the child can ask for help
Help the child remember that people care about him even when they are not present
Teach the skills of emotion management
Increase the child’s self worth
Help the child learn to sooth her over-active danger system
Give the child opportunities for effective action and for fixing problems
Give the child opportunities to play and have fun
Create a strong community
Help the child create a positive plan for moving forward in life- create hope

These things are harder than assigning two days of room time, but they are more meaningful and they create lasting change.

Remember- children do well if they can. And remember also- children act better when they feel better.

Please let us know your thoughts by clicking on "post a comment" below and adding a comment.

Exercise about Taking Responsibility

I developed this training exercise to teach people how shame interferes with taking responsibility, and how a simple conversation between a Callie care worker and a client can go wrong.

I will ask for two volunteers, one reads part of Latasha, one of Callie
Latasha- Staff
Callie- Child

VERSION ONE:

Callie is sitting playing electronic game, Latasha walks into room

Latasha: Thoughts: Oh, there is Callie. I heard she had a hard time in school today; I’d better talk to her to see what happened.

Callie: Thoughts: Oh, here comes Latasha. I know she heard I screwed up AGAIN in school today. I know she’s mad at me. I hope she doesn’t see me. I’d better hide.

Latasha: Thoughts: I am really getting discouraged, Callie doesn’t seem to be changing, I wonder what I am doing wrong.
Says: Hi Callie. Let’s talk about what happened in school today. Can you tell me what went on?

Callie: Thoughts: I knew it, she hates me now, I never should have started to like her, I bet they are getting ready to kick me out; nothing is ever going to work out in my life.
Says: It’s those stupid teachers. They are no good. I want to get out of this dumb place and go to a place with a real school.

Latasha: Thoughts: This kid will never take responsibility for her own actions. If she never learns to accept what she has done she is going to end up in jail. We have to make her understand that her actions are her own choice. Maybe she is right, maybe she doesn’t belong here. We do not seem to know what to do to help her.
Says: But Callie you must have done something to get yourself into a fight. It can’t be all the teacher’s fault.

Callie: Thoughts: See I knew it she blames me for the whole thing. And she is right I will never be smart enough to learn math, I am such a loser, and when Kristi made fun of me I just could not stand it. And now (name) hates me too I have to get out of this place!!!
Says: I hate all you f...ing people and if you get any nearer to me I am going to hit you so leave me alone!!!!

Latasha: Thoughts: She is really just impossible I cannot have a simple conversation with her. She really has to learn that she cannot talk to me that way.
Says: That’s threatening. You have to go to your room now if you are going to be so disrespectful.

VERSION TWO:

Callie is sitting playing electronic game, Latasha walks into room

Latasha: Thoughts: Oh, there is Callie. I heard she had a hard time in school today; I’d better talk to her to see what happened.

Callie: Thoughts: Oh, here comes Latasha. I know she heard I screwed up AGAIN in school today. I know she’s mad at me. I hope she doesn’t see me. I’d better hide.

Latasha: Thoughts: I know Callie has so much trouble in school, especially in math. We have been working on how to ask for help when she is confused but it is so hard for her. And I know that Kristi, the girl she had a fight with, can be so mean and pick on people’s weaknesses.
Says: Hi Callie. How are you? I heard that this weekend you made that beautiful bulletin board over there, it really adds color to the unit.

Callie: Thoughts: I know she is going to talk about school and she is mad at me, but at least she noticed the bulletin board I made. Might as well get it over with.
Says: Yeah but today really sucked.

Latasha: Thoughts: I’m glad she brought up what happened. I know this kind of discussion is really hard for her because she always feels so hopeless.
Says: Yeah, I heard you had a problem with Kristi in math, that staying calm thing and asking for help thing didn’t work out as well as we hoped today, but I also heard you calmed down and did well in art afterwards.

Callie: Thoughts: Well, maybe she doesn’t hate me, but I know I screwed up big time. I wonder if they are going to kick me out of here now? I never should have trusted these people.
Says: So I suppose I’m kicked out now right and that is fine with me because I hate this f..ing place anyway and this is a stupid school that doesn’t know how to teach kids.

Latasha: Thoughts: Is that what she has been afraid of all day? It’s even more amazing she was able to calm down. Maybe she is making progress.
Says: Oh no Callie, we are not kicking you out! Far from it! We see the progress you are making. You and I just have to figure out what went wrong today and how we can come up with some better ideas for next time.

Callie: Thoughts: That’s surprising. Well, I would like to know how to keep that Kristi from aggravating me so much- I know she was glad she got me going.
Says: Well, you can start by getting rid of Kristi.

NOTE: The difference between the two versions is not just that the Latasha mentions some positives. It is that the Latasha is operating from a THEORY, and her understanding of the meaning behind Callie’s action’s enables her to approach this event differently.

As usual I am interested in your ideas and reactions. Just click "comments".

Visit to CA LO

This past week I visited a remarkable place. It is called the Change Academy, Lake of the Ozarks, (http://caloteens.com/) and is in Missouri. CA LO is a residential treatment school formed on attachment principles. It was born two years ago from the dreams and convictions of its founder, Ken Huey, and its Clinical Director Landon Kirk. Both were working in more traditional treatment settings and felt that while good work was going on, the treatment methods did not fit their understanding of attachment and healing. So they determined to open an attachment based treatment center located in the middle of the country.

CA LO treats approximately thirty five teenagers, divided evenly between boys and girls. The youth come from all areas of the country, even Alaska. CA LO employs many creative ways to engage the families in treatment. CA LO does not use levels, points, or traditional rewards and punishments. Instead, they have developed a treatment model that describes the tasks the children must complete in order to have a life worth living, and they train staff in the empathetic responses necessary to help the children grow through these tasks. When a student does something particularly harmful, he or she is assigned a chore done with a staff, which provides reconnection with an adult and making amends to the community.

A unique feature of CA LO is their canine program. They have around 25 Golden Retriever dogs, from puppies through adults. The dogs are assigned to individual children ho provide all their care. The dogs go every where with the kids, except to meals- to school, to recreation, one free time. Youths can complete an entire process including references, a home study, etc and be approved to adopt a dog. Then they take that dog home with them when they leave! Many places have some form of pet therapy, but this is the first time I have ever seen pets so thoroughly integrated into a treatment process. The learning and love the children gain from this process is obvious.

CA LO’s model has four components: Trust of Care, Trust of Control, Trust of Self, and Interdependence. Trust of Care teaches children that that the caregivers around them will take care of their physical needs. Food, shelter, health, wellness, and hygiene will be provided by trusted adults. Trust of Control involves believing that the adults in your life can be trusted to help and guide you. Youth who are successfully humble and vulnerable enough to accept Trust of Control allow the adults and peers in their life to teach them life lessons. When youth accept Trust of Control it provides opportunity for adults and peers to provide emotional dysregulation, coaching, guidance, and physical and emotional closeness. Trust of Self occurs when a youth moves towards independently practicing and implementing what has been modeled and taught. In Trust of Self the youth moves from doing the right thing because s/he is "supposed to" or because it has worked a few times in the past, to an inner change and commitment to live life differently. Interdependence is the ultimate goal for a youth, which means learning to live life with interdependence or the ability to maintain healthy, reciprocal relationships. Interdependence defines a successful student transition from a false and selfish independence, to experiencing the value and joy of interdependence and mutual relationships. Clearly, interdependence is neither independence nor dependence but is connected living. It is a person understanding that his/her actions affect others. Instead of just taking, the youth is now also giving. (The previous paragraph was adapted from the CA LO web site.) The youth do not move up and down between these tasks such as phases. It is understood that we all have to move around and re-work parts of each over and over again.

CA LO also includes a school with many imaginative programs, and a Therapeutic Recreation department that utilizes an indoor ropes course as well as many waterfront activities. The staff at CA LO is warm and caring. They have their struggles like everyone else. However, it is very exciting to see a program that is founded on the principles I believe in.
I particularly recommend their blog, which can be found at: http://caloteens.com/blog/

Power and Trauma Informed Care

Many times both in my own agency and in agencies I have trained I have encountered staff who are paralyzed. They are trying to change their practice with the clients. Often, the environment around them has changed the rules for restraint. No longer is it permissible to restrain children for lack of compliance. There must be imminent physical danger. And/or the agency is implementing trauma informed care and is looking differently at the use of consequences.

However, in the midst of this change, staff become confused and over react. For example, Mark is taking the books out of the bookcase and throwing them to the floor. Joe, a child care worker, knows that he will not be able to restrain Mark for this behavior, so he does nothing, just stands by and watches Mark become more and more escalated. Joe pleads weakly for Mark to stop. Mark feels more and more unsafe as he senses that Joe feels powerless and ineffectual. He does not know how to stop his own escalation. Thus he acts out more to draw a response and to elicit some control from the adults.

There are many things you can do to stop a behavior without restraint. One of them is to say in a strong, powerful voice: "Stop it! You can’t do that!" It is amazing how often forbidding a child to do something stops them, even when you have no idea how you would enforce this dictate. Another is to say in a calm but intense voice: "Mark! What is wrong?" and to actively listen to the response.

People some times think that if you are no longer supposed to slam a child with consequences, you must ignore their obnoxious behavior. No! This would be just another form of neglect. Throughout the children’s lives, many people have ignored them rather than take the time and energy to engage with them. And if we ignore actions because we are scared of the behavioral result if we confront them, the child notices this and feels even more unsafe. To the child it seems that the adults cannot handle his intense emotions- so how will he possibly be able to handle them?

Dan is one of the best staff. He has a personal power, centeredness and strength. He speaks to the children in a calm, straightforward way. He is sure of his own values and able to tell a child when the child’s actions hurt him. He speaks from his heart, steps up to the children and engages deeply with them. He feels sure of the rules and expectations and does not hesitate to give directions. However, he also is interested in them, celebrates their successes, and knows their lives and preferences. He is able to relax and have fun with the children.

Staff have many sources of power with the children in addition to their power to dispense privileges, consequences and to physically restrain. After all, staff control everything that happens in the program. They can say; "I am not feeling safe enough to take you for a trip" or "We’ve all been getting along so well let’s go to the go karts!" They control access to much of the rest of the world, and regularly report on the child’s progress to those who are making decisions about her life.

And the most effective form of power is influence. Relationships. Danita cares about her team mate (primary staff contact) Lucy. Lucy has high expectations of Danita and eagerly waits to hear how each day of school goes. Lucy expects that Danita will be successful. When Danita has problems Lucy talks with her about them and together they try to figure out what went wrong and how things could go better next time. Lucy heard that Danita was mean to a new staff member Jennifer over the weekend. When Danita saw Lucy she asked to speak to her, and said she was disappointed by Lucy’s behavior. Danita said that she does not like Jennifer, she is not cool like Danita. Danita replied: "I expect you to be polite to all staff members, whether you like them or not." Because Danita cares what Lucy thinks, she is slightly nicer to Jennifer from then on, giving them a chance to form their own relationship.

Relationships are far more powerful than consequences. How many books have you read in which someone describes their life being turned around by earning 15 minutes later bed? How many describe the profound influence of one other person who changed someone’s life by being active and caring?

Trauma informed care has nothing to do with letting the children run the program. It does not instruct staff to be wimpy. Trauma informed care demands strong human beings who have the courage to open their hearts to these wounded children, to stay engaged and active through all the symptoms, and to celebrate growth and triumph. These valuable people have true power to create life long change.

Please click "comment" and let me know your reaction to these ideas.

Fear and Anger

Imagine that your teen age daughter is not home at the expected time. As the hours go on, terrible pictures form in your mind. You worry that she has had an accident or has been hurt and she cannot call you. You think about how much you love her and how awful life would be without her. You wonder if or when you should call the police. You are so afraid.

Then she comes in. Nothing happened- she was with her friends and was having so much fun she forgot to call. Now you are furious. A few minutes ago you were terrified that she was dead, now you are personally going to kill her.

There is a close link between fear and anger. When we are afraid, we are vulnerable. We feel the strength of our need of another person. We experience their ability to hurt us. We feel weak and powerless. Anger gives us power. Anger pushes away that vulnerability. Anger puts us in control: I thought you were hurt and I would die from the pain of it, I was so powerless. But now I am angry, I am going to kill you myself, I am completely in control.

We often talk about the link between anger and fear in our kids. I am more and more convinced that behind every act of aggression and violence there is fear, panic, vulnerability, hopelessness, powerlessness. Connecting with those feelings give us much more power for change.

But what about us? There are many ways in which the kids make us afraid. They may make us physically afraid, by aggressive attacks, lashing out in a restraint, biting, kicking, etc. They threaten us. Also, we feel afraid about what will happen to them on our watch- will Johnny run away and get hurt? Will Crystal cut herself badly this time and need to be hospitalized? Will I be blamed? We are afraid of censure, oversight, the opinions of our co-workers and bosses. We feel lost and vulnerable when we don’t know what to do, when our best techniques are not working, when Anthony just will not change. We doubt ourselves.

I wonder how often this fear gets converted to anger, and acted out? Maybe- hopefully- we do not actually scream at the kids or threaten to kill them ourselves. But there are many ways to act out anger- harsh punishments, refusing to help, excess bossiness, and maybe most common, distant withdrawal. All of these make us feel more in control, powerful again. We turn away from our feeling or fear and helplessness and feel strong.

At the cost of good treatment and connected, safe relationships with the kids which would promote their healing.

What if as a staff or in supervision we talked about our fears and were open about them? What if we shared our feelings of pain and hopelessness about the kids that don’t change? What if after working them through them with adults we even talked with the kids about these feelings, in a modulated way? Could we then model that an adult can be vulnerable, afraid and strong at the same time? Could we teach the kids how to have a strong relationship that includes and contains scary feelings?

When you see anger in the kids, look for fear and vulnerability. When you feel anger in yourself, look for the same things.