When Chaos Strikes

It may be a call from our licensing agency, concerned about the number of incident reports. It may be reviewing our quality improvement numbers. It might come from staff complaints, or from all the meetings and discussions and panic among the team. But somehow we become aware that one of our programs, cottages or units is not doing well. Chaos has struck. There are an unusually high number of incidents such as restraints, runaways, hospitalizations, staff and child injuries, police calls, negative discharges or other signs of dysregulation. What should we do? Where should we start in our attempts to improve the treatment environment?

Usually these times are accompanied by a cry for increasing the severity of consequences. As staff feel more frightened and out of control, they reach for some sense of power. They turn towards more punitive responses as a way to feel in control and powerful. Similarly, the children are feeling frightened and out of control. They turn to violence, aggression and threats to give them a sense of power and control. A destructive cycle takes place.

In such times it is hard to take time to step back and think about what could be happening. Yet it is during these difficult periods that we most need to examine the patterns, think about how we understand the symptoms, and take measured, careful action. Also, in periods of crisis the very things that will help prevent crisis behaviors tend to disappear. Because staff are handling crisis’s or talking about them, regular activities are not done, routines break down, individual time for the children with their therapist or the staff is cancelled, and everyday positive interactions decrease. It is essential, but very difficult, to reinstate routines and activities during crisis times. Relationships, predictability, and positive activities are our most powerful interventions.

There is a tendency to blame the chaos on one or several particular youth. If we could only get rid of Marci! Joshua needs to be discharged, he needs a place with more structure.

However, as we consider what may be going wrong, staff related issues are the first things to think about. There are many staff problems that can result in program problems. All of these result in a feeling of less safety for both clients and staff, and thus create a greater need for control and aggression. Some of these are:

o An influx of new staff, not enough training
o Staff splits and tensions: different groups such as therapists/childcare staff/teachers; first shift/second shift; etc. are not getting along, blaming each other for the problems, and not talking about their differences directly.
o Therapists are staying in their offices, are not active on unit, are not in the middle of crisis’s, and are not working closely with child care staff to examine the meaning of the behaviors.
o Vicarious traumatization and no way to talk about it or take care of one’s self and others; no processing of the effect of painful events on the staff; over-working staff
o Paralysis created by not understanding new approach: at times when programs change their approach, child care staff become paralyzed. They know what they are not supposed to do, but they are not sure what to do instead. So, they ignore behaviors and don’t engage with the clients; instead they stand by feeling helpless as a child escalates.
o Understaffing: all programs have had experiences with times when we have open positions, and the staff we have (bless them) are working extra shifts and are extra exhausted. Supervisors may be working shifts and having little time to interview potential new staff. It is hard for anyone to have time to think.
o At times a culture develops in which staff do not interact with clients. They stay in the staff office, or (against policy) text their friends on their cell phones. They institute “quiet hours” or other times the children have to be in their rooms. This weakens the relationships that are the building block of treatment.
o It is amazing the power that one toxic person can have on a team, especially if that person splits staff and is underhanded.
o If the unit leadership is not strong, it is hard to address any problems. The position of unit supervisor is often filled by promotion from child care staff. This person is expected to manage complex staff issues and agency requirements. Often, they are not given adequate management training or supervisory support. This is a crucial position that needs many resources.

If we come to the conclusion that staff issues are at the center of our problem, what can we do?

This first thing is to talk about it. Bring any issues into the open. Bring groups together and hash out differences. Of course, this is hard to do when we are in the midst of problems, but it actually is our best way out. Part of the discussion should focus on staff’s emotional reactions to recent events, and their vicarious traumatization. Pain shared is decreased and better tolerated. Loss of hope and cynicism should be addressed directly. Another intervention could be training: do we need to train more on our new method? On management and supervision? On policies and procedures? There may be staff that must be addressed individually in supervision, perhaps placed on a specific performance improvement plan. And we may need to involve more agency resources in hiring.

Another area to look at is the schedule and structure of the program. It can be helpful to look at the program’s serious incident reports to search for patterns. Are there specific times, days of the week, staffing patterns that correlate with the most incidents? One must be careful in interpreting these results, as many factors can contribute to them. Still, such analysis can provide a place to start. Some trouble areas can be:

o Not enough structure or activities, too much down time, TV or electronics time, or time when the clients are forced to stay in their rooms. For clients with racing, hopeless and despairing thoughts, these times can feel awful. The client then will do something to distract himself from his thoughts, such as cause a commotion.
o One unit that did such an analysis discovered they were scheduling high energy gym activities right before bed time, and then having many problems while trying to get the clients to sleep. They reduced restraints by instituting quiet activities in the evening.
o The children become anxious in situations with unclear expectations, unpredictability of schedule, and confusion between staff about what happens next. Planned schedules that are posted for all to see help the children feel safe.
o Too much noise, activity, chaos can be overwhelming to clients.

If an analysis reveals patterns to the problems, we can change the programming and see if it helps.

Of course, some of the source of program distress is client related. It can relate to:

o A large influx of new clients
o Negative events that have affected clients and made them feel less safe, such as observing an out-of-control event that required police intervention.
o It is important to probe for secrets, things that may be going on that we do not know about. Sexual acting out and/or bullying and intimidation are prime candidates. Getting the truth out in the open can begin a change and a healing process that will result in greater safety for all.
o Individual or collective losses, such as staff leaving, especially those that have not been discussed or grieved, can lead to acting out
o The children are constantly facing overwhelming Individual life stresses
o All teams know that certain times of year, i.e. school starting or holidays, are difficult for the clients and thus lead to many symptoms.

In these cases, we may need to be active advocates for the clients. Again, talking collaboratively with the clients about what is going on, what is happening in our community, and what we want to do about it can begin a powerful and mutual process of change. And we may also need to institute extra precautions of supervision, observation and staffing to increase safety.

The common ground here is that we assume that the behaviors are happening for a reason, and the reason is not that the kids are obnoxious. We are certain that the symptoms are adaptive in some way, for the clients and for the staff. We assume that everyone is feeling unsafe and is doing the best they can to protect themselves. We start from these assumptions to think about what could be going on, and then to take directed action to enable everyone in our community to experience less pain and more joy.

Book Review: Working with Children to Heal Interpersonal Trauma

Book Review: Working with Children to Heal Interpersonal Trauma- The Power of Play

Edited by Eliana Gil
Foreword by Lenore C. Terr
Guilford Press, August 2010
ISBN 978-1-60623-892-9

Eliana Gil is a well known specialist in helping children who have been abused. The Healing Power of Play: Working with Abused Children (Guilford, 1991) and Treating Abused Adolescents (Guilford, 1996) are two of her previous books which I have enjoyed. Her most recent book, of which she is the editor, is Working with Children to Heal Interpersonal Trauma- The Power of Play (Guilford Press, August 2010). In this book, Gil speaks out for the power of undirected play therapy, particularly sand tray therapy, to provide a vehicle with which children can heal themselves. The book comes at a time when more directive and prescriptive therapies are in favor, and when play therapy has been maligned as not sufficiently powerful for children with attachment difficulties. In addition, in this era of short term therapy, the book demonstrates the need for long periods of treatment (at times years) for children who have endured serious abuse.

The book starts with a theoretical section, in which contributors discuss the incidence of interpersonal trauma, how it impacts the developing brain and body of the child, and how children can use therapy to heal.

In the second section, Dr, Gil and her contributors tell eleven stories of children who had experienced serious, often unbearable, abuse, and who used play therapy to heal. The stories are very moving. In all cases, the therapy is non-directive: the child is shown a room full of toys, and is allowed to use them in whatever way he or she wishes. The therapist does not interpret their play, but instead witnesses and contains it. Within the stories the therapists weave theory, attention to symbolism, and their sense of what was happening with the child. A strong emphasis is placed on the feelings of the therapist (counter transference). The therapists repeatedly describe how they used supervision to understand and utilize their own strong reactions to the children. The stories are all hopeful, and in several cases in clued long term follow up which demonstrates continued progress by the child.

Working with Children to Heal Interpersonal Trauma is a reminder of the strength and resiliency that can be found in every child. It calls us back to the power of the therapeutic relationship, and the change that is possible when a child is provided the time, space and caring necessary for him or her to find her own way forward.

Eliana Gil

The Difficulty of Taking a Break

In our Risking Connection© training, we emphasize the importance of vicarious traumatization (VT). Because VT can destroy our hope and optimism, and because hope and optimism are so crucial to our work, paying attention to VT is an ethical imperative. One aspect of the discussion is: what can we do at work to decrease VT? There are many answers, and one is: take breaks.

I have recently been experimenting with actually trying to take a break for lunch. Instead of eating while I do email, write or talk, I am trying to sit and eat my lunch. I brought in a placemat and a nice bowl, and I sit away from my desk. And what I have discovered is that this is extraordinarily difficult.

Some of the difficulties are within me. I am jumpy and want to keep working. I am thinking about what I have to do. I am responsive to all interruptions. I am interested in what I am doing and do not want to stop. I feel guilty. This segment on NPR (http://www.npr.org/templates/story/story.php?storyId=129384107&sc=nl&cc=es-20100829) relates

the physical addiction we get to responding to our many media.

Some of the difficulties are external- people want to talk, meetings are scheduled at noon, there are many things to be done. We have an “always available” culture.

When I do manage to take a break, I feel refreshed and calmer. I am more thoughtful in my work.

But it is hard.

Now I am on vacation- and for me, it is also difficult to tear myself away for the vacation. It isn’t that any one is pressuring me. It is more that I love my work, find what I am doing very interesting, and I am involved in some exciting initiatives right now. I do not want to miss anything! And yet I know the value of taking some time to turn my mind in other directions, relax and absorb some of this beautiful sunshine.

How about you? Do you take breaks during the work day? Is it difficult? If you have found good ways to do so, share them! Do you find it makes a difference? Click on “comment” and share your experiences.

Visit to Seven Hills Foundation

This week I visited an agency in Massachusetts named the Seven Hills Foundation. This organization is helping us create and run our new unit, Webster House, which will serve children with both psychiatric and medical disabilities. The staff at Seven Hills have been universally generous, helpful, kind and knowledgeable with us. We visited the Seven Hills Pediatric Center, which provides long-term care. Children enrolled in their long-term care receive all the necessary medical, nursing, therapy, and leisure services to enhance their quality of life. Many residents come to them with a history of congenital birth defects, past infections, or trauma. Cognitively, residents are under the age of 12 months and non-ambulatory. The staff at SHPC has many years of experience working with residents who are ventilator-dependent, have tracheostomies, or require gastrointestinal feeding. For children who require additional monitoring, they have a state-of-the-art individual monitoring system. We also visited a group home in which six individuals live. This house looks like a regular house in a lovely neighborhood on the outside, but was specially constructed by Seven Hills to have space for reclining wheelchairs, tracks for lifts, special bathrooms and many other adaptations. The mission statement of the organization is “Dignity by Design.”

The children that are served in these two facilities are generally unable to respond differentially to life. A few may have the ability to signal yes or no. They may have some differences of responsiveness to people they have known a long time. Any positive changes in their condition are microscopic. They cannot say thank you or I appreciate what you did. It is not clear at all that what happens to them makes a difference in their experience.

Yet, the staff at these facilities are loving and interactive with the children. They constantly talk with them, interact with them. The children are well dressed, clean, and obviously cared for. Their rooms are decorated like any child’s room. They participate in school and make many trips into the community. When I asked where they go, I was told they go anywhere anyone else would go- the post office, grocery shopping, the hardware store. Staff was proud that the children had marched in the Memorial Day Parade this year. The children attend school, and the walls are lined with their art activities. When a child cooks or creates a craft project, that means that the staff moves their hand in order for them to do so. Yet these children’s lives are filled with activity, even though it is not obvious whether they can understand what is happening.

The staff was happy, friendly smiling and greeted us warmly. The facility was sparkling clean and attractive. It was an inspiring visit.

It seems to me that we can be inspired in our work by the work that Seven Hills does. We often tell staff to judge their day by what they did, not by how the kids responded. If they were caring, empathetic, playful, flexible, then it was a good day no matter how the kids behaved. At Seven Hills, staff have to do that. I am sure that they give each other a lot of support. But they cannot see immediate (or even long term) responses to their efforts from the kids. And they make the effort any way. How do they do that? How do they remain hopeful and find meaning in their jobs, when they cannot see results?

The second area is something I have written about before, in clear focus here. When a child has an obvious physical disability, we do not get angry at him for what he cannot do. We do not think that if we punish him for not doing it, he will change. Instead, we make modifications and change our expectations. At Seven Hills this is the essence of every activity. The staff finds a way that their efforts can make it possible for a child to do something or have a certain experience. They literally move the child’s hand so that the child creates art or food. They do not use rewards or punishments. If a child can get better, they gradually allow them to do more, in minute steps.

What if we could more clearly see the physical changes trauma has caused our children? What if we could see their damaged brains and body chemistry? Could we more easily lend them our brains, our thinking and planning, and provide them the support they need for success? Could we be surer that through positive experiences they would grow and that gradually they would become more capable?

Our visit to Seven Hills was moving and inspiring, and led to some thinking about how their philosophy could apply to the work we do.

Restraint and Seclusion Experiences of Youth

In response to a previous post about our restraint and seclusion reduction initiative, one reader wanted to learn more about youth reaction to the experience of restraint. We asked several of our kids of all ages to fill in the end of open sentences about both being restrained and seeing others be restrained. We then recorded oth kids reading these aloud, and played them at our kickoff event for our “Got Restraint? More healing, less holding” initiative.
Answers from children to open ended sentences about their experiences of restraint and seclusion

When I get restrained, I feel scared.
When I am in a seclusion, I feel trapped.
When I get restrained, it reminds me of when they had to hold my uncle back.
When I am in a seclusion, it reminds me of watching my mom get in the police car.
When I get restrained, staff try to help.
When I am in a seclusion, staff ignore.
After a restraint I feel guilty.
After a seclusion I feel guilty.
When other kids get restrained I feel like I need to be in a restraint too.

When I get restrained, I feel even more angry than I did before.
When I get secluded, I feel really upset, mad, and angry.
When I get restrained, it reminds me of home, because I used to get into a lot of trouble at home and my mom would restrain me.
When I get secluded, it reminds me of my mother.
When I get restrained, staff get really mad and hurt you, a little bit, but not purposely.
When I get secluded, staff open the door quickly, most of the time, when I’m calm.
After I get restrained I feel scared, angry, and hot. I get scared it’s going to happen again, sad that it happened, and angry that it happened.
After I get secluded I feel even more angry.
When I see other kids get restrained it scares me.

When I get restrained, I feel scared because everything’s going so fast, and my emotions are a roller coaster, and hurt and frustrated. I feel angry because I start to hate the staff because they put their hands on me and they put me down and I don’t like to be touched. Sometimes I’ll purposely hit them so they’ll restrain me. Sometimes I’ll be like “why didn’t you guys just talk to me instead of going straight down.”

When I get secluded, I feel angry, I feel like hurting myself because I’m only by myself and there’s nothing for me to use to cope and there’s just walls. The quiet room would freak me out cause it was all scabbed up and had writing on it.

When I get restrained, it reminds me of the past, people hurting me.
When I get secluded, it reminds me of when I get grounded.
When I get restrained, staff can get hurt, and it depends on who’s in it, but sometimes staff hold onto me real tight or get frustrated with me.
When I get secluded, staff have to do paperwork.
After I get restrained I feel angry because I don’t like when people touch me.
After I get secluded I’m stressed still.
When I see other kids get restrained I feel no one should have to go through that.

When I get restrained I feel angry, like I’m going to pay them back, cause I hate when people put their hands on me. I don’t like to be a loser-it’s like getting beat up.
When I get secluded, I feel like I will I throw up.
When I get restrained, it reminds me of my past.
When I get restrained, it makes me angry.
When I get secluded, staff shut the door.
After I get restrained, I think F all you people, are you listening to me?
When I see other kids get restrained It makes me very upset and sad.

When I get restrained I feel like I can’t breathe.
When I get secluded, I feel like the walls are closing in on me.
When I get restrained, it reminds me of when I was hit as a little girl.
When I get restrained, staff grab me too hard. They should hold us down and talk, or just talk.
After I get restrained I feel I’m even more angry, and I still have trouble breathing.
When I see other kids get restrained I think staff do it right, sometimes kids hit them and they have to get aggressive back.

Good reasons to work hard and reducing or eliminating these practices.

Transforming the Pain of Vicarious Traumatization

A central idea in the Risking Connection© approach to dealing with vicarious traumatization is the concept of transforming the pain. One important way that human beings deal with pain is to look for the good within it, to notice how going through a difficult experience changed our lives or strengthened us as people. An example of this would be the woman who says: "I certainly didn’t want to go through that breast cancer scare last year. But it did sharpen my sense of my priorities, and so I have gone back to school to finish my degree." If we can notice the transformative effects of the pain we experience in our work, we will be able to appreciate how the work changes us in positive as well as negative ways, and will build on those positive changes. This is an powerful way that we can combat vicarious traumatization and stay engaged and hopeful in our work.

One author and healer who has deepened our understanding of this process is Rachel Naomi Remen. Rachel Naomi Remen is medical director of the Commonweal Cancer Help Program, and a clinical professor of family and community medicine at the University of California Ð San Francisco School of Medicine. Her books include My Grandfather's Blessings, and Kitchen Table Wisdom. She was recently interviewed on Speaking of Faith with Krista Tippett (a show that has many episodes which illuminate our work). The podcast of the show, as well as supporting writings, can be found at:

http://speakingoffaith.publicradio.org/programs/2010/listening-generously/

In her RECAPTURING THE SOUL OF MEDICINE Rachel Naomi Remen speaks of the importance of finding meaning in one’s work:

In times of difficulty, meaning strengthens us not by changing our lives by transforming our experience of our lives, The Italian psychiatrist Roberto Assagioli tells a parable about 3 stone cutters building a cathedral in the Middle Ages. You approach the first man and ask him what he's doing. Angrily he turns to you and says, "Idiot! Use your eyes! They bring me a rock, I cut it into a block, they take it away, and they bring me another rock. I've been doing this since I was old enough to work, and I'm going to be doing it until the day that I die." Quickly you withdraw, go the next man, and ask him the same question. He smiles at you warmly and tells you, "I'm earning a living for my beloved family. With my wages I have built a home, there is food on our table, the children are growing strong." Moving on, you approach the third man with this same question. Pausing, he gives you a look of deep fulfillment and tells you, "I am building a great cathedral, a holy lighthouse where people lost in the dark can find their strength and remember their way. And it will stand for a thousand years!" Each of these men is doing the identical task. Finding a personal meaning in your work opens even the most routine of tasks to the dimension of satisfaction and even joy. We may need to recognize meaning for the resource it is and find ways to pursue it and preserve it.

Meaning is a human need. It strengthens us, not by numbing our pain or distracting us from our problems, or even by comforting us. It heals us by reminding us of our integrity, who we are, and what we stand for. It offers us a place from which to meet the challenges of life. Part of our responsibility as professionals is to fight for our sense of meaning — against fatigue and numbness, overwork, and unreasonable expectations — to find ways to strengthen it in ourselves and in each other. We will need to rebuild the medical system, not just on sound science or sound economics, but on the integrity of our commitment. It has become vital to remember the essential nature of this work and renew our sense of calling to preserve the meaning of the work for ourselves and for those who will follow.

Here are some quotes from her interview on the show:

You know, sometimes what appears to be a catastrophe, over time, becomes a strong foundation from which to live a good life. It's possible to live a good life even though it isn't an easy life. And I think that's one of the best-kept secrets in America.

I was going to say the great joys of working with people on the edge of life. The view from the edge of life is so much clearer than the view that most of us have, that what seems to be important is much more simple and accessible for everybody, which is who you've touched on your way through life, who's touched you. What you're leaving behind you in the hearts and minds of other people is far more important than whatever wealth you may have accumulated….

We thought we could cure everything, but it turns out that we can only cure a small amount of human suffering. The rest of it needs to be healed, and that's different. It's different. I think science defines life in its own way, but life is larger than science. Life is filled with mystery, courage, heroism, and love. All these things that we can witness but not measure or even understand, but they make our lives valuable anyway.

People who are physicians have been trained to believe that it is a scientific objectivity that makes them most effective in their efforts to understand and resolve the pain others bring them, and a mental distance that protects them from becoming wounded by this difficult work. It is extremely demanding training. Yet objectivity makes us far more vulnerable emotionally than compassion or a simple humanity. Objectivity separates us from the life around us and within us. We are wounded by that life just the same; it is only the healing which cannot reach us. Physicians pay a terrible price for their objectivity….

No one is comfortable with loss. Being that we're a technological culture, our wish or our first response — let's put it this way: Our first response to loss is try and fix it. When we are in the presence of a loss that cannot be fixed, which is a great many losses, we feel helpless and uncomfortable and we have a tendency to run away, either emotionally or actually distance ourselves. Yeah. And fixing is too small a strategy to deal with loss, you know.

We teach them the power of their presence, of simply being there and listening and witnessing another person and caring about another person's loss, letting it matter.

This is a quote from Krista Tippett, the host:

“The following passage from Naomi Remen's Kitchen Table Wisdom, … was written with physicians in mind. But it holds a resonant caution and challenge for all of us, I think, as we struggle to face yet not be overwhelmed or numbed by — the pain and suffering that are a fact of human existence near and far.”

"The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet. This sort of denial is no small matter. The way we deal with loss shapes our capacity to be present to life more than anything else. The way we protect ourselves from loss may be the way in which we distance ourselves from life… We burn out not because we don't care but because we don't grieve. We burn out because we've allowed our hearts to become so filled with loss that we have no room left to care."

Let’s begin a conversation about how these concepts apply to us within our work, and how we can create opportunities to discuss these ideas within our workplaces.

Do You Like These Kids?

As part of our new restraint and seclusion reduction initiative, I recently completed two focus groups with clients to ask them what they felt staff could do to decrease restraints and seclusions. Their answers can be summed up in the directive: ask me what is wrong and listen to my response.

I was dismayed by the feeling that the kids had that the staff did not really like them or enjoy being with them. They spoke of staff wanting to get away from them, have breaks from them. They said staff were at times involved in their own interests and not willing to be interrupted by the kids. They noticed staff sitting and talking together. On the other hand, they described how much it meant when staff participated in games and activities with them. They felt close to staff who listened when they spoke, remembered what they said and asked them about it later. They were quick to blame themselves for staff not wanting to be with them, because of the way they acted. But they described acting better around staff who genuinely care.

One of my colleagues remarked recently that what our kids need, and have never had, is someone whose face lights up when they come into a room. Think of your own children or those of friends. They are celebrated in so many ways! Their pictures are on the refrigerator, their events are attended, their performances little and big are applauded. But more than that, they constantly receive feedback that they are delightful. Someone loves them, wants to see them, wants to hug them, and wants to hear about their day.

Some research has shown that a critical factor in school success is the proportion of positive to negative comments a child hears during a day. How many times do our children hear their own name used in joy, as in "Stephanie I am so glad to see you!" or "Stephanie what a wonderful math paper!" In contrast, how often is their name used as a warning: "Stephanie, stop that!" or "Stephanie, don’t do that!" In their lives I am afraid it has mainly been the later.

Martha Holden of the CARE project told me that she teaches staff that their main job is to make sure that the child they are caring for has a marvelous day. What if we organized everything we do around that goal? That our goal is to help the children be happy?

The children we work with are marvelous. Every day they demonstrate strength, courage, intelligence, wit, creativity and humor. Of course, they can also be obnoxious and even scary. But if we don’t see the marvel in them, who will? And how can they possibly change and grow if they have no one who is delighted by them?

The kids in my focus group were clear what they needed. What would it take for each of us to become that staff who listens, who joins with the children in games and activities, who laughs with them, who creates positive memories? How can we become the person who shows the child that she is worthwhile by looking forward to our time together, seeking her out and obviously wanting to be with her? This engagement can’t be faked and I am not sure it can be taught. But it is what makes our jobs meaningful and what heals the children.

What Can We Learn about Trauma from Lizbeth Selander?

I have been reading Stieg Larsson's Millennium Trilogy Bundle: The Girl with the Dragon Tattoo, The Girl Who Played with Fire, The Girl Who Kicked the Hornet's Nest by Stieg Larsson (Knopf; 1 edition, May, 2010). I have seen the Swedish movies based on the first two books. This marvelous series features Lizbeth Selander. Lizbeth has been systematically badly abused and has experienced profound trauma. We root for her so strongly that in the theater when I saw the first movie, the entire audience burst into applause when she achieved revenge against one of her abusers. Yet Lizbeth is strange, difficult, hostile and quirky, much as many of our clients are. In our sympathetic engagement with Lizbeth, we can learn a lot about trauma.
How has Lizbeth been shaped by her experiences?

• She is strong, resourceful, and has many skills and strengths.

• She is fiercely independent. She refuses to take help from any one. Even when she is in the hospital she hates to call the nurse because she wants to take care of everything herself.

• Lizbeth is very private. Even with the person who is closest to a friend (Miriam Wu) she does not want to reveal anything about herself. To her, giving someone knowledge is giving them power they will probably use against her.

• She is covered with tattoos and piercings, and she presents herself as other, as an outsider. Her presentation pushes people away.

• She participates in sex in an anonymous, unconnected way, then disappears from that person’s life.

• She is fiercely protective of her mother.

• She is available for connection, but is very skittish. The guardian who treated her well earned her respect and love. But she put him through many tests, then left his hospital room and didn’t come back when she thought he was dying.

• She assumes people will treat her badly. When (in the third book) some policemen are actually respectful to her, she assumes they have ulterior motives and are trying to trick her. She doesn’t talk with them.

• She forms a strong connection to a man, but cannot trust it. When she sees him on the street laughing with another woman, she immediately assumes that she was crazy to think he would ever want her and assumes that he was just using her.

• She goes to extremes. She doesn’t check out her experiences with him. She refuses to ever talk with him again and runs away.

Do any of these things sound familiar and remind us of our clients? In the context of Lizbeth’s experience, they make sense and seem entirely understandable. If you read these books (and I highly recommend them) maybe we can use them to deepen our understanding of our client’s reactions.

I would love to talk about this further. If you are reading this series click on comment and tell me your reactions.

Vicarious Traumatization and Foster Care

"I’ve been a foster parent for sixteen years" said Michelle. "And this is the first time anyone has ever asked about how this job affects me."

The last session in my six module training for foster parents was entirely focused on them. How does this very difficult work affect them? We started with the definition of vicarious traumatization (VT) from Risking Connection© (Sidran Foundation). It is:

"VT refers to the negative changes in the helper as a result of empathically engaging with and feeling, or being, responsible for traumatized clients." We can see these affects physically, emotionally, in our thoughts, in our sense of safety, in our relationships, our spirituality, and our sense of hope.

We did the Silent Witness exercise from Risking Connection© training. In this exercise, participants write anonymously on a piece of paper three ways that their job affects them in negative ways. On the back of the page they write three ways the job has affected them in positive ways. The leaders collect the pages and read them anonymously to the group. First, we read the negative ways, then we discussed them.

The foster parents spoke of not being able to sleep because of worrying what their child will do. They described the isolation of being alienated from friends and family who do not understand why they do not just punish the child more severely. A parent described how hard it can be when she has been desperately worried about a runaway foster daughter and then the girl returns and acts mean to her and seems to think her behavior was fine. A father talked about being with his son when a planned visit with the bio mother was cancelled due to her not showing up. A mother spoke about how tired she always feels, and how she no longer wants to go out with her friends or even do her favorite scrapbooking because she just wants to sleep. One parent said that for him the hardest thing is not knowing what to do, how to respond, and beginning to doubt himself. Several parents described the effects on their biological children, who resented the attention taken by the foster child and who at times had themselves been physically hurt.

As we discussed this list, several parents commented on how depressing it was. Then Arlene said: "but it is so good to know I am not alone in feeling this way." Several people said they could have written everything on the list. The parents felt that only others in this field could understand what it is like.

We then turned to the list of positive benefits. Many parents felt that they had become better people because of doing this work. They were more patient, more understanding, and more creative. They felt they had become better parents to their bio children. In fact, many also felt that their bio children had become better people because of the foster children. Repeatedly people spoke of how much it meant that your life had a purpose, that you were doing something very important, that you were making a difference in a child’s life.

The positives do not take away the negatives. They are both real. It is through the intensity of the work that personal transformation happens.

Again and again the parents said how important it was that they could talk about the affect of the work on themselves, with people who understood.

We have to make sure that it is not sixteen more years before they get another opportunity to do so.

Born for Love: Why Empathy Is Essential--and Endangered

Book Review

Born for Love: Why Empathy Is Essential--and Endangered

Bruce D. Perry, Maia Szalavitz
William Morrow (April 6, 2010)

Bruce Perry’s new book focuses less on therapy and more on society. The book is a plea to us all to fight the many threats to the development of empathy in our children, and a passionate description of why empathy is essential to all human life.

From birth, when babies' fingers instinctively cling to those of adults, their bodies and brains seek an intimate connection, a bond made possible by empathy—the ability to love and to share the feelings of others.

In this provocative book, renowned child psychiatrist Bruce D. Perry and award-winning science journalist Maia Szalavitz interweave research and stories from Perry's practice with cutting-edge scientific studies and historical examples to explain how empathy develops, why it is essential for our development into healthy adults, and how it is threatened in the modern world.

Perry and Szalavitz show that compassion underlies the qualities that make society work—trust, altruism, collaboration, love, charity—and how difficulties related to empathy are key factors in social problems such as war, crime, racism, and mental illness. Even physical health, from infectious diseases to heart attacks, is deeply affected by our human connections to one another.

Born for Love describes the conditions that are necessary to produce compassionate adults. Although Perry and Szalavitz focus on society as a whole, it is also interesting to consider whether we are creating those conditions within our treatment programs. For example, empathy is created through the mirror neurons. Because these parts of our brain experience what we see others do, the children we treat will experience our caring responses directly. When we realize that the brain develops what it needs to be successful in the environment it faces, it is essential that we pay attention to what creates success in our environment. Does the child have to be loud and in distress to evoke empathy? If so, the brain will develop more distress.

Perry and Szalavitz emphasize the importance of safety, and how living with danger inhibits IQ development, makes it harder to fight infections, and floods the brain and so makes learning harder. This puts even more pressure on us to make sure that our treatment environments feel safe to the children who live in them.

We feel more empathy for those we think are more like us, for those who are part of "our group" and less for those we label "other". We are vulnerable to the influence of our group. What can we do to create a sense of belonging in our places? Rituals and rhythmic sharing help.

When children watch television and other media, they hear human voices but have no response to their own actions or talk. TV thus in some ways is a "frozen face" as in the famous experiments, in which a mother’s frozen face leads to escalation and then retreat in her baby.

Perry and Szalavitz report on how studying the hierarchical structure in baboons can illuminate our own response to leadership. The higher the perceived danger, the more likely animals are to blindly follow the leader. The larger the status differential between leader and follower, the more distress is seen in the follower. Sometimes depression becomes an adaptation to low status- a resignation to the impossibility of effective action. How does this relate to what happens between the youth in our programs?

Iceland, Perry and Szalavitz report, scores highest of all countries on all measures of happiness and social health. They attribute this to such factors as maternal/paternal leave and good child care but also to a feeling in that country that “We’re all in it together”. There are fewer difference and power differentials and more social cooperation. How can we develop communities like that?

In conclusion Perry and Szalavitz state that humans have a fundamental yet developmentally vulnerable capacity for empathy. In order to maximize it we need to practice love. We know that kind social contact relieves stress, and that developing empathy and relieving stress decreases both social and medical problems.

Do we practice love and offer kind social contact in our programs?

Rituals of Passage

In Risking Connection© training we read a letter from a woman who grew up in the child welfare system in the 19950s. She was asked by her therapist, Dr. Kay Saakvitne, (one of the RC authors) what she would want people who worked in that system to know. In her letter she speaks eloquently of the lack of continuity when one is moved from place to place. It is very hard to develop a secure sense of self when there is no coherent narrative of ones life, no pictures, no one to remember the various parts. People appear and disappear. They each say something different about who you are.

This letter makes me think about all the ways we create that narrative for our own kids: we tell them the story of how Mommy and Daddy met, of their birth. We describe their ancestors and say they resemble Aunt Jane. We say "all members of the… family always…" We remind our teenagers of embarrassing things they did when they were kids. When the kids are 57 they are still expected to display the characteristics that were assigned them at age 5.

The author of the letter implores us to ask our clients about their pasts in conversational ways, to help them construct their story. When possible, create a life book with pictures and mementos. When they have to move, explain why, give them time to prepare, and relate the new place to the old- for example, point out both places on a map.

What can we do to help the child put her time with us into her story? One residential (Sunrise, Kentucky) reported some interesting rituals. One is to create a memory box for a child when they arrive. During their stay put in souvenirs, mementos, pictures. When they leave, add messages from staff and kids and send it with them. Another site described a ritual in which they buy the child a necklace. They pass the necklace around to each child and staff, and each states a wish which they are attaching to the necklace to go with the child.

What hello and goodbye rituals does your program do? How do you create a sense of meaning and continuity for your kids during these crucial times of passage?

Dilemmas of Trauma Informed Care

Our difficulties in treating Mario exemplify some of the key dilemmas of trauma informed care.

Let me introduce you to Mario. He is twelve years old. He experienced severe early abuse including repeated violense both between his parents and directed towards his siblings and him, and has lost his entire family. He has been ejected from three foster homes. His IQ is low average, and his mother may have used substances during her pregnancy with him. He has been in residential treatment for a year and three months.

During the first few months of Mario’s placement, he destroyed a lot of expensive property at the agency. He trashed the gym, broke windows, destroyed a part of the school, and more. After each event he was deeply ashamed and further confirmed in his sense of himself as a horrible bad boy. He would hide under the furniture and refuse to talk with anyone. When he was not upset, he could describe some strategies he could use when something went wrong. But when something did go wrong, and it was often something very small, his emotions would well up and completely take over his mind. A staff member says that he has to wait ten minutes before going to dinner. Mario becomes overwhelmed with a sense of total hopelessness. He knows he will never eat again. His mind becomes muddled and he is unable to think. He is plunged back into his basic reality in which his needs are never met, no one can be trusted, and he has to fight for anything he gets. So he reacts- he throws something, breaks something, threatens someone. Anyone around him would be bewildered. What happened? Waiting ten minutes is no big deal. They try to explain this to Mario but he literally does not hear them. Mario’s pain gets worse and he tries to express and escape it by increasingly aggressive actions. Finally, he is contained and the storm passes. Afterwards, he feels worse than ever.

Elliot is Mario’s team mate (child care worker with a special relationship with and responsibility for Mario.) Elliot is a caring young man, and he sees Mario’s shame and pain. He works hard to form a relationship with Mario and not to give up on him no matter what he does. When Mario is calm, he and Elliot have some great times together. Elliot is proud that he is able to connect with this difficult child, and thinks that their relationship may be part of the reason that Mario has gone a month with no major episodes. Yet, yesterday Mario got into a minor argument with a peer that rapidly escalated into violence. When Elliot tried to intervene and get Mario to take a walk with him, Mario looked at him blankly and said: "I don’t know you. You don’t know me." Elliot felt hurt.

Over all Mario’s behavior improved, his property destruction decreased, and his episodes became further apart. The treatment team members were proud of what they had accomplished, and Mario himself was feeling more hopeful. So he was referred to a therapeutic foster home and began to visit a family. Almost immediately the aggression returned. After several episodes the family withdrew from consideration.

Now, Mario appears to be regressing. He has become aggressive towards people instead of just property. He has had several major, dangerous high-end events. He was hospitalized, and did well in the hospital. Staff felt hopeful and lifted all his restrictions when he came back. As one person described it: "We gave him a blank slate and he smashed that slate into pieces." Staff have noticed that he acts worse when there are fewer staff on duty, or when the shift workers are all female. Shortly after coming back Mario went on an agency trip to a baseball game. On the way back he got into such a major unstoppable fight that several policemen and supervisors needed to intervene. At this point, the team is investigating transferring Mario to a longer term hospital program.

It is always painful when we are not successful in our treatment of a child. When we have been working with relationships, with our hearts open, it can feel personally distressing. We doubt ourselves and wonder if there is more we could do. We feel hopeless for this child, and perhaps less hopeful about our work in general. In short, we feel much the way the child feels.

So how do we react to our pain? And how do we understand what is happening with Mario? It is easy to begin seeing Mario’s behavior as intentional: "he waits until staff are vulnerable and attacks." It is natural to think punishment would help: "he needs to go somewhere where he will get serious consequences for his behaviors. We are being too nice to him. He needs to understand that in the real world he cannot get away with these sorts of actions." It feels like Mario is uncaring: "We don’t have a relationship. When he is upset he does not even know me. He never seems to consider the needs and feelings of anyone else." A common reaction is to retreat, to treat Mario with distant politeness, and stay emotionally closed. It is natural to feel angry, betrayed, sad and hopeless.

Mario may need to be in the hospital. In a hospital adults can physically keep him and others safe using tools residential does not have (high staff ratio, locked doors, etc.) He probably did well in the hospital because right now he needs the feeling of safety that a hospital provides.

Yet I think it is important to re-consider what is going on here, no matter what the outcome. Here are some points for thought:

Mario is not deliberately planning his aggressive outbursts. When he says he is going to try some strategies, he means it at the time (just as I mean it when I say I am starting a new diet on Monday). When he is connecting with adults, he is not planning to trick them. When the chemicals in his muddled brain are calm, he can enjoy other people and plan a different future.

Mario is not looking for times when staff are vulnerable due to less people or all females on the shift. It is possible that at these times he feels less containment and safety, and thus more anxious and more vulnerable to over-reaction when something goes wrong.

I do not think that punishment will help Mario change this behavior. Of course punishment will make him feel worse and more shameful. Yet will it be a deterrent? I do not think that Mario would have access to an awareness of consequences when he is agitated. If he did remember them, he would not care or might feel that they would be just what he deserved. I honestly do not feel that when his brain chemicals are raging he can think to himself: if I do this, I will be in trouble so I shouldn’t do it. Unfortunately I do not think he can even remember: if I do this, Elliot will be disappointed. Instead he already feels that he is totally in trouble and already feels that Elliot is disappointed, or couldn’t possibly be trusted to like him. So what is there to lose?

I also think we overlook the role of stimulation, even from positive events. Staff were being caring and compassionate when they decided to bring Mario on the trip. However, it is possible that the excitement of the trip, although a pleasant experience, was too much for Mario. Keeping his world small and predictable might work out better.

What does Mario need? He needs to be kept safe so that he can experience positive relationships over a long period of time. He needs to learn and practice concrete steps he can take when he first starts to feel upset- and the first step is to realize when he is getting upset. He needs experiences of success and positive action. And he needs some hope- some pathway towards growing up outside an institution, some adults who will love him and stay with him.

These are all things that are very hard for our system to provide. And the pain of this situation leads Elliot to wonder: "Is there any hope for Mario? Are there some kids who never change, and who are destined to spend their lives in jail?"

Can a twelve year old be hopeless? That is a crucial question for us all.

Book Review: Denial

Denial: A Memoir of Terror

Jessica Stern

Publisher: Ecco (June 22, 2010)

I was asked to review Denial: A Memoir of Terror by the staff of its author, and I am glad I had the opportunity to do so. The author of this book is an expert on terrorism and a national security advisor. In Denial she relates her experience that when she was 15, she and her sister, a year younger, were forcibly raped in their home at gunpoint by an unknown intruder. Years later when the police reopened the case in 2006, Stern was compelled to confront the devastating experience and research the rapist’s background. In the course of doing so, she learned more about her family and herself.

For me, the most valuable part of this book was experiencing from the inside, through Stern’s clear writing, what the after-effects of trauma actually feel like. The various trauma experiences interact with other aspects of her family history to produce both strength and blind spots. At times the book was a bit confusing, as the narrator moves between experiences of the rape, experiences within her family, and present life. However, I came to feel that this reflected what it felt like to her: all these aspects creating confusing and inexplicable symptoms that were very hard to recognize or sort through. In reading the book you experience how assumptions about the world that are formed in trauma become unquestioned reality. These assumptions then influence ones’ actions in life such that they are confirmed again and again.

Stern describes vividly the various subtle and more obvious symptoms she developed as a result of her trauma. The reader can experience the intensity and confusion these symptoms cause.

Another strong theme of the book is the failure of the community within the family and outside it to support these two girls. It is astonishing how little help they got, how they were not believed, and how the case was allowed to go unsolved for so long. Stern demonstrates the unwillingness of the community to face the presence of evil in its midst. Years later, a policeman does develop an interest in solving the case and succeeds in doing so. But in the mean time the rapist has harmed many more girls. The function of denial for the individual, the family and the community is demonstrated clearly.

I would recommend this book. It gives us a rare opportunity to experience from the inside the complexity of multiple layers of traumatic experiences and how they affect relationships with family, friends and partners; influence job choice and performance; and infiltrate every part of life. In addition it clearly demonstrates the function and danger of denial.

Ah, Young Love

In your treatment program how do staff respond to romantic relationships between the youth? Do you forbid them, in the interest of preventing distractions from treatment? Do you set limits, and what are they- no sex? No holding hands? Do you respond differently to a homosexual couple that live on the same unit than you do to a heterosexual one? Do you facilitate normative teenage activities such as dates to the movies? Anyone who treats adolescents has had to struggle with these and many more questions. And the relationships are often fraught with drama, anger, broken hearts, agitation and obsession. In addition, parents, social workers, licensing and accreditation bodies are watching and have strong- and differing- ideas about what you should do.
Sally and Mark are in love. Or at least they were this morning- this afternoon, as they return from school they are angry and agitated. Rosita just told Sally that she saw Mark talking with Leticia in school. Three other girls have told her that Mark said he thinks Leticia is cute. But Kendra said that Mark told her that he only cares about Sally. The girls will not get ready for the planned softball game- they are gathered in clumps discussing this. And it’s even worse because Sally and Leticia were good friends. Now Leticia is in her room with the door closed and Sally and several of her other new friends are considering ways to kill her.

Meanwhile, on the Boy’s Unit Mark is desolate. He is in bed with the covers over his head. He refuses to do his homework or attend activity. He knows that Sally is going to break up with him and he cannot live without her. He doesn’t even like Leticia! He sticks his head out and begs his roommate Devon to call the Girl’s Unit and convince Sally that this is all a big mistake. When staff say that it is not phone time Devon becomes belligerent and insists that this is an emergency.

What’s a staff to do? All this relationship stuff is getting in the way of treatment. It is paralyzing the entire program. It is so over dramatic and messy.

I would suggest that all the drama and mess IS the treatment. First of all, of course, this is normal teen age behavior. We cannot keep kids in treatment programs for several of their teen age years and not allow them to have teen age relationships. So much is learned in these relationships, so much practiced. If we forbid them (as if we could- they just go underground) our kids will be behind and incapacitated in one more way. Isn’t it better to let them experiment in the relative safety of our programs?

What is going on here? What needs are being met? What can be learned?

Can we assist Sally and Mark in direct communication? Instead of relying on the highly unreliable assistance of all their messengers, can they take the risk to talk to each other about whether Mark wants to break up with Sally and go out with Leticia?

What about the other kids? All of them are feeling important and excited by their roles in the drama. That’s okay. We don’t really need to go outside to play softball. Maybe we should pull the girls together and have a group about relationships- a very respectful and real group. How do you know if you can trust someone? How do girls keep on being friends when boys enter the picture? How do you decide who to believe? What are you looking for in a boyfriend? Etc. These topics are central to all teenagers and they are great to discuss in groups- many important issues come up. For example, in one group I talked with girls about who they can trust and I was saddened by how certain they were that there was no one, especially no boy that could ever be trusted. In another group, one girl had called another a slut. So we wrote on a white board all the characteristics they considered slutty, and had a great discussion of whether they wanted to be slutty and in what ways they were or were not presenting themselves that way. The trick is for the adults to be real, hold to their own values, but remain curious and respectful about the kids’ thoughts and values.

Maybe one of the male staff could go in and talk to Mark about women- you can’t live with them, you can’t live without them. He could talk man-to-man about how to show a woman she can trust you, or about whatever topics emerge. Neither our boys nor our girls have known very many good men, and they desperately need to know that it is possible to be strong and kind at the same time. Another staff might talk to Devon about what a good friend he is and how he can best support Mark.

We have to have limits. One is: no sex with anyone in the program. But if we can facilitate normal teen age things, it will be so helpful to them. For example: could staff take Sally and Mark to the movies (after they recover from this setback) and sit one or two rows behind them? We also have to make sure we are equally respectful to homosexual couples, despite the added complexity of sharing living quarters.

We cannot forbid romantic relationships. We do not need to see them as a distraction from the real work. There is nothing more real or important to a teen ager than their romances. And I have seen youth grow and change because of love, start to have more confidence because someone cares about them, learn how to share themselves more directly and experience the joys of being understood. I have also seen heartbreak, despair and regression. But I’ve seen all these in my adult friends as well. This is what life is all about- and we can use every piece of the emotional upheaval as an opportunity for growth.

Trauma Conference 2010

I have just returned from the 21st Annual International Trauma Conference in Boston. This conference is directed by Bessel van der Kolk and the staff of the Trauma Center at the Justice Resource Institute (http://www.jri.org/). As usual this conference offered a unique combination of science and practice. In this article I will attempt to extract a few central ideas that I think can immediately add value to our every day work.

The conference focused a great deal on the contributions of neurofeedback, both in understanding the brain and it treatment. In addition, information continues to grow about the parts of the brain, their purposes, and the ways in which a developmental path which includes neglect, trauma and attachment disruption can derail their functioning.

The most emergent theme for me in this conference was the idea of rhythm. All human functioning depends on the establishment of rhythm, and perhaps our basic rhythms start with the mother’s and baby’s heartbeat. When infants are born, they can almost immediately respond to music. Presenters such as Ed Tronick, PhD (Infants’ Reactivity and Coping With Stress: Here Today, Gone Tomorrow?) demonstrated the exquisite musicality of the mother/baby attuned interactions, and how the tune is often led by the baby. Our interactions with babies emphasize rhythm (such as baby songs) and any parent can confirm how important routines and predictability are to the regulation of the infant’s emotions. All this rhythmic interaction has many functions for the growth and development of the baby. One result is becoming socialized to the rhythms of human interaction and social communication.

It is clear that the children we work with did not have either the attuned communication or stable rhythms in their daily lives.

This suggests an area of intervention that we do not utilize enough. Rhythmic interaction between people offers opportunity for attunement without words. This can be done in many ways: bouncing a ball back and forth, dancing, singing together, drumming, listening to music and clapping the beat, swinging, etc. These activities could easily be incorporated more into our daily lives, school and recreational activities.

I attended a workshop on SMART: Sensorimotor Arousal Regulation Treatment for Traumatized Children presented by Anne Westcott, LICSW, Elizabeth Warner, PsyD, Jane Koomar, PhD, OTR/L, FAOTA, and Alex Cook, PhD. This treatment integrates knowledge from child development, occupational therapy sensory regulation, and sensory motor psychotherapy. At their clinic they have outfitted a treatment room with various OT equipment such as cushions, large balls, wedges, etc. They utilize bodily work and rhythmic interactions between the child, the therapist and the care giver to produce regulation and a window of opportunity for connection. With this support the child can often talk about difficult topics in a way they otherwise cannot. They will soon be releasing a manual for this treatment.

Through careful research using fMRIs and Neurofeedback, more evidence has been gathered about the biological result of trauma. One important finding is that the area of the brain that is responsible for self reflection is significantly impaired. Children who have grown up in disruptive situations have less ability to think about themselves. They also have considerably less ability to recognize and interpret their own internal sensations. They cannot identify the sensation, associate it with a specific need, or figure out what to do about it. This includes the sensations of hunger, thirst, satiety, needs to eliminate, pain, and tiredness.

Think how significant this is to understanding the daily struggles we experience. Not being able to observe ones self- that has implications for the ever popular concept of taking responsibility for one’s actions. Not being able to notice and interpret bodily signals- that can be part of the explanation for the constant hygiene and toileting problems these children experience.

Inability to recognize and identify bodily sensations can also lead to serious social problems.

In examining brain waves of traumatized children, researchers discover that some parts of the child’s brain are over active and some are under active- often at the same time. Children especially have difficulty moving between states, such as between sleep and wakeful attention, or excitement and calm.

Researchers have also learned that the sleep problems experienced by children with trauma may be more significant than previously thought. We have all noticed that large numbers of our kids cannot get to sleep, or wake up, or have nightmares. However, it is now known that even when these kids appear to be sleeping they spend much less time in deep sleep than other children- and deep sleep is what is restorative and nourishing.

Understanding the biology behind the behavior we see can be helpful in not taking it personally, having patience, and deliberately designing interventions to target certain kinds of brain changes.

The presenters gave many examples of how neurofeedback had helped children, including for ADHD and even for schizophrenia. Neurofeedback also improved the musical performances of both skilled musicians and novice nine year olds, as reported by John Gruzelier, MD in Neurofeedback and its Benefits for Psychological Integration and Creativity.

Margaret E. Blaustein, PhD earned a standing ovation with her presentation Lessons from Kids and Families on the Treatment of Developmental Trauma. She brought the voices of the children and families into the conference, relating her ten lessons. They included both seeing the oak tree in every acorn (the strengths in the kids and families) and sometimes admitting that life sucks. Her strongest message was that traumatized kids are complex and deserve a thoughtful, complex intervention from us.

And as Ed Tronick, PhD said in his presentation Infants’ Reactivity and Coping With Stress: Here Today, Gone Tomorrow: The best tool is a "polymorphic stress resolver: an adult who unconditionally cares in all ways and at all levels."

That would be us.

I cannot write about this conference without mentioning the campaign led by Bessel van der Kolk to establish a new diagnosis to be included in the DSM V: Developmental Trauma Disorder. With a diagnosis that more completely and accurately captures the reality of children and adults that grow up with neglect, trauma and attachment disruptions, we can have research, medication, and treatments that really make a difference. To learn more about this diagnosis and the criteria for it, visit http://www.traumacenter.org/announcements/DTD_papers_Oct_09.pdf. To contribute badly needed funds to its establishment, see http://www.traumacenter.org/products/DTD_Field_Trial.php.

Every presenter was passionate about the importance of this change in our system.

I am sure I have only scratched the surface of the ideas presented at the conference. If you were there, or have any opinions on these subject, please click on "comment" and add your thoughts.

Children Act Better When They Feel Better

I believe that children act better when they feel better. Do you agree?

What would our worlds look like if we deeply believed this, and put it into practice? Then our mission would become to help the children feel better. How could we do that? Of course, we do that already in many ways- but what if we deliberately made helping the children to feel better our top priority?

It would be essential to define “feeling better” in a complex and multi-faceted way. Each area has many parts and of course they overlap. It could include:

Feeling Better Physically:

• Addressing any health problems
• Establishing good nutrition
• Helping with sleep
• Engaging the kids in exercise, helping them overcome their fears and shame around moving their bodies
• Providing nice, comfortable clothes
• Addressing sensory distress

Feeling Safer:

• Eliminating bullying
• Addressing signs of danger
• Being caring, welcoming, sensitive to their needs

Felling Calmer:

• Teaching self soothing skills
• Teaching yoga, meditation, neuro-feedback
• Help with life problems

Feeling Less Shame:

• Exploring areas of self blame
• Forming relationships
• Experiencing competency

Feeling more competent

• Building on strengths
• Teaching new skills
• Encouraging self expression
• Providing opportunities to help others
• Providing praise and recognition of achievement

Feeling more effective:

• Providing many opportunities to control ones own life
• Teaching and practicing conflict resolution skills
• Providing opportunities to make a difference
• Developing leadership

Feeling more connected:

• Developing strong relationships between ourselves and the kids
• Providing assistance to help them maintain relationships with family and friends outside the agency
• Providing assistance to help maintain connections with communities such as religious organizations, their own school, sports teams, etc.
• Encouraging and facilitating appropriate relationships between the kids
• Encouraging exploration of their own culture and history

Obviously these are the things we do anyway- but does this way of looking at them help understand or organize our work in a new way? If a child acted out, we can wonder in what way they are feeling bad, and how can we help them feel better. Our response should be focused on helping them feel better, not explaining what was wrong with what they did.

I am just beginning to think about this. What is your reaction? Click on comment to respond.

Accommodation

I am in the middle of a six week training of foster parents. The topic is: Trauma Informed Foster Care. The foster parents are teaching me what they need to know in order to stick with these difficult children. The information about trauma and its effects is important; the practical applications are essential.

We were talking about the idea that children are doing the best they can, and how the biological changes they have experienced create real challenges for them. One foster father said to me: "I don’t expect anything different from my foster son as I do from my biological sons. I expect him to do everything they do and if not, have the same consequences they do."

This led me to think about how we readily make accommodations for physical disabilities that we can see. Yet is so much harder to see trauma in the same way. So this led to the creation of the following skit:

I asked two foster care social workers, Jaime and Neftali, to play two brothers. One (Jamie) played the son with a badly broken leg. He had broken it when his friends challenged him to try a jump on his skate board. We wrapped Jaime’s leg with gauze and an ace bandage, and gave him some crutches. The other (Neftali) was fine. But he was angry and resentful that Jaime is getting all the attention and is getting out of doing things.

As the two sons sat in front, I gave volunteer foster parents cards with situations, and asked them how they would handle them. The first was: "Your sons attend the local high school. There are long halls, stairs, and lots of changing classes." The foster father who chose this card, John, said he would go to the school and advocate for his son, ask for a longer time to change classes, a wheelchair, use of the elevators. Immediately both boys began to object. Jaime said that would be embarrassing and he could manage it himself. Neftali said he would NOT be pushing Jaime’s wheelchair. John was sure that he would insist that the accommodations be made even if Jaime objected.

The next scenario was that Jaime’s doctor had recommended PT for his recovery. Jaime did not want to go. PT would hasten his recovery, but it was not life or death. Jaime immediately said it was stupid and he knew he wouldn’t like it and it wouldn’t help. Neftali said he should be forced to go. The foster mom, Rose, who took this card said she would insist that he at least go- he could decide what to do when he got there. Other foster parents disagreed, and said that at least by some unspecified age he should decide for himself once the pros and cons had been explained to him.

The next situation brought us to chores. The boys usually handle the outside, mowing the lawn etc. Naturally Jaime could not do this. This time he was willing to accept his limits and do nothing. Neftali said if he had to do it all he should get Jaime’s allowance. The foster parents all suggested finding other ways Jaime could help such as doing the dishes while sitting in a chair. We had a spirited discussion of allowance, whether it should be used (it is mandated by DCF) and whether it should be contingent. If someone has a physical problem and can’t do the chores should the allowance be withheld?

I thought it would be obvious why I was doing this, but interestingly when I asked the foster parents none of them mentioned the connection between the broken leg and the broken brains our children have. When I pointed this out, the parents wrestled with the implications.

We are used to the idea of being flexible to accommodate visible physical limitations. I wonder if it would help if some how we could see our children’s broken brains?

What are your thoughts? Click on "comment" to respond.

How to Enhance Hope

A central concept in our Risking Connection® teaching is that healing relationships are characterized by Respect, Information, Connection and Hope. In fact, the concept is so integral to Risking Connection that the acronym RICH has been trademarked by Sidran. I would like to look at the concept hope.
I began thinking about this today as I wrote a book review of Trauma Stewardship by Laura van Dermoot Lipski with Connie Burk. This review will be in our May newsletter- be sure you are on our mailing list to get it (www.traumaticstressinstitute.org).

Van Dermoot Lipsky describes organizations as to whether they have a hopeful, energetic feel or a defeated, listless feel. I began thinking how essential hope is to all our endeavors. Do we make enough deliberate efforts to strengthen hope in our organizations, our staff, ourselves and our clients? How can we do this? Here are a few ideas- please add yours in comments.

Organizations
1. Hold regular celebrations
2. Communicate successes
3. Share stories of clients who return to visit and are doing well
4. Reward all sorts of staff efforts
5. Share any honors, recognitions or praise widely
6. Regularly and publicly reflect on where we have been and where we are now and where we are going
7. Articulate a vision of what kind of organization we want to be. Specify values and refer to them often.
8. Organize many child activities such as plays, field days, art shows, science fairs. As many staff as possible attend and applaud.
9. When something goes wrong, pull together and identify the parts that were done well. Praise the staff for those. Be specific about what we have learned from the event.
10. Articulate our pride in our agency and specifically what we are proud of.
11. Have fun, make jokes, do silly things
12. Celebrate staff milestones (new babies, weddings, etc.)

Staff
1. Praise, praise, praise- little and big things
2. Comment on any instance of staff doing their work well.
3. Assist staff in meeting their personal goals through providing training and education reimbursement
4. Provide supervision
5. Share client success stories
6. Promote from within when possible
7. Deliberately groom people for their next job
8. Remark on extra effort
9. Make room for creativity and individual interests, like the child care worker that hooks the kids up with a horseback riding stables through their personal interests
10. Do something different
11. Encourage staff to say yes- and say yes to them
12. Be flexible whenever possible
13. Maintain a clean and beautiful environment, fix damage quickly
14. Create fun events together such as pot luck lunches or volleyball teams
15. See above organizational ideas

Personal
1. Reframe experiences to focus on what you have learned.
2. Maintain balance with work and non-work connections
3. Take breaks and vacations
4. Decorate your space when possible
5. Notice changes in clients even when small
6. Notice changes in yourself such as increasing skill, and point them out in others
7. Notice ways the work has grown you as a person
8. Set goals for areas you would like to learn more about or new things you would like to do
9. Connect with others in the profession
10. Talk about your experiences11. Use supervision and therapy.
12. Laugh.

Clients
1. Point out small changes
2. Set small goals with them, notice when they are met
3. Express delight
4. Celebrate their achievements, attend their plays, admire their art
5. Arrange for them to take extra classes in an area of skill
6. Fantasize the future when they are a famous football player and are returning to your place to speak with the kids who are there then- what will they say?
7. Show that they matter by speaking from your heart.
8. Allow them to take some risks and try something new.
9. Offer new responsibilities
10. Arrange ways they can help others
11. Encourage the older to teach the younger
12. Put them in charge of things
13. Have a Youth Council that has real power
14. Tell stories of other successful kids
15. Have fun together.

What do you think? How can we be more active in cultivating hope, which is the core of everything we do? Click on “comment” and add your ideas.

Safety Empathy Action

I have been thinking that a shorthand guide for what we need to do for kids in treatment would be:
Establish safety
Teach emotional intelligence and empathy
Promote effective action

Now if only I could make it spell a word!

Safety- nothing good can happen when the child does not feel safe. If a person is in danger mode, he cannot learn. She cannot trust enough to form the relationships that will be the vehicles for healing. He cannot sleep- and so life feels so much more difficult. She has trouble relaxing and having fun. He misses much of what is going on because of the necessity to constantly scan for danger. Fear manifests in aggression, self harm, running away, and retreat. Fear without any one to turn to is completely overwhelming and is more powerful than both rationality and reward.

Of course, safety is not an all-or-nothing state. The sense of danger rises and falls. Yet we must pay close attention to the signals of danger and safety in our programs and in our relationships with the children (and families) we serve. If we actively strive to create safety in every aspect of our environments and relationships, we will help the children be more available sooner. And if we look for fear under many problem behaviors, we will discover more powerful intervention options.

Emotional Intelligence and Empathy: We could describe much of what we do in treatment under this category. I have just finished Dr. Bruce Perry’s new book, Born to Love (will review soon). His entire thesis is the necessity for empathy for societies to function at all. And as loyal blog readers will know, I heard a presentation on emotional intelligence at a recent conference. Dr. Hendrie Weisinger listed five key skills in emotional intelligence. They are:

1. Self awareness- processing information about yourself
2. Mood management- how quickly can you change your moods?
3. Self motivation- how can you get yourself to do things you don’t want to do
4. Interpersonal expertise-Build consensus, handle conflict, accept feed back, etc. Effectiveness in interpersonal emotional situations
5. Emotional mentoring

Self awareness is the key skill that is the foundation for all others- how can you be emotionally aware of others unless you are aware of yourself? This of course correlates with the skills of feelings management.

Empathy is a key part of interpersonal expertise. How can we build consensus, handle conflict or even form relationships if we have little ability to see things from another’s perspective?

Can we more deliberately build teaching empathy into our programs? When we use restorative tasks in response to a behavior that hurt others, we could include tasks that encourage the child to see another’s point of view. My friend and Risking Connection® faculty trainer Dr. Bob Davis shared some ideas from Devereaux. These included having the child write a story of the incident (or draw a picture) from the other person’s point of view, exploring what that person was feeling before, during and after the event. To create meaningful making amends tasks, the child should first think about who his behavior hurt and in what way. Then he should consider what could make that person feel better. That in itself is practicing empathy.

Of course the most powerful way we teach empathy is by showing it ourselves. We do this in our attempts to understand what the child was experiencing when she did something, and our working conviction that she was doing the best she could at the time. We model empathy is what we say about other staff, people in the news, people in movies or TV shows.

What else could we do to increase empathy?

Effective Action- Our children come to us believing that it is not possible to influence one’s own life. What happens, happens- and it is usually bad. There is nothing you can do about it- especially because you yourself are bad. We must teach, promote and make space for effective action. Particularly we must teach our children how to fix problems that happen within relationships. We grow as humans through relational attunement, rupture and repair. Our kids have had little of the attunement, a lot of the rupture and almost none of the repair. So again we must model- reach out to reconnect when we know we have missed the mark with a child. We can also demonstrate how we work out differences between ourselves as staff.

With restorative making amends tasks, we teach children what a person does when something goes wrong in a relationship, when you screw up. At first, we make the suggestions and offer the ideas. Later kids will think of ideas themselves. And when they see that genuine attempts to work through problems result in real reconnection, they will feel hope. They will begin to trust that maybe they can count on other people.

And then we have to offer opportunities for effective action in all other aspects of our programs. Examples include a student council, opportunities for volunteering and helping others, student input in activity planning, opportunities to develop special talents, and choice in everything from food to activities.

So- that’s all we have to do- create safety, teach emotional intelligence and empathy, and promote effective action. Not easy- not simple- but very powerful.

What do you think of this formulation?

Musing on a Busy Week

Last week I had a busy and exciting week.
On Tuesday Steve Brown and I presented at the Massachusetts Department of Mental Health Child & Adolescent Restraint/seclusion Prevention Initiative Grand Rounds. Our topic was: Transforming Resistance to Enthusiasm-Implementing Trauma Informed Care. Around 100 people attended, from hospital, residential and school settings. It was great to share ideas with others who are in various stages of implementing trauma informed care. As is often true, people seemed particularly concerned with how to overcome staff resistance to this change. We shared strategies such as: relating this theory to their own lives, celebrating every success, and having those who do it naturally teach others. We received many compliments of our presentation.

On Wednesday I attended a retreat of our Klingberg Therapeutic Foster Care Department. This staff is implementing trauma informed care for the entire department, including providing a six week training for the foster parents and more intensive training for the staff. Another component has been an increased focus of the experiences of the workers. This staff is on call for crisis 24 hours a day. They often have to experience the sadness and disappointments the adolescents endure. However, they also celebrate successes- six adoption this year! Their mission is to promote mutually claiming relationships and prevent disruptions. The trauma framework has helped make sense of some challenging behaviors, and enabled the parents to take them less personally and thus have more patience with the youth.

On Friday Steve Brown and I presented a workshop at the Massachusetts Adolescent Sex Offender Coalition Annual Conference. We spoke on a new topic: He Just Refuses to Take Responsibility!!! -- Implications of Trauma Theory on the Issue of Taking Responsibility. The phrase "taking responsibility" is used in all our programs, and I have written about it here before. However, it is central to sexual abuse treatment programs. We argued that it is helpful to see the word as response ability, and to realize that this is a skill not a characteristic. What can we do to build this capability in clients? This includes creating trustworthy attachments, teaching feelings skills, and most importantly reducing shame. The 70 or so workshop attendees participated in lively discussions of these concepts.

The conference itself was very interesting. The keynote speaker Cordelia Anderson was eloquent on the ways our culture sexualizes children and produces demand for child abuse, and she called us all to action in the prevention area. I attended a workshop by Phil Rich, PhD on ten things we think we know that we don’t, in which he pointed out how contradictory research can actually be on what really helps kids. Another workshop I attended led by Melissa Malter, MSW detailed a CBT approach to decrease shame.

All in all, a very worthwhile day. It was fun to have people coming up to me to say they saw us at the Grand Rounds or attended our conference in Worchester- our community is growing!

A very full week- and I must say I am glad to have less events scheduled this week!