Change a Brain… Change a Life….

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

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

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

Relationships bring me pain and can’t be trusted

to:

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

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

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

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

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

Connection Post Discharge

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

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

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

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

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

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

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

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

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

Motivation

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

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

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

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

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

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

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

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

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

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

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

Self Awareness

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

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

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

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

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

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

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

Treatment Planning

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

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

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

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

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

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

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

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

Combine with

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

To create

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

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

This understanding is broken into:

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

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

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

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

Ideas from Moving Forward Conference

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

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

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

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

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

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

Basketball and Feelings Skills

Several boys were playing basketball outside their residential dorm. Marcus made a basket despite Jeff’s guarding him. Jeff began to taunt Marcus, saying the basket was luck, he didn’t know how to play, he was too short and too ugly. The insults expanded to include racial slurs and comments about Marcus’ mother. Marcus was flustered and missed his next shot. Jeff started to laugh. Marcus went over and punched him, hard. The staff stopped the game and brought the boys inside. Marcus and Jeff were bother restricted, and Marcus’ punishment was seven days of unit restriction because he had used physical violence.

This incident happened at a place I was training. This provided a great opportunity to put these theories into practice.

There were many men in the training, all shapes, sizes, ages, and races. I asked the men to consider that they were in a pickup basketball game with some friends and someone started insulting them, including using racial slurs. I asked for a show of hands of those who thought they could get through this situation without hitting anyone. All the men raised their hands. I then asked what they would do. Their answers included:

I would just stop the game and walk away.

I would say “hey, man, stop talking like that.” And if that didn’t work I would stop playing.

I would play better and better and wipe the person out in the game.

I would use that event as a reason to practice and make my game better.

I would remind myself that this was not very important; it’s only a game, who cares what he says.


Then I asked: what would you have to know, believe, or be able to do in order to respond like that?

After some discussion these ideas emerged:

You’d have to be confident enough of yourself not to take his words to heart.

You’d have to know you were getting upset and have some ways to calm down.

You’d have to have other good things in your life, other friends, other skills in order to know that this game was not that important and that it did not represent all of who you are.

What we want for these kids, what we are trying to achieve, is that they become these men. The taunts will always be painful. Anyone would be upset. But we want them to have what these men have- the skills that enable them to walk away and not hit someone.

And we also want to think about Jeff- how can he learn to handle someone else’s success or maybe even lose a game without resorting to racial taunting? Both the taunting and the hitting come from the same place: a deep feeling of inadequacy that results in this small game feeling like a measure of total worth.

So what will develop these skills? How can we increase confidence, self awareness, an ability to notice and modulate your own feelings, and the ability to turn bad experiences into motivation? Unit restriction will not accomplish any of those things, in fact may decrease some. Instead, if the boys do something constructive together (maybe raise money for some new sports equipment?) they will discover that relationships can be fixed, and that they have something to contribute to the world- whether or not they can always make a basket.

New Friend In Colorado

I have just returned from completing a Risking Connection in Denver, Colorado for Devereux Cleo Wallace. I met many great people who are caring, compassionate and thoughtful about children. I look forward to participating the the agency’s continuing evolution.

We were fortunate to have Dr. Jerry Yager, PsyD. participate in the training. Dr. Yager is a consunt to the agency, as well as working at the Denver Children’s Advocacy Center (DCAC). He has studied extensively with Dr. Bruce Perry. Dr. Yager has a blog at: http://www.drjerryspeaks.blogspot.com/ . Dr. Yager is a Clinical Psychologist with more than 25 years of experience in the assessment and treatment of traumatized children and adolescents. He specializes in working with adolescents who exhibit self-destructive behavior and who have severe mental illness such as clinical depression, bipolar mood disorder, post traumatic distress disorder and psychosis. Before joining DCAC as Director of Education and Training, Dr. Jerry was the Executive Director of the Denver Children's Home.

Jerry taught me some concepts that add depth to the thinking I have been doing about how brain development knowledge can improve our treatment.

First, he pointed out that all information enters our brain through the lower brain, because of course we get all information in one way or another through our senses. Thus, if the lower brain is scrambled or under developed, this will impact the processing of all information. This relates to sensory dysfunction. It also may explain some of the mis-interpretations our clients make. If the lower brain is operating in an aroused, danger state, all information is filtered through a danger/safety categorization.

Dr. Yager said that most psychotropic medications target functions in the lower brain, attempting to provide regulation. We seek regulation through relationships, through self soothing, and, when necessary, through drugs (prescribed or self chosen).

An important and underused concept is the idea of association. The brain forms neural connections between things that occur together. This is how memories are created. In good-enough parenting, the presence of an adult is associated with relief of distress (the diaper is changed) and with pleasure (food, closeness, attunement). In more difficult situations, the presence of an adult is associated with pain and increase of distress. Our kids come to us with these templates about adults: that they don’t care, can’t be trusted and hurt you. They dare not accept relationships at first. But we can use the power of association to begin to change that. At first, all we need to do is be near by when as child is experiencing pleasure. So, we provide the child with positive experiences: a regular meal, rhythmic pleasurable activities, needs met, safety. And we are nearby. We are right there, paying attention, attuning and smiling. After many repetitions, the child begins to associate adults with pleasure. And then….he may have to courage to form a relationship.

One more reason that having fun with our kids turns out to be the most powerful thing we can do!

I Have Received an Honor!

Pat Wilcox was honored with the 2011 Social Worker of Year Award by the Connecticut Chapter of NASW. At the awards banquet, Pat was recognized as a national leader in the area of trauma treatment, especially in congregate care treatment settings that work with the most psychiatrically complex children. At Klingberg Family Centers, she initiated and oversaw an organizational transformation process from a traditional, control oriented token economy treatment approach to one that is based on state-of-the-art knowledge of trauma and attachment. She is the primary creator of the Restorative Approach, a trauma-informed alternative to point-and-level systems in child congregate care. She helped bring the Traumatic Stress Institute and Risking Connection to Klingberg and has grown the programs to national and international status. She accepted the award among family, friends, and her many Klingberg colleagues and mentees. 

Rhythmic Activity

As I discussed in previous posts, I am very interested in Bruce Perry’s Neurosequential Model of Therapeutics (http://www.childtrauma.org/ ). I am thinking about rhythmic, rewarding, repetitive activities that we could add to or emphasize in our programming. These activities should be done with an engage, happy adult. I will list what I have so far. Please consider both your programming and the lives of your own children or children you have known, and give me any more ideas you can think of.
• Dance

• Wii dance

• Music

• Rapping

• Clay

• Throwing balls

• Rocking

• Swimming

• Pets

• Gardening

• Exercise

• Children’s games

• Jump rope

• Peek a boo

• Hand clapping activities

• Hopscotch

• Side by side walking

• Bouncing on "swiss ball" (exercise ball)

• Tossing a tennis ball back and forth

• Throwing wadded up paper in a garbage can repeatedly like shooting baskets

• Quick shoot basketball setups where you can repeatedly shoot baskets over and over

• Toy where you put 1 foot in a ring, whip it around as you jump over with other foot

• Hoola hoop

• See saw with another person

• Swings with two person possibilities -- seats opposite each/see saw-ish seats

• Throwing ball against the wall

• Two square game with another person

This demonstrates what a large role rhythm plays in the life of the average child.

Click on comment and add your ideas!

Hawaii Trip

I took a long trip to Hawaii to teach Risking Connection Train-the-Trainer. The people are great, exemplify the aloha spirit. The diversity seems a source of richness appreciated instead of a source of conflict. We had some fruitful discussions on culture and VT. The thirteen hour flight and the six hour time difference really messed up my body. If I ever go again I won’t fly there, work three days, leave the night of the third day, and fly all night to get home. Thankfully I did get a little chance to drink in the beauty.



VT, Culture and Complaining

I have just returned from completing a Risking Connection® Train-the-Trainer training in Hawaii. I taught some great people who are going to be very good trainers and leaders in their agency.

We were discussing imbedding discussions of VT within their agency. First we had a very interesting discussion of the role of culture in staff willingness and comfort with discussing VT. Cultural rules such as not sharing one’s feelings, trying not to stand out or be noticed at all, and never complaining are hard to overcome when trying to discuss the effects of the work on the person. As one person said: “Why should I squeak? I don’t see anyone else around here squeaking and they are all working as hard as I am. Better to just keep on going.” A therapist stated: “If the staff see the therapist being affected by the work, what are they going to do? As the therapist I am expected to be able to handle my emotions.” I believe that many of us have one form or another of these beliefs, and our agencies take advantage of this. We just keep doing wore and more, and not complaining, taking pride in how much we can do. When we urged the supervisors to model talking about their feelings, they were afraid this would be scary to their staff, who rely on their strength. How can we encourage sharing the way the work effects us without feeling we are showing weakness, scaring our staff and betraying our culture?

When I asked what the current practice was about sharing feelings about the work, these supervisors described that staff constantly talked about their feelings, both on the job and afterwards. And their feelings were anger at a certain kid, hopelessness about another, complaints about management, discouragement about the system, and general pessimism. So this provoked a lively discussion about what the difference is between sharing VT and what I will euphemistically call a complaint session. We have all had the experience of negative complaint session that spirals downward and leaves everyone feeling worse. What is the difference between that and a productive sharing of the effect of the work on us? We came up with the following ideas for what would make such a discussion healthy:

1. A willingness to look at ones’ self and the role of one’s own history in the emotions.

2. A spirit of compassion towards the clients and an understanding that their symptoms are adaptive, and that our feelings are not their fault.

3. An acknowledgement that VT is an inevitable part of our work, as we share the pain our clients’ experience

4. Looking towards positive action: how can we take better care of ourselves and each other? What can we do to make our workplace more sustaining?

5. Understand that the pain of our work is also the source of our growth and change as people

6. A consideration of possibilities for transforming the pain.

There are times when one just needs to complain. But the addition of these elements could help to turn the conversation into a healing experience.

Still, I think there may be more to this. Any ideas? Click “comment” and let me know.

What We Say Matters

I was recently participating in a training at which we were discussing the function of cutting. One participant said:

“We had a girl named Megan who was cutting to be manipulative. She was doing it to get discharged and go to a place like detention where she wouldn’t have to work on her issues.”

What are the assumptions behind this statement? How does it differ from this statement?

“Megan has been working on some difficult issues recently. This has brought up some painful feelings and she has begun cutting for relief. Sometimes she doesn’t even want to work on her issues and wishes she were in a place like detention where she wouldn’t be in treatment.”

Same facts, different assumptions, leading us to different responses.

Another place I visited I noticed how often staff made statements about how bad the children were. Examples are:

“You’d better watch out putting that in your pocket. These kids will steal it from you in a minute.”

“These kids don’t care what we say as long as they get what they want.”

“You always have to watch your back around these kids.”

The staff tended to bond with each other around how awful the kids were.

Or, consider a staff member talking about a child who says mean things: "There is nothing you can do about Jesse. We have tried everything. Jesse just likes making other people feels bad. He admits it. It makes him happy to hurt others.”

Someone describing the cutting of a foster daughter: "she just wants the foster mother to feel sorry for her."

Do you agree that the phrase "feel sorry for her" connotes an illegitimate need, something that she shouldn’t want or need? Doesn’t it imply that she is trying to get some kind of unwarranted or excessive response? Also, this phrase implies that we should resist feeling sorry for her- and by extension resist coddling her, fussing over her, or being sympathetic. Yet some cuddling and caring may be just what she needs.

We make these casual comments constantly in our many discussions about the kids. Yet by each comment we are expressing a theory, an understanding of why they are doing these things. And at times it is a theory that blames the child and implicitly accuses him or her of doing the behavior deliberately to annoy us.

When we make these comments we forget that the child is doing the best she can, that her fears and needs are legitimate to her, and that she is using the only means she has to meet them. She will only be able to change when she feels safety within committed relationships, and when she gradually learns new skills.

Try monitoring the conversation where you work, and see what assumptions are expressed in the casual comments about the children. Click on “comment” to let me know what you discover.

it is important to stop and challenge ourselves. One comment can lead to an entire attitude that will infect our response to the child and interfere with the child’s healing.

Rethinking Restorative Tasks

At a recent presentation I did for the MAAPS conference, a question from a participant and a response from my friend Bob Davis crystallized some thoughts I have been exploring about learning restorative tasks. The participant asked: “We have a girl who is constantly saying mean things about others. As a restorative task we had her do research on peace movements and on Martin Luther King. She does this well- but it doesn’t affect the behavior. She keeps doing it.”

Let’s begin with the assumption that we are trying to create a response to a behavior that will decrease the likelihood of the behavior recurring. We must start by forming a theory about why the girl, let’s call her Kathleen, is saying mean things about others. What feelings is she having at those times? What need is she responding to? How is this behavior adaptive for her?

Most likely Kathleen is feeling small and vulnerable, lonely and unloved. She has no sense of inner connection to others. She does not have any friends, is sure none of the other kids like her and that she will never have any friends. At other times in Kathleen’s life when she has felt small and vulnerable, people have hurt her. Saying mean things and getting a reaction gives Kathleen a feeling of power, of strength and control. She does not know any other way to get that feeling.

Do we think that Kathleen is mean because she does not intellectually understand that meanness hurts other people? She has received a lot of meanness in her life, and knows exactly how it feels. Do we think she does not want friends and is just not motivated to be nice to others? We know how desperately she wants friends; it is not motivation that is the problem.

Therefore Kathleen will be most likely to decrease her mean behavior when she feels better. If she feels safe, loved, strong, connected, accepted, noticed, and appreciated she will have no reason to be mean. When she learns how to make and keep friends, is absorbed in her own interesting and successful activities, and trusts adults to care for her she will be more generous and kind. Our overall treatment plan and our response to each individual event should be planned to achieve these conditions.

Another way to look at this is to consider what happened right before Kathleen was mean. The most recent time was when two other clients were playing a game together and laughing. The time before that was when she was in math, could not solve a problem, and noticed that Maria was already done with the assignment. In both cases Kathleen felt inadequate and stupid, and spiraled quickly into despair and hopelessness.

What would we like Kathleen to do when she sees two girls playing and wishes she were part of it? What would we like her to do if she feels stupid because she cannot do her math? What would you do in either of these situations?

In the first case we would like her to approach the girls gently and ask if she could play too, or find another girl and engage her in some kind of activity. This is hard to do, requiring both social skills and courage. Another option would be to approach an adult and ask for help finding an activity. This requires trust in the adult. Or, she could absorb herself in a solitary pursuit like drawing, which requires that she has some solitary activities that she know she likes.

In math, we wish that Kathleen would ask her teacher or another student for help when she can’t do a problem. This requires having enough confidence to expose a weakness, and a trust that the other will not ridicule you and will pleasantly help.

This analysis leads us to a lot of ideas of areas in which we can help Kathleen grow. To recap, she needs:

• Social skills
• Courage.
• Trust in adults
• Discovering some solitary activities that she likes
• Confidence to expose a weakness
• Trust that the other will not ridicule her and will pleasantly help.

So what can we do?

• Use a curriculum like DBT to teach Kathleen the skill of joining in or proposing a play activity
• Be trustworthy our selves, do what we say we are going to do, and create opportunities to strengthen our relationship with Kathleen
• Teach Kathleen activities she can enjoy; build on any strengths and interests she has; celebrate her work
• Help Kathleen feel confidence in herself through activities in which she teaches others, leads groups, gives to social causes, and excels
• Treat Kathleen with gentleness and compassion. Make sure she experiences many instances of friendly, non-shaming help.

What if our response to Kathleen being mean to others was to build up her skills in one of these ways? We can look at the event that triggered her meanness and give her practice in another way of handling it; we can have her teach a game to some of the younger kids; we can have her work with a staff member to use her strength to make something for others; for example if she likes to cook she and a favorite staff could make a delicious dinner for the other kids.

Which brings me to my friends Bob’s comment that Kathleen could be an expert in the Civil Rights movement, and if she still felt small and scared inside, she still will need to make others feel bad.

I really, deeply, honestly feel that when kids feel better they will act better. Yet I wonder if we could actually act from that philosophy. It is so deeply engrained in us that the kids will change if we make them feel BAD after they do something that hurts others. If we acted from this belief we would have to see their harmful actions as an expression of how horrible they feel inside, and choose responses that make them happier. And I can just hear the responses now: you are going to reward her hitting me! How are they going to learn if they don’t pay? How will they take responsibility for their actions?

What do you think? Do you agree with my assumptions about the causes of Kathleen’s meanness? Could our programs move in this direction? How can we facilitate this transformation? Please click on comment and share your thoughts.

One Hundred Names for Love

I would like to call your attention to a book I am reading. It is One Hundred Names for Love: A Stroke, a Marriage, and the Language of Healing by Diane Ackerman, (W. W. Norton & Company 2011). The author Diane Ackerman and her husband Paul West are both authors, and their marriage included much loving word play and exploration of literary connections. Sadly, Paul West, a retired English professor and the author of 50-plus books, survivor of diabetes and a pacemaker, was struck by a massive stroke that left "a small wasteland" in his brain, especially in the key language areas. At first he could not talk at all. The book chronicles the story of his recovery through their love, creative and imaginative word play, and the help of others. Ms. Ackerman, who had already written books about the brain, researched his disease and tailored a program for him that utilized his unique strengths and interests. The book is very moving and demonstrates the power of love to heal. Ms. Ackerman also shares honestly the stresses of being a caretaker and trying to keep some hold on her own work and identity.


How is this book relevant to our work? It deeply increases the reader’s understanding of and faith in brain plasticity. It demonstrates without a doubt the way that when one part of a brain is damaged, the rest of the brain can develop alternative routes to achieve the same functions. Ms. Ackerman also teaches us many specifics about how the brain works, particularly in the area of language.

Furthermore, I think that what this couple learned about how to facilitate healing applies directly to our work. The first speech therapists that worked with Mr. West used straightforward exercises using child like words and simple sentences. The process felt demeaning to Mr. West and he was increasingly frustrated and depressed. His wife noticed that larger and more obscure words were in fact easier for him to recollect. She began to build on his strengths and interests to develop playful, silly games for him. She walked a fine balance between helping him and still letting him struggle on his own. She supported his growing independence and abilities even when it meant he was in situations which were not completely safe. She sometimes felt worn out and discouraged; she sometime felt exultant because of a small gain. I think our work also goes best when we are creative, playful and engaging our clients’ strengths.

This book is an interesting and absorbing read that both teaches and inspires. I recommend it.

Crew Rowing and Repairing the Brain

I have just returned from Sacramento, California where I did a recertification for the Associate Trainers of Victor Services. It was very moving to reconnect with these skillful practitioners and experience how they had made Risking Connection their own and used it to transform their treatment programs.
While I was there I visited a local lake and saw some teenagers practicing crew racing, the sport with those long thin boats and many people rowing together. And it occurred to me that this might provide a useful metaphor for the task of healing the lower brain.

Imagine that you have been asked to coach a crew team. Although you have not done so before, you have seen the lovely boats slipping across the water as the coordinated rowers respond to the call of the leader. How hard could it be? So you agree.

Alas, when you first meet your team in action you find them to be much different from what you had envisioned. There they are, a bunch of rowers in a lovely boat on the water, with a separate boat calling out instructions. But, the leader sitting in the front is terrified, and keeps yelling: “Careful!!! We are going to drown! Oh no we are tipping over! Hold on!” and other such things. This constant stream of fear has all the rowers upset and disabled. Several are rowing frantically, but in different directions. Two have dropped their oars into the water and are sitting with their arms crossed. One is crying. The boat is turning in circles, lurching from side to side. The noise is so loud; no one can hear the instructions coming from the other boat.

(This is the disorganized brain. It results from early trauma and lack of attunement. No parts are working smoothly together, and the fear system is in full alert, drowning out all other input. Movement forward is impossible.)

As the new coach, what do you do? Do you tell them you will give them each $5 if they can do a better job and row from one end of the lake to the other? Or do you tell them that unless they row that distance successfully they will be on restriction for two weeks and not able to see their friends? Do you give them a lecture on how much better everything would be if they would just get it together and row smoothly?

(Our normal approaches to our children.)

I would suggest that the best coach would not start with rowing at all. He would start by doing lots of exercises on land. First, there would be activities to help the team members get to know each other and trust each other. These would start with easy things and gradually increase in difficulty. (Relationship forming) Then, he would begin having them experience physical challenges together. He would use all sort of rhythmic activities such as drumming together, dancing, playing ball to help them experience the feeling of being in sync and interacting smoothly with each other. Other games would increase their strength and confidence. Every activity would include elements of relying on each other, interacting with each other, helping each other to achieve success. When things didn’t go well they would develop a method for working them out. They would practice team coordination through carrying the boat together, lifting it up and putting it down, making turns on land while carrying it.

He would make sure they all knew how to swim.

The team would adopt a name, and begin a narrative of its journey from the beginnings to success. The team members would retell the story, always adding the day’s events, each night around a campfire.

Then, gradually, the team would return to the water. The challenges would be small at first. They would try regular rowboats in pairs. When they started the crew boats again they would be in shallow water. Each of them would practice leading the beat, the rhythm that coordinates them all, until they could feel it deep in their bodies and respond almost automatically. They would try rolling the boat and falling out until they felt confident they could handle any eventuality. This phase would take a long time.

(All the treatment activities of healing the brain.)

And then, the magical day would come when the team would get into the boat, row through the water together in a smooth and effective way. The youth in front would carry the beat. The team would respond in rhythm. The ideas from the second boat would be easily heard across the silent water. When a wave came, or it started to rain, or they had to make a turn, the team would laugh and solve the problem together.

(And thus the brain would become as powerful and skillful as it had always been meant to be.)

My Recent Travels

I have had the honor and privilege of participating in two special events over the last two weeks. The first was the Vermont Foster/Adoptive Family Association 24th Annual Spring Conference: Hope and Healing. At that conference I attended a one day workshop by Dr. Bruce Perry. I was so delighted to finally have a chance to hear Dr. Perry in person, after having read all his work and listened to him on video tape. When I remarked to the conference organizer that he reminded me of Seinfeld she told me I wasn’t the first person to notice that. As I have written in this blog, his ideas are opening new avenues of learning and teaching for me, and I hope to write more about them here in the future. Dr. Perry expanded on the idea that rhythmic, repetitive, rewarding physical activities with another engaged person are necessary to rebuild the brain stem of children hurt in early life.

The next day of the conference I delivered a keynote address and then led two workshops. The subject of my keynote was: What is Trauma Informed Care and What Does It Mean for Foster Care? The workshops were: The Trauma Survivor as Parent and Maintaining your Sanity While Walking in The Minefield: Helping Youth With Challenging Behaviors. I received much positive feedback for all of them.

Vermont has prioritized supporting and training foster parents. They offer this conference to foster parents and those who work with them every year, and it combines education with a break, recreation and connection. They also raise money at the conference through a silent auction and fifty/fifty raffle for a fund that provides extras for foster children. I found the foster parents to be very knowledgeable and thoughtful, tuned in to the adaptive nature of their youth’s behavior, and extremely caring and committed. I was also impressed with the professionals I met such as the conference organizer Karen L. Crowley, System of Care Manager, Family Services Division, Department for Children and Families. Vermont’s governor Peter Shumlin was present, as was the new DCF Commissioner Dave Yacovone. Their presence also spoke to Vermont’s commitment to foster parents. Vermont is emphasizing the concept of co-parenting between the foster parents and the bio parents, which made my “trauma survivor as parent” workshop especially relevant to the foster parents.

One foster parent asked me a question which we agreed we must defer to Bruce Perry. She has a teenage foster son who is very sexually active. She said that it occurred to her that he was engaging in an activity that is rhythmic, repetitive, rewarding and physical with another engaged person. Is he building his brain stem?

On the third day of the conference we watched a movie entitled “Ask Us Who We Are ~. From the program description of the film: “Directed and produced by Bess O’Brien. This documentary film focused on the challenges and extraordinary lives of youth in foster care. The film is a reflection on loss and the search for belonging and fining family. Although the film highlights the heartbreak that many foster care youth carry with them as they move through their lives, the documentary also reveals the tremendous strength and perseverance that grows out of their determination to survive and thrive. The documentary also focuses on the lives of foster care parents and kinship families that open their homes to children. Through small and large acts of kindness these adults can change the course of children’s lives and give them a sense of place. In addition, the film highlights two parents who lose their children.” It was very moving and I look forward to the time that it will be released for greater distribution outside of Vermont.

The following week I travelled to the Change Academy Lake of the Ozarks (CALO), a specialized therapeutic school that I have described previously in this blog. This school was founded specifically to utilize attachment principles to help children heal. They specialize in children who have been adopted. Their canine program allows each child to adopt and learn to care for a golden retriever, and take the dog with them when they leave. This is one of the powerful elements of the healing process.

I am honored to have been asked to be on the Board of Advisors of CALO. On this visit I got to know the program and people even more, and attended a conference CALO hosted. On the Board also are a parent advocate (who is also an adoptive parent), a lawyer who advocates for children and who is an adoptive parent herself, and an attachment specialist in private practice in the Washington DC area. For me it was a great treat to be among people who are so immersed in this trauma informed, relationship based way of thinking. I was soaking it in, being reaffirmed and recommitted to the importance of what we are doing. I learned some new ideas as well. And all this in the midst of the beauty of the Ozarks in the Spring, with many lovely flowering trees.

I feel very lucky to have been able to participate in these events.

Ten Essential Elements of a Successful Transformation to Trauma Informed Care

1. Administrative buy in: The top administration, including the Board, must understand the change and see compelling reasons to make it. They will need to support the change through their actions, financially, by presenting it to the outside world, and by demonstrating patience and hope through the inevitable roller coaster implementation process.

2. An Implementation Committee: A group of people dedicated to keeping the process moving, deciding next steps, and checking to make sure there is follow through.

3. Trainers and Champions: A group of dedicated trainers and champions who are enthusiastic and eager to see change.

4. A training role out plan. This should include who will do the training, what will the schedule be, who will attend and how many trainings will be done.

5. A new behavioral management approach: a plan for moving away from a consequence based approach to behavioral issues which includes what the agency will do instead.

6. Communication: Mechanisms to communicate to the whole agency what the change is that is being made, how is going to happen, why are you doing it, and how will you measure success. Communicate with the families and involve them in the process. Also communicate to the outside world (funders, licensing, donors, the public)the changes you are making and your hopes for improvement.

7. Celebrations of success: Share and applaud ways to share particular interventions that have made a difference, good outcomes, positive feedback, and particular staff who have done a great job.

8. Attention to vicarious traumatization: Time and space for staff to talk with each other about the ways the work is affected them.

9. Measurement: Set some goals that you hope to reach by implementing trauma informed care, such as: reduced restraint and seclusions; less staff turnover; less negative discharges; and more positive outcomes. Measure these and report the findings to the agency.

10. Fun: Make the training g fun. Invent rituals, sayings and games around implementation on the units. Give little gifts and certificates to staff who interact flexibly and warmly. Play more with the kids! Add more fun interactive activities to your daily milieu life, and make sure the staff and kids play together. Make joy your primary daily goal!

The Primacy of Safety

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What Administration Can Do to Support Trauma Informed Care

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

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

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

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

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

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

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

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

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

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

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