You Didn’t Give Up on Me

I did a Risking Connection training in Louisville, Kentucky this past week. In one section we ask participants to share success stories, as a way of reaffirming the worth of the work we do and combating vicarious traumatization. One person shared a letter he had recently received from a client, expressing her gratitude for the program’s help and the changes she and her son had made. The letter started, as such letters often do, with the phrase: "most of all, you didn’t give up on me."

Perhaps the most important thing we do for clients is not to give up on them. Sticking with them- staying around- something many of our kids and families have not experienced. Our kids have been in so many placements, so many families, and so many treatment facilities. In addition to undermining healing relationships, all these moves underscore the basic message- you are such a terrible person that no one is able to stay around you for any length of time.

In order for any of our techniques to work, we have to keep the kid with us. And many times I have experienced situations in which we had completely given up on a kid, and we were sure we could not help him. However, the child welfare system being what it is, the child did not leave. And guess what- time passed, and he got better.

So maybe we should pay more attention to exactly what makes it possible for us to keep a child. And when we are struggling with a particular child, maybe we should have a meeting specifically focused on enhancing our ability to keep her.

And what could we do to increase our stamina? Some ideas are:

1. Increase staff stamina by dividing the responsibility for the child among several staff every night. If (as we do) you have a concept of a "primary" staff (we call them team mates) then maybe a certain child needs two or three team mates. Maybe we should plan that any one who deals with this child for a long period gets a break off the unit.
2. If there is a particular horrid task (such as cleaning the room of a child with hygiene issues) let’s do it in teams, not one staff alone.
3. Let’s keep a note book of any signs of hope we see.
4. We must articulate clearly that even if we do not (yet) see any change, our not kicking this child out is a victory in itself, and we should congratulate each other for that.
5. Let’s regularly review what happened to this child, and how we understand her symptoms- what problems are they solving for her? How are they adaptive- helpful in the short term, even if they have negative long term consequences?
6. Let’s make sure we have a treatment theme (such as: Jeff is learning to trust adults) that everyone on the team including the child and family knows, and that we use this theme to frame all events and interventions.
7. Let’s plan some ideas for restorative tasks before the child is in crisis, during our treatment team. Each task should be an opportunity for the child to practice one small skill that he would need to develop to give up his current symptoms.
8. We can make sure to compliment each other lavishly whenever anyone is particularly caring, giving or helpful to this child.
9. Administration can attend meetings and praise the treatment team for their stamina.
10. Is there anything we can do to make the child feel more safe and connected?
11. Can we deliberately do something fun together, to acknowledge the effort we are making- a pot luck lunch, little presents, chocolate?

12. The most important thing is to acknowledge both how difficult and how valuable what we are doing is. If we can stick with the child, his or her entire life may be different.

This is not to say that children should never leave our programs, or that children never need a different form of care. That happens- but not as often as we think. More often, we are frustrated by the pain the child is feeling, and by his ways of making sure we feel the same pain. We think, if only she were gone, the unit would go so well. But if we do succeed in ejecting a child, another one always steps into the role.

Let’s talk actively about our feelings about the child, how hard working with her is, how much chaos she creates for us and others, and how tempted we are to get rid of her. Let’s talk about our feelings of sadness, of inadequacy, anger and frustration. Let’s remember how she got this way, how we understand her, and let’s make sure we have a strong team plan.

And then let’s re-engage with the child and hang in there. Then after he gradually starts to get better, and finally achieves that positive discharge, and does fairly well, we will get one of those letters:

Dear staff,
I just wanted to let you know I am doing well at my new home. I really miss you guys! I want to thank you for not giving up on me...

Facebook and Twitter

Do any of you people reading this blog Twitter? Do you have a Facebook page? I am considering using these services to further connect us, the people trying to do trauma informed treatment of children. It is hard to work this way- it is hard to start doing it, and hard to keep doing it. It will help if we support each other. Would you be interested in Twitter and/or Facebook connections? Let me know by clicking "comment" at the bottom of this post. Thanks!

Sarita’s Eyebrows

The door from the Girl’s Unit slammed open and Sarita erupted out, screaming: "I am not going to the...mall. I will not go to the mall. Every night he wants us to go to the mall. And I have to get my eyebrows done tonight. Someone needs to take me. Now. I am not going to the mall."

It was amazing how long and loud and with how many swears that girl could scream about not going to the mall. And I was in my office, working on a grant proposal, and I was on my last nerve just as she was. So the thoughts that were going through my mind were: "surely it can’t be required that she go to the mall. Would someone PLEASE come and tell her she doesn’t have to go to the mall so she will BE QUIET?!?!?"

It has since occurred to me that this was an illustration of a choice point for our treatment philosophy. How do we understand what is going on here?

One interpretation is that Sarita is a spoiled, demanding manipulative girl who just wants what she wants when she wants it. She wants everyone to forget about everything else except for what she needs. She freaks out every time any one says no to her. She thinks she’s special.

And that leads naturally to: well, she is going to have to learn. People can’t just drop what they are doing whenever she wants something. She will just have to wait her turn. We will have to teach her to stop yelling and disturbing people. That’s not going to get her what she wants. We won’t do one thing for her as long as she is making this kind of fuss.

Or...
Maybe there is another way to see it. Maybe, in fact, Sarita has very rarely gotten what she wants. In her life, few people have listened to her or cared about what she wants. She is not the center of any one’s universe. As she has grown up in situations of chaos, and then equally as she has lived in situations of congregate care, the only way she has been able to get anything has been to yell as loud as she can.

Maybe when she wants something (to get her eyebrows done) and someone else does not seem to be listening and is just proceeding with their plans (to go to the mall) the words in her head go something like this:
He is not listening.
If I don’t get my eyebrows down I will look ugly and no one will like me.
He does not hear what I need.
He does not care what I need.
No one hears or cares what I need.
I have no one, I have nobody.
I am no one.
I am nobody.

And then she starts to feel unbearable emotions- despair, hopelessness...
Which come out in the intensity and pressure of her speech.

Where would that thinking lead us?

It does not mean that it is okay for Sarita to scream and swear when ever she wants something. That would surely not give her a life worth living.

It does not mean that we should immediately drop everything and take her to get her eyebrows done in order to quiet her down.

But what it does mean is that we do not approach Sarita with lectures about how she should be quiet and stop bothering people and she can’t always get what she wants (which believe me, she knows).

Instead, we start with "Sarita, what is the matter?"

And then, our part of the conversation includes statements like:
You definitely do not want to go to that mall.
You have had it with that mall.
It’s very important to you to have your eyebrows done as soon as possible.
And where do you have to go to have that done?
So what you want to do is go to...
And you feel very strongly about this...

Because, in fact, Sarita will gradually stop screaming when she feels she is heard when she is talking.

And that is an experience we can give her.

49 Reasons to Do Risking Connection Training

We recently had the privilege of working with two groups of people for which we had provided Risking Connection® training. In both cases we were now providing Train-the-Trainer Training, and we started by asking the participants about changes they had noticed in their work or their agency since having the original Risking Connection®. Here is what they said (and these are verbatim!):

1. The every day milieu is different-we avoid shaming the kids and remember that symptoms are adaptations.We are more hopeful and positive- we live in solutions.

2. We teach about how to maintain and repair relationships, that it is okay to make a mistake and you can fix it.

3. There is more awareness of vicarious traumatization (VT), and we use the worksheets to discuss it.

4. We have a new awareness of what the kids have been through.

5. We process our VT and it helps us not to take things personally.

6. The staff is talking more with the kids, finding out where their behavior is coming from.

7. We understand the relationship between the kids’ background and their behaviors.

8. We engage the child more.

9. We understand the difference between shame and guilt.

10. Focus on relationships and repair helps staff relationships.

11. We look at the client’s self capacities and how we can build them.

12. The direct care workers and youth counselors are more involved in the treatment.

13. There has been a decrease in AWOL and self harm among our kids.

14. We see the power of listening and validating.

15. We tried a pilot program in one classroom, we shifted the way we look at behavior and there has been a decrease in acting out.

16. I’m using Risking Connection® concepts in animal assisted therapy!

17. There is more openness to look at kids differently.

18. There is more time spent processing, which leads to better behaviors.

19. The kids are involved in their own treatment plans.

20. We are teaching the parents new ways to understand their kids’ behaviors.

21. We have incorporated it into staff language.

22. We use Risking Connection® concepts in supervision with staff.

23. I can see differences between staff who have and have not been trained.

24. We help the kids make the connection between their behaviors and their pasts.

25. We remember that a child is doing the best he can.

26. We are using this language and concepts in training foster parents.

27. It has changed how we talk about the kids.

28. We take better care of each other.

29. We use RICH with each other and the kids.

30. We have more self awareness.

31. We took the consequence list off the wall to avoid shame.

32. We talk about the function of behavior.

33. This place feels more like a real home.

34. We stress relationships with new employees.

35. We are nicer to each other.

36. We are more understanding of the parents.

37. We understand that VT is normal and we validate each other’s feelings.

38. We are saying "yes" more to the kids.

39. We are actively listening.

40. We are more hopeful.

41. We have given the kids more self determination in running their own living units.

42. We let the students talk.

43. We have more emphasis on strengths.

44. We pay more attention to staff who get hurt.

45. We are teaching these concepts to our bus drivers!

46. We have changed our hiring practices.

47. We pay more attention to providing good transitions for the kids.

48. We are more flexible.

49. I am a kinder, gentler person.

Pretty powerful!

If you haven’t had this training yet- what are you waiting for?

When Things Aren’t Going Well

Yesterday I did a day-long training on the Restorative Approach. One of the participants asked this question:

What do you do when a certain kid just isn’t getting better, he does the restorative tasks without sincerity, he doesn’t seem to care how his actions affect others, and staff are losing their patience and becoming more punitive?

This is a very good question, and it has two parts:
What do we do to help the child?
and
What do we do to help the staff?

Regarding the child, this is the time to step back and reconsider our treatment. What has happened to this child? How do we understand his current functioning? What problem are his actions solving for him? What skills would he need to have in order to not need to do these things any more?

For example, Tyrell continuously attacks others, both staff and peers. He will apologize perfunctorily afterwards, but does not actually seem to care about having hurt someone. Tyrell was abused severely by his bio father, and then removed to live with his grand mother. Due to both health and mental health problems she was not able to care for him and he mostly fended for himself. He was removed by DCF at age 8 due to missing school and appearing neglected and uncared for, as well as not receiving medical care. Since then he has been in 7 foster homes and has had several short bits of treatment in hospitals. Most recently before this placement Tyrell was in a shelter.

So we know that Tyrell has no reason to trust adults, he has to take care of himself, he can’t afford to be small or weak or he will die, and the only weapon he has for survival is aggression. He undoubtedly blames himself for everything he has experienced. In order to decrease the aggression, Tyrell will have to feel safe. He will have to develop other ways of achieving mastery and control. He will need skills to manage his emotions, and need to begin to feel that he is worth something. And it would be good if he could gradually learn that some adults can be trusted and will actually help.

This will take a long time.

So let’s stop asking Tyrell to apologize to make amends. Instead, let’s think of what could actually help him feel stronger and more competent, and use the restorative tasks as opportunities to build skills. As it happens, Tyrell is an excellent artist and loves to draw comics. So, how about having him create a comic about a boy who fights others? Then we can show it to everyone, including the agency President, and make a lot of fuss about how good it is. Maybe he could draw a poster about anger. What does anger look like? Maybe he could create an "anger monster". Maybe gradually he could draw the boy in the comic conquering the anger monster. There is one staff, Robert, who is also an artist and likes comics and narrative fiction. Maybe he could be assigned to work with Tyrell on the comic project, and share some of his favorite comics with Tyrell, gradually building a relationship.

However, Tyrell’s behavior will take a long while to change, and it will be frustrating for staff when they are doing this excellent work and Tyrell is still hitting.

Which brings us to the second part of the question: How do we help the staff?

Often what these children need from us more than anything else is perseverance. We need stamina to stay with these children for the long, slow, uneven process of change. So how can we increase staff stamina?

Here are some ideas:

• Review the child’s history, understanding the meaning of his actions, and having a plan.
• Create a specific way of noting and sharing any progress anyone experiences with the child (we had a notebook "signs of hope with Stephen" regarding one child, and staff wrote down things like "Stephen said hello to me today.")
• Create plans to avoid having too much responsibility falling on one person- assigning different staff to alternate primary responsibility for this child each night, for example, or giving him two primary workers rather than the customary one.
• Talk about and acknowledge the frustration.
• Celebrate any good work a staff does with this child, no matter the out come.
• Have a sense of humor, make jokes about what is going on
• Do other things to have fun and connection with each other, such as pot luck lunches or sports teams.
• Remind ourselves that children who come back to visit have taught us that we never know when we are making an impact, and that children we thought were not at all involved remember everyone who worked with them and exactly what they said and did.

Do you have any other ideas about increasing staff stamina? Click comments and share them with us.

These kids have been wounded. They have learned to protect themselves in order to survive. We have to make plans that work in small steps and create tiny building blocks for the skills they need. And we need to take care of our selves and each other, because most of all the children someone to stick with them.

The Restorative Approach and Boundaries

People some times assume that because the Restorative Approach emphasizes relationships and speaking from the heart, we are throwing out the idea of boundaries. Quite the opposite is true! For relationships to be safe and healing, the boundaries must be clear, reliable and trustworthy. This is even true of personal relationships, and it is all the more true of professional relationships.

Because abuse is in its essence a violation of boundaries, it is especially important that we pay attention to boundaries when working with abused clients. Our children have experienced major boundary violations, such as sexual abuse. They have also experienced many other chronic, less obvious boundary problems. Many of our children have had to handle responsibilities far beyond was is reasonable for their age, such as an eight year old being responsible for her two year old sister. They have been way too involved in adult issues, such as being worried about the rent or finding food. They have been exposed to adult sexuality and to relationship worries. They have had to parent their parents- care for a sick mother, listen to parental problems, help ease a parent’s depression.

Often times within these inappropriate adult responsibilities our children have found great satisfaction. Janeese is proud that she of kept her two year old sister safe. Louis feels good about having been the man of the house while his mother was sick. Darlene felt special when her mother confided her problems with her latest boyfriend.

Also, being aware of adult issues and taking on adult responsibility is a survival strategy. The adults that these children have known were not capable of protecting them. If the kids didn’t do it, no one would. So when Jackie asks her therapist fourteen times if she has called her DCF worker to approve a visit yet, and also places a call to the worker herself, it is because she has no experience that adults will do what they promise to do, and she has much more experience that if she wants something done she has to do it herself.

So we come along and say- it’s okay, we will take care of everything, you can relax and be a kid now- our children’s answer is "yeah, right." They don’t believe us- and they don’t want to give up the sense of competence and strength that they have developed.

Our children pull for boundary violations. They are eager to become staff’s best friend. They try to engage with staff sexually. They continually test, asking with their behavior: who are you to me? Can I trust you? Are you really who you say you are?

It is up to us, as adults, to maintain the boundaries. We are professionals, and our relationships with the children must be primarily to meet their needs, not to meet ours.

We ask staff to speak from the heart. Yet there is a big difference between saying:
"You ran away last night and I was worried about you. I was wondering if you were safe."
And saying:
"You ran away last night and I was worried about you, and I haven’t been sleeping anyway because of my financial problems and the fact that my grandmother is sick and I can’t believe you added to my stress."

Some boundaries are clear cut:
Do not have sex with the kids. Or with their families.

But within our field there are a lot of gray areas, and a lot of disagreement between treaters. Many boundary issues arise out of good intentions- someone wants to do something extra for a child, someone feels compassion for a family.

Here are some examples of the many issues that can arise:

Margaret is a teacher and one of her students, Rachel, is having an especially hard time as her mother has disappeared and no one knows where she is. Margaret plans to come in and take Rachel to lunch this Saturday to help her through this.

Danny’s mother felt that his team mate, Seth, was particularly kind and sensitive to her during a recent episode when Danny ran away and was missing over night. She brings Seth a $30 gift certificate to a local restaurant as a thank you.

Doug recently bought his son some new expensive sneakers, and his son wore them once and didn’t like them. It is too late to return them, but he knows that Jarell is just the same shoe size as his son so he brings the sneakers in for Jarell.

Sarah is a therapist and is seeing Anita’s family. They can’t concentrate on their issues with Anita because they tell her they do not have any food in the house and do not know where to get any for that night. Sarah wonders if she should just give them $20.

Many other dilemmas arise. The issue of staff/child touch is a particularly sensitive one, and different agencies have different policies around this. Another area fraught with complications is when a staff or a child leaves the agency.

Amidst this morass of complexity, how is a staff member to know what to do? The answer is simple: talk about it. First, know and consult your agency’s boundary policy. Yet no policy can cover all the decisions we are faced with. So if you are considering doing anything out side your job description, before you say anything to the child or family, discuss it with your supervisor and/or your team. What would be the effect of this action on the child? On the group? On other staff? Are you making any implicit unrealistic promises about your role to the child? How will you feel if you do this extra thing and then the next day the child is mean to you? There are many sides that must be considered. Supervisors and team members must be alert to boundary issues on their team, and challenge decisions that seem problematic, even at the risk of seeming like the Scrooge of the team.

No matter what treatment system we are using, boundaries are crucial in creating healing relationships. Supervision and team discussions are our most powerful tools to sort through the complexity and do what is right for the children. The children cannot grow and change unless they feel completely safe in the strong, clear relationships we offer them.

My Book- The Restorative Approach

I have published a book of writing about the Restorative Approach, the theory behind it, how to implement it, common concerns and problems, and examples of the Restorative Approach in action. You can purchase it from http://www.blurb.com/- just search for The Restorative Approach. Or, email me, and I can sell you a copy for $40. I would love your feed back and comments.

Organizational Structure

Using both our own experience here at Klingberg and the experience of other agencies we consult with, we have been thinking about what organizational structure best supports a trauma informed care treatment model. We have come to believe in a structure in which a clinically trained person (a coordinator) is in charge of a treatment unit, the clinicians are assigned to that unit, and both the child care staff and the clinicians report to the coordinator. There may be a child care supervisor who reports directly to the coordinator supervises the child care staff. There is a leadership group consisting of the coordinator, the therapists, and the child care managers that meets regularly to create and implement the treatment vision. 

Recently we were meeting with an agency which was trying to adapt this recommendation to its own needs and personnel. This discussion prompted me to think about why I think this structure is best; or what I am trying to achieve through this structure. 

The ideal treatment team to implement trauma informed care will have these characteristics: (remember- I said the ideal) 

1. Clinical thinking will be integrated into every moment of the work- through every daily activity, every assignment of consequences for actions, every structural decision. What is clinical thinking? It is looking beneath the outward behavior of the child and considering why. How does this behavior relate to his past experiences? What problem is he trying to solve? How is this behavior adaptive for him? What skills does he need in order to behave differently?
   
   
2. Relationships will be emphasized at every level. Staff will be encouraged to form strong relationships with the children, and be given time and mechanisms to do so. There will be close relationships among members of the treatment team, members from all disciplines- child care workers, teachers, therapists, psychiatrists, nurses… These relationships will hold the children in a safe net. They will also provide the humor, sustenance, honesty, caring and support necessary to provide the stamina to do this hard work.
   
   
3. The treatment environment will belong to all, and decisions will be made together by the team: should our bed times be later? How can we get the kids to brush their teeth? What should we do about this recent bunch of run-aways? How do we react to the kids attempts to split us? What should we do about anger developing between the first shift and the second shift? All these questions are everyone’s business and everyone’s responsibility.
   
   
4. The team will develop the ability to discuss hard questions with each other. They will be able to accept help when a team member tags them out. They will ask each other for help. They will be able to discuss whether a given response to a child was too harsh- or too lenient. They will feel safe enough to discuss their individual reactions to certain children- those they want to kill and those they want to adopt. They will talk about how the work is affecting them personally.
   
   
5. The model for the provision of therapy will not be through once-a-week appointments in the clinician’s office. Instead, the therapists will be responsive when the kids need them or are having a crisis. The therapist will be regularly present on the unit and in the kids’ lives, and will take advantage of opportunities when the kid is receptive to connecting. They may also have appointments in their offices for those kids who can accept this, but many discussions will be held on walks, or while playing a game, etc. The therapists will participate when they can in unit fun events like celebrations and some activities. Furthermore, information about the child will be shared within the team, and the child will know this. If the child wants the therapist to not share a certain item, the therapist can honor this while hoping the child will be ready to share with a few soon. Or the therapist can work with the child to create a version to share. For example, the child may not want the staff to know the details of past abuse she is currently discussing in therapy. But she could agree that the therapist tell the staff that she is currently exploring some hard stuff from her past, so they can be prepared to help her with any reactions she may have. This communicates to the child that the entire team is part of her treatment and is there for her.
   
   
6. Every one on the treatment team will have regular opportunities to talk and think about the work, they will not be expected to just be doing it every minute they are at work. This includes individual supervision (weekly for clinicians and full time child care workers), treatment teams, staff meetings, etc. In these forums they will have a chance to learn about the child, his back ground, his issues, his plans, and current happenings in his life. They will have a chance to explore their own reactions to the child. They will share things the have observed, learned, and found helpful. They will participate in setting the course of treatment, as all will understand that every minute of the day is part of the treatment.
   
   
7. The reporting structure will be clear and organized. Every staff member will know who his direct supervisor is, what his job description is, and what his own responsibility is and what the responsibility of other team members is. The direct supervisor is responsible for guiding the professional development of her supervisees- handle performance issues, providing needed training, encouraging and praising, and helping the staff member reach his own goals. 

I’m sure some of these suggestions are controversial- and altogether they may seem impossible. Yet even within all our constraints it is possible to get quite close to this ideal. 

What do you think? Please click on “comments” and tell me your opinion.

 

CWLA Presentation

Our visit to the CWLA annual conference went well. We made some good connections and had some good conversations. After our presentation, we visited our Congressman Chris Murphy. He arranged for his aide to give us a tour of the Capitol, which was delightful.

CWLA

Come and see our poster at the CWLA Annual conference poster session in Washington on February 24th! In addition to our beautiful poster which illustrates the change to trauma-informed care and the results, a client, Ashley will be joining us and sharing her viewpoint about this change. We would love to see you!

Making Connections by Having Problems

We don’t know what to do for Katrina! She keeps cutting herself, putting cords around her neck to hang herself, and recently she has begun using an eraser to create serious burns in her skin. She has given up running away and having sex with strangers, but she keeps up the unremitting self harm. Staff can work with her for hours, and she seems better, but an hour after they leave, she cuts and they feel the whole effort was useless. We are getting so exhausted and depleted. Please help!

Discussion with Katrina, her mother and her treatment team made clear how three facets of the effects of trauma interact to create dilemmas both for the child and the treatment team.

Katrina had a history, as so many of our children do, of repeated moves, changes of caretakers, and of serious abuse in each new home. Following her adoption at age seven she had many treatment episodes such as hospitalizations, emergency shelters, in home interventions and finally residential treatment.

This history had left Katrina with the following three characteristics (as well as others):

A deep sense of shame and self hatred, resulting from blaming herself for all the abuse, the moves, the symptoms and failures she had experienced: Her self hatred combined with a lack of a sense of self- who was she really? She has a tendency to take on the personality of whomever she is with. This lack of self and deep self revulsion results in her conviction that no one could possibly just like her. It also produces the conviction that she does not deserve anything good, or to have any fun, which results in sabotaging whenever something good does happen.

A lack of inner connection to others: for Katrina, when a person is not physically present it is as though they never existed. She cannot keep a representation of them in her mind to encourage her and help her, because she has not had the relationship stability in her life that would be necessary to develop that ability. So when a staff moves away from helping her it is although they disappear completely.

No self soothing skills: Katrina had not been taught how to manage life’s ups and downs. Her models had used drugs and violence to manage emotions. She has not been taught to recognize or name her own emotions, or what to do when she feels them. Through DBT Katrina is learning some of those skills, and she can name and describe them when she is calm. However, due to her over-active nervous system, when something goes wrong she becomes so over whelmed with emotions that her skills desert her.

Like all of us, Katrina needs connection, attention and support. However, both in her homes and in the many treatment programs she has experienced, it has been hard to engage adults by doing well. Early on Katrina learned that the easiest way to draw adult connection was through problems. Although her caretakers were absorbed in their own life pain, when Katrina was suicidal they had to pay attention to her. It is almost as thought she becomes addicted to having problems.

And this becomes harder and harder to change.

Start with Katrina’s conviction that no one would want to be with her just for herself.

Then, something happens, and Katrina becomes upset. Her need for help is intense and unbearable. Life feels hopeless and frightening, and she blames herself. So she does something to hurt or erase herself, which has the added benefit of bringing in the resources she needs.

In an adult’s calming presence, Katrina can some times gradually calm down. And when she does, what happens? The adult leaves. For Katrina, they disappear completely, never to return.

And Katrina does not know how to re-engage them in a positive way. She does not even have any idea this is possible.

So- she tumbles into another problem.

The intervention strategy that will help to change this is to give Katrina a lot of attention whenever she is doing well, and to be less emotional, less intense and less involved when she is doing self-destructive things. But this turns out to be quite difficult. One reason is that Katrina is rarely doing well. When ever she does start having fun or succeeding, she stops herself, because this is not her and she doesn’t deserve happiness. However, staff can still catch the moments in which she is more relaxed or more normal and engage with her then.

And this takes incredible stamina, planning and thoughtfulness of the staff, and demands much reinforcement and praise from those supporting the staff. Because if a child this needy is NOT calling your name, is doing well and enjoying life, who would want to approach her? Better to stay back and enjoy the momentary respite. And yet, this perpetuates the pattern- that she only gets attention and caring by having problems. Staff will have to work hard for quite a while before this pattern changes- but what a gift they will give Katrina! The gift is the repeated experience (more powerful than any words) that she is a normal girl who can be competent and can receive attention, caring and connection through achievement and every day life activities. This is what she needs to experience in order to move towards a life worth living.

 

 

 

 

 

Brain Research and What To Do: Program Questions

I have recently been giving a presentation on brain research and how it can guide us to what to do in our treatment programs. I will be giving this presentation with my colleague Steve Brown at the Healing the Generations conference at Foxwoods in CT. this week. The following is a summary of some of the main points with questions for programs to consider. 

Connections between parts of the brain are necessary for emotional stability and thoughtful decision making. Brains grow and connections are created within relationships that are attuned and emotionally significant.

            What actions between people in our environments create attunement?

            What happens that strengthens relationships and adds to their significance?

            How can we increase this? 

Feelings of danger focus a person only on danger and safety. A person cannot form relationships unless they feel safe.

            What are the signals of physical and psychological danger in our treatment programs?

            What are the signals of safety?

            How can we decrease danger and increase safety?

Shame is a major barrier to relationships. The shame-based child is sure that any one who gets to know his horrible inner core will reject him, and hence relationships will only lead to pain. Shame leads to attack, to move away from others. Taking responsibility for ones actions is not possible when to do so means experiencing ones utter worthlessness.

            What do we do in our programs that adds to shame?

            What can we do to decrease shame?

            How can we talk about problems in non-shaming ways?

            The antidote to shame is sharing…To tell the secrets- what is shareable is bearable. 

Traumatic and neglectful experiences are characterized by the impossibility of effective action. There is nothing the child can do to change the situation and make it better. The child gives up on the possibility of effective action.

            What do we do that discourages or prohibits effective action?

            How can we give the child practice in effective action, to heal relationships, correct mistakes, and accomplish goals. 

Feelings management skills are the key to managing life’s ups and downs. They are learned in consistent, attuned care taking relationships which our children did not have.

            What do we do that discourages feeling awareness and communication?

            How can we actively teach and encourage the use of feelings management skills? 

When something bad happens and a child has no reliable attachments internally or externally to turn to for help; when a child is already hyper aroused and feeling in danger; when a child feels worthless, hopeless and scared; and when a child does not know how to recognize or sooth their feelings; a child is left with action. The action makes them feel better in the moment even if it has long term negative consequences. These actions that we call symptoms are adaptive for the child.

            What things that we do make this pattern worse, by leaving the child with less connection, more shame or more fear?

Which of our responses help break this cycle through understanding the symptom and helping the child the skills she needs? 

To do this difficult work and remain hopeful and healthy we need to take care of each other and ourselves.

            What do we do in our programs that decreases the opportunity and encouragement for self care?

            What can we do to take good care of each other and ourselves?          

 

 

Lost at School by Ross Greene

Lost at School: Why Our Kids with Behavioral Challenges are Falling Through the Cracks and How We Can Help Them

by Ross W Greene 

Scribner; 1 edition (October 21, 2008)

  

I have just finished Ross Greene’s new book, Lost at School. This book describes how to implement his Collaborative Problem Solving Method in schools. Although Ross Greene does not focus on trauma, his method overlaps with ours in emphasizing the need to teach specific skills. Ross Greene has done excellent work in delineating and specifying the specific thinking skills that our kids need to learn. He is also clear that points and levels, punishments and rewards are not helpful in changing behavior- that children will show better behavior when they learn the skills which will enable them to do so. 

I would like to highlight Dr. Greene’s differentiating between people who believe that "kids do well if they want to" and those who believe that "kids do well if they can". The former assumption leads adults to employ systems to make kids want to do better- rewards and punishments. The belief that "kids do well if they can" will lead adults to teach kids skills so that they have the ability to do better and assumes that the already want to. When they have the skills, their behavior will improve. 

On pages 12-13 Dr. Greene describes some common things that are said about challenging kids, and why they do not make sense: 

"He just wants attention."

            We all want attention so this explanation isn’t very useful for helping us understand why a kid is struggling. If a kid is seeking attention in a maladaptive way doesn’t that suggest that he lacks the skills to seek attention in an adaptive way? 

"He just wants his own way."

We all want our own way so this explanation doesn’t help us understand a kid’s challenges. Adaptively getting one’s own way requires skills often found lacking in challenging kids. 

"He is manipulating us."

This is a very popular and misguided characterization of kids with behavioral challenges. Competent manipulation requires various skills- forethought, planning, impulse control, and organization among others- typically found lacking in challenging kids. In other words, those who are most often described as manipulative are those least capable of pulling it off. 

"He’s not motivated."

This is another characterization that can be traced back to the “kids do well if they want to” mentality and it can lead us straight to interventions aimed at giving a kid the incentives to do well. But why would a kid not want to do well? Why would he choose not to do well if he had the skills to do well? Isn’t doing well always preferable? 

"He’s making bad choices."

            Are you certain he has the skills and repertoire to make good choices? 

"His parents are incompetent disciplinarians."

This, too, is a popular way of thinking, but it fails to take into account the fact that most challenging kids have well behaved siblings. Blaming parents doesn’t help anyone at school deal effectively with their kid in the six hours a day, five days a week, nine months of the year that he is in the building. 

"He has a bad attitude."

He probably didn’t start out with one. “Bas attitudes” tend to be the by-product of countless years of being misunderstood and over-punished by adults who didn’t recognize that a kid was lacking crucial thinking skills. But kids are resilient, they coming around if we start doing the right thing. 

The book is very well written and contains many examples and stories. I recommend this book for its clear description of the Collaborative Problem Solving Method and how implementing it can revolutionize our schools.

 

Tips for Starting Trauma Informed Care

Here are some tips for beginning the transformation to trauma informed care: 

1. Every time you talk about something a child has done, have someone review the child’s history.
2. Any time some one wants to know what punishment you should apply to a given action, ask: how do we understand why he did that?
3. Clinicians- think of a treatment theme for each child you are working with, a brief statement of the central focus of your work, such as "learning to trust adults" or "learning to handle disappointment without making things worse" or "learning to recognize emotions". Communicate this to the team.
4. Develop an individual crisis management plan with each child, noting what tends to upset them, how they show they are starting to get upset, what helps, what doesn’t help. Make these living documents, available to the whole team, used by all, and constantly revised.
5. Discuss with both staff and kids what about your program makes them feel safe, what about the program makes them feel unsafe. What can you improve?
6. Start some Youth Leadership activities- a student council, a unit group to decide unit activities, youth-to-youth mentoring, older kids teaching younger, etc.
7. Use sensory interventions, such as rocking chairs, weighted garments, blankets and fur, soft music, aroma therapy
8. Add yoga and meditation to your offerings
9. Institute a program where the kids engage in some social action to help others, such as collecting food for a food bank, or volunteering at a Senior Center.
10. Start a discussion among staff about how people are feeling about the job and how the work is affecting them.
11. Buy night lights for all kids who want them.
12. Have a staff retreat including all disciplines during which you have fun and do team building activities.

 Do you see the connection between each of these ideas and healing from trauma? If not, let me know and I will write more about it.

Which of these are you already doing?

Do you have any other ideas?

Eating at the Table

LaTasha came to the group home from a residential treatment facility where she had been for two years. Prior to that placement, she had been hospitalized seven times, was in a shelter for eleven months, had been in nine foster homes, and had suffered early abuse from her biological family. She pushed so hard to get out of the residential and was so eager to be discharged to the group home that both she and her staff were surprised at how hard the transition was for her. When she first came to the group home, she showed all the signs of feeling unsafe. She tested the staff, insulting and mocking them. She asked questions about the locks and security measures of the home. If ever a staff was uncertain about what to do or if the staff changed a rule (“yes, I guess you can go outside and hang out for a while before you do your homework”) LaTasha would say they were stupid, didn’t know what they were doing and were too young to be staff anyway. A couple of times LaTasha had become so escalated she had been taken to the local ER.

When LaTasha first arrived, she completely refused to eat. She said she didn’t like the food, it wasn’t her type of food, staff didn’t know how to cook. The Treatment Team wondered if she had an eating disorder, but there was no mention of it in her records. Then, she began taking food and smuggling it to her room, which of course was against the house rules and could bring bugs and all sorts of complications. She would some times eat snacks or make herself a late night peanut butter sandwich, but she would never sit at the table with the group. Occasionally she tried to eat her sandwich in the living room in front of the TV- another behavior that was against the rules.

Fortunately LaTasha’s group home was using trauma informed treatment and had an excellent treatment team. Led by the clinician they looked at LaTasha’s behavior and asked "why"? What function was LaTasha’s behavior serving for her? What was she expressing to the team? What emotion management capacities did she lack and need help with?

It was clear that LaTasha was scared and didn’t trust them. Being in the house and in a strange community, very different from any she had previously known, made her feel unsafe. She was in danger mode. She didn’t know the staff or the other kids. Many other people, both professional and not, had let her down and rejected her. She had gotten used to a residential setting with its inflexible structure, many staff, and locked doors. This new place seemed very weird to her and she was not sure what to make of it. She was not going to connect with these people, act like they were her family, only to be hurt once again.

The Treatment Team decided that all their efforts should be focused on helping LaTasha feel safe. One key to that would be validation- letting her know that her reaction was completely understandable, given her experiences, and in fact that anyone would feel uneasy in a new place. So, instead of insisting that she eat at the table with the group, staff began trying to support whatever arrangement felt comfortable for her, and expressing their hope that she would join them whenever she felt it was right for her.

So, they let her eat in the living room for a while- and started bringing her a tray of whatever they were eating, so she wouldn’t be stuck with peanut butter sandwiches. After a while, she began eating in the kitchen near where the others were, but not at the table. Then she came to the table, but she was wearing headphones and listening to music. Instead of telling her this was not allowed, staff welcomed her and ignored the headphones. Later, she began to wear the headphones around her neck at the table ("I am in control, I can retreat if I need to"). LaTasha now eats regularly with the group, and her overall agitation has also calmed down.

This is a perfect example of how we can implement trauma informed care in the daily details of life. The first step was for staff to move beyond "rules" and "misbehavior" and "defiance" to the meaning of what this girl was experiencing- and then to take it seriously, really let themselves feel what this move must be like for her. And then the whole team focused on helping her feel safe and welcome. They did not get caught up in worrying what if she always wants to eat in the living room-what if all the girls start doing it- soon no one will be following any rules. Instead they allowed themselves to honor the emotional reality of one particular girl, and had faith that as needs are filled people can move on.

This example is real, and was recounted by a participant in our recent Day of Learning and Sharing.

 

Day of Learning and Sharing Successful

This is a report on an event I helped plan and participated in.

On December 8, 2008 the Trauma Research Education and Training Institute (TREATI) and the Traumatic Stress Institute sponsored the Third Annual Day of Learning of Sharing. This event is provided to Risking Connection® trainers to increase their skills and knowledge in training and helping to implement trauma informed care.

The theme of this years’ event was Visible Mending, a Japanese practice in which broken bowls are mended with gold, making the repaired bowl more beautiful and more valuable than the original, unbroken vessel. The parallels to both our work and our care of ourselves and each other are obvious.

The day was attended by eighteen agencies, including agencies from Connecticut, Massachusetts, Kentucky and New York. In addition to Risking Connection® trainers, agency executives, CEOs and managers were invited to learn more about implementing trauma informed care.

The day started with each agency presenting what they were most proud of regarding training and implementing Risking Connection® concepts. These included reductions in restraints and seclusions, reduction in staff turnover, changes in agency cultures, more emphasis on relationships, implementation of evidence-based trauma treatments, and better outcomes for children. It was very moving to hear the transformation that is taking place in our field resulting in better treatment of our children.

The morning featured a presentation from Roger Fallot, Ph.D.  Dr. Fallot, Director of Research and Evaluation for Community Connections headquartered in Washington, D.C., consults nationally to agencies and mental health systems on the implementation of trauma-informed services.  He is co-editor (with Maxine Harris) of Using Trauma Theory to Design Service Systems. Roger presented on transforming agency cultures to meet the needs of traumatized clients. He emphasized the importance of five core principles: Safety, Trustworthiness, Choice, Collaboration, and Empowerment. Roger then facilitated a discussion on what agencies could do to improve their practice in each of these areas.

After lunch Patricia D. Wilcox, LCSW, Vice President at Klingberg, Risking Connection® Faculty trainer and Executive Director of TREATI, presented on

Healing the Hurt Brain: How we can use our knowledge about trauma and the brain to make our treatment as effective as possible. She connected current knowledge about brain development and plasticity with the implications for effective treatment practices. Pat focused on the role of attuned relationships, safety, understanding shame, and developing emotional skills.

Steve Brown, PsyD. Director of the Traumatic Stress Institute and Risking Connection® Faculty trainer led the group in a wonderful Vicarious Traumatization exercise using the Visible Healing metaphor. Many participants commented that this exercise was helpful to them and would be valuable to bring back to their agencies.

The day ended with a closing ceremony which emphasized our connections to each other and to the web of people trying to implement trauma informed practice and change the world.

 

 

 

 

 

 

Does Our Discipline Threaten Our Relationships?

In a recent training we were talking about relationships, as we often do. A therapist asked the following question:

"I am often called onto the floor to intervene with a kid who is acting up. I take on the role of the child care workers. I end up giving him consequences. When that happens how can I preserve my relationship with him, and not seem to him like just one more person trying to manage his behavior?"

 I was struck by what I see as dangerous assumptions beneath that question, which I will exaggerate for purposes of discussion. I think in fact these assumptions often do underlie our thinking and actions in treatment programs.

This question assumes that the therapist has a special healing relationship with the child, which would be threatened by the therapist addressing the boy’s behavior in the normal way of the program. The child care workers, on the other hand, are expected to address behavior routinely and so whatever relationship they have with the child is expendable. They are those people who are just trying to manage behavior.

I would propose that there should be no people in a treatment program "just trying to manage behavior". The first priority of every person who interacts with the child should be to form, maintain and strengthen their relationship with the child. Every relationship can be healing. Every relationship is important.

I would also suggest that none of us, whatever our role, should ever be just managing behavior. Of course, in a crisis one has to direct traffic to restore safety. But with regard to any individual child, our constant focus should be to understand the meaning and adaptive function of every symptom, and teach the child more positive ways to meet those same needs. Our programs, and all our staff, should in every way promote a sense of safety and caring. We do not ignore behavior or remain paralyzed as the child becomes increasingly upset and out of control. We intervene actively and constantly from our base of relationship to help the child calm down, and, when he is calm, to figure out how to get what he needs. Our goal is not to control his behavior. It is to help him to feel calm and safe enough to try new ways of meeting his needs.

I seriously believe that everyone in the program should be thinking this way- every child care worker, every therapist, and every teacher. Everyone should be engaged with the child from a carefully formed relationship. Naturally, the child may be angry, unappreciative, nasty, upset and uncooperative with any one of the many people on his team. Any one should then acknowledge and validate his feelings, and (when he is calm enough to hear) share their experience of whatever happened from their heart.

When we acknowledge the central importance of all the relationships between the child and the team members; when we truly believe that the child is doing the best he can; when we see symptoms as adaptive; when we react by helping the child to learn better ways to meet his needs: then we can all do all parts of the job of treating and raising these children, and we can all enrich our relationships as we do them.

Meeting Their Needs

In Risking Connection® training we focus a great deal on counter-transference, the helpers’ feelings while doing the work. Our basic point is that any feeling is okay, it is what you do with it that matters. In order to illustrate this, we use scenarios. In each scenario, the questions are: what is the staff member feeling? How could they use their feelings to enhance the treatment? How could their feelings get in the way of the treatment?

Here is one of the scenarios:

"Lucinda, a fourteen-year-old resident, told you that her aunt had called her and told her that her mother was very sick. She seemed quite distraught. You arranged with other staff for her to have an extra long phone call outside of phone time. Later you learn that she actually used that opportunity to call her boyfriend and her mother was never sick."

The usual response is that the staff member is feeling angry, betrayed, used, foolish, and ashamed. And maybe we had better think again about allowing Lucinda this relationship with her boyfriend, since it apparently gets in the way of her treatment. Our reaction is to toughen up, make sure we never believe this child again, that no child can ever trick us again. She has betrayed our trust and we will not trust her again for a long time.

We talk about noticing that this is how the kids we work with always feel. That moment when the staff member, feeling humiliated, decides never to open her heart and let any child trick him again is the place where our kids live.

In a recent training, however, a miraculous thing happened. One staff member said: what if we realized that Lucinda doing this was a sign that she was not able to trust us to meet her needs? What if we assumed that her wish to talk to her boyfriend was legitimate? It is developmentally appropriate, and also part of her understandable need to have connections, someone who cares about her, attachments.

What if we worked hard to assure Lucinda that we would like to meet her needs, and we would like to discuss how we can make sure she has regular access to her boyfriend without the necessity for lying to anyone?

What if we thought that more important than the phone rules was a chance to teach a child that adults care and that you can turn to other people to help you get what you want?

I would love to live in a world in which this kind of thinking was even part of the conversation.

Safety

Let’s consider the topic of safety.

One of the most basic, immediate and continuous distinctions our brains are constantly making is: safe or not safe? Danger or no danger? This decision is made instantaneously in any new situation by the part of the brain known as the amygdala. Any change triggers a reevaluation. In a healthy brain, the amygdala’s instantaneous decision is combined with and moderated by information from other part of the brain, that add information regarding context, past experiences, reasoning, and observations from the sensory system.

If the brain concludes: Danger! Not safe! the body’s protective system is activated. Energy is directed to the parts of the body that will be needed for fight or flight. Non-essential systems, such as digestion and reasoning, are shut down. The activation chemicals in the body/brain are released, and the alertness system turned on. The person is alert, but focused only on signals of danger and safety. The heart is beating fast, the muscles are tense, ready for action.

Think of a time you can remember when you felt seriously unsafe. A near car accident? An encounter with a threatening person? A weather-related event? Even a common example like trying to drive home from work after an ice storm can be illustrative. In fact, an even more appropriate example would be being a passenger in a car when someone you didn’t know very well was driving through an ice storm.

What did you feel like? What did you do? What happened in your body?

If there was someone in the car with you, would you have been able to have a conversation about a movie you had seen, much less about something that was troubling you? If some one told you a joke, would you have laughed? Would you enjoy the songs on the radio? Could you take a nap?

To further elucidate the experience of danger, there is the experiment with the baby mice. (Panksepp, J. (1998) Affective Neuroscience: The Foundations of Human and Animal Emotions. New York, Oxford University Press) Some baby mice had been raised in cages. They had never seen or heard of a cat. Like all baby animals, they engaged in a lot of free play with each other. The experimenters put two cat hairs in the cage. Although the mice had no cat experience, the cat hairs were wired into their brains as signifying danger. Immediately, all free play stopped. And, also significant, when the cat hairs were removed after just a few days the mice play gradually returned, but it never returned to the level it had been before the cat hairs were introduced.

So what does all this have to do with our work? It is helpful to think of the children we work with as being stuck in the danger response. Because of early, overwhelming and unpredictable experiences of trauma, their brain chemistry was modified such that they can not come back to a relaxed state.

But the wonderful news of brain plasticity is that at any age, the brain can be rewired through attached relationships. In order to begin this process, and in fact in order to be available to attached relationships, the brain must sense "I am now safe". Since the brain patterns of danger are so deep, this will not happen quickly, but it can happen.

So it is important that we think closely and observe the ways in which our treatment environments are signaling safety to our clients, and the ways in which they signal danger. As part of this we must consider ways in which we as staff feel safe in our work places.

As you look around your environment, what safety and danger signals do you observe?

Danger signals could include sarcasm, not being allowed to speak ones’ side, restraints, loud noises, disorganization, emotionally dysregulated staff, belittling comments, physically ugly places, lots of damage and disrepair, creaky doors and funny noises at night, messages from other kids, boundary violations, bullying, messages from staff to other staff, blaming and scapegoating- the list could go on.

Safety signal could include warm tones of voice, respect, politeness, promises kept, organized environments, delight, fun, relaxed kids, caring messages when upset, physical protection such as locks, clear and observed boundaries, a sense that we are all in this together, team work, pleasant physical spaces, an appreciation of strengths and competences, a real voice in decision making.

It would be interesting to have a team discussion of this question. How safe does our environment feel to the kids- and to us? It would also be interesting to ask the kids to make lists of "things here that make us feel safe" and "things here that make us feel not safe".

And as we do this, it is important to remember that unless the body begins feeling safe, the person will not be able to begin the work of healing. It’s not that they will be resistant or unwilling- it’s that their brains will not be available for that work.

Thus it is very important that we pay more attention to this subject of safety.

We Have to Hold Her Accountable… or How is She Going to Learn?

At the beginning of Risking Connectionâ training we discuss the differences between a traditional approach and a trauma informed approach. These include: The traditional approach maintains that the treater is the expert, and the client the recipient of this expertise; the main value in the traditional method is control and elimination of symptoms as opposed to collaboration and understanding the adaptive function of symptoms; and the idea that the treater should be unaffected by the work is replaced by understanding that all treaters are emotionally impacted by the work. 

As we finished this exercise in a recent training, one participant said: "I can see that in this method you do not hold the clients accountable. This will not work for me, I work in a juvenile justice facility and we have to hold the clients accountable or how will they ever learn?" Furthermore, she stated that she sees the clients as making choices, and her job to point out that there are consequences to these choices. 

This comment contains several of the most common fallacies or mis-beliefs about the trauma informed approach. We have to take these concerns seriously as they represent one of the largest obstacles to implementing this method. 

First of all there is the idea that we are recommending "not holding the client accountable". 

When you look up the definition of holding accountable you find it is associated with words like blame, find fault with, censure, to place the responsibility for, reproach, reprove, reprehend, criticize, to hold responsible; hold culpable. We don’t seem to speak of holding someone accountable for good things or positive achievements. 

We are as usual stuck in the middle of a dialectic- to use the words of DBT, the client is doing the best she can, and she needs to learn to do better. Our treatment must include both validation and a push for change. 

A child’s past and his current reality influence the choices he makes. If he is presented with the opportunity to steal a car and the urging of peers to do so, many things so influence whether he does or does not:

Does he have any self worth? Does he think there is any one who cares what he does? Has he learned values through loving attachments? Does he have a sense of hope for his life? Does he think he has anything to lose? Is he in the grip of intolerable anger, despair or fear and does he have any skills to manage whatever he is feeling? Is he mired in shame from other events and actions of his life? Does he have attachments with other friends or does he feel he will be alone forever if he alienates these friends? Does his mind have the capacity to think before he acts? 

If he decides to steal the car, gets caught, and is presented (involuntarily) to us for treatment, how can we best help him? What interventions on our part will result in him being more capable of turning away from him next opportunity to break the law? 

It would be neglectful to ignore the fact that he stole the car, to never mention it, or to act as though it was some how all right to have done so because of difficulties he has had in his past. 

It would also be neglectful to ignore the factors that contribute to his vulnerability to such actions. We would be less helpful if we did not offer treatment that increases his self worth, forms strong relationships, emphasizes the relationship consequences of behaviors, build up avenues for achievement and hope, helps him learn both emotion management skills and relationship skills, and teaches him how to calm his biology to increase his ability to think. 

A trauma informed approach confronts the behaviors directly. The treaters bring to the discussion respect, an assumption that every behavior is adaptive and solves a problem, information about change, a strong connection, and hope for a better future. 

In a trauma informed approach we answer the question: "how will he learn not to do this again?"

He will learn by a strong, respectful and straightforward investigation with his treaters of what happened and what contributed to his decisions.

He will learn through developing attached relationships. Within these he will learn values. He will have something to lose that matters. He will learn that he has strengths and talents. He will find hope. He will also learn through specific strategies to teach him emotion management and relationship skills. 

It’s not so much that we do not hold him accountable. It’s that caring and be cared about, skills and achievement offer so much more power for changes than simply explaining that if you steal cars you may go to jail. 

How would you answer this person’s comment? What are your views on this central concern about trauma informed care? We need to do much more thinking and talking about this. Click on “comment” and express your ideas.