Maybe It’s Not the Consequences

Think about a child in your program who has significantly improved. Maybe it would be that boy who recently came back for a visit after a successful discharge. Or maybe it’s the girl who has finally stopped hurting herself and running away and who is excelling in African drumming.

What do you think made the difference for this child? What actually helped him or her change and heal?

Most likely you think of the relationships, the patience, the caring. It’s the fact that your team was able to stick with him through the hard times. Maybe you were able to make some progress in connecting her with her family. You noticed that after a while she started to feel safe in the program and began to relax and play more. Probably you taught her some skills- now she asks for her crisis kit when she gets upset, and uses her distress tolerance skills. Maybe he experienced some success- it was when he started doing well on the basketball team that he began his turn around, or when he had that work study job in the kitchen and connected with the cook and started to enjoy cooking. When he finally trusted his therapist enough to tell her that he hated feeling like an idiot when it came to math, that helped too.

In short, we all know that what changes children is the web of loving, patient relationships combined with many repetitive specific skill building activities.

Yet, when we are anxious and upset about a certain child or a certain behavior, our thoughts automatically turn first to consequences.

Janessa keeps running away. Maybe we should give her a longer restriction when she comes back.

Sam continues to be mean to the other boys. Maybe we should give him a reward for every day he is not mean.

How would our programs be if we operated from the assumption that the actions we take after a behavior occurs have NO EFFECT on that behavior? That when we are concerned about a behavior, all our creativity and effort should go into creating the safety and teaching the skills that will enable a child not to need that behavior any more?

Of course this is an exaggeration, our response to a behavior does have some effect on it. But it is actually not our most powerful point of intervention.

What then would we do when a behavior occurred?

What if we thought of that moment as a time to teach a kid what you do when you screw up. This is something we all need to know (I use my skills in this area regularly). This is also something our kids do not know. When they screw up they plunge into an abyss of hopelessness, think all is lost, and prepare to be kicked out.

So we have an opportunity to teach how to repair a mistake. How do we repair our own mistakes with our friends? Apologize, explain what happened, listen to the other person’s experience and take in how they felt, do something nice for them, and make an effort not to make the same mistake again.

Of course our kids can’t do all this. Shame and self hatred make it difficult. But we can lead them to do small steps, small parts and thus gradually and slowly increase their ability to right their wrongs.

And at the same time, we continue the day to day work of helping them develop the self capacities that will diminish the number of mistakes they need to make.

What do you think of this idea? Click on comment and share your response.

Foster Care Behavioral Guidelines

Healing Parents: Helping Wounded Children Learn to Trust & Love by Michael Orlans, Terry M. Levy
CWLA Press (Child Welfare League of America) (December 30, 2006)

Creating Capacity for Attachment: Dyadic Developmental Psychotherapy in the Treatment of Trauma-Attachment Disorders by Deborah Shell; Art Becker-Weidman Wood N Barnes (July 20, 2005)

I have improved my foster care guidelines, partly through consultation with these two books.

Again, this is only meaningful when imbedded in a context of training, supervision and support. I am currently working on developing a series of six training modules to deliver to our foster care program through out the up coming year.

All comments and suggestions would be most welcome.

Guidelines for Trauma-Informed Behavior Management in Foster Care

1. This approach to behavior management is based on the understanding that problem behaviors are the child’s attempt to manage intolerable emotions such as fear, despair and hopelessness. Because the child does not trust relationships and thus has trouble asking for and accepting help; because he or she has an overly activated nervous system; and because he or she has not learned emotion management skills, the child reacts to set backs with behaviors that help in the moment but have long term negative consequences.

2. The most powerful way to change behavior will be through forming strong relationships, creating attuned communication, creating a sense of self worth, and modeling and teaching emotion management skills.

3. Interactions with the children should be consistent with the Restorative Approach. They should display the qualities of playfulness, love, acceptance, curiosity, and empathy.

4. Whenever possible parents should promote attunement with their children. When there is a break in attunement, the parent should address it and reconnect.

5. Parents must understand that they need to help the child regulate his emotions, by remaining calm them selves, using soothing words, and naming and validating feelings.

6. Many children are shame based and do not feel worthy of life. Parents should be aware of the pervasiveness of shame, be careful not to shame the child, and understand the paralyzing effect of shame.

7. As the child begins to feel safe, her need for problem behaviors will decrease.

8. Building the relationship is more important than changing the behavior. In fact it is necessary before the behavior can change. Prioritize alliance, not compliance.

9. Behavioral difficulty should be handled through re-direction and persuasion. Consequences should not be threatened or imposed except as a last resort. Children can be kept closer in (i.e. kept to house, in sight of parents) when they have acted out, but should constantly be re-evaluated as to whether this is still necessary.

10. Points Levels and behavior charts are not used.

11. As soon as the child is back on track after any incident, they should resume normal activities.

12. Children who are having difficulty should be kept closer to parents. They should not go on trips or off on their own.

13. When a child is agitated, escalated or out of control, all parent efforts should be directed towards helping them calm down. This can be done through listening, validating, taking a walk, quiet, adult closeness and calmness. There should be no discussion at this time of consequences or better ways to handle things. These can be discussed later when the child is calm.

14. If a child has a major problem, they should be given a restorative task consistent with the problem they had. The task should include the elements of learning, making amends and reconnecting. In other words, they should be given opportunities to repair damage done, make amends to people hurt, restore damaged relationships, and do something nice for the family.

15. Until the child has completed their restorative tasks, they should not participate in extra or just-for-fun activities. They should be part of all regular activities. This means all regular therapy and school unless parents determine it’s unsafe for the child to be in these activities. They could go to bed earlier to get energy for their restorative work.

16. When the child has completed their restorative task, they should return to all normal activity.

17. Isolation to any room should not be used. Children become regulated in the presence of regulated adults.

18. Restrictions can be used (car, pool, etc). These are used when a child is not safe while doing these activities. They should be for short times such as a day or two and constantly reevaluated.

19. Children can be asked to leave the family area (if possible, with an adult) to calm down or re focus, and then return in a short time (5-15 minutes), but this should be done only rarely- children are most likely to calm down when close to calm adults, not when sent off by themselves.

20. Structure is extremely important and the children need a highly structured day with planned activities, and they are helped by knowing what will happen next. Families maintain order throughout the day by such mechanisms as plans, describing what will happen next, taking turns, quiet time, and game playing. Alternating quiet activities with more energetic activities helps the kids contain their emotions. When kids are unsafe, keeping them to a small circle of activities and people is helpful; taking them to events like large family picnics may be a set up for difficult behavior. Choices should be limited. Free time, alone time, and going to bed are particularly difficult and should be supported by the adult. Events in which there is a lot of noise, confusion and stimulation (such as shopping) can also be difficult for some children. The adults should try to structure the child’s day so he experiences success, not put him in situations for which he is not prepared. Routines, rituals and ceremonies are very helpful in establishing a safe structure in the home.

21. Bedtime and hygiene are particularly sensitive times for children who have experienced trauma. Problems in these areas should not be addressed through punishments or rewards. The children should be supported through parent closeness and creative interventions such as music, night lights, bubble baths, etc.

22. When a child’s behavior begins to deteriorate, the first question to ask is: is she feeling safe? The second question is: is she over stimulated?

Guidelines for Trauma-Informed Behavior Management in Foster Care

I am working on training and materials to adapt the Restorative Approach for foster parents. As one piece of it, I am developing Behavior Management guidelines for foster families. The guideline will be meaningless unless embedded in a training program that teaches how to understand trauma, how to help children heal, understanding symptoms as adaptations, the use of the relationship, and taking care of ourselves. However, I do think it will be useful to give parents specific ideas about what we expect them to do. Here is what I have so far, and I would greatly appreciate feed back. Just click the word "comment" below. Thank you.

1. This approach to behavior management is based on the understanding that problem behaviors are the child’s attempt to manage intolerable emotions such as fear, despair and hopelessness. Because the child does not trust relationships and thus has trouble asking for and accepting help; because he or she has an overly activated nervous system; and because he or she has not learned emotion management skills, the child reacts to set backs with behaviors that help in the moment but have long term negative consequences.

2. The most powerful way to change behavior will be through forming strong relationships, creating attuned communication, creating a sense of self worth, and modeling and teaching emotion management skills.

3. Interactions with the children should be consistent with the Restorative Approach. They should display the qualities of playfulness, love, acceptance, curiosity, and empathy. (Daniel Hughes)

4. As the child begins to feel safe, her need for problem behaviors will decrease.

5. Behavioral difficulty should be handled through re-direction and persuasion. Consequences should not be threatened or imposed except as a last resort.

6. Children can be kept closer in (i.e. kept to house, in sight of parents) when they have acted out, but should constantly be re-evaluated as to whether this is still necessary.

7. Points Levels and behavior charts are not used.

8. As soon as the child is back on track after any incident, they should resume normal activities.

9. Children who are having difficulty should be kept closer to parents. They should not go on trips or off on their own.

10. When a child is agitated, escalated or out of control, all parent efforts should be directed towards helping them calm down. This can be done through listening, validating, taking a walk, quiet, adult closeness and calmness. There should be no discussion at this time of consequences or better ways to handle things. These can be discussed later when the child is calm.

11. If a child has a major problem, they should be given a restorative task consistent with the problem they had. The task should include the elements of learning, making amends and reconnecting. In other words, they should be given opportunities to repair damage done, make amends to people hurt, restore damaged relationships, and do something nice for the family.

12. Until the child has completed their restorative tasks, they should not participate in extra or just-for-fun activities. They should be part of all regular activities. This means all regular therapy and school unless parents determine it’s unsafe for the child to be in these activities. They could go to bed earlier to get energy for their restorative work.

13. When the child has completed their restorative task, they should return to all normal activity.

14. Isolation to any room should not be used. Children become regulated in the presence of regulated adults.

15. Restrictions can be used (car, pool, etc). These are used when a child abuses the rules around activities to the point where safety is compromised. They should be for short times such as a day or two and constantly reevaluated.

16. Children can be asked to leave the family area to calm down or re focus, and then return in a short time (5-15 minutes), but this should be done only rarely- children are most likely to calm down when close to calm adults, not when sent off by themselves.

17. Structure is extremely important and the children need a highly structured day with planned activities, and they are helped by knowing what will happen next. Families maintain order throughout the day by such mechanisms as plans, describing what will happen next, taking turns, quiet time, and game playing. Alternating quiet activities with more energetic activities helps the kids contain their emotions. When kids are unsafe, keeping them to a small circle of activities and people is helpful; taking them to events like large family picnics may be a set up for difficult behavior. Choices should be limited. Free time, alone time, and going to bed are particularly difficult and should be supported by the adult. Events in which there is a lot of noise, confusion and stimulation (such as shopping) can also be difficult for some children. The adults should try to structure the child’s day so he experiences success, not put him in situations for which he is not prepared. Routines, rituals and ceremonies are very helpful in establishing a safe structure in the home.

18. Bedtime and hygiene are particularly sensitive times for children who have experienced trauma. Problems in these areas should not be addressed through punishments or rewards. The children should be supported through parent closeness and creative interventions such as music, night lights, bubble baths, etc.

19. When a child’s behavior begins to deteriorate, the first question to ask is: is she feeling safe? The second question is: is she over stimulated?

Thanks again for any ideas or suggestions you may have.

The Talk

I am beginning to work on an adaptation of the Restorative Approach for foster parents. As part of that project, I have been re-reading Dan Hughes latest book:

Attachment Focused Parenting (Daniel Hughes W.W. Norton & Co.; 1 edition March 16, 2009) particularly the last section on reducing attachment resistance. I came across the following section:

"Many children who resist turning to their parents for both safety and exploration of the self and the world tend to develop similar strategies for self-reliance and coping. These strategies reflect the psychological reality that they are responsible for both their own safety and for learning about the world. They... cannot rely on their parents.. They tend to tell other- including their parents- what they are convinced is best and what others should do. They tend to want to decide the best course of action for themselves and to oppose the decisions of their parents and others.

These children also try to avoid any event that might be associated with prior events involving fearful and shaming experiences. They develop a strong avoidance of memories of those prior events as well as any current situations that might elicit those memories. These children, in a fundamental way, may never feel safe since they fear parts of their own mind. Not only are they hyper vigilant about external events, they are equally hyper vigilant about allowing parts of their inner life to enter awareness. They often react with intense rage or terror when seemingly routine events- associated with past traumas- elicit an intense emotional response. Parents may facilitate perceived safety by controlling what their child is exposed to in the external world. It is much harder for parents to increase their child’s sense of safety when his fears originate within himself.

Given that these children have not relied on their attachment figures in any consistent manner, they are also likely not to show the developmental skills that children with attachment security tend to manifest. Their emotional experience and expressions tend toward the extreme, lacking a "thermostat" that will create flexible regulation. Their ability to reflect on the events of their lives tends to be weak, as they react to situations, often in a repetitive and rigid manner driven by fears regarding safety." (p. 177)

I think the idea of the traumatized child being afraid of what is inside himself has profound implications.

To further quote Daniel Hughes:

"Without attachment security, a child is less likely to turn to his parents for guidance as to how to be successful. He is also less likely to acknowledge his mistakes and try to correct them. He is less likely to communicate his difficulties and ask for help. As a result, he is less likely to learn from his mistakes and so correct them. Rather, he is more likely to make the same mistake again and again. This most likely will create a pervasive sense of failure. Rather than ask for help, he is likely to rely on himself more, become even more hypervigilant and controlling. With structure, supervision and limited choices, his environment makes success more likely and failure more difficult. Until he can learn from his mistakes, they have to be kept to a minimum by his environment.

There are many different reasons why children who resist attachment have trouble learning from their mistakes. First, their pervasive sense of shame causes them to deny mistakes, have excuses for them, or blame others. Second, they often have developmental disabilities that place them in situations that they are not prepared for. They tend to be raised or taught according to their chronological age rather than their developmental age. Basic skills of self-direction, impulse control, frustration tolerance, and delay of gratification tend to be weak, leaving them at a high risk for failure in many situations." (p. 185)

This seems to me further illuminate the problems that occur when staff in treatment programs try to talk to kids about their mis-behavior. Staff then say: "He will never take responsibility for his behavior" and are disappointed when the children don’t change. So we have scenarios like this:

Staff is approaching Mark to discuss what happened in school today:

Mark is new here but I really like him. I know he’s has had a rough life
Still, he can’t go around hitting people like he did in school today.
I have to get him to understand what he did wrong and take responsibility for his behavior.
I know Leroy can instigate other kids.
I will explain to Mark that if he just asks staff for help when Leroy bothers him things will go much better.
I will explain that if he doesn’t hit anyone for the rest of the week he can go to the movies with us on Saturday.
At first I didn’t think he was listening but then he began to agree with what I was telling him.
I’m sure the rest of the week will be better.

Mark is being approached by staff with a serious look on their face:

Someone is coming towards me. She looks angry. Danger! Danger! Mobilize all defenses!
I don’t trust her. I just met her a few weeks ago and she seems mean.
I know I screwed up in school again today, what a total loser I am, but the class was so confusing and I didn’t get the math. The teacher was busy with the other kids as usual and besides I know she doesn’t like me. Leroy was giving me that smirk like Joe used to and what could I do but push him away and I was afraid I was going to do much worst things.
She’s coming over here to kick me out or punish me or something bad I know it I know it.
La la la la la la I cannot hear a word she is saying who cares it doesn’t matter
I tell her what happened was Leroy and the teacher’s fault and this place sucks and I hate everyone here.
I try to shut out her words, she is smiling but I know that is fake. I agree with whatever she says trying not to hear it. I have my own ways of protecting myself against Leroy.
FINALLY she is going away and I can get back to my Nintendo DS

Sound familiar?
Will the rest of the week go better?

What could the staff have done differently:
Take longer to connect before going into the problem.
Identify the feelings Mark must have had in school and emphatically validate them.
Understand the math difficulty, get the teacher’s help.
Connect with Mark around how scary this place is.
Apologize that the staff didn’t see he was having trouble.
Hope that he will be able to trust them enough to tell them when he gets upset.
Meanwhile say they will look out for him and try to be more alert for when things go wrong, he is over whelmed or other kids are getting on his nerves.

Maybe it sounds too hard or too much time or a luxury- but dealing with the fights and restraints that could emerge from this scenario takes a lot of time.

And doesn’t Mark have to learn that hitting is wrong and he should take responsibility for his actions?

No, he has to learn that not understanding the math doesn’t mean you are no good and that someone can assist you, that he can trust people, that adults will help him, and how to notice when he begins to feel frustrated and upset and what to do to calm himself down.

Trauma Conference Part Two

On the second day of the conference, the general speakers were:
Glenn Saxe speaking on Complexity Theory
Dan Hughes speaking about the use of the body in therapy
And
Bessel van der Kolk on Developmental Trauma Disorder

Glenn Saxe is one of my favorite theorists and writers. His book, Saxe, Glenn; Ellis, B. Heidi; and Kaplow, Julie B. Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach (2006, The Guilford Pres)s does the best job of any I have read to conceptualize a model for working both with the child themselves and with the system around the child.

At this presentation Dr. Saxe was talking about his latest fascination, complexity theory, which is the science that investigates how schools of fish or flocks of birds maintain their complex, moving patterns with out a leader or a plan. Dr. Saxe is using this theory to look at the complex patter of a traumatized child in his or her social systems, and stated that the theories will help us understand which changes will be most powerful, and where we could intervene to gain the most effect.

Daniel Hughes has long been an inspiration of mine, and was part of our beginning down the journey towards trauma informed care. His book: Hughes, Daniel. (1998). Building the bonds of attachment: Awakening love in deeply troubled children. Jason Aronson served as our guide book as we invented this new model. More recently, I have appreciated his newest books: Attachment Focused Family Therapy, (W.W. Norton & Co.; 1 edition May, 2007) and Attachment-Focused Parenting: Effective Strategies to Care for Children (Norton Professional Books, March 2009). At the conference Dr. Hughes was emphasizing the role of non-verbal communication within therapy. In fact he wondered why we call it "non-verbal" communication- 80% of our communication is what he would term "body communication". Since trauma is held in the body, it is essential that the therapist deliberately use all body communication to facilitate and deepen the therapeutic process. This includes:
Matching vitality and affect of client
Congruent with verbal communication
Awareness of other’s nonverbal meaning
Clear, nonambiguous expressions
Flowing- gradual, regulated, changes
Gaze- direct, warm, open, interested, responsive
Voice- variable, responsive, relaxed, open, animated
thoughtful, alive, empathic.
Gestures- animated, expansive, dramatic, responsive
Posture- open, moving/leaning forward

Dr. Hughes showed some wonderful videos to illustrate his points. However, he was especially prod of the picture with which he began his slide show- a lovely picture of his daughter and her daughter in attuned communication.

Bessel van der Kolk then presented on his work on establishing a new diagnostic category for the upcoming DSM V- that of Developmental Trauma Disorder. Dr. van der Kolk started by relating the history of the trauma diagnosis- noting that there is a new phrase for the effect of war on soldiers in each war, and it reflects the weapon predominated in that war (such as "shell shock"). The PTSD diagnosis was created in the aftermath of the Vietnam war, in an attempt to get funding and medical care for the veterans, and has proved effective for adults who experience trauma in adulthood.
However, there has been recognition of the profound difference between adult onset PTSD and the clinical effects of interpersonal violence on children, as well as the need to develop effective treatments for these children. It has become evident that the current diagnostic classification system is inadequate for the tens of thousands of traumatized children receiving psychiatric care for trauma-related difficulties.
PTSD is a frequent consequence of single traumatic events. Research supports that PTSD, with minor modifications, also is an adequate diagnosis to capture the effects of single incident trauma in children who live in safe and predictable caregiving systems. Even as many children with complex trauma histories exhibit some symptoms of PTSD, research shows that the diagnosis of PTSD does not adequately capture the symptoms of children who are victims of interpersonal violence in the context of inadequate caregiving systems. In fact, multiple studies show that the majority meet criteria for multiple other DSM diagnoses.

Therefore, the goal of introducing the diagnosis of Developmental Trauma Disorder is to capture the reality of the clinical presentations of children and adolescents exposed to chronic interpersonal trauma and thereby guide clinicians to develop and utilize effective interventions and for researchers to study the neurobiology and transmission of chronic interpersonal violence. Whether or not they exhibit symptoms of PTSD, children who have developed in the context of ongoing danger, maltreatment, and inadequate caregiving systems are ill-served by the current diagnostic system, as it frequently leads to no diagnosis, multiple unrelated diagnoses, an emphasis on behavioral control without recognition of interpersonal trauma and lack of safety in the etiology of symptoms, and a lack of attention to ameliorating the developmental disruptions that underlie the symptoms. Most children exhibited posttraumatic sequelae not captured by PTSD: at least 50% had significant disturbances in affect regulation; attention & concentration; negative self-image; impulse control; aggression & risk taking. These findings are in line with the voluminous epidemiological, biological and psychological research on the impact of childhood interpersonal trauma of the past two decades that has studied its effects on tens of thousands of children. Because no other diagnostic options are currently available, these symptoms currently would need to be relegated to a variety of seemingly unrelated co-morbidities, such as bipolar disorder, ADHD, PTSD, conduct disorder, phobic anxiety, reactive attachment disorder and separation anxiety.

Suggesting that an alternative diagnosis was necessary to capture the spectrum of coherent symptoms of children exposed to interpersonal violence and disruptions in caregiving, van der Kolk (2005) proposed the creation of a Developmental Trauma Disorder diagnosis and described the broad domains of impairment and distress that characterize these children and adolescents.

PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER

A. Exposure. The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:
A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence; and
A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse

B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following:
B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization
B. 2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions)
B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states
B. 4. Impaired capacity to describe emotions or bodily states

C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following:
C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues
C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking
C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation)
C. 4. Habitual (intentional or automatic) or reactive self-harm
C. 5. Inability to initiate or sustain goal-directed behavior

D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:
D. 1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation
D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness
D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers
D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other adults
D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance
D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others

E. Posttraumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D.

F. Duration of disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months.

G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at two of the following areas of functioning:
· Scholastic: under-performance, non-attendance, disciplinary problems, drop-out, failure to complete degree/credential(s), conflict with school personnel, learning disabilities or intellectual impairment that cannot be accounted for by neurological or other factors.
· Familial: conflict, avoidance/passivity, running away, detachment and surrogate replacements, attempts to physically or emotionally hurt family members, non-fulfillment of responsibilities within the family.
· Peer Group: isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, age-inappropriate affiliations or style of interaction.
· Legal: arrests/recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, disregard or contempt for the law or for conventional moral standards.
· Health: physical illness or problems that cannot be fully accounted for physical injury or degeneration, involving the digestive, neurological (including conversion symptoms and analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe headaches (including migraine) or chronic pain or fatigue.
· Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training): disinterest in work/vocation, inability to get or keep jobs, persistent conflict with co-workers or supervisors, under-employment in relation to abilities, failure to achieve expectable advancements.

(Material adapted from:
Proposal To Include A Developmental Trauma Disorder Diagnosis For Children And Adolescents In Dsm-V, Bessel A. van der Kolk, MD, Robert S. Pynoos, MD, 2009)

At the conference Dr. van der Kolk discussed the complex political process that is involved in changing the DSM. The proposed new diagnosis would create sweeping changes, in that it postulates that early childhood trauma is actually at the root of other diagnosis, such as Borderline Personality Disorder. Many grants, insurance payments, and other funding streams are shaped by the DSM, and such a profound change might threaten many established programs. This change has at the time of the conference been rejected by the DSM committee. It will be fascinating to watch the process and the evolution of our understanding.

I highly recommend this trauma conference, which is held every year in Boston. It is the only conference of the many I attend which so effectively combines science, social issues, advocacy and clinical practice, and brings us the most current thinking in our field.

Steve Brown on Workshop at Trauma Conference

I attended a workshop entitled "Divided Mind, Divided Body: Interventions for Working with Dissociated Parts in Traumatized Individuals" by Kathy Steele, MN, CS and Pat Ogden, Ph.D. The workshop was about doing therapy with dissociative survivor clients integrating talk therapy and a body-oriented therapy called sensorimotor psychotherapy. While the workshop was about adult clients, there were a few themes relevant children. First, the workshop talked about an important factor worsening the impact of trauma, and often leading to dissociation, is the inability of the body to act -- being frozen during traumatic experiences. When unable to fight or flee, the body freezes -- but freeze mode is like having your foot full force on the gas and the brake at the same time. Therefore, in addition to emotional, cognitive manifestations of trauma, people have enduring somatic effects in their body from these childhood experiences -- patterns of how trauma shows itself and lives in the body. Part of the idea of sensorimotor psychotherapy (totally oversimplified) is that people are made aware of and asked to tune into their bodily sensations and take action with their body that was kind of action they would have wished to do at the time of the traumas.

Second, is the idea of every persons "window of tolerance." All of us have a "window of tolerance" of arousal or feelings we can tolerate or manage. Above this window of tolerance is is hyperarousal (often associated with body's danger response) and below the window is hypoarousal (numbness, deadness, etc). Traumatized children and adults have narrow windows of tolerance and quickly go out of the window, sometimes rollercoasting between hyper and hypoarousal. Our job is to help them and teach them to get back into the window. Much of the therapist job is to urge clients toward the "edge of the window" so they feel some affect, but not push them out of the window when they feel out-of-control. This is the true art of being a trauma therapist, walking this fine line. Body oriented therapies often talk about the "pendulation" of the the body's physiology. In normal development, infacts and children experience stress and are comforted by attachment figures -- the arousal up and comes down, up and down. Children learn to regulate their own stress over time. In unhealthy development, a child is stress and not soothed so the bodies smooth pendulation up and down never happens -- they get stuck in hyperarousal or hypoarousal mode -- and don't know how to return their body within window of tolerance. In our moment to moment attuned interactions with traumatized kids we are reteaching them and their bodies this pendulation.

20th Annual International Trauma Conference

20th Annual International Trauma Conference

June 4-6, 2009

Boston, Mass

I have just returned from the 20th Annual International Trauma Conference in Boston, Mass. This conference is put on by Bessel van der Kolk and the Trauma Center at Justice Resource Institute (http://www.traumacenter.org/). It is such an exciting and inspiring conference, because it blends science and clinical expertise is a way that is unique in my experience, as well as containing an advocacy, social and moral component.

I attended a day long pre-conference work shop entitled: Reorganizing the Disorganized Brain, with Ruth Lanius, MD, PhD, Eric Vermetten, MD, PhD., John Gruzelier, MD. , Rachel Yehuda, PhD., James Hopper, PhD., Laurence M. Hirshberg, PhD., Alexander McFarlane, MB BS, (Hons), MD, and Bessel A. van der Kolk, MD. This workshop examined how trauma affects brain regions that support intense emotions while decreasing (a) activation in the CNS regions involved in the integration of sensory input with motor output, (b) the inhibition of emotional expression, (c) the organization of self-experience, and (d) the translation of experience into communicable language.

The first speaker was Ruth Lanius. She uses fMRI to study the brains of trauma victims and discover the effects on various parts of the brain. In this presentation Dr. Lanius was focusing on the default state of the brain, which is how the brain looks when we are not doing anything in particular. She has discovered that the parts of the brain that are related to self reflection, creating a self narrative, and self awareness are almost non-functional in the default states of trauma survivors, while being very active in those of the control groups. Therefore, biologically trauma survivors are less able to be self aware and notice and name their emotions. They develop a post traumatic alexithymia. Alexithymia is a psychological construct that refers to difficulties identifying and labeling emotional states. Alexithymic individuals with PTSD may experience intense emotional-physiological states (e.g., fear, anger, and dysphoria) that are poorly integrated with, and modulated by, higher-order verbal cognitive processing. Therefore these individuals may report that they either do not know what they feel, or cannot feel anything at all.

This ability to self reflect, this part of the brain, is developed through attuned relationships with loving care givers. What cannot be communicated to another cannot be communicated to the self. In order to develop self reflection and self awareness, some one must reflect on the child and be aware of them- tell them their story. This is what our children either have not had or have had in fragments.

Eric Vermetten, MD, PhD is a military doctor from the Netherlands. He works primarily with veterans who return from deployments in Iraq and Afghanistan. He reported on the good results his team is finding from neurofeedback.

James Hopper, PhD is a delightful presenter. He spoke of the Buddhist concept of the mind, and how that integrates with what modern biological science is discovering. He described how trauma gets in the way of being able to experience (and enjoy) the present moment. This of course interferes with the experience of pleasure and the richness of life, but also with the development of a narrative and self awareness.

The rest of the day was given to explaining what neurofeedback is, and the amazing results that are happening in 20-30 half hour sessions. I would love to add neurofeedback to our treatment- is any one doing it? I know that Kevin Creeden does it at his place.

The actual conference began on Friday. The first speaker was Rachel Yehuda, PhD who spoke on Mothers, DNA and the Transmission of Trauma. She is my new heroine. She is a bio chemist, very smart and rigorous in her work. And she is funny, irreverent, caring and always questioning. She started by saying she has more questions than answers- but a later speaker said she was lying. Her specialty is the blood chemistry and genetics, and the effects of trauma.

Rachel taught us a lot about the complexity of blood chemistry. One point she made is that cortisol is the substance in the blood which is responsible for stopping the human danger response. People who suffer from trauma have low cortisol, so PTSD can be thought of as a failure to effectively end the danger response.

But the main point Dr. Yehunda was communicating was that the chemicals that are in our bodies can actually interact with our genes and change them, through a mechanism she explained. So in this way trauma can be transmitted through the generations.

The next speaker was Alexander McFarlane, MB, BS (Hons) MD, who spoke on Integrating Past and Present: PTSD as an Information Processing Disorder. Dr. McFarlane, who is from Australia, discussed the fact that although we often realize the presence of flashbacks and dissociation in traumatized individuals, in fact the damage to thought processing is much more profound. Through careful fMRI studies Dr.McFarlane showed a large difference in the amount of processing going on in the brains of trauma survivors. In short, it’s not just that these kids are having flashbacks and dissociating, even doing their math is much harder for them.

Harry Spence, JD was the Commissioner of the Child Welfare agency in Massachusetts, and is no longer. He said he could speak more eloquently about the system now that he was not in charge of it. One important point he made was that the system was strongly influenced by the high profile case- the child death that makes headlines in the paper. In such situations there is tremendous pressure to scapegoat a social worker. At times this has been done, and the social workers are very aware of this possibility. So, Dr. Spence made the comparison between the experience of the workers and the families they serve- both are demoralized, under-resourced, distrust authority, and are overwhelmed. Another excellent point was that trauma work demands work in teams- and child welfare workers do not have any access to a team. Furthermore, the system almost prohibits workers from examining their own reactions to the work- silence is demanded from the workers. There is no culture of self examination. Young people are making life altering decisions about children and families with little team support, little self awareness, and emotional distress.

Dr. Spence spoke of the moral endeavors that all our organizations are engaged in. He said that workers join organizations- child welfare, the military, education- with the goal of doing good. All too often, however, they feel betrayed by their leaders. The compromises that are made erode the purity of purpose. When the workers are blamed or treated badly they become less connected to their moral purpose. Their moral universe shrinks- not it is just their unit, or their best friend and themselves that are doing good. They adopt a "who cares, it’s not my job" attitude towards the larger organization.

Dr. Spence called on all leaders and administrators of organizations to keep and enhance the moral commitment of their workers, by highlighting the moral victories of the organization, the ways in which the organization does good and changes the world.

In the afternoon I attended a workshop by Jane Koomar, PhD, OTR/L, FAOTA; Elizabeth Warner, PsyD; and Anne Westcott, LICSW. They were describing a program in which they integrated sensory intervention techniques into the therapy room. They used large balls, weighted blankets, rhythmic activities, and other sensory techniques to help the child regulate their body. Both in individual and family therapy this resulted in the child being much more open and available for both connection and discussion. Their video tapes were moving. This is something we could all do in our treatment centers without too much difficulty.

I will write about the second day next time, plus Steve Brown has written up the workshop he went to on Dissociation, which I will also post here.

As usual, all comments welcome. Did any one else attend the conference? Add your impressions by clicking on the word "comment" below.

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?