Risking Connection throughout Connecticut

I had a delightful experience this past week. I attended a Focus Group called together through the Connecticut CONCEPT grant. This is a federal grant that Connecticut has received to make the system of care more trauma-informed. This focus group was to question providers about their thoughts on the ways in which the system of care was trauma-informed, and how it could be improved.

The Focus Group consisted of about 15 providers, among whom I only knew a couple.

What was so moving is that when the questioner asked questions around agency practices that were trauma informed, almost all the agencies started talking about Risking Connectionâ. The providers spoke of using Risking Connectionâ as their main staff training vehicle, and requiring it for all staff. They described how RC had changed the way they operate with regard to clients. They spoke so enthusiastically about how important their participation is to them.

Another thing that was important to me was that when the questioner asked about attention paid to vicarious trauma, the providers again spoke of Risking Connectionâ. They credited RC for having brought their attention to these phenomena. They described many interventions their agencies had instituted to pay attention to VT and to make space for workers to discuss how the work was affecting them.

People also mentioned that having their trainers participate in our ongoing training and consult groups was important.

I didn’t expect any of this when I went to the Focus Group. It was so refreshing to hear how strong the influence of Risking Connectionâ is within Connecticut.

When a Treatment Program Becomes a War Zone

I have written before about the development of a siege mentality in treatment programs (10/06/15). In that blog I described trauma-based thinking and its effects on both the clients and the staff. I also wrote a blog post on 9/11/10 entitled When Chaos Breaks Out in which I examined how to address a program that is in trouble. I would like to revisit these issues in a systematic way here.

In this post I would like to specifically address the situation in which a program has become demoralized and overwhelmed, and is just trying to make it through the night. Programs in this state rely excessively on the use of force, restraint or intervention teams. Structure and programming are lost. The staff are in a state of fear, and just move from one crisis to another. The staff are often responding to their fear of what could happen if this situation got worse, not what is happening at the moment. The clients are not feeling safe, and thus are acting more aggressive.  For both the staff and the kids there is a sense of imminent catastrophe.

How Do Good Programs Become War Zones?

There are many factors that can contribute to the development of a battle mentality in a program. The process is cyclic and can start with any combination of these factors.

·         Influx of a new, more difficult population

·         A new type of client for this agency without enough specific training

·         Significant staff turnover, in child care staff, therapists and/or leadership.

·         Not enough training for new staff

·         Understaffing and resultant over working of staff

·         Change in available resources.

·         Implementation of a new treatment approach.

·         Lack of integration of therapists into treatment program

·         Changes in regulations governing care, such as limits on the use of restraint and seclusion

·         Serious incidents of staff assaults

Signs that a Program has Moved Towards a War Zone Culture

·         Staff injuries increase.

·         Child injuries increase.

·         Lack of structure, few activities planned or carried out

·         Inconsistent application of limits

·         Increasing numbers of power struggles leading to restraints

·         Over-reliance on control.

·         Over use of calls for assistance, relying on a paging system the clients can hear

·         Living areas look bad, damage is not repaired, areas are not clean

·         Treatment plans are not communicated or followed through

·         Staff do not feel they are part of the treatment. They do not see the connection between their work and the child’s goals

·         Therapists are staying in their offices and not interacting with child care workers or hanging out in program spaces

·         High turn over

·         Supervision does not take place

·         Individual therapy does not reliably take place as therapist is handling emergencies

·         Routines are not followed

·         Use of sick leave increases

·         People speak of the clients in hopeless, blaming terms

·         Splits occur and deepen between parts of the team, and staff blame each other and administration for the problems that are occurring. There is an “us vs. them” mentality.

·         Staff reduce interactions with clients, stay in the office more, start texting their friends during work.

·         People are not sure how to intervene when problems begin (because they know they are trying not to use restraints or rely heavily on consequences) so they do nothing and feel helpless as they watch a client becomes more and more escalated.

How Can the Program Regain Its Treatment Focus?

When an agency becomes aware that one (or more than one) of its programs has deteriorated towards a war zone operation, there are roles for each group pf people that the program may want to start immediately. Follow through mechanisms should be established to track implementation. Data about restraints, staff and child injuries, hospitalizations, arrests and negative discharges can provide reliable information to evaluate the impact of interventions.

Senior Leadership

·         Begin the conversation- start talking about what is going on and the reasons for it.

·         Convey hope in the possibility of turn around

·         Establish contact with every staff member who is hurt.

·         Speak warmly and hopefully of the youth.

·         Recognize staff achievement.

·         Remind staff about their reason for doing this work, the mission, the importance to the youth.

·         Make resources available for change effort.

·         Articulate over all program expectations, such as what is meant by imminent danger and when restraint can and cannot be used, or when to call the police.

·         Congratulate team members on their stamina in sticking with a certain child, reminding them that it is the most important thing they can do.

Mid-level Leadership

·         Lead change effort

·         Establish clear expectations and methods to measure them, and regular review periods to evaluate progress, including who will be responsible. Be careful not to let sympathy for the difficult time staff is experiencing result in a relaxation of the expectations. If there are reasons the expectation was not met, how will be overcome those reasons during the next time period?  If the administration just accepts the reasons and communicates: “oh well I guess there is nothing we can do” they are replicating the paralysis felt by staff and thus increasing it.

·         The following table illustrates some areas in which expectations can be clear and monitoring mechanisms established. This is not an exhaustive list, it is just meant to illustrate the kind of clarity that is important.

Child Care Staff Expectations	Person Responsible for Implementation	Monitoring Mechanism
There will be two planned activities per weekday and three per weekend/vacation day.	Unit Supervisor	Schedules passed in, comments written on each activity, spot checks
Each child care staff member will have a chore towards the cleanliness of the unit and will complete it on each shift they work.	Unit Supervisor	Chore list passed in, spot checks
Each child care worker will be assigned three youth as their special responsibility. They will spend at least ½ hr. individual time with each of these youth per week.	Unit Supervisor	Progress notes
Therapist Expectations	Person Responsible for Implementation	Monitoring Mechanism
Therapists will attend staff meeting weekly	Clinical supervisor	Meeting attendance sign in
Therapists will make sure that the child care staff understand the children’s goals and how that is translated into what the child care worker does	Clinical supervisor	Therapist and staff report
When a child is in crisis therapist will connect with child and staff within 4 hours or will designate someone to do so	Clinical supervisor	Observation, progress notes

Further interventions for middle management:

·         Added resources in a targeted way. For example, have a cleaning service do a thorough cleaning of a unit as soon as the staff and kids have created a cleaning schedule to maintain the cleanliness.

·         Articulate and model the expected method of interacting with the kids- be involved, caring, flexible, respectful.

·         Clinical management can be clear with therapists, from the hiring onwards, that they are expected to be part of the team and not doing outpatient therapy in their office. Teach and give examples of how to translate treatment goals into unit activities for staff.

·         Clinical management guide and model for therapists how to lead team in clinical thinking. The therapists and clinical management establish clinical thinking by responding to every attempt to discuss a problem behavior by asking: how do we understand this behavior? When we understand the adaptive nature of the behavior we can respond by helping the child to learn to meet these same needs in a more positive way. The clinicians also make sure to share the formulation with the team, to establish a treatment theme, to connect problem behaviors to past history, and to suggest restorative responses based on the team’s understanding of the skills a child needs to learn.

The Child Care Workers and the Therapists

It is counter-intuitive but the essential that when a unit is in crisis, the staff must move towards the youth, not away from them. The natural human response to harmful behavior is to move away. This can manifest by emotional distance, by increased strictness, by lack of activities, by staff spending more time in the office, or simply by frowns and disapproving looks. By their behavior the youth are telling the adults that they do not feel safe or connected. We have to make plans to increase their connection to adults. How do we do this?

·         Schedule time for staff to spend with one-to-three clients, doing a pleasurable activity.

·         Organize team building activities, using consultation from recreational therapists if available.

·         Have as many fun activities as possible.

·         Use music, dance, singing, jump rope rhymes, hand games to knit the community together.

·         Develop a cottage song, a mascot, a logo, a saying.

·         Celebrate anything good that happens, even if small.

·         Have a box in which anyone can put a note about a good thing they saw a kid or a staff do, read it out at community meetings. Give awards, but not competitive ones, ones that anyone who meets some criteria can receive.

·         Have community meetings. Have all participate. Talk about what is happening, what kind of place we want to live, what we can do about it.

·         Decrease room time. Spend as much time together, doing activities.

·         Do the kids’ hair. Have a spa night. Feed them. Do anything to care for them and make them feel better.

·         Clean and decorate the unit. Involve the kids.

·         Fix any damage. Involve the kids.

·         In Treatment Team talk about the kids that are the hardest to connect with. Review their history- why did they have to learn to put up such walls? Encourage compassion. Discuss their strengths and interests. Can staff find a way to participate in these interests with them?

·         Keep a notebook about the most difficult kids called “Moments of Hope” and ask staff to write down any good things that happen with that child.

·         Congratulate each other on the team’s stamina in sticking with this child.

·         Make specific plans to support that stamina, like trading off who reaches out to the most hostile kids.

·         Remind each other about other kids you have known who seemed to reject all efforts and later came around.

·         In treatment team develop restorative ideas for each child that are significant, require thought, and are related to their treatment.

·         Teach specific feelings management skills.

·          Use feelings management skills yourself and label out loud that you are doing so.

·         Validate the feelings behind the behavior.

·         Express an understanding that this is the best the kid knows at the time- and the hope and confidence they will learn better.

·         And tell them, and show them, over and over again, all the good things you see in them and how delighted you are by everything positive (and even neutral) that happens.

Even this partial list of interventions seems like a daunting task. It is. What is more daunting is not doing it and remaining in paralysis. A specific plan with clear responsibilities and methods of measurement will begin to create change. As people notice change, there will be an increase in hope. Hope brings the energy to make more changes. And fairly soon people will be feeling pride in their workplace again, and the kids will be gradually getting better…slowly…with many backslides…but they will be demonstrating that they feel more connected and relaxed. Then real effect treatment will be occurring.

Building Hope

Last week I attended and presented at the MASOC/ Massachusetts Association for the Treatment of Sexual Abusers 14th Annual Conference on The Assessment, Treatment and Safe Management of Sexually Abusing Children, Adolescents and Adults. I particularly enjoyed being part of a gathering of NEARI Press authors, and celebrating my soon-to-be-released book. It is in the NEARI press catalog and is expected to come out in June. Steve Brown also presented, his workshop was entitled: “I Can’t Get that Picture Out of My Head” – Vicarious Trauma in Work with Sexual Abusers – What It Is and What We (and Our Agencies) Can Do About It? My presentation was entitled: How to Use the New Brain Science to Provide More Effective Treatment- and to Have More Fun at Work. I guess you are doing okay as a presenter when the only improvement suggestions you get are to make the presentation longer. I was very moved when later in the day a woman I did not know came up to me and said: “that was the most helpful presentation I have ever been to”. If you are reading this in CT, I will be presenting on the same subject at the NASW Annual conference this Friday.

I attended a workshop entitled Parenting with Love and Limits (PLL): A Promising Practice for Sexually Aggressive Youth by Paul Castaldi, MSW. The presenter referred to a meta-analysis of the amount of improvement in treatment (I did not get the citation). He stated that the one variable that consistently correlates with improvement is the creation of hope.

So this made me start thinking: how do we actually create or enhance hope? Many of our clients have good reason to feel hopeless. We serve children who have no adult connections, children who have been hurt and betrayed repeatedly. We serve adults whose own early trauma histories have never been attended to and who feel despair about the ways in which their symptoms have interfered with their parenting. The system we work within is certainly not always responsive or able to give people what they need. Where then do we find the hope?

I think we often assume that we have to give clients concrete facts in order to create hope. We talk about pointing out their strengths, and remarking on instances of improvement. We try to create opportunities for clients to learn and grow, and to experience success. All this is of course extremely important.

But I think we underestimate the hope that is created by forming an attuned, mutually respectful relationship. In such a relationship the client feels seen and heard. They feel a sense of belonging, of being part of something. Early templates about relationships always being associated with hurt and loss are challenged. The client gradually builds a secure base, a place he can return with triumphs or with pain. The client also builds an inner connection: he takes the treater into his mind, creating a caring voice that can soothe him in times of stress.

The very participation in a respectful relationship creates hope that there may be other relationships like this in the future. Maybe there are some people that can be trusted. Maybe love is a possibility after all. The opportunities in life expand.

As the relationship experiences difficulties (the child hits the staff member for example) and these are worked through and the relationship persists, new hopeful possibilities emerge. What if it is not true that whenever you do something wrong the other disappears? What if it is possible to get through hard times and reconnect?

One profound way that enduring relationships increase hope is through their effect on shame. Shame is the sense that deep within me I am no good, that I have a rotten center, and that anyone who gets to know me will turn from me in horror. But what if in fact this doesn’t happen? The antidote to shame is to be known, to share the secret self, and to have the other person not be repulsed. This is so hard to accomplish, because the person who experiences shame is so reluctant to share his true self, which he feels is so horrible. But if we are able to create a relationship that is strong and safe enough, and the client does share with us the parts they hide, we have a precious opportunity. By validating and not turning away, we begin to heal the shame. Consider how much hope flows into a person’s life as shame decreases, and the possibility of being a normal human emerges.

So, here are more reasons why we must emphasize the relationship as the vehicle of healing. This means providing time and space to build relationships, and creating policies and procedures that promote and honor them. It also means taking good care of our staff so that they have the stamina to stay open-hearted in these difficult relationships, and attending to the vicarious traumatization that is created by doing so.

And it also means paying attention to the personal transformation that can occur for us as treaters through increasing hope. Our own personal hope grows when we watch hope blossom in a child or a parent that has been wounded by life through no fault of their own, and who now is open to the possibility of love in their world.

Doing Dialectical Behavior Therapy

As I have mentioned, we use Dialectical Behavioral Therapy in several of our programs. I have attended an intensive training, read Marcia Linehan’s books, and attended many other trainings. I highly recommend th new book by Kelly Koerner, Doing Dialectical Behavior Therapy.  (Doing Dialectical Behavior Therapy: A Practical Guide (Guides to Individualized Evidence-Based Treatment)  Kelly Koerner PhD Guilford Press; 1 edition, December 2, 2011). Dr. Koerner uses many case examples to describe what  the therapist actually does in this complex therapy. In true dialectical spirit, Dr. Koerner demonstrates both the complexity and difficulty of the therapy and the use of the theory and structure to provide guidance in what to do. Dr. Koerner starts with an overview of the bio-social origins of Borderline Personality disorder. She identifies the core problem, emotional dysregulation. She then describes the key DBT strategies.

Dr. Koerner uses straightforward language, humor and case examples to create a road map to follow in difficult, complex cases through a formulation and a treatment plan. She shows how to use the specific DBT hierarchies to plan the case interventions. She demonstrates the use of the chain analysis to provide direction for the therapist and client. At all times Dr. Koerner respects the difficulty of the change process for both the client and the therapist. She demonstrates deep respect for the client and operates from the assumption that the client is doing the best she can and still must do better. In the lengthy transcriptions of sessions, she demonstrates how the therapist avoids being distracted from the change task while respecting the client’s pain and lack of skills.

 One interesting section is the one in which Ms. Koerner examines the use of relationship contingencies in shaping behavior. This is an area that we do not use deliberately enough. Another refreshing aspect is that Dr. Koerner is always aware that it may be the therapist, not the client, who is creating the problem.

 Validation strategies are the key to successful therapy. The client cannot respond to change strategies without extensive validation. And Dr. Koerner states and demonstrates how accurate, precise validation is the most powerful, and describes what, when and how to validate.

 Dr. Koerner teaches us how to hold a dialectical stance toward the therapy itself, and use dialectics to help us decide what to do next. She ends with a description of the role of the Consultation Team in supporting the therapist.

I think that anyone who is doing DBT will be greatly enriched by reading this book.

Saying Goodbye

At Klingberg we are saying goodbye to many people and many things at many levels. We are closing several of our residential programs, discharging our kids, and laying off some of our staff. It is a sad time.

I am completely committed to the principle of supporting kids in family homes whenever possible. We are developing several new programs to aid that effort. I am excited about these new possibilities.

However, it is the end of an era for us. We did very good work in our residential programs. We used a trauma-informed, Risking Connection based approach. We love our kids. We have been looking through old pictures and marveling at all the wonderful things we did together: Boston trips, picnics, camping, fancy dinners, and all the everyday moments. As we look through the pictures we remember how much we learned from each child.

Klingberg has a reputation for excellent treatment of the most severely wounded children in our state. The children who came to us were lost in a morass of self-hatred and hopelessness. Because of their pain they often had to resort to extreme behaviors. We were okay with that. When David came out with blood streaming down his face from self inflicted wounds, the nurse calmly cleaned and bandaged his wounds, and his team mate calmly asked him what was wrong. When Autumn ran away, we welcomed her back and began working on safe places she could go when she was upset. When Dawn was aggressive and mean to staff, we made safety plans, and we didn’t turn against her and carefully reviewed her diary card about what led up to the event. When Sharon recently felt that her discharge plan was shaky and pulled the fire alarm, we understood that she was trying to get our attention in the best way she knew how. Because of the assets we have, we were able to stick with kids more or less whatever they did. And this led to an incredibly high number of ultimate positive discharges (around 90%) when they were finally able to feel safe and worthwhile. It is sad to see the treatment system we worked so hard to create be dismantled.

We are saying goodbye to some talented staff, and wish them well at our sister agencies that have been lucky enough to hire them. Some staff have moved to other Klingberg programs.

We are saying good bye to our present kids, some to placements we are confident about, some to ones we wonder about. For all we have sent them off with hope and support.

So many kids come back to Klingberg to visit and talk about what their stay meant to them. Jennifer brought her daughter and was overheard to say to her: “this is where Mommy became a person.” Now when the kids come back, who will they find?

It is sad to see the empty rooms.

We are trying to do good, careful goodbyes with everyone. We are acknowledging each others’ sadness. We are working hard on moving into the future.

One of our former Directors always used to say: “Change is hard. Change is good.”

I hope so.

Improved Advocating through Risking Connection Training

We did a consultation this week with an agency that received both the basic and train-the-trainer Risking Connection training. They have proceeded to roll out their own training and have experienced major changes in their culture. They particularly emphasized how important their new awareness of vicarious traumatization had become. Staff have been saying that they feel more committed to the organization than ever now that they regularly have a place to share the effects of the work on themselves as people.

They also mentioned something I hadn’t thought of before. They felt that they were much better advocated for their clients now that they understood the trauma framework, the concept of symptoms as adaptations, and what helps trauma survivors heal.

This is really true. First, by understanding brain science and the effects of trauma, treaters can become more articulate in describing why punishment is not the best response to problem behaviors. They can describe how making amends can teach the youth hope in relationships, and how learning skills can help him be less likely to repeat the behavior. By understanding the behavior and the need the youth was trying to meet, they can recommend a specific intervention which will help the youth learn to meets his needs in a more positive way. They are more confident because their ideas are grounded in a theoretical framework.

Often when people think of “doing trauma work” they mean that the youth is retelling the details of her traumatic experiences. Through understanding both the trauma framework and modern brain science treaters can explain the benefits of other areas of treatment. It is NOT TRUE that recreational activities, fun events, creative pursuits such as music and art, cooking, and relaxing with others are just time fillers in between the “real therapy” that happens in the clinician’s office. Using the trauma framework treaters can specify exactly what step in healing each activity is designed to accomplish. Changing the child’s template about relationships, re-building her brain, increasing her sense of self-worth and teaching feeling skills are all happening during these every day parts of life. When a treatment team is well trained they can describe and document each step of the day by describing its connection to healing.

Another area of advocacy is speaking up for the services a child will need after being discharged from your program. The trauma frame work gives treaters specific justification for gradual transitions, as few changes as possible, continuity of relationships post discharge (with boundaries), support services for biological and foster parents, special education, and respite/mentoring.

What other ways has learning about trauma improved your advocating for your clients? Please click “comment” below and let me know.

Healing the Generations 2012

I had the privilege of attending the Healing the Generations conference at Foxwoods this past Thursday and Friday. As usual, Alice Forrester and her Clifford Beers team put together a highly informative and restorative conference, with great organization and good food. The theme of this year’s conference was Trauma and the Brain.

What struck me the most was the fact that many different researchers and practioners, all coming from difference disciplines, focus and research methods all reach the same basic conclusions. These seem to be…

Relationships matter. There is so much evidence now of neglect and abuse impacting brain development, and of the possibility for healing within relationships.

Childhood stress impacts brain development in many areas, and thus has great implications for both education and physical health.

Healing cannot be maximized with just verbal interventions. Treatment that includes body based activities has the most potential. These include EMDR, yoga and meditation, but also include walking, rocking, tossing a ball back and forth, etc.

Music has tremendous power to organize, heal and sooth the brain.

I also learned about several promising treatment programs that were showing results with both children and parents. One interesting approach presented by Phil Fisher, PhD. From Harvard videotaped parents’ interactions with their children and then edited out clips of the parents doing good things, like attending and responding to their child. They played these clips back to the parents and said, do more of this. I liked the building-on-strengths approach.

Another intervention called RULER was described by Marc Brackett, PhD. It was a method for teaching emotional intelligence within schools. Dr. Brackett stressed the importance of teaching the method to “everyone with a face” including administration, cafeteria staff, teachers, etc. It sounded very promising.

I presented on Using the New Brain Science to Do More Effective Treatment…and Have more Fun at Work. I got a lot of compliments on my presentation.

One of the most moving workshops I attended was a dramatic skit about vicarious traumatization by the Post Traumatic Stress Center in New Haven. Through a play they demonstrated the feelings of vicarious trauma that are part of our work. It generated a lively discussion among the audience.

Over all, a very worthwhile experience.

My Book: Trauma Informed Treatment: The Restorative Approach

My book, Trauma Informed Treatment: The Restorative Approach, is coming out this spring, published by NEARI press. Here is what Kay Saakvitne, PhD said about it: Dr. Saakvitne is the author of Risking Connection, Trauma and the Therapist, Transforming the Pain, and many other books, chapters and articles:

"Pat Wilcox conveys the accumulated wisdom of her years working with children too often overlooked by others in this remarkable and inspiring book. The Restorative Approach has the potential to radically change child mental health treatment (and parenting) for children with challenging behaviors and histories of trauma. Integrating current research on trauma and treatment with practicality, compassion, and ethics, Wilcox presents a compelling case for the Restorative Approach as a best practice in trauma-informed child treatment. The book is exceptional in its many detailed clinical examples of effective interventions making it immediately accessible and useful to all staff. Wilcox’s full exploration of all objections to the Restorative Approach convinces the reader of her complete understanding of the real conditions under which most child mental health settings function. Ultimately this book is inspirational; it offers hope for children, their families, and mental health professionals working with them. It should be required reading for all staff working with children in mental health systems. "

Taking Care of Mercedes and her Mother- a Cautionary Tale

Mercedes is ten years old. Her developing brain was affected in utero by medications that her mother was taking. She experienced neglect and domestic violence while growing up. She has been in several placements and received various episodes of treatment. `Her mother, Maria, who also has three other children, has remained committed to her and has been involved in her care. Mercedes was placed in residential treatment, and she and her mother were working on reconnecting. Meanwhile Maria is trying to manage her job as a cleaning woman, caring for her three children at home, and taking some courses to become as nurse’s aide. This is a dream she has had for a long time and she is excited to be making progress.

In the program, Mercedes was one of the more difficult residents. She quickly became extremely agitated when her needs were not met immediately, and was often severely violent with both staff and other residents. The program was helping her by having a single staff assigned to her. Whenever that staff saw early signs of dysregulation they would help Mercedes use sensory interventions, physical activity and distraction to avoid a major episode. Mercedes was also on several medications. In therapy Mercedes and her therapist would go for walks, complete puzzles, use art, and clap with music to give Mercedes experiences of regulation in the presence of a positive adult and to build and regulate her lower brain. Mercedes does want to learn how to stay calm, and she feels bad afterwards when she hurts someone. Her mother Maria was attending regular family therapy and taking Mercedes on short visits. The focus of these was to support Maria and Mercedes in having some enjoyment and positive experiences together to rebuild their bond. This combination of intensive treatment was beginning to work, and Mercedes was now occasionally noticing her own beginning distress and herself asking to use her crisis kit. She and her mother were just starting to practice some skills she could use at home.

However, the current thinking in child welfare is that youth under 12 should not be in residential treatment. So, Mercedes was discharged home, and many supports were arranged for the family. Since then, she has been unremittingly violent, beating up her siblings and sending a child in one of her programs to the hospital. Maria has arranged for the siblings to stay at her mother’s for the weekends so that Mercedes won’t hurt them. Maria herself is exhausted and hopeless. She has had to drop one of her courses and is finding it difficult to complete her work in the one she continued.

What went wrong?

I have to warn you here that my understanding of what is needed to help has become somewhat radical, as you will see through my comments.

First, as Mercedes left the program, her mother stopped her medications. She did so because she believed that her pediatrician had told her that these medications might lead to diabetes. Maria’s own mother has diabetes, and Maria has seen firsthand the problems it causes. She doesn’t want this for her daughter. Maria explained to the unit psychiatrist that she planned to do this, but he did not alert anyone.

Maria and Mercedes were given generous help as Mercedes was discharged home. They were given an in-home team of a therapist with behavioral training, a parent aide and a psychiatrist; Mercedes was enrolled in a therapeutic after school program with a therapist, family therapy and a psychiatrist; and Mercedes attended a special ed out of district school with special ed teachers, a therapist and the possibility of a psychiatrist. Yet all this help wasn’t enough.

So, a ten-year-old child who cannot utilize verbal therapy now has three therapists. These therapists have different theoretical understandings and have not spoken with each other. Furthermore, Maria is expected to cooperate with the in home team and have family meetings with them. They are suggesting that she create a sticker chart through which Mercedes could earn little toys by not being violent. Maria created one with the therapist, but she usually forgets to fill it out. If she does fill it out and does not give Mercedes one of her points, Mercedes becomes furious and another rageful episode is triggered. So when she remembers it at all Maria usually gives Mercedes all her points. Maria feels bad about this- it feels like just one more way she has failed Mercedes and been a bad mother, as she thinks she has been all of Mercedes’s life.

Maria is also expected to attend family therapy at the after school program. Well, at least this sometimes includes a meal. But in the therapy she usually hears a long description of what Mercedes has done wrong that week. Maria feels awful that her daughter sent a child to the hospital. But she has no idea what she is supposed to do about it. She can feel it coming that this program is going to kick Mercedes out, and then what is she supposed to do in the afternoons? She can’t quit her job but knows Mercedes cannot be left alone with her siblings.

And school… that’s just another place that calls her with stories of Mercedes horrible behavior. All these people tend to blend in her mind anyway and she can’t usually remember their faces.

So what would be better?

Prior to Mercedes discharge there should be a meeting of all the service providers. In this meeting, it would be flagged that mother is against medication. The providers would decide which psychiatrist will take over the case. That psychiatrist will meet with Maria and respectfully explore her concerns about diabetes. The truth about any connection of the medications with diabetes will be explored, and a plan will be created that does not involve Mercedes going off all meds just as she makes a major transition.

The therapists will decide just what each of their roles is, with both Mercedes and mom. What treatment will be most helpful for mom? How can we avoid overstressing her with demands that she attend various meetings?

Equally important, the team will agree on their approach to Mercedes. Preferably they will all agree on a single message that all team members can use in their work, such as, we are working on ways to calm yourself down when you are upset so that you stay safe and don’t huts anyone else.

I do not think sticker charts are any help at all in this situation. If Mercedes knew how to act better she would. Instead, the in home team can be very valuable in helping Mercedes practice her calming strategies in the real life situation. Ideally, one of the therapists will make a chart with Mercedes about things that help her stay calm. This chart will be shared with all team members and they will all use it. Mercedes will have tools, such as a sensory kit, in all parts of her life and the same help from all her providers to use it when she starts feeling agitated.

Mercedes has a very troubled relationship with her three siblings. She is very angry that they got to stay with their mother while she has been out of the home. Plus those siblings have their own problems and often say and do things they know will agitate her. Here too is an important role for the in home team. They can do activities with Mercedes and her siblings, perhaps one at a time, and be there to avert arguments and violence. The activities should be short at first and very pleasurable to help build a bond between these children.

Let’s ask Maria what would really help her. Maybe some community activities could be found for the other 3 kids so that Mercedes and Maria have time together. Maybe Maria needs some time on her own to do her school work- can the in home aide take care of all the kids for an hour or two, using that time to work on their connection?

One therapist could start an email list or list serve so the each provider writes about what happened in their segment every day and all the providers read it. This will help create a cohesive team. It would be especially important to share all positive events and successes.

The keys to the intervention being successful and to Mercedes being able to stay home are:

• Coordination, communication clear roles and a mutually agreed approach among the team

• Medication management that is respectful towards mother and addresses her concerns

• Listening to the family and doing what actually helps them instead of what further overwhelms and demoralizes them

• Physically based activities for Mercedes in which the experiences and practices bodily regulation

• An emphasis on activities that increase fun, connection and joy between the family members.

It is not just the quantity of help that we give people that ensures success. It is the well planned, respectful and coordinated help.

And wouldn’t it be great to discover that Mercedes had been able to stay home and that she was calmer a year later?