Trauma Treatment for Children

Risking Connection for Foster Parents Curriculum Available

2012-02-12T05:00:00.000-08:00

Exciting news! The Traumatic Stress Institute announces the completion of the Risking Connection© Training Curriculum for Foster Parents. This curriculum would also be appropriate for teaching biological or kinship parents. The development of this curriculum is consistent with Sidran and the Traumatic Stress Institute’s philosophy of adapting the Risking Connection© ideas for various populations. The Foster Care curriculum joins Risking Connection® in Faith Communities: A Training Curriculum for Faith Leaders Supporting Trauma and adaptations for primary care physicians and for domestic violence treaters in expanding the scope of the Risking Connection© philosophy.

The release of Risking Connection© for Foster Parents comes at a particularly opportune time. In Connecticut as well as across the nation states are relying less on residential treatment to treat their most stressed children and youth. Instead, they hope to develop foster families for these youth. The key to the children being able to heal is to limit disruptions, to offer the foster families enough support that they can keep the child. One important element in that support is training. Understanding trauma, how it affects children, and how they can heal helps the family define the behavior differently. They see that it is not about them, but instead an understandable adaptation to the child’s circumstances. For example, Chelise always had trouble at bed time. She would not turn out her light, kept getting up and often had her music on long after her foster mother Barbara told her to turn it off. Barbara defined this defiance: I am the adult, Chelise should respect me and do as I say. The foster placement disrupted. But when Chelise was placed with Lynn, Lynn immediately understood that Chelise was scared at night. Lynn provided a night light, encouraged her to listen to soft music and stayed by her door until she fell asleep. This was the beginning of a long relationship.

The curriculum also contains specific suggestions about how to respond to behavior that hurts others; and tools for assessing foster parent beliefs and practices.

If foster families are to care for children who have experienced trauma both they and their support team need to pay attention to the vicarious traumatization(VT) they will inevitably experience. Foster care has unique features that contribute to VT. The child is in the family home and the family has no place to escape. Biological children and extended family may be affected by the child’s behavior and may not understand the parents’ actions. The parent is often handling crisis’ alone and without much back up. Therefore it is crucial that the family and their helpers learn about what VT is, how to recognize it, strategies for managing it, and ways to achieve vicarious transformation. The Risking Connection curriculum covers these topics and gives the foster parents tools and techniques to manage this part of their jobs. One foster mother in a Risking Connection class said: “I have been a foster mother for sixteen years and this is first time anyone has asked me how the job affects me!”

Risking Connections for Foster Parents contains six two and a half hour modules. These modules can be taught once a week for six weeks or combined in other ways, such as on two Saturdays. The modules cover these topics:

1. The Trauma Framework and Introduction to Vicarious Traumatization
2. Symptoms are Adaptations
3. Healing Through Relationships
4. Managing a Crisis
5. Responding When the Child Hurts Others
6. Taking Care of Ourselves While Doing This Difficult Work

The modules contain many exercises and small group discussions. Every effort has been made to use the word “child” instead of “client”, to use examples from home situations and in other ways make the material accessible to parents.

Our plan is to train specific Foster Care Trainers. If a current Associate Trainer wants to become a Foster Care Trainer they will be expected to attend a short training that introduces them to the new materials. Foster Care Trainers will be required to have taken the RC Basic course (original or foster care version) and to become trained as a trainer. We hope to have some foster parents join us as trainers, so we can establish training teams of a clinician and a foster parent.

Please join us in celebrating this exciting new expansion to our mission to change the treatment of children who have experienced trauma.

What is Happening in Your World?

2012-02-05T05:49:00.001-08:00

I have neglected my blog for several reasons. Among them are:

1. I am in the final editing stages of my book, and that has taken every writing minute.

2. Big changes have been happening at my beloved agency involving a lot of time and emotions

3. And let’s not even get into the injured knee and the abcessed tooth..

Now it’s time to check in again and I’d like to hear from you. What has been going on in your wold? How has your implementation of trauma informed care been going? What are the stress points? Any dilemmas that you would like help with? Have you been affected by budget cuts and if so, how does it affect your provision of trauma informed care? Any recent success stories?

I would reall like to reconnect with you. I can even throw in a copy of my book A Kid’s View of Trauma, a book to use for psycho ed for kids about trauma for anyone who responds. So please, hit comment below and respond to these questions.

I look forward to hearing from you and to restarting and revitalizing this blog.

Serving Children in the Community

2012-01-11T08:26:00.001-08:00

For years there has been a national trend towards moving children out of residential centers, and building up community treatment options so children can live in families. In Connecticut we have been moving in this direction for a long time. Recently our new Commissioner has accelerated the progress. She is determined to change residential completely, and eliminate most of it. To this end, my agency Klingberg Family Centers is in the process of closing our residential treatment center and developing new community options. If you would like to know more about our process, you can find it at:
http://traumaticstressinstitute.org/2012/01/klingberg-family-centers-shifts-services/

I wonder if it is possible for all children to live in families, especially those with long trauma histories. Many of our children have been in 16 foster homes or more. They don’t trust families. They have learned to guard their hearts. Professional care gives them the chance to get close to people at their own speed, without the pressure of someone expecting to be their parent.

I remember the six year old that we told that an adoptive family had been found for him. He4 asked if DCF would still visit. Thinking this was the answer he was looking for, we said no. He asked: “then who will I tell when they start beating me?”

I think of the behaviors we can barely manage with 4-5 trained staff, including severe aggression.

I think of the slow but clear progress the kids make over time.

Will this be able to happen in foster care? Will the family be able to hold the child long enough for trust to develop?

If we can really give the families enough resources so that they can keep the children, then that will certainly be the best gift we could ever give these kids. That would involve trauma training for the families, intensive support, clinical treatment, appropriate schools, and recreational opportunities at their level.

This is happening all over the country- how is it working in your state? Click on “comment” below and let’s all learn from each other.

Happy New Year! Welcome to 2012.

2012-01-02T05:55:00.001-08:00

As I look back over 2011 I remember many wonderful experiences. I was so surprised and honored to be chosen CT NASW Social Worker of the year. I was also delighted to participate in a round table discussion at the UConn School of Social Work that was later featured in the UConn Alumni magazine. That caused even people I swim with to congratulate me! I presented at some wonderful conferences. The Vermont foster care annual conference comes to mind- amazing to find my name on a program with Bruce Perry, and great to hear his presentation. I also remember the ATTATCh conference, the Health Care for the Homeless training, and my wonderful visit to CALO (during which I had no voice). Participation in the Carter Center Mental Health Symposium was a great honor and extremely valuable. I also taught some wonderful Risking Connection basic trainings and Train the Trainer events,

Largely due to the efforts of my colleague Steve Brown, 2011 was the year we entered electronic teaching and started offering webinars to our geographically distant trainers. We are beginning master the technology and hope to expand the offerings this year. And speaking of our Associate Trainers, we had some excellent Consult Groups this year. Notable among them were Kathy MacAfee on presentation techniques, a seminar on the role of grief in our work, and our Day of Learning and Sharing. In that event Kay Saakvitne presented about the trauma survivor as parent. I always learn a lot from Kay. I am particularly proud of the Associate Traianer consultations. Through them we increase the knowledge and sophistication of the treatment offered to trauma survivors, as well as strengthen the community of providers doing thIs difficult work. Every event includes some focus on vicarious traumatization.

Our colleague and friend Laurie Pearlman has recently been developing the concept of vicarious transformation, and I was lucky to be able to hear her speak about this at the ATTACh conference. This refers to the positive ways our work changes us, and to what elements of our work maximize positive change. Expect to hear more about this in 2012.

One sustaining element of our work is our participation in a Transformation Summit which is our collaboration with the personnel of Sanctuary and CARE. We help each other with all the challenges of promoting system change.

A very exciting development in 2011 was that my colleague Steve Brown's research paper on Risking Connection was published in a peer reviewed journal. Congratulations to Steve, that involved a lot of hard work.

There were also difficult parts of 2011. At Klingberg and around the country non-profit agencies are feeling the pain of state budget crisises. When money is tight, training and supervision are often areas that get cut. Yet these times of treating increasingly challenging clients with less resources are the very times when it is most important to think about our work and to use our resources most artfully. Treatment efficacy is strongest when the treater is operating from a theory.

What will 2012 bring to the Traumatic Stress Institute? We are almost finished with an adaptation of Risking Connection for teaching foster and biological parents. This curriculum is timely as states are moving away from congregate care and utilizing version of foster care for troubled youth. Training in trauma can preserve placements as the foster parents learn to unerstand the behavior and not take it personally. We are also developing trauma informed in home services to support families in keeping kids.

We are working on oour version of Risking Connection for professionals in the Developmental Disabilities field. We would welcome the participation of any one with expertise in that area.

I hope to meet many of you either when you bring me to your agency for training or when you talk to me at conferences.

Perhaps this is the time to announce that I have written a book about the Restorative Approach, or all I know about working with kids in congregate care. It is in the editing stage now, and should come put this spring.

Let's hope that 2012 brings us further down our path of transforming treatment settings towards trauma informed care. Let's hope we have the good health and strong spirits to continue to change the world.

I welcome your thoughts on what you achieved during 2011 and your hopes for 2012. Just click on comment below.

Insights from Dr. Kenneth Hardy

2011-12-11T05:04:00.001-08:00

I had the privilege of listening to Ken Hardy as he presented at the NASW CT specialty conference on social justice. He focuses on oppression, which of course has a lot of overlap with trauma.

Dr. Hardy is a Professor of Family Therapy at Drexel University and the Director of the Eikenberg Institute for Relationships in NYC. He has written several books including Teens Who Hurt: Clinical Interventions to break the Cycle of Adolescent Violence (Guilford Press, 2005) and, with Monica McGoldrick, ReVisioning Family Therapy: Race, Culture and Gender in Clinical Practice (Guilford Press, 2008).

Dr. Hardy described people as divided into three groups: jailers, helper, and healer. Jailers value correction over connection. They protect the prevailing order even at the cost of crushing the human spirit. Their primary goal is to keep order, and they use the tactics of demanding obedience or ejection. Their words are: Not here! Out of here! Dr. Hardy pointed out that there is a lot of recruitment and rewards pushing people to become jailers in our current society.

The helper is well intentioned, and tries to intervene in the face of injustice and harm. They try to restore order, but do not focus on preventing injustice from happening. Many of us in the social services world find ourselves in this position.

The healer is a visionary who tries to challenge the established order and to rejuvenate the human spirit. He values connection over discipline. He establishes mutuality. His work is not just a job, it is a passion. He works on behalf of the human condition, to make a better planet. He is in the business of manufacturing hope.

Dr. Hardy suggested that the way to become a healer is by embracing one’s own suffering, turning towards one’s own pain instead of denying it. We have all been oppressed in some way. Look at your own invisible wounds, find and speak your own authentic voice.

In our programs, is there pressure to become jailers? Are we encouraged to become healers?

Shame was a central topic for Dr. Hardy. He spoke that we are even ashamed to admit we feel shame. Shame is a powerful force that cannot be named or spoken about, because it is associated with weakness. Shame arises from the devaluation of human dignity. The more a person’s basic dignity has been eroded and assaulted, the more that person will demand respect, and will be aggressive rather than suffer further degradation.

Further, Dr. Hardy described “learned voicelessness”. This is what happens to a person whose dignity has been degraded, and who has been unable to speak. Of course this applies to children who cannot speak of their abuse. The more a person has been silenced, the stronger their rage. The role of the healer is to help the person find and speak their voice, and transform their rage into outrage that is channeled into action to change the world.

I felt this description illuminated my thinking about effective action: that trauma with its inherent helplessness over time convinces the victim of the impossibility of effective action in their own life. Our job is to re-teach that effective action is possible. Add to that, trauma and its secrecy silencing the voice, and our job is also to help the person regain their voice. We have to be careful that our treatment programs do not themselves demand silence from the clients.

I was very moved by Dr. Hardy’s presentations, and I look forward to reading his books. Stay tuned for book reviews!

What if... A Post-Penn State Fantasy About the Prevention of Child Sexual Abuse

2011-11-27T04:32:00.000-08:00

Here is the second article written by Dr. Steve Brown

by Steve Brown, Traumatic Stress Institute

Roxanne is a fictitious 27-year-old mother of six-year-old Sarah. A single mom since Sarah’s birth, Roxanne has finally found the “love of her life”-– 35-year-old Justin. He’s got a steady job, only drinks on weekends, and seems to just adore Sarah. He loves playing with her and even has been willing to babysit whenever Roxanne needs a girls’ night out. Quite frankly, Justin almost seems too good to be true.

Six months ago, Roxanne and Justin were ready to take their relationship to the next level so they moved in together. Justin pays most of the rent and gas so things are looking up financially for Roxanne. They have even talked about marriage, prompting lots of chatter between Roxanne and her girlfriends about when Justin was going to “pop the question.”

Sarah was SO happy when Justin moved in. She’s never really known her father and always felt jealous seeing her best friend playing with her dad in their front yard. She secretly hoped her mom and Justin would get married.

Three weeks ago, Roxanne grew concerned when Sarah started to wet her bed, something she had not done for years. Sarah also seemed especially clingy at bedtime, not wanting to say goodnight or to go into her bedroom alone. Roxanne needed to lay down with her at night in order to get her to go to sleep.

Once, when Roxanne went to lay down with Sarah, Sarah’s bed smelled like cigarette smoke. She didn’t smoke, only Justin did. In the morning she asked Justin if he had been in Sarah’s room and he shook his head, looking at her as if she was crazy. Another night, Justin came home late and Roxanne happened to wake up and hear the door to Sarah’s room creak. She thought it was strange because Sarah almost never gets up to go to the bathroom in the middle of the night. A third time, Roxanne found Justin’s shoes underneath Sarah’s bed -- “That’s strange," Roxanne thought, “well, maybe Sarah was just playing her make-believe games and used Justin’s shoes.”

In a post-Penn State sex scandal world, maybe, just maybe, the following would transpire.

Like millions of other Americans, Roxanne has been riveted by the news about the alleged sex abuse by Jerry Sandusky at Penn State. On CNN’s Late Night with Anderson Cooper, she sees an expert talk about how most people think of sex abusers as creepy perverts, lurking around playgrounds, but in fact over 70 percent of sexual abusers are known, and often loved, by the children they abuse. They point out that true prevention of sex abuse will only happen when mothers, grandmothers, neighbors are alert to the possible signs of troubling behavior by their boyfriends, uncles, the next door neighbors. They need to pay attention to their gut feelings when they think something isn’t right about the sexual behavior of the person they know. It’s hard to face the possibility that someone you’ve trusted may be hurting a child, even harder to speak up.

Suddenly, Roxanne flashed to the smell of cigarette smoke in Sarah’s bed – “why on earth would Justin be in Sarah’s bedroom without me knowing about it. There must be an explanation. Maybe he was just tucking her in that night and I didn’t know about it. Maybe I’ll ask Sarah.”

When Roxanne asks Sarah, Sarah looks away and doesn’t say anything. When Roxanne asks her again, “Has Justin ever come into your room at night?” she quietly says, “no.”

“This isn’t possible,” Roxanne thinks, “Justin is SO good with Sarah. He adores her and she seems to like spending time with him. There’s no way. Finally, I’ve found the man of my dreams. Everything is working out. I might even get married. I love Justin. But, I can’t stop thinking about this.”

The next night Anderson Cooper reports:

“One of the most disturbing parts of the Penn State sex abuse scandal is how many people likely either had direct information or suspected Mr. Sandusky of abuse and failed to come forward and speak up on behalf of the victims. They were passive bystanders, not active ones. Think how many victims could have been spared if JUST one of those adults had come forward and had the courage to not let it rest.”

Roxanne suddenly feels like she’s been kicked in the stomach. “How many times now have I had this yucky feeling about Justin. I keep wanting to put it out of my mind. WHY does it keep nagging at me? All those people at Penn State, they looked the other way. Am I looking the other way? It CAN’T be possible, but maybe…I have to talk with someone.”

The next day Roxanne has lunch with her girlfriend. “Can I talk to you about something? This is going to sound so strange, but I just can’t get it out of my head…” and she goes on to tell her friend about what she has observed ending with “I’m sure it’s nothing, right?” Her friend looks stunned, “I CAN’T believe you’re saying this. Justin has always struck me as a little creepy. I never told you this, but I saw him sort of hitting on a 13 year-old girl. I didn’t think anything of it, but it was WEIRD. Once, when I was at your house, I heard him tell Sarah that her butt was cute in her tight jeans. I didn’t think it was anything so I didn’t tell you. But, it did seem really inappropriate. ”

Two days later, Justin came home again in the middle of the night. Roxanne stayed awake this time. Again, that creak of Sarah’s door. When Roxanne burst into the room, she saw Justin lying next to Sarah on her bed. He immediately stood up and yelled, “What the hell are you doing here? I was just tucking Sarah in.” Justin had clearly been drinking. Roxanne threatened to call the police unless Justin left immediately.

When she talked to Sarah about what had happened, Sarah said that Justin had been coming into her room numerous days in the past month. He always woke her up, lay down next to her, and talked about how she was so special. He always had alcohol on his breathe. He’d kiss her face and rub her back. When Roxanne asked if he had touched her on her private parts, she said “no”, but she hated when he came in. She couldn’t fall asleep at night thinking it might happen again. Roxanne said, “Sweetie, I’m so sorry this happened. He will never do that again to you. I promise. I swear.”

As Roxanne sat awake in bed that night, she could barely contain her rage. "But, at least I caught it before anything really bad happened. It could have been like those boys at Penn State. Thank God I trusted my gut. Thank God I talked with someone. Thank God I spoke up!!!”

Now THEN we’d be making progress on preventing sexual abuse of children.

Preventing and Reporting Child Abuse: The Questions Raised by the Penn State Scandal

2011-11-20T06:05:00.000-08:00

This excellent article was written by my colleague Steve Brown, PsyD.

Last week, a Pennsylvania Grand Jury indicted former Penn State defensive coordinator Jerry Sandusky for sexually abusing eight boys over the course of a 15-year period. The indictment also charged two top university officials with perjury and failure to report what they knew about the allegations. The indictment has kicked off a firestorm of media attention both in the sports world and the US at large. On November 9th, the Penn State Board of Trustees fired legendary football coach Joe Paterno and Penn State President Graham Spanier. Allegedly, a graduate assistant told Paterno that he observed Sandusky abusing one of the boys. Paterno reported this to Athletic Director Tim Curley although did not follow up later on the matter or alert legal authorities himself. The indictment stated that President Spanier was made aware of the incident reported to Paterno as well.

In any particular abuse situation there is an abuser, a victim, and (almost always) bystanders. This is true in bullying, street violence, as well as child sexual abuse. One of the most important questions that the Penn State situation, and cases like it, raise is -- what is it about the nature of intimate sexual violence that stops so many bystanders from taking action when they either have direct information that abuse has occurred or, more commonly, just an inkling that something might not be right.

It is true that men like Mr. Sandusky can often be well-regarded, upstanding citizens, involved in the community, even loved as a role-model by many. However, it is ALSO true, as has come out in the press, that numerous people had direct knowledge of, and even directly witnessed, Mr. Sandusky sexually abusing boys. Despite this knowledge, they were passive bystanders, not active ones. If any one of these adults took appropriate action to report this to the proper legal authorities, maybe the abuse would have ended with one or two boys rather than eight. Maybe the victims would have been given help and protection.

While some adults in this situation had direct knowledge of the abuse, I'm guessing there are likely many others who had troubling gut feelings about Mr. Sandusky --family, neighbors, players, coaches, etc. Many such people are now wracking their brains about what signs they might have missed, why didn’t they trust their gut, and, most importantly, what prevented them from coming forward. These are good and important questions. Even Joe Paterno, whose Penn State football team proudly extolled a reputation for being “squeaky clean” and whose motto was “success with honor,” could not see clear to act on his moral responsibility to protect current and future victims. It is especially disturbing that those with direct knowledge could not muster the resolve to actively speak out.

However, for all of us, there is this critical question -- WHAT prevents us from speaking out, not ignoring what we see, paying attention to these gut feelings, checking them out, talking with a friend or colleague about them, and ultimately taking action to alert the proper authorities?

I think there are complicated answers to this question.

Much of it relates to our societal denial about the reality of child sexual abuse. We SO want sex abuse to be about the creepy pervert, the stranger who abducts and molests our kids. Let’s just put them all on sex offender registries, attach GPS devices to their ankles and we’ll be okay. We DON’T want to admit that 90 percent of sex abuse is committed by people known by the victim and the family – our brothers, uncles, fathers, stepdads, and…yes…coaches.

If we do speak up, we are intruding on the privacy of the hallowed family --whether it be a family unit or the Penn State family. Sometimes, we don't know what signs to pay attention to in these men. Even if we do, we don't want to get involved: “I told my supervisor. If they don’t act, it must not be that big a deal. Anyway, if anything happens, it’s on them, not me.”

We especially don't want to get involved when there are powerful people and institutions involved. When those institutions have “squeaky clean” images to uphold, we don’t want to be responsible for tarnishing that image. If we do raise our concerns, we risk social rejection. We also need to have some comfort with our feelings related to the shrouded area of sexuality and the language of sex to get involved and speak up. If we speak up (as an adult bystander or a victim), it is HIGHLY likely that things will get worse in the short term although hopefully better in the long term.

Many people, playing Monday morning quarterback, are outraged about the fact that bystanders didn't speak up (and we should be outraged by this case), but this does NOT recognize the reality of the barriers listed above. Until we grapple as a society with these many barriers, we will make limited progress on prevention.

Child sexual abuse prevention, led by organizations such as Stop It Now!, seeks to answer exactly these questions – how do we help adult bystanders recognize the signs of sexual abuse, talk with others about what they are seeing, and find the courage and words to speak up. Unlike Penn State, most often it is a wife speaking up about (or to) her husband whom she sees repeatedly coming out of their daughters’ bedroom in the middle of the night; a neighbor speaking up about (or to) a beloved neighbor who frequently has boys coming in and out of his house; an adult niece speaking up about (or to) a great uncle who always wants to play video games in the basement alone with a 10 year-old relative.

This is not an easy subject to raise when the abuser is the primary earner for the family; when he is well-loved, even by the son or daughter he is abusing; when he is the founder of organizations for vulnerable kids which do a lot of good; when speaking up means a crisis will ensue.

To prevent sexual abuse, we must ALL struggle with these questions. Perhaps the Penn State situation will move us a little closer to speaking up as ACTIVE bystanders, not passive ones, looking out for the well-being of our children and those who cannot speak for themselves

Connecting Theory to Action

2011-11-13T17:35:00.001-08:00

This is a long post that summarizes the way that the Restorative Approach provides a bridge between theory and action in treatment programs.

The Restorative Approach translates what modern science has learned about trauma and how it affects the brain into specific strategies for daily interactions with the children. The following points summarize the connections between theory and daily actions.

The Restorative Approach recognizes that a traumatized child’s brain is different, in that the prefrontal cortex is less developed. Because of that trauma-related difference, the child is easily overwhelmed by emotions. In treatment programs using the Restorative Approach, staff members understand that they will have to act as the child’s prefrontal cortex for awhile, teaching problem-solving rather than punishing a child for seeming to ‘choose’ to act out emotionally when the child is doing the best he can. The staff members’ brain building tasks include helping the child with selective attention, working memory, self-observation, and response inhibition. Further, the staff respond to the child’s emotional dysregulation with calming techniques rather than with thinking interventions.

A traumatized child typically has a strong, even over-developed, response to any situation perceived as dangerous. Using the Restorative Approach, staff members aim to soothe the child whose emotions are blowing up, to reassure him or her rather than get into a power struggle. The last thing a staff member trying to help an emotionally dysregulated child would do is back him or her into a corner. Instead, staff use soothing techniques when the child is upset. They teach uses of emotions and how emotions contain information, and actively teach self soothing. The staff provide and identify safety. One part of this is to talk before doing something, and to provide predictability. The program uses crisis kits and crisis prevention plans. Staff are aware that child will notice everything that they do, how they treat each other, their tone of voice, and their expressions.

Because of their focus on danger, the child may miss a large part of what goes on around them. Staff will have to coax child to have fun and point out joys in life.

Traumatic events that are experienced prior to the acquisition of language may return to the child as flashbacks, as though he were reliving, not remembering, the experience. At times the child may dissociate to manage the pain of his experience. Staff can teach grounding techniques that return the child to the present.

The physical underdevelopment of the child’s brain results in him having more difficulty accessing his verbal memory. Therefore, staff do not rely on verbal planning alone, and whenever possible use multi-model interventions such as charts, pictures, art, dance and music.

The child whose life has been unpredictable has confused, few or no regular bodily rhythms. Staff help develop bodily rhythms by maintaining predictable structures and offering rhythmic activities such as yoga and dance. The child also has an under-developed ability to sort out social cues, so staff are clear in communication and use simple language. They teach social interpretation through movies, books, etc.

Lake of early reliable care combined with trauma and attachment disruptions result in a child whose connection with his own body has not been reliably established. Therefore, he may have difficulty regulating their body functions. Staff can help through offering repetitive, rhythmic, rewarding activities to rebuild the lower brain, the part that controls the body. The child may have difficulty sleeping, so staff will not punish bed time problems, but instead look for ways to help child relax such as night light, reading, or music. Staff will therefore handle hygiene issues with sensitivity and understanding of complexity (symptoms are adaptations), not with consequences, and will find opportunities to teach healthy sexuality.

Because the child has had less attuned interactions, his brain is less integrated and he has more trouble with generalization from one situation to another. Staff therefore make connections explicit and specifically make comparisons between various aspects of life, distinguishing past from present. They give the child opportunities to practice new skills in many arenas and settings.

Children who grow up with neglect and trauma are not taught how to recognize or name emotions, so it is up to treaters to teach them the names of emotions and model healthy emotion. This includes the recognition of bodily sensations of emotions. The child may experience his emotions as moving from extremely aroused to extremely shut down quickly with no apparent rational. Staff can help child develop awareness of his own emotions and their stages, and develop tactics for each stage.

The hallmark of trauma is the victim’s lack of control. He cannot influence what is happening to him, and he is used to fulfill someone else’s needs. He is not treated like a person. After repeated exposure this powerlessness generalizes to all situations. The child learns that no effective action is possible in their life. Therefore it is important that treatment systems do not replicate this experience, and that they allow many opportunities for active participation in decisions involving the youth. They can also respond to problems by guiding the youth to fix damage they have created and repair relationships they have hurt. Because of this previous lack of control, the child may value control above all else. The program can give child control whenever possible, collaborate with him, and focus on him learning to control himself as opposed to staff controlling his behavior. Because control is so important, and lack of control is associated with victimization, the child may cover up vulnerable feelings such as fear and sadness. Staff can create safety to allow the child to share vulnerable feelings, and model having vulnerable feelings in a healthy way.

The child believes that everything that has happened to him is his own fault. To heal he must develop a sense of safety in which he can share what he finds shameful and receive compassion. Staff can also point out his strengths and achievements.

The child’s experiences have taught him not to trust adults. Programs can provide a different experience by being trustworthy, and by emphasizing trustworthy relationships. They can point out how present relationships are different from past relationships. The child expects the worst in relationships, and so may push people away. Staff understand the adaptive aspect of the child pushing the adult away, stay committed, and don’t pull back. They verbalize and validate the child’s fears.

The relationships in the child’s life have often violated his boundaries, involving him in adult problems and activities, requiring him to perform tasks beyond his abilities, causing him to be the caretaker of adults. Therefore the child is uncertain about boundaries and tests them. Staff can maintain firm yet flexible safe boundaries, be aware of the complexity of boundaries in child’s life, discuss boundary issues openly with each other and with children, and also seek supervision around these issues to identify their own reactions so that they don’t interfere with the work.

The child has not been taught how to handle problems in relationships. When he has had relationship difficulties, the other person has often just disappeared. He may have seen adults handle problems with drinking, drug use or violence. Staff has the opportunity to provide relationships that stick with the child. They can model relationship skills, speak from their hearts and share their own modulated emotional reactions. They can always address the relationship aspects of events, provide paths to work through relationship difficulties, and actively teach social skills. Since he does not trust others, the child may have trouble asking directly for what he wants. Staff can encourage direct communication and practice and model skills of making requests. They can say yes when possible.

Similarly, the child has not learned how to handle something going wrong without making it worse. Staff can teach distraction and calming techniques, help the child develop a list of tactics to improve situation, offer child alternatives, not consequences, when he is becoming agitated. and develop with the child a list of many positive coping tactics for handling pain.

Because of both his past and present situations, the child often feels hopeless. Staff can help through pointing out skills and gains. Also, they can teach and support the child in advocating for himself.

Working with children who have survived trauma, neglect and attachment disruptions caused strong reactions in all treaters. The trauma informed program is aware of vicarious traumatization, and imbeds in daily operations opportunities to discuss the effects of the work, care for one’s self and other team members, and encourages practices which promote vicarious transformation.

Carter Symposium on Mental Health Policy

2011-11-03T06:59:00.001-07:00

I had a wonderful time attending the Carter Symposium. For me, the experience was composed of many parts. These included the inspiration of Mrs. Carter herself; the many interesting and intelligent people I met; some inspiring people I already knew and heard again; and the facility itself and the professional and efficient way the conference was run. My most overwhelming impression was that so many people in so many widely differing areas of the helping professions are transforming how they provide services based on our increasing knowledge about trauma. It may turn out that research about trauma, its effects and how healing takes place will be the revolution of our century!

The first keynote conversations were about the National Child Traumatic Stress Network (www.nctsn.org) In addition to all the wonderful treatment and service provision projects NCSTN has facilitated, they are collecting significant data about all the clients served and all the outcomes of various forms of treatment. This rich national data set gives us all sorts of opportunities to learn about the experiences and symptoms of the children seeking help, and most importantly, what helps them and their families.

Following the speakers was a Poster Session. I had the Traumatic Stress Institute poster on display and enjoyed many conversations with my fellow participants. Next to me was a friend from Connecticut, Jason Lang from the Center for Effective Practice, whose poster describes the Connecticut implementation of TF CBT.

After the delicious dinner, Christine James-Brown, the CEO of the CWLA spoke.

On the second day, the first speaker and panel addressed the increasing awareness of trauma in the child welfare system. The plenary speaker was Brian Samuels, M.P.P. Commissioner, Administration on Children, Youth and Families, US Department of Health and Human Services. He emphasized that the goal of his department was well being, not just permanency. He presented interesting statistics that showed that children who achieve permanency or are adopted do not in fact get better afterwards. Their symptoms continue to get worse. This speaks to the need for specialized treatment services for older adoptive children, and those adopted out of foster care. Speakers then presented several specific interventions for the child welfare population.

Particularly interesting was Dr. Sandra Bloom who presented her theories of how organizations themselves are living organisms, and as such experience trauma and exhibit all the trauma symptoms. She described the Sanctuary Model as a way to heal from this trauma.

The next set of speakers addressed the increasing awareness of the role of trauma in the Juvenile Justice System. The plenary speaker was another Connecticut representative, Julian Ford, PhD. He described his intervention, TARGET. The moderator and the following speakers acknowledged that the Juvenile Justice system is just beginning to implement any trauma informed practices, and that there is resistance. Judge Steven Teske, JD was especially articulate on the importance of educating judges and involving them in the solutions.

This was followed by concurrent sessions. I attended the session about Care Giving and Parenting. I heard two excellent presentations. Patricia Barron, M.A. spoke about helping military families who have a parent deployed away from home, and included excellent resources for agencies wanting to help. Jeanne Miranda, M.P.A. described a specialized intervention she and her team were developing at UCLA to treat children who have been adopted from the foster care system. Both speakers combined personal experience with professional knowledge: Ms. Barron herself is in a military family, and Ms. Miranda is an adopted mother of children from the foster care system.

I have to report that on the way back from these sessions I personally met and spoke to Mrs. Carter, and followed up by giving her my TSI materials. That was so moving! She is a true heroine. She is 84 and had just returned from observing an election in Tunisia (I think that was where it was).

The summation focused on what we can personally do with the material we learned, how we can bring it back to our own practice. It was very inspiring, especially the concluding remarks by Mrs. Carter.

This was all held in a beautiful location, which is also the home of the Carter museum. The staff and volunteers were so helpful, the food was delicious and the conference was very well organized. All in all, an excellent experience.

Patricia Wilcox to Attend Carter Symposium on Mental Health

2011-10-25T03:59:00.000-07:00

This year’s 27th Rosalynn Carter Symposium will focus trauma and its long-term effect on children. It will be webcast live.

The National Association of Children's Behavioral Health (NACBH) will be ably represented by Beth Chadwick, President and Pat Wilcox, Klingberg Family Centers Traumatic Stress Institute who will be joining an illustrious gathering of national leaders, advocates, policy makers, practitioners and researchers as they meet to bring this most pressing issue into greater focus and resolution.

27TH ANNUAL ROSALYNN CARTER SYMPOSIUM ON MENTAL HEALTH POLICY TO COVER TRAUMA’S LONG-TERM IMPACT ON CHILDREN EXPOSED TO JUVENILE JUSTICE, WELFARE, AND DOMESTIC VIOLENCE

Estimates suggest that millions of American children and adolescents experience trauma each year, through exposure to physical or sexual abuse, a life-threatening illness, natural disaster, or the loss of a loved one. Although effective treatments are available to prevent the long-term impacts of trauma on a child’s intellectual development and physical well-being, most traumatized children do not have access to these services.

On Oct. 26-27, the invitation-only, 27th annual Rosalynn Carter Symposium on Mental Health Policy will bring together more than 200 health advocates, policy-makers, practitioners, educators and researchers from across the country to discuss ways to remove barriers to providing mental health services for children at greatest risk for trauma—especially those exposed to domestic violence, child welfare, and the juvenile justice system.

The event is open to the media and will be webcast live on www.cartercenter.org on Oct. 26 starting at 1:00 p.m. (EDT) and on Oct. 27 starting at 8:30 a.m.

Oct. 26 Agenda Highlights:

For a full schedule: http://cartercenter.org/resources/pdfs/health/mental_health/2011-mental-health-symposium-agenda.pdf

• 1:00 – 1:05 p.m., Welcome: Thomas Bornemann, Ed.D., director, Carter Center Mental Health Program
• 1:05 – 1:15 p.m., Opening remarks: former U.S. First Lady Rosalynn Carter

• 1:15 – 2:15 p.m., Keynote: “Childhood Trauma in America: Findings from the National Child Traumatic Stress Network”

o John Fairbank, Ph.D., co-director, National Center for Child Traumatic Stress, Duke University Medical Center; and

o Ernestine Briggs-King, Ph.D., director, Data and Evaluation Program, National Center for Child Traumatic Stress, Duke University Medical Center

Background on the Rosalynn Carter Symposium on Mental Health Policy:

The Rosalynn Carter Symposium on Mental Health Policy is part of the Carter Center’s Mental Health Program, which works to decrease stigma and discrimination against people with mental illnesses as well as promote positive policy change on mental health issues.

Visit www.cartercenter.org to learn more about the Carter Center’s Mental Health Program, access resource material such as reports, the Center’s mental health journalism archive, and expert Q&As.

"Waging Peace. Fighting Disease. Building Hope."

A not-for-profit, nongovernmental organization, The Carter Center has helped to improve life for people in more than 70 countries by resolving conflicts; advancing democracy, human rights, and economic opportunity; preventing diseases; improving mental health care; and teaching farmers in developing nations to increase crop production. The Carter Center was founded in 1982 by former U.S. President Jimmy Carter and his wife, Rosalynn, in partnership with Emory University, to advance peace and health worldwide. Please visit www.cartercenter.org to learn more about The Carter Center

Where are My Glasses?!?

2011-10-16T07:55:00.001-07:00

Carlos storms into the nurse’s office. “Are my glasses here yet?” He demands in a loud voice.
“No” Amy, the nurse, says. “I haven’t heard from them. I’ll call you when I get them.”

“Well did you call them?” Carlos asks.

“No, they will call us when they come in, Carlos.” Amy replies.

“You should call them! I’ll bet they have them already!” Carlos is becoming more agitated.

“Carlos I’ll let you know if I hear from them.”

“No! Call them now! Give me the number! I’ll call them! Why can’t I call them? Give me the number!” Carlos was becoming angrier. His staff starts to move in. As the staff starts to encourage his return to the unit Carlos yells “I’ll bet they are already made! Give me the number! No one understands that I need those glasses! I can’t see! Doesn’t anyone care?”

After Carlos leaves, Amy can be heard saying “that child is so demanding! He thinks the world revolves around him and no one has anything else to do besides call about his glasses. He has to learn to be more patient and respectful.”

The problem is that Amy and Carlos live in different worlds, and hence have developed different world views.

Amy’s world is orderly. If you send a prescription to a glasses company they make the glasses. As soon as they are done they call you. You pick up the glasses right away and deliver them to the child.

Carlos’ world is quite different. In his world, what he needs is no one’s priority. If he needs new glasses, no one will pay attention. If by some chance the prescription makes it to the company and the glasses are made, they will languish in some back room for months. If they get to the doctor, no one will call for weeks; when they call, no one will pick them up. The only way that the glasses will get to him is if he takes it on himself to call and remind them, and calls often.

Carlos does not think that the world revolves around him. He in fact thinks that the world does not notice or care about him at all, unless (maybe) he yells loudly.

Understanding this will help us reassure Carlos, tell him how long it takes to make glasses, exactly when we will call, and keep him updated often about progress.

Maybe we can be the adults that teach Carlos that some adults can be trusted and do care.

Vicarious Transformation

2011-10-10T15:32:00.000-07:00

I have had the privilege of hearing Dr. Laurie Pearlman speak twice in the last month. The first time was at the ATTACh conference, where she was a keynote speaker. The second was in a distance learning training that the Traumatic Stress Institute did for its trainers. This was an interview with Dr. Pearlman by Dr. Steve Brown of TSI.

Laurie is developing the concept of “vicarious transformation”. We always discuss vicarious traumatization (a term she also invented) which refers to the negative effects on helpers of working with trauma survivors. Vicarious transformation refers to the positive changes in the helper which come about through empathetic engagement with traumatized people and active engagement with the changes in ourselves.

In Risking Connection© training we do an exercise which draws from participants both the negative and the positive ways that their work has affected them. In the positive section, people often say that they have grown as a person, become more patient, more tolerant, a better listener, a better parent. They also report that they are more grateful for what they have been given, and that they are inspired by the courage and resilience of the people they work with.

It is these effects which Laurie is naming vicarious transformation. She says: “through opening ourselves to the darker parts of the human experience, we may grow. When our hearts and minds are open to whatever we encounter, our humanity is enhanced.”

Dr. Pearlman stresses that in order to experience this growth, it is necessary that we turn towards the suffering we see. We of course want to deny it, to diminish it, to turn away, We convince ourselves that this could never happen to us. But when we are receptive, it is easier to care, and to enter into a genuine reciprocal relationship with our clients. Just as we feel their pain more acutely, we appreciate their strengths more directly. We experience the human potential in a deeply heartfelt way.

Dr. Pearlman recommends some techniques that can help us maximize the potential for vicarious transformation. These include receiving psychotherapy, journaling, yoga, meditating, praying, symbolizing our experiences creatively, and befriending emotion.

This exciting new concept helps us articulate why we stay in these difficult jobs. I look forward to further exploration by Dr. Pearlman, and by all of us in the treatment community.

The Adult Attachment Interview

2011-10-02T16:38:00.000-07:00

As part of the same ATTACh Conference workshop with Michael Trout, Karen Buckwalter, LCSW from Chaddock presented the Adult Attachment Scale. The Adult Attachment Interviewis a twenty question guided clinical interview with a specific scoring protocol. It was developed by Mary Main and her colleagues, and has extensive research validation to support it. A parent’s score on the Adult Attachment Interview is highly correlated with the attachmenmt reaction of their child in the strange person test.

The questions themselves can be the beginning of thoughtful discussions. They include questions such as:

• Choose five adjectives or words that reflect your relationship with your mother starting from as far back as you can remember in early childhood.

• To which parent did you feel the closest, and why?

• When you were upset as a child, what would you do?

• Did you ever feel rejected as a young child?

• What is your relationship with your parents (or remaining parent) like for you now as an adult?

The carefully trained administrator who understands the scoring system can group the adult into one of five categories:

• Autonomous: They value attachment relationships, describe them in a balanced way and as influential.

• Earned autonomous: Someone whose childhood does not contain good relationship experiences, but who has nevertheless achieved some autonomy, probably through other non-family caring relationships.

• Dismissing: They show memory lapses, minimize negative aspects of their childhoods and deny personal impact on relationships. Their positive descriptions are often contradicted or unsupported. This Karen called act and don’t feel

• Preoccupied: Experience continuing preoccupation with their own parents, have angry or ambivalent representations of the past. This would be feel and don’t act

• Unresolved/Disorganized: Show trauma resulting from unresolved loss or abuse.

Karen was careful to point out that people’s scores and types can evolve through positive adult relationships.

Karen presented several possible uses for this interview. Testing therapists and staff who work with traumatized children helps them become more self aware of their own backgrounds and styles. This will help them understand some of their reactions to individual children and families. Testing foster parents has the same benefits. Some audience members have been using the interview with some foster parents, and reported that others are very resistant to doing it.

This interview offers fascinating ways to develop the self-reflection that is so essential in our work.

Michael Trout at the ATTACh Conference

2011-09-25T12:37:00.000-07:00

I have just returned from a wonderful week immersed in learning about new treatment ideas and meeting marvelous people. I have a lot to share. This week I am going to focus on Michael Trout, who I had the honor of meeting at the ATTTACh conference (http://www.attach.org/). Michael is the author of the Multiple Transitions video that we include in our Risking Connection training. This video, which our participants always find so moving, can be purchased at the Infant Parent Institute store (http://infant-parent.com/). Many organizations have begun to use it to train new staff, and I highly recommend it.

Michael Trout is the Director of the Infant Parent Institute which engages in research, clinical practice and clinical training related to problems of attachment. He was the founding president of the International Association for Infant Mental Health; was on the charter Editorial Board of the Infant Mental Health Journal; served as regional vice-president for the United States for the World Association for Infant Mental Health; and currently serves on the board of directors (and as editor of the newsletter) for APPPAH — the Association for Pre- & Perinatal Psychology and Health. In 1984 he won the Selma Fraiberg Award for “ . . . significant contributions to the needs of infants and their families.” Mr. Trout has produced 14 clinical training videos that are used by universities and clinics around the world, including the six-hour video training series, The Awakening and Growth of the Human: Studies in Infant Mental Health. He has also written and produced four videos focusing on the unique perspective of babies on divorce, adoption, loss and domestic violence. The most important part of Mr. Trout’s work continues to be in his quiet private practice where he sees individuals and families of all ages on a daily basis.

I attended a work shop by Mr. Trout on the topic of the therapist as a secure base for their clients. He showed videos and led the audience in an experiential exercise to demonstrate attunement. Mr. Trout shared three actions that are essential for the therapist to create a secure base.

Wonder: The therapist must approach the patient with genuine curiosity and awe. He must remain interested in this person’s story, this person’s experience. This wonder can be side tracked by theories. If the therapist thinks he already has the situation figured out, his mind will only go down one path and he will close his eyes to contrary evidence. Hearing others describe the patient, or reading their record, can also interfere with wonder. Hurrying, or having a pre determined agenda, are also problems. When the therapist keeps his mind open in wonder and curiosity, he will deeply hear the patient, and that person will know they have truly been seen.

Following: The therapist must be in pursuit of the patient. The therapist does not come in with a pre-decided agenda. He follows where the client wants to go and what the client wants to talk about.

Holding: This takes many forms. Its opposite is dropping. It means creating a feeling for the client that the therapist has his back. You won’t starve, I won’t leave, we will work this out together. It may require active advocating for the client.

These are the elements of creating a secure bases for the client.

Mr. Trout ended his workshop with a meditation from a CD that can also be purchased at the Infant-Patent Institute store. I plan to add it to my training. It comes from this CD (I include the description from their web site).

The Hope-Filled Parent

What could meditation mean to a foster mother who has learned to arise at 5:15 each day, in order to have 10 minutes of quiet before she begins the careful morning ritual needed for awakening her deeply troubled child without a meltdown? What could meditation mean to an adoptive father sitting alone at midnight, pondering what was happening to the peace of his home, the safety of his other children, and the intimacy he used to share with his wife? Could meditation make a difference to those foster or adoptive families who are on the brink of placement disruption, who are about to conclude they can simply not make it through another day?

Use these meditations in any way that suits you. There is no right or wrong way. If you find one that particularly speaks to you, you may find yourself listening to it every day, at about the same time. Maybe you will invite your spouse to join you, on the screened-in porch. Maybe you will listen to the entire CD on certain nights of despair, or listen to a funny one in the kitchen, while whistling. But it is my hope that you will find something herein that restores hope, that challenges your feelings of impotence that reminds you why your efforts are far from being in vain.

A Week of Travels

2011-09-18T06:54:00.000-07:00

I am leaving today for a week of travels. I will go first to Detroit, where I will present at the 2011 National Health Care for the Homeless Regional Training. I will be speaking about Vicarious Traumatization. I also look forward to attending the conference, and hearing a presentation about Trauma-Informed Care by Scott Petersen, LCSW, and CADC; Laurie Hardin, MSSW.

On Tuesday I will travel on to Omaha, Nebraska, where I will attend the ATTACh Annual Conference, Attachment and Trauma Through the Eyes of a Child. I will have the opportunity to hear Edward Tronick, PhD speak about Peek-a-boo, Culture and Social Development: How Infant Meaning-Making Processes Are a Central Mechanism in Governing both Typical and Pathological Child Outcomes. I have heard Dr. Tronick at the Boston trauma conference, and I always learn a lot from him. I am also looking forward to hearing my dear friend and author of Risking Connection (among many other achievements and books) Laurie Anne Pearlman, PhD, Laurie will speak about Vicarious and Secondary Trauma: The Costs of Caring. I am also planning to learn about Integrative Treatment for Complex Trauma in Adolescents (ITCT-A) from John Briere, PhD. Karen Buckwalter, LCSW & Michael Trout, MA are presenting The Therapist as a Secure Base. It will be interesting to meet Michael Trout and tell him how much his video Multiple Transitions has meant to our Risking Connection learners.

There are also many other great leaders in our field at this conference. I will be discussing The Restorative Approach on Friday afternoon. I also look forward to seeing my friends from CALO. CALO is a sponsor of the conference.

If you are attending either of these conferences, please come up and say hello. I would love to meet you.

Trauma Informed Care and Homeless Services

2011-09-11T04:46:00.000-07:00

Since to day is that last day of my vacation, I thought instead of writing a new post I would share this artcile from SAMSHA. It is about trauma informed services for the homeless, but is applicable to all services.

Trauma-Informed Care 101

http://homeless.samhsa.gov/Resource/Trauma-Informed-Care-101-46857.aspx

Author(s): Guarino, Kathleen

Description: How can providers help care for people who have experienced trauma? People who are experiencing traumatic stress do not relate to the world in the same way as others. They require special care. In this article, the HRC shares best practices for trauma-informed care. These include understanding trauma and its effects, creating safe physical and emotional space, supporting consumer choice and control, and integrating trauma-informed care across service systems.

Some people experience very few traumatic events in their lives. For others, experiences of traumatic stress are chronic. Research and experience tell us that for people experiencing homelessness, rates of trauma are extraordinarily high. Many who enter the homeless service system have experienced violence, loss, and disruptions to important relationships from an early age.
Additionally, people who are homeless experience the loss of place, safety, stability, and community. These losses are also traumatic. They have a major impact on how people understand themselves, the world, and others. People who have experienced multiple traumas do not relate to the world in the same way as those who have not. They require services and responses that are uniquely sensitive to their needs.

What makes an experience traumatic?

•The experience involves a threat to one’s physical or emotional well-being.
•It is overwhelming.
•It results in intense feelings of fear and lack of control.
•It leaves people feeling helpless.
•It changes the way a person understands themselves, the world and others.

Becoming Trauma-Informed

We know people can and do recover from trauma, and we want to provide services and environments that support healing. To be a “trauma-informed” provider is to root your care in an understanding of the impact of trauma and the specific needs of trauma survivors. We want to avoid causing additional harm to those we serve.

What does this mean in practical terms? How is this different than business as usual? Here are some concrete practices of trauma-informed care.

Understanding Trauma and its Impact

Educating providers on traumatic stress and its impact is essential. Trauma survivors, particularly those who have experienced multiple traumas, have developed a set of survival skills that helped them to manage past trauma. These survival strategies (like substance abuse, withdrawal, aggression, self-harm, etc.) make sense given what people have experienced. But they can be confusing and frustrating to others and often get in the way of current goals.

Without an understanding of trauma, providers may view those they serve in negative ways. Providers might describe behaviors as “manipulative,” “oppositional,” or “lazy.” Yet these behaviors may be better understood as strategies to manage overwhelming feelings and situations. Trauma-informed training can help providers understand these responses and offer trauma-sensitive care.

Promoting Physical and Emotional Safety

Traumatic experiences often leave people feeling unsafe and distrustful of others. Creating a sense of physical and emotional safety is an essential first step to building effective helping relationships.

Safe physical environments may include:

•Well-lit spaces
•Security systems
•The ability for consumers to lock doors
•Visible posting of consumer rights
•Culturally familiar decorations
•Child-friendly spaces

Practices that help to create a safe emotional environment include:

•Providing consistent, predictable, and respectful responses to consumers across an agency
•Asking consumers what does and does not work for them
•Being clear about how consumer information is used
•Providing opportunities for consumers to engage in their own cultural and spiritual rituals

Supporting Consumer Control and Choice Situations that leave people feeling helpless, fearful, or out of control remind them of their past traumatic experiences and leave them feeling re-traumatized. Ways to help consumers regain a sense of control over their daily lives include:

•Keeping consumers well informed about all aspects of their care
•Providing opportunities for consumers to give input into decisions about how a program is run
•Allowing for consumer control over their own spaces and physical belongings
•Having clear boundaries around and giving advanced notice for room or apartment checks
•Ensuring that consumers have input into their service goals
•Using interventions respectful of and specific to cultural backgrounds
•Maintaining an overall awareness of and respect for basic human rights and freedoms regardless of housing status.

Integrating Care Across Service Systems

Becoming trauma-informed means adopting a holistic view of care and recognizing the connections between housing, employment, mental and physical health, substance abuse, and trauma histories. Providing trauma-informed care means working with community partners in housing, education, child welfare, early intervention, and mental health. Partnerships enhance communication among providers, and help minimize consumers’ experiences of conflicting goals and requirements, duplicated efforts, and or of feeling overwhelmed by systems of care. It helps build relationships and resources to provide the best quality of care possible.

Becoming trauma-informed means a transformation in the way that providers meet the needs of those they serve. The ideas above are only a beginning. Change happens as organizations and providers take these ideas, as well as their own, and use them to evaluate and adapt their approaches to care.

Hiring for Trauma Informed Care and a Prize

2011-09-04T07:23:00.000-07:00

Agencies have discovered ways to determine whether a candidate is comfortable working in a relationship-based approach. In some cases agencies have developed a statement that describes their treatment approach and asked candidates to read and decide if they can work that way, and return it signed if they want to proceed with the hiring process. It is useful to ask candidates how they deal with stress and what self care practices they find helpful. Another way is through the use of scenarios.Other options include:

Ask a candidate about a time when he or she was successful in making a change and what helped him or her
Ask a candidate with prior work experience to describe a client that they felt especially connected to, and one they found it difficult to connect with, and why. This question looks for self awareness of differing response to different clients
Ask a candidate about a time when someone helped him or her, a teacher or a mentor or anyone significant in their life. What did that person do that was helpful?
Ask what do you think might be the most difficult time of day for clients
Ask what can staff do to make clients feel safer/ more comfortable around bedtime and/or shower

Offering the candidate an opportunity to observe in the milieu can clarify both for the candidate and for the employer whether or not there is a fit.

What have you discovered that is helpful? Press comment and enter questions and scenarios you use. I will offer a free copy of my book "A Child's View of Trauma" to one of the entries that includes their email (so I can contact you). This book is for clinicians to teach kids about trauma. Please join in- I will share the ideas in this blog. Click COMMENT.

Everyday Life through a Trauma Lens

2011-08-30T08:58:00.001-07:00

Jenna’s mentor just called and her therapist, Eileen, is talking to the mentor before transferring the call to Jenna. But she can hardly hear what the mentor is saying because Jenna is banging on her door. “That’s my call!!” Jenna yells. “Stop talking with her!” This feels like the last straw to Eileen. Can’t Jenna just give her a minute? Jenna is always so demanding. Whatever she wants, she wants it now. She asks for the same thing over and over. If there is a delay, she becomes angry and starts calling Eileen belittling names. This makes Eileen less interested in doing whatever Jenna is asking for. Whenever Eileen is involved with one of the other girls, Jenna interferes. She doesn’t have any friends because she is just as demanding and bossy with her peers. Really, Eileen has taken Risking Connection© training and has been inspired to understand her client’s behavior as trauma related. This has helped her respond to Marcelis’s cutting, and Tenisha’s running away. But this constant obnoxious behavior from Jenna is something else.

Eileen has explained to Jenna that her insistence gets in the way of getting her needs met. She has reminded Jenna that she always keeps her promises whenever she can. But Jenna keeps being loud, demanding and rude. She is so self centered, thinks the world revolves around her and she should have everything her way. Maybe they should institute some kind of reward… Jenna could get a prize for polite behavior?

Stop! Just like when we consider the big symptoms (like self harm) let’s try the trauma lens on the everyday behavior that drives us crazy. So, as usual, we start by trying to understand WHY Jenna acts this way.

Every adult in Jenna’s life has let her down. Her mother has been in and out of her life, and in and out of drug involvement and treatment. When she stops using she and Jenna have some wonderful times. But when Jenna least expects it her mother disappears again into the drug world. This has left Jenna caring for her two twin younger brothers, although they are both in foster homes now. Earlier in her life Jenna fed, changed and played with them when her mother was not there. Jenna did her best not to share with anyone at school how bad things were at home, but despite her best efforts DCF became involved after a report from the twins’ doctor. Jenna didn’t fare much better in the four foster homes she has lived in. She experienced one episode of abuse and repeated interpersonal conflict leading to disruption. Jenna’s aunt Mary has been an important person in her life throughout all this. However, Mary too has vacillated about whether Jenna can live with her. Recently after a difficult visit she told Jenna that she cannot live there, and she has started proceedings to get custody of the twins.

Does Jenna act demanding because she thinks she deserves and should get everything she wants? No, she acts demanding because in her life she has never gotten anything she wanted, needed or deserved. Adults have not cared for her the way they should have. She has had to rely entirely on herself. The only way she has survived is through relentless demanding and grasping whenever she could. She does not trust adults, and there is no reason she should. Furthermore, underneath her bluster Jenna is sure that everything that has happened to her is her own fault. It is her fault that her mother went back to drugs, it is her fault that the twins were placed, it is her fault that her aunt doesn’t want her. So she is sure that if adults are talking about her, they are saying something bad. She knows that no one would want to spend time with her, or be nice to her, or take care of her. She will only get what she wrestles from the world.

So now that we understand Jenna’s behavior does that mean we just accept it? No. Jenna will not have a life worth living if she keeps alienating people by being demanding and insulting. So how do we proceed?

One idea would be for Eileen to begin exploring with Jenna how her ability to speak up for what she needs has been and is a strength. But I do not mean saying this perfunctorily and moving on to how she needs to learn to communicate better. I mean discovering times when Jenna saved herself and her twin brothers from death. Were there times when Jenna successfully helped her mother and brothers? Were there times when she got herself what she needed? Stay with exploring the strength Jenna has developed for a LONG time with no hint of wanting her to change. Communicate a genuine appreciation for a little girl who had to find a way to protect herself and her brothers because absolutely no one else was doing it.

Meanwhile, Eileen and all the staff can constantly validate the need beneath Jenna’s demands. Validate without adding “but you shouldn’t talk to me that way ” or “you can’t have everything, you have to think of others.” Instead say, “Jenna it’s hard when you know adults are talking about you, you are sure they are saying something bad. Jenna, you wish Marci could spend all her time with you. Jenna you want Shayna’s book so much you couldn’t wait and you took it.” A constant stream of validating the feelings beneath the words.

And we all should be as completely reliable and trustworthy as we can possibly be. If we have to change something, we should acknowledge it directly. And we should point out when we fulfill our promises, NOT with any implication that Jenna should have known to trust us. Just say: “Jenna, I said I would call your worker today. I did, and here is what she said.”

Is there any possibility that Jenna could use her ability to advocate for the good of others? When she is ready could she call (after rehearsing) a bowling alley and negotiate a discount for the program? Could she collect all the girls’ preferences for activities and present them to staff?

It would be great if Jenna could participate in a social skills training group, such as a DBT skills group. There she will learn interactive skills along with others, without reference to her particular issues.

And most of all, as Jenna feels safer, more appreciated, happier, more included, more trusting and more able to meet her needs she will be able to let her guard down and become more gentle. Then we may reach that miraculous day when Jenna says: “ I tried to talk to my DCF worker about a clothes voucher but it didn’t go too well. Could you help me figure out how to do it better?”

Trauma Informed Foster Care

2011-08-21T10:54:00.001-07:00

Foster parents are a precious resource in our child welfare system. They offer traumatized children what they need most: a loving family. The best thing that could happen to a child who has been wounded is to live with a family that loves him, accepts him, and sticks with him. Foster parents come into their role from all walks of life and for every possible reason. Every family constellation is represented. Some foster parents are relatives of the child, or have known him in some previous capacity. Many have experienced their own traumas and see providing foster care as their way to give back.

Being a foster parent to a trauma surviving child is quite different from being a staff in a treatment facility. You are in your own home, and there is no immediate backup. You may have other members of your immediate family present, such as your biological children. You are trying to integrate the child into your actual life, your extended family, your neighborhood, your favorite activities.

Child care staff in treatment programs are taught a method of interacting with children that is significantly counter intuitive, and is usually completely unlike the way they were raised. But they have a team, other workers, treatment professionals and policies to help them maintain these strange practices. Foster parents do not have any of these readily available. Instead, they have a chorus of extended family members and friends telling them they should be stricter and not let the child get away with so much. It is much harder to change one’s style of parenting in one’s own home where one has successfully raised one’s own children.

The most important gift that a foster family can give a child is permanency. The children are damaged by disrupting and moving over and over again. The education and support we give foster parents should be primarily aimed at giving them the stamina to stick with the child. Keeping these children is very difficult as they put the family through such extreme behaviors, all based on their own assumptions about relationships. Yet the foster parent has the most power to heal this child, but helping the child to experience pleasure and associate it with other people; and by building the child’s brain through rhythmic, repetitive, rewarding activities.

One of the most powerful determinants of how a family responds to behaviors is how they define them. For example, Natalie is a twelve year old girl who has severe difficulties at bedtimes. She was placed with the Bruce family, and they defined her bed time behaviors as defiance. They had told her to turn out her light and go to sleep, and she kept getting up. The Bruce’s case manager asked them to sit in her room, read her a story, and talk with her, and to give her a night light. Mrs. Bruce thought this was just being too indulgent; she would never let one of her own kids get away with this. Did Natalie have no respect for her? Besides, Mrs. Bruce said, she could tell that Natalie was enjoying her presence in her room. This was just rewarding bad behavior. The placement disrupted.

Then Natalie was placed with a single mother, Mrs. Harris. She immediately connected Natalie’s bed time behavior with her having been abused and left alone. She started using music to help Natalie fall asleep, and gave her a night light. They developed a bed time ritual that they both enjoyed which included reading a book and then singing a good night song to each other. These interventions did not make everything perfect and there were still many other behaviors to deal with. Buy Natalie gradually began going to sleep more easily.

When we train foster parents in understanding trauma, how it affects children, how it relates to their current behaviors and how they can heal, we offer them a new framework for understanding their child’s behavior. We help them not to take the behaviors so personally. We must stress that these behaviors are adaptive and reflect what has happened to the child. The child is doing the best he can, and will do better when he is happier, feels seen heard and connected, and when he feels safer. All our training efforts should be directed towards this end.

We are currently creating a training program for trauma informed foster care, and would love to hear from anyone who has any experience with this. Just click on the word “Comment”,

Change a Brain… Change a Life….

2011-08-14T05:23:00.000-07:00

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

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

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

Relationships bring me pain and can’t be trusted

to:

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

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

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

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

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

Connection Post Discharge

2011-08-07T10:17:00.000-07:00

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

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

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

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

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

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

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

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

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

Motivation

2011-07-31T16:47:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

Self Awareness

2011-07-24T13:35:00.001-07:00

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

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

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

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

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

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

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

Treatment Planning

2011-07-17T11:45:00.000-07:00

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

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

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

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

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

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

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

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

Combine with

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

To create

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

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

This understanding is broken into:

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

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

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

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

Ideas from Moving Forward Conference

2011-07-10T12:19:00.001-07:00

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

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

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

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

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

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

Basketball and Feelings Skills

2011-07-02T04:39:00.001-07:00

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

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

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

I would just stop the game and walk away.

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

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

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

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

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

After some discussion these ideas emerged:

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

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

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

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

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

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

New Friend In Colorado

2011-06-26T06:15:00.000-07:00

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

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

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

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

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

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

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

I Have Received an Honor!

2011-06-19T11:24:00.000-07:00

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

Rhythmic Activity

2011-06-12T09:20:00.001-07:00

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

• Wii dance

• Music

• Rapping

• Clay

• Throwing balls

• Rocking

• Swimming

• Pets

• Gardening

• Exercise

• Children’s games

• Jump rope

• Peek a boo

• Hand clapping activities

• Hopscotch

• Side by side walking

• Bouncing on "swiss ball" (exercise ball)

• Tossing a tennis ball back and forth

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

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

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

• Hoola hoop

• See saw with another person

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

• Throwing ball against the wall

• Two square game with another person

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

Click on comment and add your ideas!

Hawaii Trip

2011-06-04T04:45:00.000-07:00

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

VT, Culture and Complaining

2011-05-30T09:29:00.000-07:00

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

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

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

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

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

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

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

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

6. A consideration of possibilities for transforming the pain.

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

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

What We Say Matters

2011-05-15T09:09:00.001-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rethinking Restorative Tasks

2011-05-08T08:40:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

So what can we do?

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

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

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

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

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

One Hundred Names for Love

2011-05-04T04:58:00.000-07:00

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

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

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

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

Crew Rowing and Repairing the Brain

2011-04-24T07:08:00.001-07:00

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

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

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

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

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

(Our normal approaches to our children.)

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

He would make sure they all knew how to swim.

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

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

(All the treatment activities of healing the brain.)

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

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

My Recent Travels

2011-04-18T05:41:00.000-07:00

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

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

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

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

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

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

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

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

Ten Essential Elements of a Successful Transformation to Trauma Informed Care

2011-04-03T05:36:00.001-07:00

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

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

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

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

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

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

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

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

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

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

The Primacy of Safety

2011-03-27T09:59:00.001-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What Administration Can Do to Support Trauma Informed Care

2011-03-20T08:12:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

It’s All for You, Mallory

2011-03-13T05:45:00.001-07:00

Picture Mallory sitting in the Main Lounge. She is a large sixteen year old girl in tight garish clothes. Next to her is an over turned couch. She is surrounded by glass from the window she just broke. Her legs are swathed in gauze bandages covering the cuts she just inflicted on them, and there is blood on the carpet. The wail of the fire alarm she pulled is giving voice to her pain. Her face is frozen.

Everything we are doing is for you, Mallory. For you, who was abused by a relative repeatedly over five years. Your mother struggled with her own abuse history and depression, and has made several suicide attempts. She is not able to endure your pain, but she cares about you. She has advocated for you as you have travelled between treatment programs and hospitals.

Because of the transformation we have made at our treatment center, someone is holding your hand. No one is talking to you about consequences. There is compassion and caring in the eyes of the staff who look at you.

When you have left for the hospital, the staff discussion will center on your pain, not that you were difficult or annoying. Your team knows that you read an article in the paper today about your molester. They understand how this would be unbearable. They are shaken and disturbed, and they are feeling with you, not feeling angry at you.

Because of the changes we have made, everyone appreciates how hard this incident was on Mallory’s team, and immediately people rush to comfort her therapist, the people who saw her cut, all those who helped. We are aware of how this difficult work takes its toll on us all as we stay present with Mallory’s sadness.

We know we have work left to do when the policemen says sarcastically to Mallory “well, I guess someone’s angry” and the EMT threatens to drag her to the ambulance. And we are working on it through a grant to train the police force and have regular fun activities shared by the police and the kids. This has made great improvements in our cooperation as agencies- but today wasn’t our best day. Still more to do.

Nothing that happened to you was your fault, Mallory. You are not being manipulative and just wanting attention. You are unbearably unhappy, and you have every right to be. We are honored to be by your side, even when it doesn’t go well, even when you are not cute, even when we are exhausted and far from perfect, even when the system lets all of us down.

When Mallory is in the ambulance ready to go to the ER she asks her special staff member Rebecca if she can have a hug. Mallory is covered in blood and Rebecca hesitates. “Here, I’ll put on my coat” Mallory says. They hug.

We are trying to change the world for you, Mallory.

Becoming Naked

2011-03-06T08:29:00.000-08:00

Today I would like to ask for a consultation on a certain behavior- namely, taking off all one’s clothes.

Davonte is 12 years old, and is small for his age. He has a history of extreme abuse, and has lived in 19 places. He exhibits many problem behaviors, such as aggression and threatening. However, one of the most common is taking off all his clothes and coming out of his room. He often makes statements about how great his body is and how he will someday be on magazine covers. Sometimes he will respond to and matter of fact directive to get dressed, other times that will lead to a full fledged meltdown.

What is the adaptive function of this behavior? What does it communicate and/or accomplish? What needs does it meet?

We see this behavior quite regularly, in boys and girls, in younger children and in adolescents. Often children take off all their clothes within a crisis, but other do so in every day times and when it is unexpected.

Obviously this same behavior means different things to different youth, but what are some of the possibilities, just to start us thinking?

Some possibilities that occur to me are:

1. To shock and get a reaction

2. To keep people away

3. To test whether someone is going to molest them or use them sexually

4. To determine whether people will accept their real, true self

5. To replicate what they saw in their family

6. Because a child is uneasy about his or her body, they want to see if people are revolted

There must be many other thoughts.

I am sure that Davonte does not disrobe because he is happy about his body and wants to show off how wonderful it is. Instead I feel certain his behavior comes from a place of fear and shame, in which he fears that there is something inadequate, awful and disgusting about his body.

Have you had experience with this behavior in your settings? How have you come to understand it? How have you and your team responded?

Please click on comment and share your experiences so we can all learn from each other.

Responding to Martin’s Threats

2011-02-27T06:20:00.000-08:00

In his fifteen years before his admission to residential, Martin has been repeatedly abused by multiple people, including horrifying sexual abuse. When first admitted he was primitive and reactive, unable to trust anyone, easily panicked and always alert for danger. Whenever he felt threatened he lashed out, often physically. Gradually however Martin began to feel safe and was able to form some relationships with staff. His outbursts became less frequent and less severe, and he was more often able to participate in fun activities. He demonstrated an ability to draw and created some amazing cartoons. Both he and the staff are beginning to feel some hope for his future. He and his therapist are talking about a possible move to a group home or a foster family.
It was very discouraging then when the report came from school that Martin was suspended for threatening his teacher. He became extremely agitated, would not go to his next class, threw some books, and told the teacher that he was going to kill her with a knife. He was so intense that the teacher was frightened, and a restraint resulted.

What happened here? How do we understand this behavior? What should our response be?

Martin will not have a life worth living if he often becomes so agitated that he threatens to kill people, destroys property and disrupts whatever is going on. There is no doubt that we need to help him change this behavior. What is our most powerful strategy to achieve that change?

Punishment is the first idea that occurs to everyone. Martin needs to learn that he cannot treat people this way. He should be suspended from school for three days, and not have any activities or fun events during that period. Then maybe next time he will think twice before threatening someone.

But will he? In fact, the problem is that Martin cannot think once when he is agitated, much less twice. The punishment will confirm Martin’s world view: that he is a horrible kid who continually does bad things, and that the world is a place where he has no role, where people do not like or accept him.

Because Martin has formed relationships with his treatment team he was able to tell them several days later what had happened in this incident from his point of view. First, Martin is feeling anxious because discharge is being discussed. He is facing leaving the first place he has experienced any success and formed connections. That day, Martin was scheduled to go to art class. He had been dreading art since the last class earlier in the week. Martin has decided that the art teacher, Mr. Howard, is a homosexual. Mr. Howard has been very nice to him and encouraged his drawing skills. Martin has started to like Mr. Howard. Last class, while helping him with a project, Mr. Howard put his hand on Martin’s shoulder. Martin knows this is the first step towards Mr. Howard molesting him. He is terrified. The only way he can protect himself is to avoid art. But Miss Lesley, his home room teacher, didn’t understand this (nor did he tell her). She kept insisting he had to go to art. Martin was terrified and flooded with feelings of being small, vulnerable and powerless to prevent abuse. So he tried to save his life by threatening people and getting them away from him. He did not have to go to art or see Mr. Howard.

It is quite likely that throughout his life Martin will encounter situations that evoke his previous abuse and make him feel desperately afraid for his life. What do we hope that he will be able to do when this happens?

We hope that Martin will feel safe enough and trust someone enough to turn to them for help. We hope he will have one moment of realizing what is happening to him, one moment of considering that it may not be the truth that the art teacher is going to molest him, it may be related to his past. In that moment, he could say to someone: can I talk to you? I need help.

What would Martin need in order to do this? He would need to trust people. He would need to experience that the world has safety in it, that there are people who will not hurt you, that in fact people may care and want to help. And he would need to develop some self awareness so that he can recognize when he is having feelings related to his past and be able to stop for a moment and consider whether in this case the present is different from the past. This is a very hard thing to do.

When Martin is in the grip of panic related to his past abuse, the thought that he will be grounded if he threatens this person is of no use at all. His cortex (analytical thinking) is not available to him. Even if he could remember that he will be grounded (and he can’t) being grounded would be infinitely preferable to being molested by the art teacher, an event he sees as a complete certainty if he does not get out of going to art.

So what can we do to help Martin?

When he is not upset, his therapist and others close to him can talk to him about these things, teach him about trauma, and help him understand the connection between past events and current behavior. Together with him, they can mourn and deplore the horrible things that happened to him. And they can begin to identify the situations that are most difficult and most likely to bring up feelings of the past. Martin can begin to observe what the first signs in his body are that he is becoming upset. Staff can also learn with him what are the early signs of anxiety, and can identify them to him.

In the crisis, it would be helpful if someone noticed when Martin was beginning to be agitated. There are many more options if we catch this event when it starts and before it has escalated into a full meltdown. In either case, it is helpful if staff approaches Martin asking what’s wrong, what’s bothering you, rather than by telling him what to do. Martin will not be able to tell anyone what is really bothering him when he is agitated. Their faces (even those he likes best) will be the faces of his past abusers. So staff should employ any calming techniques they know. Can Martin go for a walk? Can he draw? Can he play basketball? Does he need to be alone, be with someone? There should be no focus at all on making him do the next thing he is supposed to do. All the focus should be on helping him feel soothed, accepted, and calm.

What if this doesn’t work, and Martin threatens or hurts someone? What can we do afterwards? Remember that once Martin regains his sense of being in the present he feels very remorseful that he hurt someone. He also feels more shameful than ever. So what can he do to make amends to that person? He can talk with Miss Lesley. She can speak from her heart, in a modulated way, and tell him how scared she felt. She can relate that to how scared he must have felt as a little boy when people threatened and hurt him. Together they can plan some strategies for the next time Martin feels scared. Maybe Martin can also do something to make Miss Lesley’s life easier, like clean up the classroom or do some other chore for her. And what about learning? Could Martin draw a cartoon illustrating how the world looked to him right before this happened? Can he start a comic strip about a boy who is learning that the present is different from the past, and make different episodes as the boy learns new things?

The theme here is that Martin will not be less likely to threaten people if we make him feel worse. He already feels about as bad about himself and his life as a person can feel. He will be less likely to threaten people if we help him feel better. He will be less likely to threaten people when he trusts them, feels safe, and is relaxed.

There is a particular opportunity in this situation. If Martin feels up to it when he is calm, it would be great for him to meet with Mr. Howard in the presence of someone he trusts. He could plan this in advance. And of course Mr. Howard would have to be comfortable and at ease in this discussion. Mr. Howard could assure Martin that he will never in any way molest him. He could apologize for putting his hand on Martin’s shoulder, and say that he did not realize how scary that would be for Martin but he can completely understand how it would be given Martin’s experience. He could say that he hopes he and Martin can continue to work together as he sees that Martin has a lot of art talent. But he understands that might be scary for Martin, so could they set up any plan for when Martin gets nervous? Maybe he can leave the art room and go back to home room. Or is there anything else that could help that Martin can think of? This conversation and their subsequent work together can become an extremely important corrective experience for Martin. Maybe there are people in the world that are friendly and want to help you and will not hurt you. This is what we hope Martin can come to believe.

It’s not that we are letting Martin “get away with” threatening the teacher. Punishment is irrelevant here. What we are trying to do instead is to use our most powerful relationship tools to help Martin learn how to identify and cope with his understandable panic responses so he will not feel his life is in danger and thus will not need to threaten others in order to save his own life. It is a long process, requiring many repetitions. We have already seen progress in Martin and with this awareness we feel hope for his happiness.

Revolutionary Ideas about Treatment

2011-02-20T07:59:00.001-08:00

In my last two blog posts I have written about incorporating the ideas of Bruce Perry and those of Risking Connection to create a new approach to congregate care treatment.

Let’s see if I can put this all together.

Foundational ideas:

1. Our children were injured early in their lives, therefore their lower brains have been damaged. This part of the brain is involved with bodily regulation, the calmness/alertness cycle, the danger response and the regulation of emotion. It has tendrils into all parts of the brain.

2. Early experiences create templates or patterns of relationships deep in the lower brain. These templates are what the person expects from relationships, their deepest assumptions about what kind of world this is and how people treat you.

3. Brains can change and be healed at any age, and it takes a lot of repetition.

4. Parts of the brain change only while you are using them.

5. Whatever you use in the brain gets stronger; you get better at whatever you do most.

6. Things that happen together repeatedly become wired together, associated with each other and thus in the future the presence of one evokes the other.

7. Human connection is in itself reinforcing because it stimulates our reinforcing brain chemicals. If a person gets inadequate supplies of the reinforcement of connection they are more vulnerable to other activities that stimulate these same chemicals, such as self harm, drugs and risky behaviors.

8. Because of early trauma, neglect and attachment disruptions the biochemistry and brain structures of our clients have been changed. They have become caught in the human danger response, which leaves them hyper-aroused, over responsive, and with difficulty regulating and relaxing. They may also have developed a dissociative, freeze response to stress.

9. Because of early unresponsive and/or abusive caretaking, the children have developed templates or expectations that people are not trustworthy, will hurt you, and do not care about your needs.

10. Change is possible through repetitive healing experiences.

11. People act better when they feel calmer: safer, welcome, accepted, competent and at ease.

What does this mean about what we should do in treatment programs?

Every person in the treatment program must understand that their first and primary job is to help the client feel better. What can I do today to help this child feel safer, more appreciated, welcome, noticed, connected? Feeling better, less afraid, less hopeless will free the child to take the risk of acting better.

Especially at the beginning of treatment, we must deliberately fill the child’s day with activities that are physical, rhythmic, and regulating. This would include rocking, music, drumming, dance, Wii games, throwing and catching a ball, etc. The non-verbal connection with animals is also healing. As the child participates in rhythmic activities his own bodily rhythms and cycles will become more regular.

These activities must be done with active, engaged, hopeful adults. Using the body activates the lower brain. Pairing lower brain activity with positive relationships will gradually change the template the child has about relationships.

Since whatever a person does, they will get better at, we should make sure our children spend their time being successful, having fun, and enjoying positive interactions.

We should make sure every child experiences many positive human connections throughout their day.

What are the program implications of this way of thinking?

We can be much more deliberate and planful about our use of recreation- both recreation therapy and all the recreation/ down time in the day in our milieus. We can make sure the activities are tailored to develop the brains of the children we have, at whatever stage they currently are, and are fun and interpersonally rewarding.

What about therapy? Do we no longer need it? Nothing could be further from the truth. In the early stages of treatment, the therapist can e primary source of reparative connection. He or she can incorporate these principles by having a rocking chair in their office, using art and music, walking while talking, and making sure the appointments are positive and fun. As the child feels safer and calmer, he or she will be more available for cognitive approaches. The cognitive part of the brain inhibits immediate action on impulses, and needs increased strength to successful do so. Any discussion, reading, talking (about anything, like sports or the weather) builds this brain skill. Therapy interventions such as TF CBT or Target are still very helpful, especially after the child has made some progress. Therapists can also incorporate these principles into group and family work. They can assist the family and child in engaging in joyful games that may heal the brains of both. Groups that cook, read and discuss books, do crafts, take walks can build all parts of the brain. And with the team the therapist has an essential role in leading staff to think beneath the behavior, consider how it is adaptive and plan how we can help the child meet his or her needs in a less destructive way.

And perhaps most importantly this theory demonstrates in a new, more urgent way the importance of taking good care of our staff. If a child is playing Dance, Dance Revolution and the staff is at the side of the room texting his friends on his cell phone, the child may be having fun but her templates about human relationships are not being changed. The template that people really don’t notice or care is being strengthened. As an agency we must prioritize keeping our staff happy, hopeful, engaged and energetic. The staff’s ability to offer warm, rewarding, joyful connections to the clients is ultimately the only tool we have to use.

What is your reaction to these ideas? Please click “comment” and share your thoughts.

These Kids Will Act Better When They Feel Better

2011-02-13T04:38:00.000-08:00

In May I wrote about what it would mean if we really believed that children will act better when they feel better, and discussed what "feel better" would really mean. Feeling better includes:

• Feeling safer

• Felling calmer

• Feeling more connected:

• Feeling better physically

• Feeling less shame

• Feeling more competent

• Feeling more effective

I am struck with the connection between this way of thinking and our understanding about how the brain changes. The brain changes in a use dependent way: what happens often is strengthened; what is not used withers away. What happens together is associated, which means that one thing evokes the other. Many repetitions are needed to change something previously learned or associated. We also know that human interaction is intrinsically rewarding, and that if humans do not have enough of this reward they are more vulnerable to seeking other rewards such as those available from cutting, drugs, aggression, etc.

We want our children to associate human contact with pleasure and help. We want them to experience that life can be a fun, positive rewarding experience. We want them to know that when difficult things happen, you can turn to others for help and use your own skills to surmount them.

It is true, then, that our main function in treatment should be to help each kid have a great day. (Idea courtesy of Martha Holden, CARE project, Cornell). Because having a great day will establish new patterns and templates in their brains. Having fun with staff, repeated many many times, will begin to change their expectations of interactions with others.

I was talking this over with a friend, and he asked: does this mean we should just let the kids do whatever they want, and sit around and eat candy all day? No, it does not. For one thing, feeling better is a complicated phenomenon, and includes all the aspects above- so it demands many activities and challenges. Felling better necessitates lots of the delicious rewards available through social connectedness. For another thing, we have to consider the group. Each person has to have a great day in a way that does not impede the other people having a great day. And thirdly, there is the staff. In order for the child’s template of relationships to change, there must be a genuine, positive engagement with adults. To do this, staff must be feeling hopeful and caring. So promoting anything that hurts or pushes away the staff does not achieve our brain-changing goal.

Therefore, we should be discussing how to create a milieu containing the most possible highly engaged, physical, rhythmic fun for the staff and the kids. Now that would be an interesting treatment team meeting!

Changing the Brain and Having More Fun

2011-02-06T05:41:00.001-08:00

What do we know about how to change the brain?

•Brains develop and change sequentially. The lower part, which concerns the body, the danger response, and emotional reactions, develops before the higher part which involves words and analytical thinking.
Brains develop and change in a use-dependent way. If you use a part more, it gets stronger. If you dn’t use it, it withers away.
What fires together wires together. Things that repeatedly happen together get associated in the brain, and the next time one happens it brings up the other.
In early years of brain formation, patterns are set in to the brain which determine our assumptions and expectations of life. If a child is hurt by people in the early years, they expect people to hurt them from then on.
If you want to change a part of the brain, you have to use it. So, if you are talking, you are not changing the lower part of the brain. You are only affecting the thinking part.
Many repeptitions are needed to change a previously learned association or pattern.

So what is the radical significance of all this for our work?

Our children in residential have almost all been wounded early in life, during the formation of the lower, bodily, emotional and danger response parts of their brains. And, the early patterns that they have established are that people hurt you and leave you. This is what we need to change, before we can work with the thinking, verbal part of the brain. We want to change their expectations of other humans. We want to pair human contact with positive emotions and good results, to undo that old pairing of human contact and pain.

In order to reach the lower part of the brain to change it, we have to engage it. And how do we do that? We involved the child in physical activities with movement and rhythm. These could include music, dance, drumming, rocking, swings, planting a garden, massage, shoveling snow. And, we pair these activities with positive interactions with other people. We make sure they are fun and engaging and done in connection with adults.

Do you see the implications of this? We have always maintained in our training that the daily life in the milieu and the relationships with the mental health workers are powerful forces for change. Now we can see even more clearly that having fun with the kids in physically engaged, active ways, is the very thing we have to do in order to change their brains. And now we can do this more planfully and with targeted goals.

Another implication is this. As we know, our kids are acutely perceptive about other people’s moods and emotions. This also reflects their earliest brain development. They had to develop this perceptivity to stay alive and anticipate the next dangerous event. So they will know if the adult is actually engaged with them, actually having fun and feeling positive and affectionate. If the adult is distant, sarcastic, punishing or distracted and texting on their phone this will not change the brain. In fact, this will confirm and further strengthen the patterns already established. So, in order to be successful in our change process, we need to take good care of our staff, so that they feel energetic, hopeful and available.

Isn’t this amazing? It turns out that having a lot of playful, energetic, engaged fun with the kids is the best thing we could possibly do! Get out that Wii and play Dance, Dance Revolution, and make sure the staff dance too, and laugh a lot…. Do it again and again. And you will be changing brains.

Hope

2011-02-02T13:05:00.001-08:00

Recently our girls have been expressing their intense and unremitting pain. Latasha finds so many creative ways to hurt herself- she eats staples, bangs her head, and hits herself in the face hard enough to make herself bleed. Jessica is so sure that her family is blaming her for revealing her sexual abuse by her uncle that she tried to hang herself. Shahara ran away and tried to pick up some older men. Marguerita takes off her clothes and tries to scratch herself all over, and then she swallowed an open safety pin. We send them to the ER, they come back in a few hours. We surround them with caring, and they feel only despair.

These girls see no hope. They have no one in the world who they are sure loves them. They hate themselves and blame themselves for everything that has happened in their lives. They see no road to any positive future.

The staff and therapists feel a great deal of caring and compassion for these girls. And yet, their behavior is exhausting. It’s hard to believe that Latasha couldn’t just stop it. And we explained to Sharara the dangers in running away, can’t she see them? We are used to getting through crisis’s, but this unremitting repetitive anguish is so draining.

And the problem is that we don’t see any hope either. When Marguerita expresses her certainty that her life will never be better, we wonder if it ever will. And we can’t think of any concrete reassurance to offer her, anyone who loves her, any good thing that is coming soon.

We forget that we are the hope. What the girls need from us is not a specific reassurance that something good is happening. No, what they need is much harder to provide. They need us to be with them in their pain, feel it with them and not turn away. They need us to see their worst and not give up. They need us to care when they are hurting, and keep caring, validate their pain, and not be disgusted. This is the real, substantial gift we can give them. Hope is created when they experience the possibility of true human connection. There are people in the world who accept you as you are, care what has happened to you, and listen. There are people you can trust who do not hurt you. There are people with whom you are safe.

This isn’t the only thing we have to do in treatment. We also have to teach skills, calm biological activation and develop self worth. But it may be the most important.

So, we have to sustain ourselves and each other, because this is hard, much harder than giving advice or administering restrictions. We are doing the most important work in the world, and real engagement will transform both the girls and us. And what could be more hopeful than that?

2011 NATSAP Annual Conference

2011-01-23T09:05:00.000-08:00

I have just returned from presenting at the 2011 National Association of Therapeutic Schools and Programs (NATSAP) Annual Conference in Tucson, Arizona. NATSAP was created in January of 1999 to serve as a national resource for programs and professionals assisting young people beleaguered by emotional and behavioral difficulties. Their members include therapeutic schools, residential treatment programs, wilderness programs, outdoor therapeutic programs, young adult programs and home-based residential programs. For me, this is somewhat of a new world. Instead of the child welfare/ mental health world, this is the private school, wilderness program, self pay plus insurance pay world. Yet the children we all treat have remarkably similar symptoms and behaviors, despite some differences in socio-economic backgrounds. Like child welfare programs, the schools and programs within this organization are learning about trauma and adapting their treatment accordingly. And they face familiar difficulties in doing so.

I met many interesting people in the course of these two days, and hope to develop training relationships with some. I also spent time with my friends from Change Academy Lake of the Ozarks (CALO) and enhanced my ongoing respect for what they are doing. Take this opportunity to check out their program at http://caloteens.com and learn about their unique animal assisted attachment based program. They also have an excellent blog, found at http://caloteens.com/blog .

One workshop I attended was The New Brain Science: Can it Make Treatment More Effective? Presented by Linda Zimmerman CEO/President and Kurt Wulfekuhler, Clinical Director Sandhill Child Development Center Los Lunas, New Mexico. The Sandhill program has adopted the teachings of Bruce Perry, and uses The Neurosequential Model to direct their treatment. The presenters reviewed Bruce Perry’s six core principles:

1. The brain is hierarchical.

2. Neurons and neural systems change in a use dependent fashion.

3. Brains develop in sequential fashion.

4. Brains develop most rapidly in early life.

5. Neural systems can be changed, and the more complex (higher) are more easily changed than the lower.

6. The human brain is designed for a different world than the one we now inhabit.

The presenters showed examples of how mapping a child’s experiences and competencies can pinpoint the areas of his brain that most need to grow, and thus suggest therapeutic interventions. A central tenant is that if the lower parts of the brain are damaged, they must heal before the upper parts can change.

Interventions that help the lower parts of the brain heal are sensory motor, not verbal. Examples would be touch, swinging, rocking, swimming, drumming, neurofeedback and music. The presenters also emphasized the importance of intensive aerobic physical exercise as well as good nutrition in promoting brain growth.

Extensive repetition is necessary to change the lower parts of the brain. But the presenters showed brain maps that demonstrated the change that is possible. This was very interesting to me as I would like to incorporate more of the sensory motor learning into our programs. Are any of you using this approach? Please share your experiences by clicking “comment”.

Brittany in Transition

2011-01-17T06:53:00.000-08:00

Brittany has been part of our agency for many years. She started on the Junior Unit, graduated to the Girls Unit, and then transferred to one of our Group Homes. She has had many ups and downs. But right now she is driving the staff crazy.
Brittany has been completely defiant. She will use the phone whenever she wants to for as long as she wants to. Whenever anyone asks her to do anything she swears at them and tells them she doesn’t need them, they cannot tell her what to do. She is nasty, calls staff names, and is threatening. She led several peers on an AWOL a few nights ago. The other girls are complaining- how come Brittany is getting away with this behavior? Maybe they should begin to act like she does.

Leah, the supervisor, talked with Brittany. Brittany maintained that she does not want anything from the house or anyone in it. She said: “You cannot change me. This is who I am.”

The staff is frustrated. Brittany is making them feel disrespected, ineffectual and useless. They are worried about the stability of the house. They are tired of all this nastiness. Brittany is restricted, and they cannot see any way she will be able to get off restriction. In fact, they are considering whether her visits to her foster home should be contingent on better behavior. Especially because Brittany taunts them with the fact that she can act however she wants and still go on visits. The situation is particularily frustrating because staff members have a connection with Brittany and care about her, and it feels like she is rejecting that connection and pushing them away.

The first question is always: how do we understand this behavior? What is happening in Brittany’s life? What might she be feeling? What needs is she trying to meet?

Brittany has started a transition to a foster home, the Thompsons. She has lived with the Thompsons in the past, but had to leave their home due to her behavior. However, they retained a connection with her and are now willing to try again. They have been through a lot of major episodes with Brittany and have not given up. But the Thompsons are not yet completely sure that Brittany can live with them. They are having her for weekend visits, which are going well, and are exploring their options in therapy. No date for discharge has been set. Brittany has been doing well in her public school, and it is also unclear whether Brittany will be able to stay in that school if she does go to the Thompsons, since they live in a different town.

Brittany has made many statements about being eager to go to the Thompsons and leave this stupid group home behind. At times she has also expressed doubts about the Mrs. Thompson. She is not sure she likes her or can trust her. Recently when Brittany was going through a medical problem she asked staff not to tell Mrs. Thompson because she was sure it would make Mrs. Thompson hate her.

It is so hard, in the midst of Brittany’s defiance, to see how scared she is. This is the most difficult situation in the world for her. She is attempting to take a leap of faith and trust her fate to an adult and a family. This has not worked out in her past. Many people have not been able to stick with Brittany. And in fact she has a previous disruption from this very family, although they retained their connection. Brittany is preparing to leave the agency that has raised her and has been her home for years. She is leaving the group home that has been her base and her success. She knows all too well how much more precarious a foster home is than an agency. And furthermore, the time frame is indefinite, the arrangements are unclear, and it is not even certain that she is going.

Brittany is trying to make it work. She is behaving well at the Thompson’s and also at school. But when she is back in the safety of her group home, all her tension comes out. The message is her defiance is: “I don’t need you! I won’t miss you! It is perfectly fine that you all are pushing me out the door into an unknown and unreliable future because I never liked you in the first place!” Her unwillingness to accept direction and help is her extreme method of convincing herself that she can depend on herself and she will be fine whatever happens. Her heightened agitation, constant drama and behavioral episodes are her way of escaping the tension she feels so acutely right now. She is sure that this placement with the Thompsons will not work out. She knows that she is an awful girl that no one could ever want or love. She cannot bear to trust again and risk being disappointed. She daily expects the news that the placement plans are cancelled. She hates to say goodbye to the staff she depends on. Yet, part of her longs for the love of a family, for normal life, for a future.

And, she has no idea when she will go. This is in part a feeling of safety- she doesn’t have to leave yet. In part it is frustrating- I want to move on! And in part it is just tense.

So if this is our working hypothesis, what should staff do? What they should do is the hardest thing possible- look past the defiance and the obnoxious behavior, see the frightened little girl inside, and move closer to comfort her. First of all, they should talk about all this: “It is often hard for kids to leave, no matter how much they want to. It still feels scary.” Or: “I’m sure you feel worried about whether it will work out with the Thompsons, and part of you really wants it to, and part of you is afraid it won’t. Sometimes that is so hard that you try to believe you don’t even like the Thompsons.” Validate that these feelings are natural and to be expected. Brittany will reject these interpretations, and insist that no, she is eager to go and that the staff is just stupid. But somewhere inside she will hear what is being said and be comforted. Talk with the group as a whole about how hard transitions are, and if possible encourage all of them to share feelings they have had in making changes (like what about when they came to the group home?) and how they have managed them, Anything that is possible to make the transition process as clear and transparent as possible will also help Brittany.

Find ways to remind each other as staff of Brittany’s history and what a difficult leap of faith she is trying to make. And remind each other that even as she feels safe enough to rant and rave, you are playing a priceless and important role in Brittany’s life.

Administrative Support for Trauma Informed Care

2011-01-02T04:46:00.000-08:00

A crucial factor in the success of any transformation to trauma informed care is the support of the leadership. There are many ways this support much be demonstrated, including financial support for training. One important way is the administration’s response to behavioral incidents.
Expectations are conveyed in many ways throughout an agency. Does the administration value control and lack of disruption more than anything else? Can the administration tolerate certain level of organizational disruption in making the transition, including such things as staff confusion, conflict within treatment team, resistance to change, and increased property destruction? Trauma informed practice encourages staff to be flexible and to offer choices to the clients, even when the result is that the client is not immediately brought under control. Can the administrators support this?

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

What messages are sent in this two minute interaction? That not upsetting the Board in more important than what is happening to Maggie; that in fact what Maggie is feeling and saying is unacceptable and shameful and should be hidden; and that the job of staff is to get Maggie to quiet down and stop bothering people. These two minutes can undermine months of training. If staff are blamed for not quieting disruptive behavior, they will blame the children for their dysregulation.

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

This example also points out that it is important to share the principles of trauma informed care with the Board of Directors. They need to know why the agency is making this change, and how it will affect agency functioning. Both possible positive and possible negative ramifications must be shared with the Board.

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

The Holiday Monster

2010-12-28T10:01:00.000-08:00

Everyone who works in a congregate care program knows that there are more behavioral problems during the holidays. The escalation usually starts around Thanksgiving. We explain it to each other: “you know, it’s the holidays.” Yet have we taken the time to look at the components of the holiday experiences of our children, and from that understanding plan how to best support them during this time?

Memories are a central part of the holidays. For our children, both good and bad memories can hurt. If they have warm and caring memories, they feel sad and angry that they are no longer with their families. Many children also have painful holiday memories of fights, alcohol, abandonment and other types of pain. These become vivid as the holiday season approaches.

We are all surrounded with media images of what the holiday season is supposed to be. On Christmas or Hanukah you should be surrounded by loving family and friends, eating huge piles of delicious foods, and opening wonderful gifts that change your life forever. It’s not just that our children’s holidays do not fit this picture. It is the meaning they ascribe to that difference. What does it mean about me that I have no family, no feast, such a different holiday? There is an underlying message in the media that suggests that if you do not have these things you are a loser and it is somehow your own fault. Our kids are prone to thinking everything is their own fault anyway. So holidays are not just disappointing, they are one more source of shame: I must have done something terrible because I am the only child in America that is not having a happy day.

Then there are the gifts. Many places like ours are inundated with generous donations during the holiday season. We receive more presents than our children can possibly use, and we save some for distribution throughout the year. The kids get to ask for specific presents, and then get many more they do not choose. So they should be happy they are getting all this very nice stuff, right?

But what is this gift receiving experience like for our children? They know the gifts were not chosen by someone who knows and loves them. They know that people give gifts out of sorrow and caring about their plight. They may receive gifts from family; they may not. Often the donated gifts are more than their family could afford. What does all this feel like? It is wonderful that people donate gifts and it means a lot to the child that receives them. Yet, there is a hollowness, a disappointment, because the gifts are not the same as love.

A child may build up expectations around the holidays. Maybe my mother will finally come and visit. My father said he would send me a video game. Often, these are disappointed. Luckily, some children are able to spend time at home. In fact, we facilitate them going home if it is at all possible. Sometimes our wish that the child be at home for this one important day may even overcome our common sense. So a child who has not gone home in a long time does, and may or may not have a good visit. Either way, it evokes a lot of complex emotion.

Then there is the inevitable let-down. The holidays are over. Nothing has changed. My life is still the same and I still have no plans for my future.

So what can we do to help our kids with this holiday season? The most important thing is to validate, rather than try to cheer them up. It might be helpful to share that there are many people who do not have a picture perfect holiday. And to acknowledge that gifts from strangers feel different from gifts from families; and that it sucks to be stuck in a residential at Christmas or Hanukah. Give them an opportunity to talk about their memories of past holidays, good and bad. Talk about their feelings about their families, any contact they are going to have, anything they are going through. Don’t try to point out the good things- at least not at first.

Another thing to watch out for is over-stimulation. In our efforts to offer many treats to our kids we can ignore the fact that too much good stimulation can be overwhelming to them. Getting over tired reduces their already limited coping ability. Lots of noise and activity can wind them up and they do not know how to calm down. For some kids, a low key mellow celebration might be best. If there are parties, make sure to alternate them with down time, time to relax, talk about what you are feeling, and to engage in quiet activities with people you know. Remember that strangers are scary to some of our kids. It is easy to underestimate how stressful it may be for certain kids when members of the public attend agency events. Will my abuser be one of them?

Schedules and predicting what is going to happen, where it will be, who will be there, how long it will last is helpful. Also predict any stressors or issues that might come up. The child may dismiss what you say, but it can still be helpful when the event happens. Involve the child in planning for success. Is there a signal he can give you if he has had enough at a party? Will it help if he sits next to you, or brings his stuffed animal, or takes a nap before the party? Remember in doing this you are not only helping the child with this particular event, you are teaching him a method to anticipate and conquer stress which he can use throughout his life.

The adults caring for the children are also often stressed out by the special demands of the season and the pressure to do more, plan more, accomplish more. They may be experiencing their own holiday stress outside of work. And on the actual holidays themselves, the children may be cared for by part time staff they don’t know as well. Furthermore, we experience vicarious traumatization from participating in the childrens’ pain. It can feel especially sad to see children managing without their families through the holidays. Anything we can do to support each other and acknowledge the pain to each other will help us offer regulation to the kids.

Most importantly, watch and listen. Pick up early signs of stress. Give the child plenty of time close to regulated adults, when he can talk, be validated, and just be connected with someone who cares. After all, isn’t this really what we are all looking for during the holidays?

Working with Regulatory Agencies

2010-12-05T05:45:00.000-08:00

Providing treatment for children in a congregate care setting is a complex job. There are so many parts to what we do, and we are constantly on the edge of disaster. Thank heavens most of the things that could go wrong don’t. But the behaviors are so dramatic and life threatening, the staffing so stretched, the tasks so many, and the stakes are so high. Every day includes many many interactions with the children, designed to help them get through the day, change and improve, have fun and relax, or just manage life. In addition we have all the physical care of our living spaces. We provide everything necessary to raise the children, from food, clothes, supplies and living space to medical care and education. We must document everything we do following regulations of various agencies and accreditation bodies. There is so much to do on a given shift!
Sometimes things do go wrong. These can range from egregious, deliberate wrong doing, to mistakes of omission by a harried staff, to errors in judgment, to just plain accidents. When something goes wrong, we are often visited by representatives of regulatory agencies. It is their job to investigate what happened, make sure that the care being provided meets acceptable standards, and make suggestions for improvement. It is essential that such agencies exist and that we maintain oversight of the care that is being provided to children.

However, I wonder if it would ever be possible to apply what we know about how people change to the relationship between regulators and service providers. I believe that care would be improved by maintaining a RICH© relationship between the regulators and the agency staff. RICH means treating each other with respect, sharing information, establishing and maintaining connection, and creating hope.

In the situation in which a basically sound agency did something wrong such as inadequate documentation or imperfect handling of an incident, and therefore needs to improve in some way, what actions on the part of the regulators would make improvement most likely to happen? I think that if the agency felt understood and respected, had information about better ways to do things, had a relationship with the regulators and felt hopeful about the possibility of change they would be most motivated to strive for excellence.

Both the treatment agency and the regulating agency have a common goal: providing excellent treatment and care for children. One essential component of the agency’s ability to do this is retaining committed, enthusiastic, hopeful staff. The work itself makes this difficult, as staff working with these children and families experience significant vicarious traumatization from the pain they share with the clients. If the staff feels constantly criticized; if they feel that nothing they do is ever good enough; if their good work is not noticed or appreciated; if they have to spend large parts of their time in meetings explaining what they have done; and if they feel that there is no way to win this vicarious traumatization is compounded.

In our training we stress that there are two sides to a relationship. If we feel that the relationship is our main tool of healing, we must pay attention to both sides. The staff cannot offer a caring relationship to the children if they themselves do not feel cared about and well treated. Just as it is crucial how agencies treat their staff, it is equally important how the staff is treated by the surrounding community. If the staff begin to feel that there is no way they can succeed within the child welfare system; if they experience constant criticism and no recognition, they will feel hopeless. And hope is a crucial component of our work with the children, who are often hopeless themselves.

So how could this be different? First, it would help if outside agencies instituted a method of praising and recognizing the hard work of treatment staff, and called meetings to convey positive impressions at the least often as those for negative issues. Another important factor is the attitude of inspectors when they are in the agency. They, too can mention good things they see and want to encourages, as well as acknowledging the hard work of individuals. They can express appreciation for extraordinary efforts, and display understanding of the complexity of the work.

Agency staff expects correction and suggestion, and is usually eager to improve. This can be offered in a spirit of respect and mutual desire to improve the lives of the children. And when changes are made, they can be acknowledged and celebrated by both agency and regulatory staff.

In short, it would be great if we adults treated each other in the way that we are advocating treating the clients.

What are your experiences with regulatory agencies? Has anyone had good, mutually respectful relationships you can share? Click “comment”.

Thoughts on Developing Resiliency

2010-11-29T09:57:00.000-08:00

As I begin to write about resiliency, I have to mention what Geoffrey Canada said when I heard him speak at a National Council conference. He said he was not that interesting in studying what helped people succeed despite bad situations; he was interested in creating fewer bad situations.

Still, when I heard Mark Katz, PhD speak at the Joint Commission Behavioral Management Conference I was struck by the overlap between his presentation and our training. Dr. Katz is the Director of Learning Development Services, a Clinical and Consulting Psychologist in San Diego, California, and author of the book On Playing a Poor Hand Well, published by W.W. Norton and Company (1997). In the book, Mark explores the lessons learned from those who've overcome adverse childhood experiences, and discusses ways of incorporating these lessons into our existing system of care. http://www.learningdevelopmentservices.com/

In his presentation, Dr. Katz emphasized that the meaning people attribute to misfortune is a key factor in their ability to overcome it. He stated that: “The meaning we attach to adverse experiences can determine whether we view ourselves as resilient and courageous, or helpless and hopeless.”

Dr. Katz reported on a study that identified beliefs that interfere with the ability to overcome adversity. These are perceiving adversities to be permanent, pervasive and personal. (Seligman, 1992)

• Permanent – the perception that things will never change
• Pervasive – problems are evident not just in one life area, they’re pervasive
• Personal – It’s all your fault.

Seeing our adversities in these ways increases the likelihood of psychological problems; it may also weaken our immune system. Developing these beliefs when young may be especially impairing.

On the other hand, perceptions that foster resilience (Seligman, 1998; 1992) are that:

• Adversities are temporary – the perception that things will get better
• Adversities are limited – Things may not be going well in one area but they are going well in others areas
• Not personal – The person sees that he is doing the best he can under the circumstances and that it is not all his fault.

Dr. Katz identifies a key factor is resilience is fostering a sense of mastery. This includes highlighting, nurturing and expressing strengths and talents, and things you feel passionate about, feeling you’re making a contribution, and the belief that our actions can alter our destiny. So, people are able to rebound from a difficult past by learning to attach new meaning to adversities past and present, aided in large part by their ability to:

• Re-shape personal identities around longstanding strengths and talents,
• Re-frame personal limitations and vulnerabilities within the context of these strengths and talents, and
• Find or create social contexts where they felt valued for their contribution.

It is interesting to note that the three attitudes that Dr. Katz identifies as particularly harmful are exactly those that are created through trauma. His work highlights the importance of treatment programs deliberately organizing interventions to change these beliefs. The child who is experiencing abuse from his or her family does not see any hope, and thinks that their current situation is permanent. Because the neglect and abuse is so pervasive and repetitive, it affects every aspect of the child’s existence. And in our training we emphasize the role of shame. This child feels that the abuse is his fault, partly because that gives him some possibility of control, as well as to preserve his connection to his parents, and because he is told it is his fault.

What can we do in our programs to convey hope and to show the child that adversity is temporary? First and foremost we must create experiences in which the child is successful, is happy, and experiences joy. We must offer opportunities for the child to explore his strengths. We must coax the child to play. And then we must take care of ourselves and each other so that we can maintain our hope, and thus be able to show hope to the child.

If the child has these experiences of play and success, she can gradually experience that while some areas of her life may be troubled, other parts are not. The pain can be compartmentalized in an adaptive way.

Help a child to emerge from shame is a slow and meticulous process. We must be careful not to rush to reassure the child that whatever happened was not his fault. Instead, we must provide space for him to explore his thoughts and feelings, and share his secret fears and concerns. The antidote to shame is sharing and receiving and empathetic response.

It is important to note that Dr. Katz emphasized a sense of mastery as a key to resiliency. In our training we explore the concept of effective action. The essence of trauma is not being able to change it, control it, or have any power to influence what happens. In our treatment programs we must make sure we do not replicate a sense of powerlessness. Instead, we must offer children lots of ways to take effective action in their own lives. These can include having choices in activities, food and unit functioning; being involved in planning meetings for their lives and advocating for their own wishes; and participating in helping others, volunteer work, helping causes they care about, etc.

The overlap between the literature about beliefs that support resiliency and the evidence about healing from trauma strengthens our understanding of the importance of addressing these areas directly and planfully.

Update on My Travels

2010-11-21T13:55:00.001-08:00

In October, my colleague Steve Brown and I taught both Risking Connection© and the Restorative Approach© to Child and Family Service of Hawaii. This excellent agency is especially interested in improving the services in their group homes for girls. They also have an array of other programs which will benefit from being trauma informed, such as domestic violence shelters and in home services. The staff was eager to learn and felt that this approach was exactly what they had been looking for. And this was the first training in which I was given two leis, one at the beginning and one at the end of the training.

I also did a Risking Connection© training with Dr. Kay Saakvitne in at Elmcrest Children’s Center in Syracuse, New York. I appreciated the staff there who had the courage to embrace change in their methods and appreciate the possibilities within trauma informed care. It was also a treat to teach with Kay, one of the original authors of Risking Connection©. I always learn a lot from her. One highlight of this training was the flock of wild turkeys outside the window of the room in which we were teaching. I guess they were also seeking some knowledge!

Two weeks ago I was an invited speaker at the Joint Commission and Joint Commission Resources Annual Behavioral Health Care Conference in Chicago. I was proud to share the stage with such notables as Pamela S. Hyde, JD, Administrator, Substance Abuse and Mental Health Services Administration; Amy Dworsky, PhD, Senior Researcher, Chapin Hall – University of Chicago; Paul Schyve, MD, Senior Vice President, The Joint Commission; David A. Litts, OD, Director, Science and Policy, Suicide Prevention Resource Center; Mark Katz, PhD, Director, Learning Development Services, Clinical and Consulting Psychologist; Kim Masters, MD, Medical Director, Three Rivers Midlands Campus Residential Treatment Center and Mary Cesare-Murphy, PhD, Executive Director, Behavioral Health Care, The Joint Commission. There was some very interesting information about the future directions of SAMHSA, the ramifications of health care reform for mental health. It was fascinating to hear the latest research and prevention efforts regarding suicide. The discussion of resiliency had some intriguing ramifications for treating trauma- the subject of another blog post.

I received many compliments on my presentation and had some good conversations with folks about what they are doing. And, the Joint Commission staff treated me so well!

Then last week Steve Brown and I travelled to Whitehorse, Yukon Territory, Canada. We taught both Risking Connection© and the Restorative Approach© to the Child Assessment and Treatment Services of the Yukon government. Included in this group were staff from Residential Youth Treatment Services and Child Abuse Treatment Services (C.A.T.S.). Also participating were staff from Alcohol and Drug Services. First let me say that it is a long way from Connecticut to the Yukon Territory. And lost bags, delayed flights and phones that stop working do not help. But it was most certainly worth it all to work with these excellent treaters. Providers working in the Yukon deal with situations of multi-generational abuse, extreme poverty, long standing drug and alcohol use, and lack of resources. I was extremely impressed with their compassion for and commitment to their clients. Two social workers we have come to know each spent over a year living in (different) remote First Nation communities for over a year to get to know the people and their culture. In the residential programs, they never eject a child. If the child runs away, gets drunk, does anything, they are still welcome back. No one was focused on consequences and they did not use points and levels. All staff seemed immersed in understanding the adaptive nature of the behaviors, and could see clearly the pain beneath the behavior. We had many wonderful discussions within the training, and the staff eagerly soaked up our framework and methods as a way to organize their thinking and their work. Through the kindness of everyone towards us, we were able to explore some of the beautiful area surrounding the town, and even go cross country skiing. I look forward to our return in April for the Train the Trainer.

I am extremely fortunate that my work brings me to such diverse and beautiful places and introduces me to so many committed, caring and intelligent people.

Explanation of the Restorative Approach for Parents

2010-11-07T03:57:00.000-08:00

I am trying to create an explanation of the Restorative Approach for parents, to be given to them at admission. This is what I have so far. Any suggestions?

Welcome to Klingberg Family Centers! We appreciate the opportunity to work with you and your child. We hope the following explanation of our approach will be helpful to you in understanding how we do things at Klingberg.

We believe that all healing takes place within relationships. We will do anything we can to create a strong relationship with your child and with you.

We understand that children and adults do things to try to meet their needs in the best way they know how at the time.

Many of the children and families that we work with have experienced bad things in the past. These difficulties have changed them.

If people have been hurt by other people, they stop trusting. They do not believe that relationships can be a source of help and can be counted on. Instead they have come to see relationships as unreliable and painful. So, it is important that we try to show the children and families we treat that relationships can be trusted and that other people can help.

When bad things happen to people, they start seeing the world as a dangerous place. It feels important to always be alert and looking out for danger. This makes it hard to relax, have fun and sleep. We hope to offer our children and families as safe place where they can learn to relax and learn ways to stay calm.

Many of the youth we treat have not learned the feelings skills that we all need to get through the hard things in life. It is very important that we teach them these skills. Often, the children cannot remember that anyone loves them or is on their side. They have a hard time thinking about people who care when those people are not near them. So we hope to strengthen their relationships with people who care (especially you and your family) and teach them ways to keep those people with them in their hearts.

The children we work with have often come to believe that they are no good and that everything that has happened to them is their fault. We work with them in many ways to develop a strong and healthy sense of their strengths and abilities.

A lot of the children in our programs do not know how to deal with their feelings. They cannot notice their feelings when they are small, name them, or get through them without making things worse. We will ask you to join us in teaching the child how to understand and react to feelings, including teaching them some skills to calm down and get through bad times.

When something goes wrong for one of our youth, they do not trust that others can help them with it. They are already feeling hyped up and anxious. They do not know what to do with all the feelings they are having. So they start to feel very bad, hopeless, and scared. They do something that makes them feel better in the moment, like yell, hit someone, hurt themselves or run away. They feel better at the time but then they have made things worse.

We have to help the child learn better ways to meet their needs, ways that do not hurt them and others.

When one of our children does something that hurts others, we try to figure out why they did it. What need were they trying to meet? Then we think about what they would have to know in order to handle this situation differently next time.

We give them a restorative task that offers them a chance to learn or practice a skill that will help them next time.

Also, we believe that the children need to learn how to make up for damage that you cause. So, when a child hurts others we expect them to make amends, to do something good for the person or people they hurt. So the child will receive or create a restorative task to make life better for the people they hurt. We will help you use this approach within your family if you would like.

Sometimes it may seem that the learning and making amends tasks are not enough when the child does something hurtful. You may wonder if the child should also have a punishment or a restriction. We believe that punishments do not help the child change very much. Instead, what will help them change is to learn skills so that they can meet their needs in a better way.

We urge you to talk these ideas over with your therapist, and let them know any concerns that you have.

We look forward to being part of the healing journey for your child and you.

What Should Be Earned?

2010-10-31T05:02:00.001-07:00

In creating our traditional behavior management systems, we operated from the premise that earning rewards and privileges would be the principle motivator for the children in treatment to change. We expected the children to change their behaviors so that they could earn more points and go up in the levels. In order to interest them in doing this, we had to have as many aspects of daily living as possible be contingent. Because we couldn’t actually neglect or abuse the children, we were already limited in what parts of life we could make the children earn. We were not allowed to use food, for example. So, we looked through the day and considered what could be part of the level system. We asked the children. And each system ended up with lots of things that the children could not have unless they were on a certain level. These ranged from extra TV and Nintendo time, to later bedtimes, to posters on their walls, to trips and special events, to lining up first in lines, to contact and visits with their families. The theory was that the more important the privilege was to the child, the harder he or she would try to control their behaviors and earn the higher level.

However, we have now learned that this formulation ignores many aspects of what we know about trauma, how it affects people and how they heal. Points and levels approaches assume that the main problem for these children is motivation. Rewards and punishments increase motivation to do well. But these children are already motivated to do better, they just can’t. They do not have the skills. When you do not have skills, increasing rewards and punishments actually makes behavior worse, as you feel pressure and resentment at being rewarded and punished for something you cannot control. Imagine if some part of your paycheck was based on your flying from office to office. You might make a few tries, but quickly you would give up and be angry and resentful.

Another factors ignored by level systems is the role of shame. If a person has experienced significant trauma, they are often shame based, which means that they feel that they are no good, different and worse from others, and totally unlovable. Being on a low level reinforces this familiar shame, especially when the levels are posted on a public board. Since success seems so impossible, why even try.

What if we actually believe that children act better when they feel better? If children are safe, happy, enjoying life, feel cared about, and are surrounded by trustworthy relationships, they will in time be able to be kinder, calmer and more trustworthy themselves. This assumption would lead us to give the children everything we could as soon as they were admitted. We would make their rooms warm and welcoming and allow them to personalize them. We would offer them many fun activities and warm relationships. We would give them support so they can experience success. Our goal would be to make our units places where the child learns that life can be good, safe, warm, and happy.

More specifically:

Children’s contact with their families should never have to be earned. The greatest predictor of success after residential treatment is how often the child connects with his family during treatment. There are already so many barriers, both practical and psychological, between the child and his family. Our job should be to facilitate as much contact as possible. We should not have visiting hours, the families should be welcome at any time. We must try to provide whatever practical help we can in areas such as transportation and child care. And we must make sure the family feels welcomed and not shamed when they visit. If the child or family is unsafe, we can provide visits at our facilities, supervised if necessary. But contact should be a right, not an earned privilege.

Also, we must keep in mind that children need fun, leisure activities, and play for many reasons. It is through play that children learn and grow, experience success, develop friendships, and experience joy. Many activities such as music, electronic games, dance, art and crafts can also be ways to self soothe and to get through difficult periods without making things worse. How are children going to learn to use coping skills if we tell them that they can’t have coping activities until they show us through their behaviors that they have already mastered coping?

The only time it makes sense to have a privilege be earned is when a child needs skills to be able to use that privilege safely. For example, a child who is repeatedly running away should not be given the privilege of going on walks alone. More autonomy and less supervision should be a result of responsible behavior. As children achieve their treatment goals, and as they show increasing ability to let adults know when something goes wrong or is bothering them, they can be supervised at increased distances. If a program wants a formal system for this kind of earning, it is best handled through a long term phase system linked to treatment goals. Advancement through the phases should be a team and child decision reached after discussion, and not based on point totals. Children should not go down in these phases.

It is certainly a good idea to suspend a given activity in response to a child’s behavior. For example, a child just hit a staff, then wants to go to the mall. The staff should reply: “Of course we are not taking you to the mall today. I do not trust that you will be responsive and not have a meltdown like just happened. However, work on your restorative tasks, let’s figure out together what just happened, and I’m sure we will go to the mall together in the future.” How long this suspension lasts should not be based on a pre-set time period. It should be determined by the child completing his restorative tasks and his attitude.

People worry that without many things to be earned the child will have no incentive to get through the day. Why should he finish his dinner, do his chores, go to bed if there are no points to be earned by doing so? Well, he should finish his dinner because it tastes good and he is hungry, or, it should be fine that he does not finish his dinner. He should do his chores and go to bed because he is asked to and is part of the community, because he gets help and encouragement from those around him and because he will not be able to do the next fun thing until he does so.

Look over your own system. What is currently earned? Do those things need to be earned? What do you think would happen if we gave the children every joy we possibly could for free just because they are alive?

Click comment to let me know your reactions to these thoughts.

The Characteristics of a Good Trauma Informed Residential Therapist

2010-10-24T04:17:00.001-07:00

The most essential characteristic of a therapist that will succeed in a trauma informed congregate care treatment program is that he or she likes the children and their families. This probably cannot be taught. These children can be difficult, demanding, and try anyone’s patience. If the therapist does not find them delightful, cannot see their goodness, does not look forward to being with them, she will have nothing to help her get through the bad parts. The children generally feel hopeless. They do not see their own worth and cannot imagine a positive future for themselves. If the therapist cannot do that, who will? And at times the therapist holds the hope for the whole team. One role of the therapist is to see a picture of how this particular child would be if he were at his best, even while remaining aware of the child’s current reality. The therapist who genuinely cares about and appreciates the children and their families can do this.

A therapist in a congregate care setting must be flexible. The day never turns out as one expects. Things rarely go as planned. It is time for an important family meeting and the child is at the park. An individual session is scheduled but another child is threatening suicide. The therapist is going to do her paperwork and the licensing inspector drops in for an unscheduled visit. Roles shift between people. The child needs to talk with her now. A person who needs a predictable day would not be happy in this setting.

Working with a therapeutic team is a particular experience. For some, it feels wonderful to have so much help and support. For others, it is difficult to have to share everything, discuss everything and make decisions within a group. The therapist who enjoys teamwork will be the most successful in congregate care. Often the teamwork is frustrating. There are factions, problems, disagreements. The therapist tells twenty six people about something and the twenty seventh complains that she wasn’t told. Decisions are made and then not carried out. Interpersonal issues between team members can be intense. Yet the treatment team can be the most powerful intervention possible in helping a child to change. And as the therapist struggles with the pain and difficulty with the work, it can be sustaining to have a team to share with. The team can laugh together, cry together and care together about the clients. The therapist that flourishes working in this complex environment will have the ability to form relationships with other staff, will assume good intensions in fellow workers, will give and accept feedback, will handle disputes openly, and will notice and praise the positive efforts of others.

At this level of care, a therapist must be able to tolerate chaos and intensity. The symptoms that the children display are frightening and are often life-threatening. There is usually more than one child in crisis at once. The families too can be angry, demanding, sad and scary. The systems around the child are often inadequate and frustrating. The therapist must know how to stay calm herself in the face of the agitation of others. She must prioritize and respond to the problems step by step. She must also be able to tolerate strong emotions in the clients, and stay with the client as they experience their pain, longing, anger and sadness.

In order to do this the therapist must have or develop good self care skills. All therapists will experience vicarious traumatization. The therapist must use their team to help them through difficult times. Outside of work the therapist needs strong supports and connections in order to maintain a work/ life balance.

A sense of humor is crucial for surviving and thriving in these jobs. Self awareness is also essential. The therapist needs to notice her responses to individual children and families, and use these responses to deepen her work. She should accept seek out and accept help in this area from her supervisor and her team. She should monitor her vicarious traumatization and know when she needs a break.

There are many skills and much knowledge that a therapist should have, but these can be taught in supervision or through workshops and training. If the therapist is eager to learn and grow, the agency must only provide the opportunity. In addition, the therapist must know or learn writing skills and have the ability to document and do treatment planning. Of course, the therapist must be responsible, come in on time, and be self motivated in completing her job requirements. Often, some on call duties will be part of the job.

It would be wonderful if agencies had the ability to pay this paragon what she is worth!

Recent Travels

2010-10-17T05:17:00.001-07:00

On the first of October I presented a Keynote speech and a workshop to the Midwest Regional Conference of the National Association of Therapeutic Schools and Programs. It has been interesting and rewarding to get to know these programs, which include both therapeutic residential school and Wilderness Adventure programs. They are beginning to utilize trauma informed care in their treatment approaches in unique ways.

I then travelled to Hawaii with my colleague Steve Brown to provide Risking Connection and Restorative Approach training to an agency there, Child and Family Service. It was a wonderful experience. It is certainly the only training at which I have been presented with two leis, one at the beginning and one at the end. I loved the Aloha spirit of the people in our training- they were so welcoming and helpful. The emphasis on multi cultural awareness was very moving. We can all learn from the way Hawaii incorporates all cultures into daily life. We had both agency personnel and representatives of the State Department of Mental Health in attendance. With four separate trauma related national grants, Hawaii is working hard to change their practice and offer more trauma informed services. We look forward to our ongoing work there. And of course exploring the island was wonderful- those beaches, turquoise water and waves! I snorkeled with bright colored fish and sea turtles.

This week I will be presenting two guest lectures: one at Hampshire College in Amherst, MA and one at St. Joseph’s College in West Hartford, CT. I am looking forward to the interaction with the students. It is encouraging to see information about trauma being included in college curricula.

Then I move on to upcoming trips to Chicago, Syracuse and the Yukon territory of Canada.

It’s a busy fall!

Succession Planning

2010-09-26T04:37:00.000-07:00

This was the last week for Klingberg Family Center’s President of eighteen years, Rosemarie Burton. Rosemarie has retired to spend more time with her twin granddaughters, as well as to develop her executive consultation business, By Your Side Consulting (www.byyoursidenc.com).
Rosemarie has been an exemplary president for Klingberg. When she started eighteen years ago, Klingberg had 95 staff, two programs and one location. As she leaves now, we have over 400 staff, around 15 programs and seven locations. In addition, the agency has grown in skill, sophistication and expertise.

Rosemarie has set the tone for the agency by her unswerving commitment to the children and their families. Rosemarie has taken each of the children in our programs to lunch on their birthdays and other special occasions. She enjoys the children and is deeply committed to their quality of life. Therefore in addition to focusing on securing the latest Federal earmark for the agency, Rosemarie arranges for the kids to have baseball uniforms, or for a talented girl to obtain an acting scholarship, or for a boy who is interested in architecture to tour the office of an architect friend of hers. She has demonstrated daily that the children and their families take precedence over anything else.

Rosemarie models the fact that high ethical standards and a sharp, practical business sense are not incompatible; in fact they support each other. Financial integrity and a commitment to excellence reinforce each other.

Several years ago Rosemarie began to talk about her retirement. Although none of us wanted to hear about it, her long and careful process has resulted in an excellent transition for the agency. Our new president, Dr. Steven Girelli, was chosen after a careful national search, and he has been amply prepared to assume his new role. All the many people, from staff to Board members to kids and families to donors to legislators who will miss Rosemarie have had many opportunities and ceremonies to say good bye. Rosemarie’s retirement party is next week and should be a major event with people from all eras of her life. Everyone is of course anxious about a major transition and this process has helped with that anxiety.

But for Rosemarie, succession planning has not been limited to finding and preparing her own replacement. Throughout her tenure at Klingberg one of Rosemarie’s strongest commitments has been fostering the growth of her staff. She has paid attention to staff at all levels and offered them opportunities to grow, be promoted and meet their profession al and personal goals. She has done this by offering conferences, training, taking people with her as she participated in national forums, and by spending time with people, encouraging and guiding them. She has especially focused on the women and minorities on the staff. At every level of the organization people have been identified who are doing a good job and showing promise, and experiences they need to grow toward the next step have been offered to them. So not only has the Presidential transition been smooth, the growth of the organization has been facilitated. Another benefit is that if staff feel they have opportunities, they stay with the organization.

I am certainly one of the people who has benefitted by Rosemarie’s encouragement. Much of who I am and what I am doing professionally has been made possible by Rosemarie’s ability to embrace new ideas and find the resources to move towards the future. Knowing Rosemarie as a person and a friend has taught and inspired me. I will miss her in so many ways. I am also confident in Klingberg’s future as we move forward under the skillful leadership of my friend Steve Girelli.

This multi-facetted succession planning is one important source of strength for a non-profit agency.

Trauma Informed Care in Wilderness Programs

2010-09-19T04:58:00.000-07:00

I have just finished a presentation at the New England Regional Conference of the National Association of Therapeutic Schools and Programs (NATSAP). I think it went well, I received a lot of positive feedback. The members were very welcoming and kind.

I had an interesting discussion with a gentleman from Utah about the application of trauma informed care principles in Wilderness Programs. His program serves youth who have gotten in trouble, often with drugs but also many other things, and who are not adjudicated but would become so if no action was taken. These are self pay by parents. The kids and staff go on month long hiking and camping expeditions. Therapists come out to meet with the youth weekly.

Some of the principles I teach match very well with their philosophy. Certainly, the whole experience is about teaching skills. The concept of building self worth is also central. The experience of needing to depend on others and work as a team develops a new template for relationships, that they can be helpful and trustworthy. The staff have the skills that the kids need to survive, and so the kids have to depend on them, and may begin to learn that they can trust some adults.

Wilderness programs also demonstrate to the child that their actions affect individuals and the community, so the concept of responding to misbehavior with making amends to individuals and the community fits well. We discussed the possibility that a child who has delayed the group progress can do chores for the others or do extra work to make the trip move forward.

There is a sense in some programs that you can’t let the youth get away with anything, and that understanding the adaptive nature of their problems could be seen as an excuse.

I would be very interested in hearing from anyone who works in wilderness programs. Have you incorporated trauma informed care? In what ways do you think it fits with your thinking? What areas have been hard to incorporate? Let’s start a dialog.

I have two more NATSAP presentations upcoming, and look forward to deepening this discussion.

When Chaos Strikes

2010-09-11T07:40:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Book Review: Working with Children to Heal Interpersonal Trauma

2010-09-05T10:21:00.000-07:00

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

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

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

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

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

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

Eliana Gil

The Difficulty of Taking a Break

2010-08-29T05:06:00.000-07:00

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

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

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

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

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

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

But it is hard.

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

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

Visit to Seven Hills Foundation

2010-08-22T04:45:00.001-07:00

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

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

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

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

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

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

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

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

Restraint and Seclusion Experiences of Youth

2010-08-15T04:41:00.000-07:00

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

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

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

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

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

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

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

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

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

Transforming the Pain of Vicarious Traumatization

2010-08-08T05:40:00.000-07:00

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

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

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

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

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

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

Here are some quotes from her interview on the show:

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

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

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

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

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

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

This is a quote from Krista Tippett, the host:

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

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

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

Do You Like These Kids?

2010-08-01T05:00:00.000-07:00

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

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

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

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

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

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

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

What Can We Learn about Trauma from Lizbeth Selander?

2010-07-18T05:01:00.000-07:00

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

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

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

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

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

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

• She is fiercely protective of her mother.

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

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

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

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

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

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

Vicarious Traumatization and Foster Care

2010-07-10T05:18:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

2010-07-01T08:47:00.000-07:00

Book Review

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Rituals of Passage

2010-06-27T10:02:00.000-07:00

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

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

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

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

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

Dilemmas of Trauma Informed Care

2010-06-20T17:08:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Book Review: Denial

2010-06-13T05:24:00.000-07:00

Denial: A Memoir of Terror

Jessica Stern

Publisher: Ecco (June 22, 2010)

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

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

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

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

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

Ah, Young Love

2010-06-08T14:16:00.000-07:00

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

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

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

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

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

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

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

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

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

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

Trauma Conference 2010

2010-05-23T15:26:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That would be us.

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

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

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

Children Act Better When They Feel Better

2010-05-18T04:30:00.000-07:00

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

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

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

Feeling Better Physically:

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

Feeling Safer:

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

Felling Calmer:

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

Feeling Less Shame:

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

Feeling more competent

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

Feeling more effective:

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

Feeling more connected:

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

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

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

Accommodation

2010-05-09T07:25:00.000-07:00

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

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

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

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

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

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

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

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

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

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

How to Enhance Hope

2010-05-02T12:50:00.000-07:00

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

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

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

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

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

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

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

Safety Empathy Action

2010-04-18T10:04:00.000-07:00

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

Now if only I could make it spell a word!

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

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

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

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

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

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

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

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

What else could we do to increase empathy?

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

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

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

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

What do you think of this formulation?

Musing on a Busy Week

2010-04-12T03:56:00.000-07:00

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

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

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

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

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

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

The Process of Change

2010-03-29T17:51:00.000-07:00

A cold and rainy weekend in March in New England provides us the opportunity to consider the process of change.
In nature, change never happens in a straight line. The seasons do not move from winter to spring through each day being one degree warmer than the day before. Instead, we have a warm day, and we notice buds on a tree. Then it snows. The crocuses come up, then the temperature drops and we wonder if they will survive. It’s very cold and raw, yet we see some skunk cabbage by the side of a river. We get discouraged, and say things to each other like "I am so done with winter. Is it ever going to warm up?"

Yet if we compare May to February, everything is different.

In February, if it is 45 degrees, we say: "A warm spell!!"

In May, if it is 45 degrees we say: "It is so cold!"

The parallels with our work are obvious. The children don’t get better each day in a clear progression. One day, Juan responds with kindness when another boy is upset. Staff make hopeful remarks to each other. The next day, Juan says something very mean to that same boy. Staff feel hopeless. Marcie has not had a restraint in months- maybe she is changing? Then she does and all feels lost.

Yet often when we compare this month to last year at this time, Marcie is substantially different. She is going to school and doing her work, and has not hit anyone in months.

We loose track of these changes. Now we complain with great intensity that Marcie is using a sarcastic tone when she speaks to us- forgetting that a year ago she would have hit us.

We have to learn to look for the snow drop in the snow, the red buds on the spring trees in the cold. Let’s rejoice in the warm day and point out the yellow willow to each other. When we see the small yet certain signs of change, we will have the strength to hang on through the raw days. Remembering to notice changes over time will help us celebrate the miraculous transformation we help our children achieve.

Emotional Intelligence and Trauma

2010-03-21T10:49:00.000-07:00

I have just returned from the National Council annual conference. It was an excellent conference, very large. I enjoyed the keynote speakers especially: Howard Dean, Malcolm Gladwell, Geoffrey Canada, Lee Cokerell from Disney and others.

I attended a workshop given by Dr. Hendrie Weisinger about emotional intelligence at work. He quoted research that shows that emotional intelligence correlates much more highly with having a good life than any other measure, including IQ. He described the problems that bring people to therapy as failures in emotional intelligence. Therefore, we should be more deliberate in teaching EI skills to our clients. So, I wondered how the ideas of emotional intelligence interacted with our ideas about trauma.

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

Self awareness is the key skill that is the foundation for all others- how can you be emotionally aware of others unless you are aware of yourself? This of course correlates with the skills of feelings management. I remember at the Bessel van der Kolk conference seeing evidence that the part of the brain that provides self awareness and self reflection is under developed in survivors of trauma.

In Risking Connection® training we read a letter written by a woman who grew up in the child welfare system. She describes eloquently how her repeated moves and continual re-defining by various families resulted in her not developing a sense of who she was and what her characteristics were. In short, she had no continuous self narrative.

So if self awareness is a key skill of a happy life and our clients are impaired in this area, what should we do? We should be consciously creating a narrative with the client. We should teach them self observation, including how to notice emotions in their bodies, patterns about themselves, awareness of their own strengths and weakness, a sense of their own skills and interests.

Mood management is also a key area of difficulty for our clients. Too much of their behavior is mood dependent- the child wants to be a lawyer, but because she discovered a stain on her shirt she is dropping out of school. At first we may have to support, cajole and help the kids in learning how to change their moods and to get through them without derailing. Hopefully they will improve in doing this on their own once they experience that it is possible.

Self motivation is another hard one. How do you get yourself to do things you don’t like to do? I usually promise myself a reward when it’s finished. Also, I picture other people who will be pleased. So I guess inner connection comes in here- being able to hold the awareness of someone who cares what you do, even when they are not physically present to help you complete the task. If we say to a child, let me know how that turns out, I will be waiting to hear from you, we are developing this skill.

Interpersonal expertise- how to defuse situations, handle conflict, work through differences, build consensus, accept feed back- of course this is a focus of much of our efforts. The Dialectical Behavioral Therapy skills manual by Marcia Linehan offers one excellent curriculum for teaching these skills.

Emotional mentoring means teaching others- and actually, we do see these among our clients when one gives another good advice. We can encourage this.

Strategies that Dr. Weisinger gave included:

1. Learn to listen to how you talk to yourself. Five minutes 3X/day listen to what you are saying to yourself- change your self talk
2. Write down three statements on a card that put you in a good mood, keep it handy
3. Use emotional self instruction. Create a learning aid. What would you want “Little You” to be whispering in your ear to help you manage the situation. Remind yourself that you have options.
4. Praise- write down behaviors you want more of in others, then praise when you see them (Imagine if we taught kids to do this with staff?)
5. Physical arousal- learn how to physically relax. Learn to notice when you are tense. Tension and relaxation exercise. Four components of relaxation exercise: Quiet environment; physically comfortable position; key image or phrase; passive attitude. (the quiet environment is hard to come by in some of our programs.)
6. Humor 10-14 good laughs a day- Get staff and kids together and have joke sessions
7. Can change our responses to difficult situations- the real problem is my own response. Then you can do something about it

It would be interesting to incorporate some of these strategies into our work.

Gloves and Lying

2010-03-14T05:57:00.000-07:00

An example from a recent Risking Connections® training demonstrates simple, free interventions we can use to implement trauma informed care- and also demonstrates exactly how hard they are to do.
Juan constantly lies, according to the staff of his group home. He lies to avoid consequences or to avoid admitting he has done something wrong. He also tells lies about things that are happening in his life- such as that he has a girl friend in school. He doesn’t have a girlfriend! He makes up whole stories that simply are not true. For example, staff gave him some new gloves the other night to replace the pair he lost. Now tonight he is saying that he doesn’t have any gloves, that no one will ever give him any, and that none of the staff care if his hands are freezing off.

It is such a normal human response to argue with the truth of these assertions. You KNOW you gave him gloves Tuesday night. He has probably just lost them again or left them in school. Juan really has to learn to be more responsible! We don’t have enough money around here for an endless supply of gloves. And what is this story about a girl friend! You know from talking with his teacher that mostly Juan is a loner in school and has few friends. How is he going to manage life if he keeps lying? So it seems important to tell him that you know this is not the truth and how can you trust him if he keeps lying.

What is happening with Juan during these events?

His hands are cold and he cannot believe he cannot find his gloves again. He feels like such an idiot and a loser. No one likes him, no one cares about him, and no one should- who would want to be around such a jerk? He feels stupid and unloved, and plus his hands hurt. Saying no one has taken care of him enough to give him gloves expresses his emotional truth. Certainly he cannot admit to having lost the gloves again, then everyone will be mad at him, as usual.

What if staff IGNORED the truth/falsehood dimension of the situation and just reacted to the emotional and physical reality? What if Mark, Juan’s favorite staff, said- "Hey Juan I see you have no gloves, let’s find some you can wear." And when Juan said "No one ever gives me gloves" Mark could say "You’re feeling right now that no one cares enough about you to help you- so let me see what I can do to help you right this minute."

How hard would that be? Mark might feel that if he doesn’t confront the lie Juan will have put one over on him, or will never learn that it is not okay to lie, or will start telling more lies to get what he wants. He might feel that he needed to defend staff against Juan's charge of neglect, point out that staff have been responsive and would never let Juan go without gloves. But I would suggest that Juan will need to lie less when he develops a new view of the universe- that this world is a place where people will help you, where people care what you are feeling, where they do not shame and blame you. Only then would Juan be able to admit that he left his gloves at school.

And what about the girlfriend? Juan is desperately lonely at school and is sure he will never fit in there. He thinks none of the kids like him or ever could. Especially not the girls. So when he comes home he creates a new reality, life as he wishes it could be.

What if Mark were to reply: "wow it would sure be nice to have a girlfriend at school. What do you like in a girl, any way? What kind of girl would be the perfect girl friend for you?" and start a discussion of girlfriends in general. At some point Mark could ask, "If you wanted to make friends with a girl, what would be the first thing to do?" and start teaching social skills.

Note that Mark just side steps the true/not true question and again, reaches for the emotional reality. He doesn’t believe or challenge Juan’s story. He just turns it into a discussion of an important subject to Juan- girls. He avoids shaming Juan further (“Juan, I talked to your teacher an in fact you do not have a girlfriend”) which would just lead to Juan’s needing to lie even more.

What would it take for us to respond like this much of the time? When we are away from the situation in a training it all sounds like a good idea, yet in the pressure of real life we find ourselves reverting back to arguing about the lie. Time to think and plan, time to consider what needs the child is meeting, and to choose a more thoughtful and healing response are essential.

What do you think about the likelihood of this sort of response in your setting? Click on comment and let me know.

Connection in California

2010-03-13T04:37:00.000-08:00

I received the following email on Friday afternoon. What a wonderful way to end a long and successful week!
Pat,

I wrote to you in May of 2009 and shared that I am a therapist in a Level 12 co-ed group home in San Luis Obispo California. We had recently changed our residential treatment program from a CBT based program to a Relationship Based model and we were having some growing pains. Since then we have made some tremendous growth, yet there are just a few things that keep us coming back to the table. Each time it does my thought is "what would Pat do," and more often than not due to the AMAZING blog you share we are able to work through the issue. ...

I have to say that is was an article that you wrote that finally helped change our program. For years I worked as line staff and was pleading to make some changes and then I found Pat and your blog. Thank you doesn't even express how much I appreciate, respect and admire you..you have started a movement toward healing these children. "Change your thoughts, you change your world." ...

And I want to leave you with this quick story...we have a young man who has been in our program almost two years. When he would get upset at times his coping skill would often be breaking the T.V. or other items the other kids enjoyed using. His response when given feedback by the kids or staff was to defend himself and say "I don't care." Within 3 months of us changing our program he sat in a group meeting with the other kids and said, "I know I broke the T.V. and I am working to fix it," he also had the other kids jump in to help him in that process. It was AMAZING!!!

Anna K. Yeackle, LMFT
Program Therapist
Transitions Mental Health Association
The Youth Treatment Program

Thank you Anna... people like you are the reason we continue our efforts to change the world.

Dr. Robert Davis to present on Benefits and Implementation of Trauma Informed Care

2010-03-08T07:03:00.001-08:00

Risking Connection® faculty trainer Dr. Robert Davis to present on Benefits and Implementation of Trauma Informed Care at the Doctor Franklin Perkins School in Lancaster, Massachusetts.

This workshop will describe efforts to implement a trauma-informed approach to residential treatment and an on-campus school environment. Over a five-year period, this multifaceted initiative resulted in substantial reductions in both physical management episodes and staff injuries. Research in the area of trauma-informed practices within residential schools is still in its infancy.

Objectives:

1. Participants will learn about the national movement toward use of trauma-informed strategies.

2. Participants will learn about the benefits of training interdisciplinary staff in Risking

Connection®, an established curriculum for working with traumatized youth.

3. Participants will learn about numerous trauma-informed milieu and/or classroom approaches which can be integrated into existing evidence-based models of treatment.

4. Participants will learn about future directions in trauma treatment for youth, including

several body-based interventions.

5. Participants will learn ways to anticipate and overcome many of the institutional challenges of implementing trauma-informed treatment.

Presenter:

Robert Davis, Psy.D. Director of Clinical Services, Devereux Rutland, MA

Dr. Robert Davis has served as the Director of Clinical Services at Devereux as well as the Chief Psychologist of Devereux’s APPIC-approved Predoctoral Clinical Training Program. He also is a Faculty Trainer for the Risking Connection® Training Program for which he has trained multidisciplinary staff from congregate care settings throughout the country.

The workshop will be from 9:00 a.m. to 2:00 p.m. The cost is $45 for Members and $65 for Non-members. (Lunch is Included in registration fee).

To Register: copy this link into your web browser:

http://maaps.org/cde.cfm?event=300568