Dare to Transform 2008

I am leaving today to present at the Dare to Transform Conference sponsored by the National center for Trauma Informed Care, a part of the Center for Mental Health Services. I will be presenting with my colleague Dr. Steve Brown, a co-worker Samantha Morris and an adolescent consumer Ashley.

This is the official description of the conference:
Dare to Transform capitalizes on the momentum building since 1994 for trauma informed systems change to bring about a revolution in human services delivery. The Center for Mental Health Services (CMHS) has been sponsoring conferences that have defined the agenda of what needs to be done to recognize, understand, spark, and speed the healing and recovery process from violence and trauma. From Dare to Vision in 1994, to Dare to Act in 2004, and now Dare to Transform in 2008 we are moving closer to real action for positive and lasting change. At the National Center for Trauma-Informed Care (NCTIC).

With the Dare to Transform trauma summit, the stage has been set for a revolutionary learning exchange devoted to trauma-informed innovation and systems transformation. Joining in this experience are consumers and survivors; policy makers; administrators and those providing staff support; service providers; and other advocates who have a stake in this transformation. Dare to Transform is the boldest expression yet of what needs to and can be done to bring about change - and you are a part of it!

Our Goal: Revolutionizing Human Services with Trauma-Informed Care

Find out more about the conference at: http://www.daretotransform.ning.com/

Our workshop:

Friday 1:15 pm to 2:15 pm Workshop Sessions
Georgian Room Creating a TIC Culture of Connection in Child Serving Agencies
Pat Wilcox, Klingberg Family Centers
Steven Brown, Director, Traumatic Stress Institute of Klingberg Family Centers

This presentation explores the joys and struggles of implementing and providing trauma-informed, relationship-based treatment to children and adolescents. This approach utilizes Risking Connection® trauma training and the Restorative Approachtm implementation model. One agency's process will illustrate the reasons change is necessary, how the trauma-informed model compares to a traditional control-oriented model, how to utilize training, how to facilitate the process of changing an agency, barriers to change and how to address them, and long-term benefits of transformation.

Please come by and say hello!

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Beauty Review: Schick Quattro - Razor for Women

Summer makes several beauty related issues a priority. Light summer clothes and beach season means we are all concerned with the issues of smooth skin. And, of course, getting rid of unwanted hair is one of the top priorities. Smooth beautiful legs and sexy bikinis are a must for the sunny season. In summer we depilate more often than in other seasons. That’s why the time it takes and the

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What We Know About Trauma…

The Restorative Approachtm creates a milieu management system that is based on what we know of the effects on a person of early repeated trauma and attachment disruptions. The following makes that connection more explicit.

Biological Disruptions in the Brain and Body

Less developed pre-frontal cortex
More easily over whelmed by emotion
Over developed response to danger
More difficulty accessing verbal memory
Confused, few or no rhythms
Less integrated, has more trouble with generalization
Less connections and conductivity
Lives at a hyper aroused state
Is always very alert
Sees danger every where, therefore misses a large part of what goes on due to focusing on danger

Create the Need To:

Staff has to act as cortex for the time being
Actively teach problem solving rather than punishing
Help the child with selective attention, working memory, self observation, and response inhibition
Don’t respond to dysregulation with thinking interventions- respond instead with calming and soothing
Reassure, don’t get into power struggles, don’t back child into corner
Do not rely on verbal planning
Use multi-model interventions such as art, dance
Maintain predictable structure
Offer rhythmic activities such as yoga
Be clear in communication
Make connections between various aspects of life explicit
Practice new skills in many arenas and settings
Be aware that child will notice everything
Actively stress safety
Look for ways to help child relax such as night light, reading, music

Negative Assumptions about Self and the World

The child has learned that no effective action is possible in his life
Blames self for the events in his life
Feels worthless and less-than others
Feels hopeless

Create the Need To:

Avoid shaming interventions or interventions that dictate passivity
Develop competencies
Build trusting relationships
Develop a sense of safety in which child can share that which he finds shameful
Allow many opportunities for active participation in decisions involving the youth
Respond to problems by guiding the youth to fix damage they have created, repair relationships they have damaged
Point out strengths and achievements, skills and gains

Difficulties with Relationships

Has under-developed ability to sort out social cues
Has difficulty trusting adults
Values control above all else
Expects rejection
Does not know how to handle problems in relationships
Has trouble asking directly for what they want
Is uncertain about boundaries and tests them
Evokes strong feelings in others around him

Create the Need To:

Be reliable and stick around
Be aware that child will notice everything
Be clear in communication
Teach social interpretation through movies, etc.
Emphasize trustworthy relationships
Use the language of the heart and communicate the relationship effects of behavior
Provide relationships that stick with you
Give child control whenever possible
Collaborate
Provide paths to work through relationship difficulties and to restore damage done, to make amends
Staff model relationships skills and actively teach social skills
Practice and model assertiveness
Say yes when possible
Maintain firm and flexible boundaries
Be aware of complexity of boundaries in child’s life
Staff discuss boundary issues openly with each other and with kids
Culture of self awareness and team development

Lack of Learned Emotion Management Skills

Unable to recognize or identify emotions
Does not know how to sooth themselves
Does not know how to handle something going wrong without making it worse
Has many negative coping tactics for handling pain
Moves from extremely aroused to extremely shut down
Covers up vulnerable feelings such as fear and sadness
May experience flashbacks and dissociation

Create the Need To:

Teach names of emotions
Teach recognition of bodily sensations of emotions
Help child develop awareness of own emotions and their stages
Develop tactics for each stage
Actively teach and model self soothing
Teach distraction and calming techniques
Develop a list of distress tolerance tactics
Offer child alternatives not consequences when child is becoming agitated
Look for adaptive function of symptoms
Collaborate with child in developing other strategies to solve problems
Create safety to share vulnerability
Model having vulnerable feelings while remaining strong
Teach grounding techniques

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Notes from the Trauma Conference 2- Effective Action

Another concept stressed at the trauma conference was effective action.

Why do we have emotions in the first place? Why is it evolutionarily beneficial to feel?

Emotions are there to create action. An organism that can move about in the world has to have some way of evaluating various choices and what the impacts will be. It has to be able to move towards actions that will keep it and its species alive, and move away from those that are harmful. So the goal of emotion is to make the body move. The brain is the organ that moves the body. So the body sends signals to the brain, known as emotions, and the brain evaluates these signals on many levels. There is the emergency response of the amygdala: quick, but not too subtle. Just am I in danger? If so, can I run away? Fight? Or do I need to freeze?

The woman on a hike is dreaming of her new boyfriend when she sees a curvy dark object in the path ahead. She jumps back before she is even aware she has seen it. Her heart is beating fast. Her attention is focused on the object. All thoughts of her boyfriend are gone.

If the organism has time the higher brain can step in and make more subtle decisions. Is this situation relevant to me? How does this compare with other sensations I have felt? What is the most effective action in this situation? Should I suppress my habitual fear response and do something else?

Cautiously the woman approaches the object and gathers more data. It isn’t moving. It has bark. It’s a stick! She is able to move it out of the path and keep hiking, but it is several minutes before she feels relaxed again.

The emergency response is essential to the survival of the human race. Its goal is effective action to survive the threat. We spend stress hormones on effective action- that is what they are for. One part of the emergency response is to seek attachment- the human attachment needs go up in danger mode. This too makes sense from an evolutionary point of view, as the other person can help over come the danger.

The goal of emotions is to effect physical movement and regain equilibrium.
Through effective action and through connection we return to homeostasis.

But the traumatized child is blocked from any action. And the people to whom he looks for attachment help are the people who are hurting him. Fight or flight reactions with no effective action leaves the body stuck. Successful action returns the body to homeostasis. With no action possible, the person is left with a template that nothing you can do makes any difference.

One writer who has explored this concept extensively is Peter Levine, whose newest book is Trauma Through a Child's Eyes: Awakening the Ordinary Miracle of Healing
by Peter Levine, Maggie Kline
North Atlantic Books; 1 edition (December 26, 2006) http://www.amazon.com/Trauma-Through-Childs-Eyes-Awakening/dp/1556436300/ref=sr_1_2?ie=UTF8&s=books&qid=1215136060&sr=1-2



So how can we integrate these concepts into our treatment settings?

Let’s think carefully about how we can expand our children’s experience of effective action.

In every day life we can use all the principles of youth driven treatment: student councils, consulting youth on decision making, peer mediation, etc.
We can give the kids ways to help the greater community through volunteering and social action.
We can help them develop competence in many areas and act for themselves through making their own phone calls, arrangements, advocating with their DCF worker, writing letters, attending meetings about their life, etc.

And when something goes wrong, the Restorative Approach(tm) promotes effective action. Through restorative tasks and making amends, the child learns how to solve their own problems and make up for the harm they caused.

A child who assaults some one and then has to spend hours alone in a room has just had one more experience of no effective action being possible, one more experience of "there is nothing I can do". He feels more shame than ever. He is suck with all the danger action hormones with no where to go.

A child who assaults some one and then works it out with them, does a chore for them, works on a chart about what happened, and heals the relationship is left with a feeling of "there is something I can do". He still feels bad about what happened, but feels he is a person who can accomplish something, and make things better.

The principle of encouraging effective action will be a great guide for us if we keep it in the forefront of our treatment decisions.

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Notes from the Trauma Conference: Emotional Awareness

I have recently returned from Bessel van der Kolk and the Trauma Center at JRI’s (http://www.traumacenter.org/) annual conference (https://www.themeadows.org/events/index.php?rm=event_details&param1=show&param2=27&). It is my second year attending, and again I found it a fascinating and rewarding experience. The overall theme was trauma and the body, with a heavy emphasis on understanding the brain, the roles of various parts, and the impact of trauma. The JRI group are becoming more and more convinced of the importance of including body work in therapy for traumatized patients, and have recently received an NIMH grant to study the use of yoga in trauma treatment. They also recommend EMDR, dance, drama, art and other non-verbal therapies.

One concept stressed by many of the speakers that seemed important to our work is the concept of emotional self-awareness. Regulation of emotions is not possible unless you are aware of emotions.

Trauma causes people to become disconnected from their bodies and numb to their emotions. People keep active, display symptoms, engage in risky behavior, all in the service of not feeling what they are feeling, as they only associate feelings with intolerable pain.

Lane and Schwartz have identified stages of emotional awareness- awareness of:
Physical sensations
Action tendencies
Single emotions
Blends of emotions
Complex emotions

The higher stages recruit higher levels of the brain.

Emotions are felt as bodily sensations. The vagus nerve carries information from the body to the brain, however it is two-way. Therefore you can change how you feel by moving your body. Thus the efficacy of dance and rhythmic movement in helping change our emotions.

How do we become emotionally aware? Through a securely attached relationship with other human beings. Through attuned interactions in which the other person names emotions, recognizes them, expresses them in sync but with a little twist. Through small ruptures in attachment which are soon mended. Through caring others connecting our bodily sensations with the names of emotions and with the suggested action steps. Through people validating our emotions, exploring them, paying attention to them. Through valued others taking our emotions- and theirs- into account when making decisions. Through these complex and oft-repeated processes, we develop the ability to notice our feelings, to name them, to reflect on them, to use our higher brain (pre-frontal cortex) to inhibit our immediate emotional responses when necessary, and to take effective action.

We do incorporate many of these processes in treatment. Most therapists have a feelings chart, for example. But I think we could be much more deliberate and conscious about it. If we understand that one of the basic problems our clients face is the lack of emotional self awareness, we can purposefully incorporate this training into all aspects of our interactions. This can be done through naming emotions we observe, validating, asking for the bodily sensation, teaching Wise Mind (DBT concept), feelings charts and thermometers, and many other ways. Treatment teams could discuss clients in terms of this skill (the first step in the Risking Connection® feelings management skill) and make plans as to specific actions to take for each client.

We cannot teach emotional regulation until the clients can recognize an emotion when they see one.

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Feeling Sorry For Her

A central assumption of our approach is that symptoms are adaptations- these kids are doing these crazy things for a reason. The problem behavior is a solution for the child. It is accomplishing something, getting the child’s needs met, in the short term, even though there are longer term negative consequences.

In order to practice this thinking, we give training participants a scenario:

Alexandra is a 14-year-old-girl who has a history of trauma and multiple separations from her mother. She has a history of self-injury and suicidality. She has been placed in this home for six months, and her foster mother has noticed that in the last month she’s been opening up to them in a new way that she has not before. Last week, it was announced that one of the other kids in the home was going to be leaving to go to a group home. This morning her mother observed that she was wearing long sleeves even though it was 90 degrees out. When her mother asked why, she told her to "f__off." She eventually revealed that she had been scratching herself with a paperclip.

We ask people to consider:
What are 2 or 3 hypotheses about how Alexandra’s self injury might be adaptive for Alexandra? What problem (s) might it solve, how might it help in the moment, even though it leads to negative consequences in the longer term?

And then to:
Choose one hypothesis. If this hypothesis was true, what are possible ways the foster mother might help Alexandra to solve that same problem with fewer negative consequences?

In a recent training that I did, people responded (as they often do) "she is doing it for attention". So why does Alexandra need attention? (She may be scared of opening up to the foster mom and then possibly losing her as the other child is going to.) Why doesn’t she ask directly for what she needs, or express her fear directly? (She doesn’t know how, she can’t be that vulnerable especially now when the relationship feels tenuous.)

One participant added: "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 Alexandra needs.

Of course, there is every reason to feel sorry for Alexandra, or to feel sorry about what has happened to her. She has had a very difficult life, and terrible things have occurred that were not her fault. Her basic needs have not been met. She has not been safe. These experiences have changed the basic biology of her brain. Her life has not included much relaxation and fun. She has not been taught that she is worthwhile, special, and that people love her. She has not been shown the feelings management skills she needs for life.

Yet when we say "she wants us to feel sorry for her" we are forgetting that Alexandra 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 a committed relationship, and when she gradually learns new skills.

Although using the phrase "feeling sorry for her" seems like a small thing, it is important to stop and challenge ourselves. This phrase can lead to an entire attitude that will infect our response to the child and interfere with her healing.

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Was He In Control?

Luke and Jason ran away last night. But they didn’t go far- they broke into the school and destroyed the kitchen. They broke several appliances, wrote mean things on the walls, and dirtied the place.

As staff discussed this incident one question that came up was: were the boys in control of their actions?

This often seems to be a key question for staff. It has many ramifications as to how they feel the incident should be handled. Although people do not articulate their assumptions, I think that they are:

The more we decide that a kid is "in control" the more we feel we should respond with punishment.

The more we think the kid is not in control, the more we can be understanding and respond in a more "helping" or "treatment" way.

Our sense of how "in control" they are is based on factors like whether they generally are psychotic, whether they appear emotionally dysregulated, whether the act is an impulse or planned, etc.

I think this is a false dichotomy.

First of all, I think we can all identify acts which require planning, but in which the person is not in control- compulsive sexual or other addictive behavior for example.

There is also a moral component here. The "in control" side includes elements of being deliberate, doing this on purpose to hurt others, and slides rapidly into labeling the boy a bad kid.

But most importantly- I don’t think that saying a child is "in control" answers any questions or even changes the questions.

Let’s postulate that those two boys had total control of their actions, planned this event for weeks (although in fact they didn’t), and were not apparently dysregulated at any time.

The question still remains: why?

With all that control, why did they choose this particular action? How was it adaptive to them? What needs was it meeting? What message was it expressing? What kept them from meeting those needs or expressing that message in a more positive way?
I would still assume that their attachment disruptions, lack of consistent positive parenting and early trauma is relevant to the needs they are meeting and to their inability to meet those needs in other ways.

And, I would assert that the response does not change. What would make a child be less likely to consider trashing a kitchen? After all, most kids don’t. Why not?

I think that this behavior would be less likely if the child:

Felt loved
Cared about some people and did not want to disappoint them
Knew that others expected the best from him
Expected that adults would most often meet his needs
Felt hopeful
Cared about the people who would suffer from his actions
Even knew that people would suffer
Had a sense of a future, of goals and a trajectory towards them that seemed possible
Had some skills to manage sad, disappointed, scared and hopeless feelings
Felt that he was a good person who doesn’t do things like this
Had a sense of belonging to a community and being responsible to that community

How can we increase these things? Mostly in day-to-day life, before and after the behavior, through all our treatment strategies which honor and build relationships, help children internalize relationships, increase self worth, and create feelings management skills.

But in response to the behavior? Will punishment increase or decrease these feelings and life assumptions?

Restorative tasks, making amends, working with people to fix the damage, and looking at what was going on will increase the above protective attitudes.

And the question of whether or not the boys were in control will fade into insignificance.

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