Trauma informed programs and staff assault?

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Trauma informed programs and staff assault?

I am wondering if people working in programs taking a trauma-informed approach are seeing a heightened level of aggressive or assaultive behaviour against staff – or are working in environments where an elevated tolerance level for aggressivity against staff is expected?

Just curious.

Thanks

Andrew Middleton
Atlantic Youth
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Andrew

Understanding trauma allows us to make sense of some complex behaviours, particularly aggression and violence. An elevated tolerance would naturally emerge from a sound understanding of the behaviour. However, tolerance must not be confused with acceptance. There is behaviour that is entirely unacceptable and must be addressed as it will interfere with the key professional agendas (promoting independence, maximising choice, enhancing social inclusion, etc.). Professional staff whose job it is to challenge this behaviour must do so in a manner that is caring and supportive. Intolerant responses are likely to display similar attributes to the root cause of the trauma and would therefore be detrimental to a young person’s experience.

I hope this helps; it’s a very superficial summary of a complex interplay between understanding, acceptance and tolerance.

Ni Holmes
Scotland
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Great question, Andrew. I think, yes, trauma can lead people to withdraw from others or strike out toward others. Our role is to be with them in ways that lend to them seeing more options and choices than they currently do. Today at the Scottish Institute for Residential Child Care, the morning speaker had a profound thought:

We do much about making people feel safe on the outside but need to ensure people are safe inside. In place, in self, among others.

James Freeman
California USA
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If the practices are done properly it reduces traumatic responses, reduces restraint and reduces harm to staff and children. The practices do not encourage increased tolerance of aggressive behaviour. If staff members are not properly trained, or do not follow the practices it increases reactivity. Many programs in the US have had tremendously positive results and programs have become much more responsive to children’s developmental needs – reducing liability and harm.

Stacy McRae
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Hi Andrew,

I work in residential care and have noticed a big difference, where youth have lost respect for YCWs and have become very aggressive. I don't believe hands-on (CPI) is therapeutic but youth need firm verbal cues and boundaries. They need to know when they are being disrespectful and their acting out is not okay, there’s consequences to their actions.

I think we have really lost hold of what YCWs work is all about, and are now just maintaining behaviors, "we" have basically allowed this to happen.

Jo MacDougall
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As a recent graduate I feel that I was under prepared for the amount of abuse both physically and emotionally staffs receive. I feel that when I first started in group care it was a rare event to see a restraint, but as the time went on I witnessed more and more. I believe that it is youth dependent which influence other youth responses. As we began to receive more intakes from the GTA abuse increased. In dealing with this my employer became accepting of the abuse staff were undergoing and a norm was set that this was OK. As a team member its best to express concerns about heightened abuse situations and really consider if your facility is equipped to handle an escalation of assaults and why this is happening. But in short, yes I have seen an increase of staff assaults ranging from minor to extreme.

Emma Hall
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If you work with those who have been traumatized/ deprived/ abused from an early age, this may be useful: "Severe Attachment Disorder in Childhood – a guide to practical therapy” . It’s at Springer, or see www.attachment-disorder.net.

If you want the broad view of children without parental care globally, I’m a co-editor of this issue which we present at the WAIMH Edinburgh Congress next Tuesday:
http://onlinelibrary.wiley.com/doi/10.1002/imhj.2014.35.issue-2/issuetoc

Or, have a look at the latest news at wwwfairstartglobal.com
We are still working to create a two-year international master in pedagogic and organizational development here in Denmark.

Best from Niels Peter Rygaard
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Recently I was working with a young woman who is new to our program and new to residential care. She and most of the other female residents in the program are currently in a state of crisis and exhibiting very unstable (unpleasant) behaviours. I'm sure many would describe this young woman as "disrespectful", "rude", "verbally abusive", "hateful", "selfish", "aggressive"...

Toward the end of the day I looked at this young woman (really just a girl) and said "Kara (not her real name) you know I like you even though you are acting this way and there's nothing you can do to make me not like you." I purposely chose to say "like you" rather than "care about you" because I felt she was a girl who didn't believe too many people liked her. Her response was "But I'm trying really hard to make you not like me." To which I replied "It's not working."

Now wouldn't it be lovely if I said Kara threw her arms around me and said "Oh thank you for caring about me, for seeing past my fear and hurt, for helping me to trust you, a stranger, when I can't even trust my own parents to take care of me. Well she didn't. She promptly replied "F*#k you Kim." (Which personally I thought was a really great response.) But the next time I encountered her she was a little different and the time after that she ran to me to tell me something that had happened to her that day.

I know I have a long road ahead of me in terms of developing a relationship with this girl that is based on mutual respect and trust, one where she doesn't scream at me, call me names and try her best to make me not like her. I'm trying to adopt a trauma informed approach, which to me means first and foremost seeking to understand how the experience of abuse, neglect and abandonment shapes a person's world view – creating irrational beliefs that lead to those behaviours we deem negative, dysfunctional etc. My job is to respond to those behaviours in a way that doesn't reinforce those irrational beliefs, trigger memories of trauma or cause more trauma.

This doesn't mean that I condone behavior that is aggressive, rude or disrespectful but getting to the place where I can help a young person change that behaviour is a process that takes understanding, patience, caring and time. It's not an easy job we do but educating ourselves about trauma and a trauma informed approach to youth care is a step in the right direction to maintaining a high standard of practice when the going gets tougher.

Kim Nicolaou
Dartmouth, Nova Scotia
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Hi Kim,

What a moving and insightful contribution. It is all about meeting people where they are at and accepting them unconditionally and sticking in for as long as it takes. Good luck.

Peace
Jeremy Millar
Scotland
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"All children are capable of success, no exceptions."

Drake Fu
Kids At Hope
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Amazing tonight of all nights I decide to read this email and it has hit me hard in my face, you are totally right. Trauma informed practice that's amazing too often and too easily we work with these kids and we get annoyed at them for the behaviour they display. We do this job for a reason we are in this helping profession for a reason, we don't agree with the kids challenging behaviour but we need to stop think about what they have experience and progress forward supporting and guiding our kids with understanding and tolerance. Let them swear short what ever we know it's not truely directed at us personally. If stick by them they eventually learn to trust us and once again have faith in humanity.

Thank you for sharing this with a social worker who has become tired and annoyed and who has forgotten about her kids trauma. I feel awakened from reading this.

Mariesa Williams
New Zealand
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I completely agree Jeremy. It is so heartwarming to see Kim's enlightened approach. She is able to put her love for the world above ego and in so doing, she is an inspiration to us all. It lifts my spirits to know that there are people like the two of you in the world.

Regards,

Lynne
Liverpool
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There is a fantastic podcast on trauma informed care for anyone interested. You can download it free from: http://socialworkpodcast.blogspot.co.uk/2013/04/an-overview-of-trauma-informed-care.html

Werner Van Der Westhuizen
South Africa
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Great thread of insightful process we all go through. This is like discovering a polluted lake and taking on the opportunity to clean it up.

Hector
Sedgwick, Maine, USA
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Many years ago the classical psychoanalyst Otto Rank declared that all psychiatric “problems” could be traced back to “Birth Trauma” – and Freud agreed with him. The underlying assumption is that trauma occurs in the process of separation between self and other. If this is so, there are two possible approaches – to treat the “trauma”, or facilitate a reconnection between self and other through relationships. Clearly, psychiatry has opted for the former. Hopefully, “informed” Child and Youth Care practitioners will choose the latter.

Gerry Fewster
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Gerry, I am curious of your opinion on whether dominate culture social work and the managed mental health care system has leaned more towards the former rather than the latter? Trauma informed care appears to focus on the trauma, labeling persons as traumatized and in need of specialized care provided by specialized expert practitioners in short hour long (45 minute hours) to address skills and reduce trauma identification often at the expense of authentic relationship with caring others. Will the "industry" come back to relational work?

Peter D.
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I wonder whether there are not more possibilities. But if the underlying assumption is that trauma occurs in the process of separation between self and other, I think there are more than two possible approaches. I think that assumption could be right, or it could be wrong, or it could be partly right/wrong. I think it is possible that with some children it is right and with others it could be wrong, so our approach could be either approach, or a combination of both, depending on our assessment.

Werner
South Africa
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Yes, I believe the growth of ‘professionalism’, based largely upon the medical model, has led to the depersonalization of human services. Like so many aspects of life of this troubled planet, we seem creating the very problems we set out to resolve. On the other hand, I don’t believe the “industry” has ever been founded in relational work. For many years I’ve argued that Child and Youth Care is the one discipline that could make relationship development the core of its professional identity. I live in hope.

Gerry Fewster
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Sad to say (or is it good to say), that each child youth care agency has it's own philosophy. Many are embracing trauma informed care. My experiences with many agencies is that – " our mission statement is........... and so on..........which makes us a leader in the field". Some times the core values of the child care profession make it into the mission statement. For other agencies, they may embrace parts of it on none. Some facilities are lead by true child care workers, others have social workers trying to do the clinical thing, and even others (like psych hospitals) nursers actually are in charge of the child care staff. And a few other agencies seem to express deep concern for the child – but their day to day practices tell another story. Also in the mix are state or provincial licensing and funding authorities that have their own philosophies that trickle down. And those seem to change from time to time by the "regime in power" at the time. Over the years I have heard these great pontification on how every one must "do this with our new direction" – only to hear about another task force to develop to a new mission and strategy (and encourage everyone to get on board with our next new bold direction).

So with Trauma informed care, that seems like a great lead statement, until we look at the details of what is wanted. So I guess it is great that individual agencies do have the autonomy to develop their own mission with input from staff – and lets hope they hit the mark of what we all want for our kids in care. It seems the poor child child/youth care worker is always at the bottom of this system of care – well no, make the kids at the bottom (even though it may be stated that kids need to be empowered).

Gene Cavaliere
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Where do you see hope Gerry? I am thinking more and more about getting out of the mainstream professionalized system and starting a business employing young adults transitioning out of institutionalized settings and providing them with paid work and mutual aid casework groups to support them in navigating the world interdependently. Taking off the hat of social worker... ITs just not the system of social caring I had hoped it would be. Too scripted into neat boxes which serve to protect the profession more than they do empower people. I've also thought about entering into academia but I'd like to stay working with people directly.

Peter D
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I like the way you think Peter D! Great question Andrew. Although I have been working with teens and families for the last 15 yrs, my background is working with Adults with Developmental delays. I have always used the same philosophy with the teens that I used with those adults. Regardless of your diagnosis, there are things you can and things you can’t do to function independently in society. Let’s use their strengths to help them be the best they can be instead of legitimizing the reasons they can only be average.

Delia Noel
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Colleagues, I have been a reader of CYC-Net discussion threads for the last 14 years – occasionally making a comment or two along the way. However, I am particularly intrigued by the whole concept of trauma-informed programmes, where it has come from and what is the value of thinking this way. A few thoughts that I would like to add to the discussion/ on-going dialogue on the matter would include (of course, I am speaking from a very particular context – both geographical and culturally). Also the points tend to be separate with some overlap, but not meant to be sequential:

Cohort of children not being met within traditional services
The main thrust, as I understand it, is that there is a cohort of children in care for whom the current mental health services is not being met within the traditional CAMHS & Psychology Services. The presentation of this cohort of children usually does not meet the diagnostic classifications of the DSM-IV. However, the presentation and behaviours of these children is a cause of huge concern to child care practitioners and mental health services in our own Area and for whom there is a common recognition that services as they were currently configured were not meeting their needs. This was captured by Margaret Dejong of Great Ormond Street Hospital, London, and the Institute of Child Health, UK. In Clinical Child Psychology and Psychiatry 10/2010; 15(4):589-99. when she noted:

“The current classification system DSM-IV inadequately captures the range and type of psychopathology seen in the “in care” population of children. A combination of pre-natal influences, early interpersonal trauma involving the primary care giving relationship , disturbed and disrupted attachment relationships and other significant losses and adverse environmental effects produce a complex constellation of symptoms and a pervasive impact on development that is difficult to categorise.”

These children often end up within our residential services
To focus on children in care (particularly residential care) was in recognition that many of children’s mental health needs of the general population and in main care settings are met appropriately within traditional CAMHS and Community Psychological Services. However, there are a number of children – usually those that have ended up in residential care following numerous placement breakdowns – that have complex trauma, attachment-related trauma for whom services struggle to meet their mental health needs. The presentation of their mental health needs is often obscured by their challenging behaviour – or as Andrew wondered at the beginning of this discussion thread, if people working in trauma-informed settings are seeing heightened level of aggressive or assaultive behaviour. I would argue that these children’s mental health needs are further obscured by their non-compliance and non-engagement with services and that the fact that they do not fit into current classification of DSM-IV.

The presentation of this cohort of people is readily observed with those children coming into our residential services, I am also aware that the presentation of their behaviours often begin to manifest in earlier foster placements and, indeed, in pre-care i.e. at home situations as Dejong states as above: early interpersonal trauma involving the primary care giving relationship , disturbed and disrupted attachment relationships…

Services not nuanced enough to pick up in primary/community care settings
However, I don’t believe that our services are nuanced enough or orientated towards ‘picking up’ these children earlier due to the above factors i.e. not easily categorised and the significance or awareness of the impact of disturbed and disrupted attachment relationships is not picked up till after numerous placement breakdowns. Also, we need to recognise that the disruption of these relationships have happened in pre-verbal stage of the child, therefore, the child/ young person is not able to tell us about this trauma and unless behaviour is picked up in pre-schools or early school – it may be pre-teen, early adolescence before ‘society’ recognises these children.

No common definition of trauma-informed care
The fact that there are a number of terms being used to describe the mental health needs of children in care or on the edge of care. Along with trauma-informed care one is now reading of complex trauma, complex traumatic stress and developmental trauma and term 'disorder' is sometimes appended, we also note the term 'attachment-related and trauma-related' difficulties. The pockets of thinking in this way seems to be parts of the United States, New Zealand and Britain – however, while one suspects that they are speaking about the same cohort of young people there is no agreement in what term is to be used – which adds to the difficulties in speaking about ‘trauma-informed’ care or systems. Some agreement of what term to be used would be helpful but we need to be clear that the presentation of these children encompasses complex traumatic stress and developmental trauma and trauma-related difficulties.

Presentation of Need and best-fit within child care residential services

I think the above behoves us in care settings, then, to be clear in our understanding of the difficulties being presented in our young people not just in their outward behaviours, but in the knowledge that early complex trauma and developmental trauma underpins that behaviour. Therefore, what care settings are presented with are young people deeply suspicious of adult care givers, hyper-sensitive – having to be on survival mode at all times, the impact of which much of the developmental tasks of childhood are profoundly interfered with.

Without trying to elaborate a complete model of trauma-informed care for residential services, in essence there are two critical elements in the provision of residential services to these young people:

The centrality of relationships (with all the attendant qualities implied in this); and,
The ability of managers to sustain and ensure the cultural milieu of therapeutic care is maintained and
that there is congruency between presentation of young person’s needs, the objectives of the
placement and the ability of staff to deliver on these in a trauma-informed way.

It would appear to me that Social Care Practitioners, Child Youth Care Workers are best situated to respond appropriately to this cohort of young people – due to their ability in engage in the life-space of young people, to work very formally in informal lived settings, to develop strong appropriate relationships with the young person, to go beyond the presenting behaviour and keep focused on the central task. What these young people need (and what care staff can create the milieu to provide) are safety, self-regulation, self-reflection regarding processing of thoughts, feeling and actions, to be engaged in appropriate relationships with care staff, to have positive affect enhancement and to integrate the traumatic experience as the trauma exposure had seriously impaired the young person’s attachment, self-regulation and ability to achieve developmental competencies.

Finally, I think this is an opportunity to re-invigorate our residential child-care services. A lot of the core competencies and skill-sets are in place; what is needed is the theoretical framework to understand the needs of the children and the champions both within our services for the children (care staff and managers) and in our interface with other disciplines to educate, focus our colleagues on our trauma-informed care. If we get this right, we will put residential care work back to the core of what residential care work is about and we begin to build on the shoulders of those who are and continue to champion residential child care around the world ...

Respectfully
Kieran Campbell
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Hello all,
Can I contribute this piece, that I just re-read today, to the discussion.

http://www.goodenoughcaring.com/the-journal/winnicott-and-residential-work-2/

The distinction between the hopeless and hopeful child is kind of counter intuitive and therefore extremely important in guiding our practice in the life space. Therapy that creates hope also creates conflict, both internal and external, that is then acted out. Our task is not to give up or give in but to maintain a holding environment and survive!

Peace
Jeremy Millar

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Trauma informed programs and staff assault?