Children's Voice May/June 2008

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A Restorative Approach to Residential Care

By Patricia Wilcox

It's been a busy morning on the unit, and Tanya, a child care worker in a residential treatment facility, is struggling to complete the point cards and fill out the communication log before breakfast. She hears two roommates beginning to argue and is wondering if she needs to intervene. Twelve-year-old Jason explodes from his room and announces in a loud voice, "I am not going to take a shower this morning!" This is all Tanya needs. She says to him, "If you don't take a shower, you will be out of the program and not earning your points." "I don't care," Jason replies. "If you don't get all your points, you won't be able to go with us to the bumper cars this afternoon," Tanya retorts. "I don't give a damn and you can stop bothering me you...," Jason yells back. And they continue, perhaps into a restraint, as Jason grows increasingly agitated.

What did Tanya miss? She forgot to ask "Why not?" when Jason refused to take a shower. If she had, she might have discovered Jason is hallucinating in the shower, or that being naked and vulnerable is scary for him. Or, as was the case on this particular morning, she might have learned Jason thinks his hair is just perfect for once, and he is not going to risk ruining it.

These possibilities are solvable problems. Staff, for example, could stand outside the bathroom door and talk to Jason while he showers. Or Jason could use a shower cap. In traditional programs, however, we have placed so much emphasis on following rules, points and levels, and earning privileges that we lose sight of the meaning and function of behavior. Children are not skilled at explaining to us what they are experiencing or what they really need. When we lose sight of meaning and function, our treatment options are limited and our power for healing is stunted.

Programs treating severely traumatized children universally report that the children being served at each level of care are exhibiting more severe, long-standing, and resistant symptoms. Traditional point-and-level systems are not holding with these children; their need to be in control is much stronger than any motivation provided by unit privileges. Rewards and punishments increase motivation, and motivation is not the primary problem for these youth. The problem is their attachment difficulties, their sensitized nervous systems, and their lack of emotional skills.

Klingberg Family Centers, a large mental health/ child welfare agency in New Britain, Connecticut, that treats children with the most serious difficulties, is pioneering a trauma-informed approach to congregate care of children with serious emotional disorders. Many of the children treated at Klingberg have suffered early trauma--physical and sexual abuse, domestic violence, and multiple caregivers within their biological families. In the child welfare system, they often suffer more abuse and experience more moves. They present with serious problems of aggression, suicidality, self-harm, property destruction, and unsafe choices.

Klingberg once relied on a traditional points-and-levels approach in its congregate care programs, including residential, acute residential, extended day or afterschool treatment, and special education school, but the approach was not working and was not transferable to a home setting. Klingberg's treatment program transformed into a trauma-informed approach by adopting what it calls the Restorative Approach and using the Risking Connection foundational trauma training curriculum.

Using Relationships To Create Change

The basic tenet of the Restorative Approach is that relationships provide the strongest motivation to people. The treatment method emphasizes the relationship effects of behavior. What behaviors bring you closer to another? What behaviors hurt and alienate others and distance you from your community? When you hurt others, how can you make amends?

If we believe that relationships are our strongest tool in creating change, then everything we do should be informed by our understanding of what will strengthen relationships. This is where our power for change lies.

Based on this theory of change, we do not use time-based restrictions, isolation, and loss of privileges when the child acts out because these rely on the motivating aspects of reward and punishment, which are ineffective in trauma treatment. Under the Restorative Approach, all minor problems are handled by redirection. When children hurt others, disrupt the community, or cause serious property destruction, they are assigned restorative tasks. These tasks should provide an opportunity to make amends, and they should provide teaching of skills that will help the child avoid similar problems in the future.

How can a child who has assaulted staff or damaged property make amends? He can do something for that staff member--write an apology, talk over what was going on, draw him a picture, write and sing him a song, or pick him a bouquet of flowers. He can make popcorn for all the kids on the unit to pay back for the disruption he caused. He can help fix the property he damaged.

How can a child who has had a fight with a peer learn skills to avoid future fights? She can be assigned practice in getting along, like playing a game positively for half an hour. She can role-play a relationship problem with staff. She can interview three people and find out how they handle a friend letting them down.

If a child has injured or had difficulty with a particular staff member or peer, that person should be central in establishing and working through the restorative work. The theme here is that instead of doing time, the child is learning skills and reconnecting with people. Restorative tasks that offer a way to reconnect and make amends teach a valuable skill everyone needs--knowing what to do when one has messed up. These tasks not only reestablish connection, they teach children they have something valuable to offer in relationships.

Using the Restorative Approach does not take more time or more staff. Restraints take time, as do power struggles, counting points and assigning levels, and providing ineffective treatment. In the long-term, the Restorative Approach saves time because it is effective and leads to positive behavior change.

Case Examples

To provide trauma-informed treatment, all staff must recognize the biological changes that accompany trauma. Children who have experienced early, repeated, and multiple abuse are left with disturbed biological regulation systems. Their ability to relax, calm down, soothe themselves, and rest is compromised.

The actions of LaShanna, a young resident, are a good example. When LaShanna's mother doesn't come for a visit, or when LaShanna even thinks about that happening, she experiences an intolerable emotional state. She feels jagged, irritable, hopeless, and disconnected. As a release and a way of emotionally regulating herself, she breaks windows and destroys furniture.

In a crisis, using a trauma-informed model such as the Restorative Approach, all we should be doing is helping the child calm down. We do this primarily by listening and validating: "So, you are really upset by what happened with your mother. I can understand that." We remain calm ourselves and use a gentle tone of voice. We are patient. We work with the child, suggesting compromises, offering options. We help the child reconnect with significant people. The staff that the child is particularly mad at, for example, withdraws from the situation and the child's current favorite staff comes in.

Being near regulated adults regulates children. That means that in a crisis, using the Restorative Approach, we must keep the child near us, avoiding the use of seclusion, if at all possible. And we must stay regulated ourselves through the support of our team. It doesn't help LaShanna to be confined to her room after she's broken the furniture. In fact, it is unbearable for her, and she does something else to escape the prison of her room and of her mind.

We can further help LaShanna by providing her with methods to change the intensity of her pain and hyperarousal without hurting herself or others, or even the furniture. These would be things like going for a walk, moving around, accomplishing something active but not very difficult, or engaging in an activity that provided a distraction, such as cooking.

We have to take her by the hand and do these things with her. We have to be active to engage her and almost drag her into another space. Hopefully, we get better at noticing the early signs of her distress and intervening. Eventually, we hope LaShanna will notice her own signs of distress and use her own interventions. But we are a long way from that place.

A trauma-informed approach acknowledges the importance of shame. Most of the children have been seriously abused, and they feel it is their own fault. They are completely sure in their hearts that they are no-good, worthless people. Punishment that includes isolation and public humiliation further reinforces this internal certainty.

Much of our clients' behaviors can be understood as desperate attempts to avoid being vulnerable. Joey, a boy who is small for his age, enters the unit insulting everyone, making death threats, talking about his gang affiliations, and the weapons he claims to have hidden in his room. Aaron is scheduled for discharge. He becomes aggressive and angrily attacks his favorite child care staff. Katie is desperately hurting herself, refusing all offers of help, screaming that she needs to go to the hospital shortly after moving to a new group home.

Caregivers can go far by looking at every episode of aggression and realizing they are the result of fear. Our best help to these youth is to provide safety, soothe them, and help calm the activated nervous system. Only then will it be useful to point out positive and joyful aspects of life and draw them slowly into an experience that includes more than survival.

Transforming Staff Thinking

Agency transformation depends on staff developing a new understanding of trauma, its effect on people, and how to heal trauma through relationships. Providing trauma training for all staff is fundamental in changing their approach to the clients.

At Klingberg, all staff must attend Risking Connection training. Risking Connection is a registered trademark of the nonprofit Sidran Institute, based in Baltimore. Risking Connection, a foundational trauma training, offers a three-day, interactive experience that helps staff understand children in a new way and see their behaviors differently, hence connecting with them in a new way.

The basic premise of Risking Connection is that symptoms are adaptive and best healed within a RICH (Respect, Information, Connection, and Hope) relationship. The underlying trauma framework is that childhood traumatic experiences lead to traumatized development, including disrupted attachments, a sensitized nervous system, and impaired self-capacities. These self-capacities are inner connection, self worth, and feelings management. When the youth encounters a current stress, he experiences an intolerable emotional state. He only knows negative or extreme coping strategies. We call these coping strategies symptoms. They include retreat, self-destruction, and other destruction.

Implementing the New Approach

Trauma-informed care can be implemented without committees, program change, or the elimination of our points and levels system.

When youth are upset, we often give up on trying to get them to take responsibility for their actions. Instead, we can paraphrase what a youth says: "So, you are very angry about being sent up from school? It doesn't seem fair to you?" Emphasize any feelings the young person imparts, particularly any other than anger: "You are discouraged, you are sad, you are frustrated, you were hurt."

Then we can ask what else is upsetting him. During all of this we keep our breathing slow and our voice calm. And then when--and only when--we notice some de-escalation on his part, do we consider where to go from there. The child is upset and wants this, the adults think this is necessary, how can we go forward? Wherever we can compromise, be creative, or use unique solutions, we do so.

We can encourage staff to speak from the heart, and to use "I" statements, such as "When you ran away, I was so worried about you. I couldn't sleep because I worried that something bad would happen to you." Or, "You just hit me. I am not ready to give you a hug. I feel hurt and upset right now. I'm sure we can work this through later, but right now I need some time to calm down before I can reconnect with you."

This is not to say that risks in implementing the Restorative Approach don't exist. There is always the possibility that there will be emotionally disregulated staff, staff with poor boundaries, or staff with overly intense reactions, either positive or negative. We have to teach people how to speak from their hearts, while maintaining good boundaries and emotional regulation. This also becomes a team issue, because a well-functioning team will allow staff to confront each other directly when boundaries are being jeopardized. Finally, it also becomes a supervision issue to be handled directly and vigorously by the unit manager.

In the End, Better Outcomes

While this change is not easy, it is worth the struggle. Based on extensive field observations, a trauma-informed approach produces better outcomes for children who have suffered multiple attachment disruptions and trauma.

The Restorative Approach offers hope for a more healing environment and a more meaningful experience for both staff and children. It is also transferable to the outside world, where levels and points do not exist. The Restorative Approach restores our focus to the most important and powerful aspects of our work with children and each other, which are our mutual and respectful caring relationships.

If an agency chooses to adopt the Restorative Approach, upper management must clearly embrace this direction and remain unequivocal about its decision. Training is also the key to success. Staff who work hard to care for wounded children need the best possible tools and the most caring working environment. And most importantly, the children and families who have been treated so unfairly deserve the most effective treatment possible, leading to the deepest and most lasting healing.

Patricia D. Wilcox LCSW is Vice President for Strategic Development with Klingberg Family Centers. She can be reached at 860/832-5507 or patw@klingberg.com. Learn more at www.klingberg.org and www.riskingconnection.com. Read her blog on trauma-informed treatment.


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