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A Call to Children’s Residential Treatment Centers: Please, Please Do Your Own Trauma Work

 

“Sanctuary is a place of joy and creative innovation, of sympathy and solace, and of transformation.”

- Sandra L. Bloom & Brian Farragher, Restoring Sanctuary

Over the past two decades evidence has mounted regarding the prevalence of adverse childhood experiences (ACES)1-3, the effect of these experiences on health-status and functional outcomes in adulthood4, the impact of trauma on neurodevelopment5-8, and its disruption of the capacity to feel safe5- 10. Most of the youth in residential treatment centers (RTC) (50%-71%) have been exposed to trauma11, 12. As many as 92% have endured multiple traumatic events13. The American Association of Children’s Residential Centers14 has explicitly acknowledged that “many children in residential treatment manifest complex traumatic stress reactions that […] have been ‘hard wired.”’ And that “these children’s abilities to use cognitive processes or draw accurately upon memory is limited as a result of their traumatic experiences.” Nevertheless, therapeutic measures that rely heavily on cognitive processes (e.g., CBT, TF-CBT) linger as the standard of care in these organizations15. Even as the term trauma-informed has been integrated into the popular culture, RTCs have been challenged to fully incorporate the systemic changes necessary to provide effective trauma-informed care 16, 17 and to recognize trauma-specific clinical interventions which consider a neurodevelopmental perspective15-17.

Trauma-informed care is more than a set of Guiding Principles hung on a wall to be reviewed at monthly staff meetings18. It is more than a two-day training that is never fully integrated into the cellular structure of the organization. It is a fundamental change in “an organization or system’s culture, behavior, actions, and responses”19. It is a holistic approach which requires courage, commitment, and the implementation of an iterative process inviting the opportunity for open, non-judgmental dialogue among stakeholders at all levels, rigorous evaluation, trouble-shooting, and supportive follow-up.

There are several recognized and valid barriers to effective systemic change in RTCs14-17. One of the most significant, and sorely under-recognized, is the extent of the organization’s own trauma20 – the collective implicit memory that continues to drive old paradigms even after new methods have been introduced. It is difficult, for example, to implement a system which deemphasizes power and control within a typically hierarchical organizational structure. Like the children it serves, an organization’s seemingly intractable behavior is a coping mechanism; it relies on what it knows in order to stay safe – or viable.

Trauma is often processed nonverbally5-7, 19, 21, 22. Persistent fear-states impede the ability to “benefit from social, emotional, and cognitive experiences”5-9, 22. This is not only true of children who have endured developmental trauma, but also of the organizations to which the most critically affected children (and their families) turn for help. In organizations, as in individuals, trauma operates insidiously. It informs written and unwritten policy, attitudes, practices, behavior, and ultimately, the felt sense of safety that lays the groundwork for meaningful change.

Without fully accounting for what is operating beneath the surface, demonstrable, authentic trauma-informed care may be beyond reach20. Despite the best of intentions, it remains a set of guiding principles which are aspirational but not necessarily achievable.

Within a trauma-driven organizational structure, all systems are on high alert. Change is subverted by implicit fear. Most significantly affected are the relationships between the organization and its stakeholders. It seeks to appease those with relatively more power (e.g., accrediting bodies, payors) while marginalizing, intentionally or not, those with less (e.g., employees, families). The organization’s behavior is a fully adaptive response to the larger culture within which it operates. There is a fixed mindset that fails to see trauma (organizational or individual) as a root cause of otherwise inexplicable behavior.

This inflexible mindset carries into the treatment milieu where a child’s behavior is seen, not as adaptive, or as a symptom of what underlies it, or as a means of communicating an unmet need, but as a de novo problem which must be extinguished. Behavior alone is addressed without regard to its origins or functional utility. When treatment is not successful then, at least in some cases, the conclusion is that the child is not working hard enough or is not sufficiently engaged in the therapeutic process.

Trauma obviates the organization’s capacity for the perspective-taking that would lead to deep understanding and openness to change. It is stuck in defensive mode. The organization cannot provide trauma-informed care because it has not done its own trauma work!

I am the parent of a 9-year-old boy who has been in a residential treatment center for 18 months. He is bright, engaging, energetic, compassionate and, as the result of early trauma, he acts out aggressively. He was severely neglected and physically and emotionally abused from the moment of his conception to 23 months of age. At times he is infant-like and wants to be held. At other times he is fearful of predators that no one else can see. He is alternately playful and disinterested, close and detached, empathetic and provoking, silent and rageful. No matter what his internal state, he is a little boy. He has been away from home for a very long time – so long that he has nearly stopped believing in home – and yet he awakens every morning and finds his way through the day in the best way that he can. To say that he is brave is not enough and what would be enough cannot be conveyed with words.

My son has been tried on at least a dozen medications and has been working with a behavioral therapist since his admission. He has amassed six DSM diagnoses. His behavior today is as it was on day one. His trauma has scarcely been addressed. The overarching assessment is that he is not working hard enough, that he is acting out intentionally, that he is not sufficiently engaged in his treatment. He is 9.

In its publication Changing Communities, Changing Lives23, SAMHSA’s National Center for Trauma Informed Care, refers to trauma-informed services as “a new social movement […] sustained by the emerging hope that things could be different.”

According to innovators Bloom and Farrager20:

The current challenge for everyone in human services is how we unwittingly, and often in the name of science, erect barriers to recovery that prevent self-organizing change in the individual life of clients and in our organizations as well. We must wrestle with the fact that our diagnostic categories often shame clients from the moment the enter care. Our rigid hierarchies frequently prevent participation and innovation when what we actually need are staff members who can exercise almost constant creativity in order not to be drawn into traumatic replays of previous negative life experiences in the lives of the clients we serve. (p.30)

The challenges of becoming an effective trauma-informed organization are considerable for sure. Taken as an opportunity, and not a burden, they present a unique platform for organizational learning, healing, and growth. Among so many other things, the efforts inure to the benefit of a milieu that becomes a sanctuary for healing and where little boys are not subject to blame for unintended treatment outcomes.  

Yes, things could be different.

References

  1. Huges, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C.,…& Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health, 2(8):e356-e366. doi: 10.1016/S2468-2667(17)30118-4.
  2. Larkin, H., & Records, J. (2007) Adverse childhood experiences: Overview, response strategies, and integral theory. Journal of Integral Theory and Practice 2(3), 1-25. Retrieved from https://www.researchgate.net/p..._and_integral_theory
  3. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V.,…Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 354–364. doi: 1016/S0749-3797(98)00017-8
  4. Copeland, W. E., Shanahan, L., Hinesley, J., Chan, R. F., Aberg, K. A., Fairbank, J. A.,…Costello, E. J. (2018). Association of childhood trauma exposure with adult psychiatric disorders and functional outcomes. JAMA Network Open, 1(7):e184493. doi: 10.1001/jamanetworkopen.2018.449.
  5. Perry, B. D. (2008). Child maltreatment: A neurodevelopmental perspective on the role of trauma and neglect in psychopathology. In T. Beauchaine & S. P. Hinshaw (Eds.) Child and Adolescent Psychopathology (pp. 93-129). Hoboken, NJ: John Wiley & Sons. Retrieved from https://childtrauma.org/wp-con...ology_Chapter_08.pdf
  6. van der Kolk, B. (2003). The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatric Clinics of North America, 12, 293-317. doi: 10.1016/S1056-4993(03)00003-8
  7. Perry, B. D. (2001). The neurodevelopmental impact of violence in childhood. In D. Schetky and E. P. Benedek (Eds.) Textbook of Child and Adolescent Forensic Psychiatry (pp.221-238). Washington, D.C.: American Psychiatric Press, Inc. Retrieved from https://childtrauma.org/wp-con...vel_Impact_Perry.pdf
  8. Schore, A. N. (2001). The effects of early relational trauma on right brain development, affect regulation and infant mental health. Infant Mental Health Journal, 22 (1-2), 201-269. doi: 1002/1097-0355(200101/04)22:1<201::AID-IMHJ8>3.0.CO;2-9
  9. Hambrick, E. P., Brawner, T. W., Perry, B. D., Brandt, K., Hofmeister, C., & Collins, J. O. (2018). Beyond the ACE score: Examining relationships between timing of developmental adversity, relational health and developmental outcomes in children. Archives of Pediatric Nursing, In Press. doi: 1016/j.apnu.2018.11.001
  10. Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication and self-regulation. New York: WW Norton & Company.
  11. Bettmann, J. E., Lundahl, B. W., Wright, R., Jasperson, R. A., & McRoberts, C. H. (2011). Who are they? A descriptive study of adolescents in wilderness and residential programs. Residential Treatment for Children & Youth, 28(3), 192-210. doi: 10.1080/0886571X.2011.596735
  12. Jaycox, L. H., Ebener, P., Damesek, L., & Becker, K. (2004). Trauma exposure and retention in adolescent substance abuse treatment. Journal of Traumatic Stress, 17(2), 113-121. doi: 1023/B:JOTS.0000022617.41299.39
  13. Briggs, E. C., Greeson, J. K. P., Layne, C. M., Fairbank, J. A., Knoverek, A. M., & Pynoos, R. S. (2012). Trauma exposure, psychosocial functioning, and treatment needs of youth in residential care: Preliminary findings from the NCTSN Core Data Set. Journal of Child and Adolescent Trauma, 5(1), 1-15. doi: 1080/19361521.2012.64641
  14. American Association of Children’s Residential Centers. (2010). Redefining residential: Trauma-Informed care in residential treatment. Milwaukee, WI: Author.
  15. Casey Family Programs. (2016, March). Elements for effective practice for children and youth served by therapeutic residential care (Research Brief). Retrieved from https://www.casey.org/media/Group-Care-complete.pdf
  16. Hodgdon, H. B., Kinniburgh, K., Gabowitz, D., Blaustein, M. E., & Spinazzola, J. (2013). Development and implementation of trauma-informed programming in youth residential treatment centers using the ARC framework. Journal of Family Violence, 28 (7), p. 679-692. doi: 10.1007/s10896-013-9531-z
  17. Zelechoski, A. D., Sharma, R., Beserra, K., Miguel, J. L., DeMarco, M., & Spinazzola, J. (2013). Traumatized youth in residential treatment settings: Prevalence, clinical presentation, treatment, and policy implications. Journal of Family Violence, 28 (7), 639-652. doi: 1007/s10896-013-9534-9
  18. Substance Abuse and Mental Health Services Administration (SAMSHA). (2014, Spring). Guiding principles of trauma informed care. SAMSHA News, 22(2). Retrieved from https://www.samhsa.gov/samhsaN...ding_principles.html
  19. Flatow, R. B., Blake, M., Huang, L. N. (2015). SAMSHA’s concept of trauma and guidance for a trauma-informed approach in youth settings. Focal Point: Youth, Young Adults & Mental Health. Trauma Informed Care, 29. Retrieved from https://www.pathwaysrtc.pdx.edu/pdf/fpS1510.pdf
  20. Bloom, S. L., Farragher, B. (2013). Restoring sanctuary: A new operating for trauma-informed systems of care. New York: Oxford University Press.
  21. Levin, E. (2009). The challenges of treating developmental trauma disorder in a residential agency for youth. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 37(3), 519-538. doi: 10.1521/jaap.2009.37.3.519
  22. van der Kolk, B. (2005). Developmental trauma disorder: toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401-408. doi: 3928/00485713-20050501-06
  23. Substance Abuse and Mental Health Services Administration (SAMSHA). (2012). Changing communities, changing lives. Retrieved from https://www.nasmhpd.org/sites/...rochure_FINAL(2).pdf

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This article speaks so eloquently to the energy operating underneath the surface of unhealed trauma in organizations, and how it tragically plays out undermining the true goal of the organization healing trauma.  Thanks for sharing.

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