trauma informed residential care: the role of the tci system in meeting developmental needs and...
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ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Trauma informed residential care:
The role of the TCI system in meeting developmental needs and improving
outcomes for young people in residential care
Diana Boswell, Thomas Wright InstituteDavid O’Rafferty, ac.care rural South Australia
The question is not “What is wrong with you?” …but “What has happened to you?”
Sandra Bloom
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
A C W A 2 0 1 2 T R A U M A I N F O R M E D R E S I D E N T I A L C A R E T WI / A C . C A R E
Racism as Amygdala Alarm
racism
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
GRAND THEFT AUTO – the most popular video game ever – moves pornography and violence into the mainstream.
Players gain strength points by having sex with prostitutes, and then regain money points by killing them.
Approximately 75% of 12- to- 16-year old boys have played the game.
Olfman, 2008
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Young people in pain
… grief at losses and abandonment; persistent anxiety about themselves and their situation; fear of or even terror about a disintegrating present and a hopeless future; depression and dispiritedness at a lack of meaning or sense of purpose in their lives... or a state of numbness and withdrawal
(Anglin, 2002, p. 109-110)
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
IMPACT ON GROWTH AND DEVELOPMENT
• Chronic state of high stress• Interpreting neutral cues as threat• Explosive patterns of fight/flight
behaviour• Extreme patterns of freeze
behaviour• Limited resilience• Adult wary in relationships• Deficits in thinking skills
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Yet one recurring observation about resilience and coping with trauma is the power of healthy relationships to protect from and heal following stress, distress and trauma. This relational modulation of stress is mediated by two interrelated and broadly distributed systems in the human brain: the stress response systems and neural networks involved in boding, attachment, social communication and affiliation
Bruce Perry, 2009
Relationships are the agents of change
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
The three pillars of intervention in cases of complex trauma
“Clinicians have learned to focus on issues of: 1. safety, 2. affect regulation, coping and self-
management skills, as well as on the 3. therapeutic relationship itself...”
van der Kolk & Courtois, 2005
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
The primary impact of traumatic stress is a breakdown in the capacity to regulate internal states like fear, anger, and sexual impulses.
van der Kolk (2005)
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Kids in stress create in adults their feelings and, if not trained, the adults will mirror their behaviour
(Long & Fecser, 2000)
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Co-regulation Coercive
regulationAwareness of own feelings No awareness of own
feelings
Focus on child’s feelings Focus on child’s behaviours
Goal: helping child to calm Goal: stopping ‘bad’ behaviour
Soothing , assertive tone Loud, aggressive tone
Absorbing child’s invective Retaliating to child’s invective
Meeting immediate needs Ignoring child’s needs
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Therapeutic Crisis InterventionEdition 6
Residential Child Care Project Cornell University 2009
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Stress Model of Crisis
THERAPEUTIC CRISIS INTERVENTION
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
THE TRIUNE BRAIN
THE SURVIVAL BRAIN (brain stem) is first to develop and handles automatic biological functions like heart beat and respiration. Also called the reptilian brain, it reacts to threat or danger signals from the amygdala, triggering fight or flight reactions. Traumatic events can engrave strong descending pathways from the emotional brain to the survival brain. The more these circuits are activated, the stronger they become (cells that fire together wire together). A hypervigilant brain is quick to react and kindles survival reactions in stressful situations. THE EMOTIONAL BRAIN (limbic brain) motivates behavior in all mammals. The amygdala (almond) scans for danger or opportunity, instantly triggering emotions, particularly fear and anger, and warns the survival and logical brains. The amygdala reads emotional cues in tone of voice, facial expressions, eye contact, and gestures. Emotionally charged memories are also stored in the hippocampus and elsewhere. Emotions shape logic by many ascending pathways. Humans are highly social and when not under threat, the primary (default) emotion is social interest.
THE LOGICAL BRAIN (prefrontal cortex) is the “executive” in charge of language, reasoning, regulating emotions, tapping memory, predicting consequences, problem solving, and coping. Brain scans show this area is blank at birth and is wired (myelinated) by life experiences. The left brain specializes in logical thinking and positive emotions while the right brain handles nonverbal information and monitors distressful emotions. Attunement with caregivers wires the logical brain to regulate emotions. The brain is very resilient and continues to develop into the mid-twenties.
Survival Brain
Emotional Brain
Logical Brain
“We want to raise children whose
reasoning brain can triumph
over theimpulsive brain”
Phyllis Stein & Joshua Kendall
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Children must learn to know what they feel, put those feelings into words, or find some other symbolic expression … otherwise they simply have no story.
Bessel van der Kolk
(van der Kolk, 2005)
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
The Goals of Crisis Intervention Are To
SUPPORT: environmentally and emotionally to reduce stress and risk
TEACH: children better ways to cope with stress
THERAPEUTIC CRISIS INTERVENTION
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Skills Building Pyramid:
THERAPEUTIC CRISIS INTERVENTION
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Ac.care Residential 24 / 7 Emergency Accommodation
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Ac.care Residential 24 / 7 emergency houses
• Took over the program in 2010 September • 3 houses in rural areas in South Australia• 4 beds per house• Target group 0 to 18 • Double staff each shift• Up to 3 staff during the weekdays day shift • Running over budget• P&P from FSA and some from another agency• Initial training when first established, little on going training • Ad hoc staff meetings• High staff turn over• High staff injury rate • Excessive property damage
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
• Incidents 2009 – 2010
1: Injury to Staff2: Injury to Youth3: Staff alleged assault by youth4: Youth Alleged assault by youth5: Restraint or Physically Controlled6: Major Disturbance7: Property Damage8: Self Harm9: Drugs and or Alcohol10: Absconded 11: Other
106 2009 to 2010 7 11 7 8 9 10 11 8 0 10 25
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Therapeutic Strength Based Care • By January 2011• Name changed to TSBC• Staff position name changed from Support Workers / Carers
to Therapeutic Support workers, now a professional role. • New P&P specifically for TSBC• Fortnightly structured staff meeting• Rosters rewritten to ensure work life balance, single staff
passive night shift, House Supervisor to work on the floor from 11am to 2pm each day when possible
• Engaged Clinical Psychologist to assist staff with reflective practice and help develop strategies for dealing with underlying trauma based behaviour and to provide clinical supervision
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Continue• Commenced 6 weekly case conferences, by inviting
stakeholders, setting agenda, chairing meeting and completing minutes
• Monthly training day with all staff, delivered by C P on topics such as
• Brain development and trauma• Implicit and explicit behaviour • Pervasive shame • Other training such as case noting • Houses now operating from a therapeutic framework• Program returning a surplus, which is fed back into the houses• Practice influenced by research and looking at best practice by
people such as Dr Bruce Perry, The ChildTrauma Academy; Martha Holden of Cornell University; Berry Street and Take Two
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Ac.care Residential 24 / 7 Emergency Accommodation
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
1: Injury to Staff2: Injury to Youth3: Staff alleged assault by youth4: Youth Alleged assault by youth5: Restraint or Physically Controlled6: Major Disturbance7: Property Damage8: Self Harm9: Drugs and or Alcohol10: Absconded 11: Other
106 2009 to 2010 7 11 7 8 9 10 11 8 0 10 2541 2010 to 2011 3 1 1 2 0 7 2 0 2 3 20
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11
Incidents 2010 - 2011
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
TCI Implementation
• September 2011• Staff trained in TCI by Dec 2011• Before TCI, something missing to tie it all together• TCI creates a framework in which all staff can operate
from to ensure consistence of care and responses. • TCI is an intensive 4 day training program • We also conduct a 4 hour review sessions every 6
months
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
1: Injury to Staff2: Injury to Youth3: Staff alleged assault by youth4: Youth Alleged assault by youth5: Restraint or Physically Controlled6: Major Disturbance7: Property Damage8: Self Harm9: Drugs and or Alcohol10: Absconded 11: Other
106 Series 1 2009 to 2010 7 11 7 8 9 10 11 8 0 10 2541 Series 2 2010 to 2011 3 1 1 2 0 7 2 0 2 3 2046 Series 3 2011 to 2012 0 8 2 8 0 5 6 0 0 2 15
1 2 3 4 5 6 7 8 9 10 11
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11
ACWA 2012 Trauma Informed Residential Care TWI/ac.care
Summary • Staff are operating in a professional therapeutic role • Staff now have an understanding that underlying
trauma affects behaviour • Staff now respond to the trauma in an informed way
which aims to increase positive outcomes for client and staff
• Staff use reflective practice at staff meetings to review interactions with clients
• Staff have formal supervision 6 weekly • Staff are more engaged and empowered in their role• A reduction in sick days and staff turnover• Staff operating as a team with a team approach• Houses now operate as therapeutic homes
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