trauma informed residential care: the role of the tci system in meeting developmental needs and...

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


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


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


PREMATURE SEXUALISATION


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)


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


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


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


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)


Kids in stress create in adults their feelings and, if not trained, the adults will mirror their behaviour

(Long & Fecser, 2000)


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


Therapeutic Crisis InterventionEdition 6

Residential Child Care Project Cornell University 2009


Stress Model of Crisis

THERAPEUTIC CRISIS INTERVENTION


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


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)


The Goals of Crisis Intervention Are To

SUPPORT: environmentally and emotionally to reduce stress and risk

TEACH: children better ways to cope with stress



Skills Building Pyramid:



Ac.care Residential 24 / 7 Emergency Accommodation


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


• 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


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


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


Ac.care Residential 24 / 7 Emergency Accommodation



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


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



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


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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