Trauma Informed Care

Transitions, Change and Loss

chaos and change

This time last year I’d not long arrived in Kansas and it’s been a long time since my last blog, I just want you all to know that this blog site is far from finished as there are many more reflections, topics and visits I want to share with you all.  Obviously I’m home now and have been on Australian soil for some time.  The title of this blog which was already next in line for publication is also true and reflective of why it’s been so long between posts… transitions, change and loss, but more about that later on…

Visiting Mount Saint Vincent Home I spent time reflecting on the impact of change, loss and transition.  On my first day with them, the Clinical Director Kirk Ward, advised me that they were facing all sorts of changes, transitions and loss.  It was coming up to the end of the school year and children were graduating out of the school, out of the program or going off on summer break for the day treatment clients, there had been some staff turnover resulting in a lot of retraining of new staff and to top it off the County had started to refer a slightly different demographic of child.

As a result of all of this, staff and clients were struggling.  Emotions were running higher, people more reactive and that week staff and I often reflected on the struggle they faced given old strategies were not working as successfully as they had been.  When we are faced with challenges as such it’s not surprising that we think it’s time to try something new or change things up.  We can find ourselves feeling stressed and anxious about the seemingly little impact we are making.  We know from my prior blogs and the work of Dr Perry and Dr Siegel that the more stressed we become the more reactive we become.  The more reactive we become the less we are able to really think creatively and reflectively about a situation.  This is a universal human phenomenon, not only does it happen to our troubled and traumatised clients, but it happens for every one of us.

When we are stressed and reactive, the danger in changing it up or trying something new is further increasing the uncertainty, predictability and routine and in turn further exacerbating stress levels and reactivity of all involved.  I’m not saying that we should always soldier on and hold firm to our way of operating, not in the least as it could very well be the way we are doing things is problematic or part of the issue.  What I am saying though is that we need to take space, calm ourselves so to really be able to think more reflectively and creatively about what we are doing, and how we move forward in making a difference in the lives of others.

My time with Mount Saint Vincent home highlighted again the absolute importance of staff being emotionally regulated and emotionally safe within themselves.  The ability to take time as a staffing group, reflect and seek supervision and manage ourselves is paramount in the treatment, care and healing of trauma. I was impressed with the clinical, residential and educational team at Mount Saint Vincent and their ability to support children and young people at times of emotional and behavioural escalation.  Staff would come away from these situations and interactions concerned and worried for the wellbeing of the children, the success of their interventions, in turn requiring regulation and support from each other and their management.   However when engaged and interacting with the young people in their program and the emotional and behavioural distress these kids demonstrated, the Mount Saint Vincent staff were focussed, centred, and on the whole all about co regulating these kids.  I witnessed clever use of movement, music, and sensory input to keep young people regulated and/or regulate them.

The challenges facing Mount Saint Vincent during my visit could easily have derailed them, left them focussing on new and different strategies. I’m not saying as a program emotions weren’t running high and the staffing group were certainly concerned, but I watched them rally together and co regulate each other so as to not to let the transitions, chaos and loss their program was experiencing result in organisational reactivity, but instead continue in the provision of safe, predictable and thoughtful care to their clients.

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Mount Saint Vincent Home

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Mount Saint Vincent Home

In stunning Denver Colorado, surrounded by snow capped mountain ranges, I spent the week of 2nd to 6th June 2014, at Mount Saint Vincent Home. This was my second visit to Mount Saint Vincent in as many years and approaching the gateway on my first day, for the first time in weeks, I felt a sense of familiarity and connection.

Mount Saint Vincent Home is located  just a short bus ride from downtown Denver and is situated on a 16 acre property, offering a running track, football field, multiple playgrounds and a swimming pool.  Founded by the Sisters of Charity Leavenworth Kansas in 1883, Mount Saint Vincent had it’s origins as an orphanage.  With social change and the move away from orphanage based care to out of home foster care and residential treatment, Mount Saint Vincent moved with the times and now prides itself on being a treatment center for children ages 3 – 13 years.

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Mount Saint Vincent specializes in treatment of children who have suffered abuse, neglect, trauma and/or mental illness, offering services with a child-focused but family centered approach acknowledging the importance of the family in a child’s healing and recovery.  Referrals to Mount Saint Vincent Home come largely from the County Human Services Department of Child Protection, School districts and other mental health services.

 Mount Saint Vincent offers a variety of services to clients including:

  • A 36 bed residential treatment program consisting of 3 cottages each housing 12 children
  • Individualised day treatment programs for up to 55 children
  • In home treatment and follow up services
  • K – 8 School program that affords children developmentally matched education rather than chronological determined education.
  • An early learning child care program

All of the services offered by Mount Saint Vincent operate under their treatment philosophy that focuses on the regulation of a child rather than compliance; that care is developmentally appropriate and matched and that they afford a child an environment of safety that allows children to ‘try on’ and develop positive relationships.

Mount Saint Vincent has some very innovative service elements including:

  • Creative Arts Therapy team who provide music therapy, dance/movement therapy and art therapy;
  • An animal assisted therapy program onsite using dogs and guinea pigs and offsite using horses
  • An onsite volunteer tactile therapy program offering clothed massage, yoga, meditation/mindfulness, bach flower remedies and reiki for example.
  • Individual Therapy
  • EMDR
  • Swimming
  • Bike Riding
  • Gym
  • Group Therapy Programs including Lego Group and Psychodrama
  • Sensory tool boxes for each child and program
  • The school program has a dedicated mental health clinician to support the inclusion of developmentally matched regulatory activities for the students so to assist in maintaining a state of regulation, coupled with an intervention team able to take students in the moment and provide co-regulation for children to assist them back into classroom learning activities.msv swimming pool

Like everywhere else I had visited up to this point, the staff at Mount Saint Vincent Home are dedicated, passionate and committed to making a difference in the lives of children.  I watched and listened to staff talk openly about their love of the work, the challenges it brings and most importantly the changes they feel privileged to be part of in the journey of these children.  Like all services operating with the public health system there were clearly challenges that the programs were having to manage and deal with, but that aside the Mount Saint Vincent team not unlike Sandhill, Cal Farley’s, Sumner Mental Health and Alexander Youth Network were thoughtful, authentic and so very respectful in their work with children and families.

In 2013 Mount Saint Vincent Home’s Creative Arts Therapy team published an awesome resource called, “Doodles, Dances and Ditties: A Somatosensory Handbook”.  This book is a collection of creative, sensory and movement based activities you can use to regulate children.   You can get it on their website http://www.msvhome.org or via amazon – where I see it now comes in a Kindle version.

somatosensory-handbook

Greater and Less Than – Lessons in learning Through Movement

Somatosensory activities and education, this is a topic close to my heart.

GREATER THAN

For a little over two years now I have been consultant and then project manager of a pilot project in Australia looking at the inclusion of patterned, repetitive somatosensory activities in primary school classes.

So often we hear teachers and educators ask about strategies for managing traumatised children and their resultant behaviours in the classroom.   All too often in my clinical practice teachers have looked at me, perplexed when I suggested they could include somatosensory activities into curriculum.  In fact I had almost got to the point that I believed this maybe wasn’t achievable and that I had to enlist an education champion to help me articulate my meaning more clearly.  The latter may still be the case, but in Charlotte NC I had the professionally heart warming experience of watching a relatively new teacher to the Alexander Youth Network (AYN) Psychiatric Residential Treatment Facility (PRTF) School do exactly what I’ve been talking about for years.

The PRTF School do what most neurodevelopmentally and “trauma” informed education programs do, by providing frequent “brain breaks” for their children.  Essentially this is where they step down from academic learning and engage in some form of somatosensory activity such as playing outside, water play, sand play, play doh, calming corners with sofas, bean bags, blankets and soft toys etc. They do this routinely, repetitively and frequently – in fact given the arousal and dysregulation of the children AYN sees in its PRTF, these breaks seemed to work best when applied every 10 or so minutes.  Having access to a staff member dedicated to leading these breaks and co-regulating the children in between them worked a treat as well.   All of this impressed me, but what really stood out was this one teacher who found a way to incorporate somatosensory activities into curriculum based learning!IMG_7140

You know maths and mathematical concepts is a difficult gig at any school, let alone a classroom of children struggling with emotional, social and behavioural difficulties.  So when this teacher came in to teach the concepts of less than and greater than I thought to myself this will be interesting.

Immediately on entry into the room, she invited the children to the front of the class and had them all stand or sit around her as they preferred. She didn’t get flustered or annoyed when children came and went from her teaching space and in doing so, actually appeared to manage keeping them around her and in the vicinity of learning for the whole exercise.  Each child was given a piece of paper containing a number, each child read their number out aloud.  The greater than symbol was drawn on the board and there was minimal question and answer time to ensure that everyone understood the concept of the greater than symbol.

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Less than & Greater than

Then engaging the students in an activity based process, moving them around she asked them two by two (based on those most engaged in the moment) to identify their number and stand either side of her – as she held the greater than symbol.  The student’s task – to put themselves in the right spot – who’s number was greater than the other.  Each student excitedly took their turn and much celebration was had as each pair got it right.  In addition to the movement which we know provides sensory and motor based regulation to the lower parts of the brain, this teacher relied on her voice to ensure up regulation and down regulation in the moment and what was most impressive was that she made the lesson punchy and brief.  In and out in no more than 15  minutes and a key mathematical concept was taught and grasped by these children.

Can somatosensory activity be incorporated into curriculum?

I think it can.  It might take a bit of creativity and planning, and maybe even a shift in basic education philosophy about how to teach children, but I still think this is very achievable.

Alexander Youth Network

 

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In the last week of May I journeyed to beautiful Charlotte in North Carolina to spend the week with my colleagues at Alexander Youth Network (AYN).  AYN’s main campus or headquarters, and the home of it’s Psychiatric Residential Treatment Facility (PRTF) and one of their Day Treatment Programs, is located on a picturesque 60 acre property with buildings nestled in a woodland area with open grounds and recreation areas for their clients.  This campus also houses facilities including a gym, indoor swimming pool and cafeteria.

AYN is a non profit community based organisation receiving funding from fees for services (medicaid, insurance and the like) as well as contributions from individuals, corporations, foundations and government agencies.  AYN serves children ages 5 to 18, who are referred from hospitals, physicians, parents, schools and from state and county organisations such as department of social services and juvenile justice.  AYN serve over 7000 children each year.

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Surrounding woodlands

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Woodland Trail

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Deep in the woodland trail

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Alexander Youth Network Grounds

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Onsite Playgrounds

AYN provide an array of mental health treatment for serious emotional and behavioural difficulities including: diagnostic and outpatient services, community based programs, multisytemic day therapy, therapeutic foster care and an onsite, 36 bed psychiatric residential treatment facility.  The idea being that children, young people and families accessing their services can move from service to service with established working relationships of trust within the one organisation.  Added to this is the strong grounding the staff have in child development, trauma, attachment and neurodevelopment as a core component of their orientation and ongoing training.

AYN array diagrams 2012

It was a contrast to go from services that have decisively removed themselves from the medicaid system or appear to have more flexibility than is given from the public health system and as a result appear better funded and able to provide longer term intervention for their clients.  At AYN the financial resourcing struggle of service delivery was evident in comparison to the private services I had visited.  While the AYN staff were at times a bit despondent about this, I was nonetheless impressed at what they were offering and able to offer.  There is something about not having resources at your fingertips that can contribute to a creative resourcefulness and the team at AYN do this well.  In fact when it comes to neurodevelopmentally informed and respectful interventions AYN have lots to offer:

  • Individual therapy including EMDR, play therapy, sand tray and an awesome play room furnished largely by donation and financial grants
  • Art Therapy including pottery and their very own kiln
  • A ropes course for adventure therapy
  • A Labyrinth
  • Occupational Therapy with a motor and sensory furnished room including a swing and tunnels.
  • Physical Therapy
  • Reiki
  • Swimming
  • Vegetable and flower bed gardens and gardening program
  • Woodland walking trails
  • Playgrounds
  • Gym
  • Developmentally matched classrooms that afford children regular (every 10 – 15 mins) brain breaks and recreation
  • Classrooms that are highly sensory and provide calming, alerting and regulating activities including rocking chairs, bean bags, chill out areas and such
  • Bike program whereby each PRTF child has their own bike.

 

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Art Therapy room including Kiln

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Play Therapy Room

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Play Therapy equipment

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Play Therapy Room – role play and dress ups

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Play Therapy puppets

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Play Therapy sand tray and figures

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Occupational Therapy room

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Developmentally matched classrooms

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Chill out area in classroom

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Of more concern to me than their financial resourcing issues, were the systemic restrictions being placed on AYN in relation to the length of service delivery they are able to offer their clients.  The public health system funding children coming into the PRTF, those clients with the most serious of emotional and behavioural disturbances, are placing pressure on the service to treat and “repair” these children in 3 months.  The years of clinical practice, much of the theory out there, and my more recent acquisition of neurodevelopment and trauma expertise have taught me that it takes more than 3 months to form a trusting relationship with some of these kids.

 And we know that it is only in the context of such trusting relationships that these children can being to heal.

So with that knowledge I take my hat off to my colleagues at AYN and their ability to work within a public health system that places considerable restraint on their ability to really heal these kids.  The staff I met talked openly of the 30 day review process they have to undertake to retain or regain funding for ongoing work and the associated challenges. Despite this, the passion and commitment for their work and the children and families they serve sees them rise daily to these challenges and provide meaningful connections and healing opportunities for North Carolina’s more vulnerable citizens.

 

Cal Farley’s Boys Ranch: A Shirttail to Hang Onto!

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I had the absolute privilege of spending the week of 19th – 23rd of May in Amarillo Texas on Ranch at Cal Farley’s residential treatment centre.  It is hard to know where to start when describing Cal Farley’s and my experience there. One blog is not going to even remotely capture the breadth of what the service offers.  First and foremost I have to acknowledge the absolute generosity of the Cal Farley’s team from their Chief Operating Officer, Clinicians, Training team, House Parents and well basically everyone on the property. My visit was catered for most generously and my schedule was very busy – largely because there was just SO much to see and in the spirit of my Fellowship,  I didn’t want to miss a thing.

Cal Farley’s is a one of a kind service, of this I’m pretty confident.  It is one of America’s largest privately-funded child and family service providers specializing in both residential and community-based services at no cost to the families of children in their care.

Yes you read me right, NO COST!

The founder of the Ranch, Cal Farley was quite a visionary for his time and in 1961, he established the Cal Farley’s Boys Ranch Foundation. Contributions from the Ranch’s friends and supporters provide approximately 30 – 40% of the funds required to meet total annual operating expenditures. Through the foresight of Cal Farley and his Board of Directors, the remaining funds required to operate are available through the Cal Farley’s Boys Ranch Foundation.

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Cal Farley Statue

Cal Farley’s operates like a small town – in fact it’s almost big enough to be a small town.  It hosts a chapel, fire station, it’s own bank and post office services, has it’s own independent school district, complete with administration, including their own superintendent, elementary, middle, and high school.  An activity centre, gym, pool, football field, indoor horse riding arena, rodeo stadium, athletics field, stores and the communal dining hall.  Many of the staff live on site at the Ranch, which in addition to the staff homes, hosts 28 residential homes each of which caters up to 12 children and young people.  At capacity Cal Farley’s can have up to 260 children and young people at a time.  Residential homes are staffed by 2 sets of house parents, the lead house parents and relief house parents. The residential homes as you can see from the photos are all designed similarly and provide a very homely feel.

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Example of Cal Farley BR home

 

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Kitchen/Dining

 

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Living Room

 

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Bedroom

Neurodevelopmentally informed interventions/activities included (and I will probably leave some out):

  • Individual Therapy
  • Neurofeedback
  • Play Therapy
  • Art Therapy
  • AAT – largely equine based including colt and filly training and Rhythmic Riding
  • EMDR
  • Adventure Therapies – Ropes Courses, Kayaking, Trail Rides, Challenge course
  • Rocket Club
  • Computer Lab
  • Woodwork Studio
  • Robot and other electronics programs
  • Rodeo skills
  • Drumming
  • Archery
  • Gardening/Agriculture
  • Agriculture workshop – where they built a trailer for example so that they could transport their livestock to agricultural shows.
  • Mentoring of younger children by older children
  • Capacity for vocational training and part time employment

All of this is embedded in a community where relationships serve as the key to success.  As I wandered around Cal Farley’s I had to remind myself that this was a service for children and young people who had mental health, emotional and behavioural problems, because often what I saw and experienced seemed just like any ordinary community.  The importance of relationships whereby the kids were positively supported, contained and nurtured by multiple adults in their daily experiences was evident in the way the children and young people conducted themselves in the community. I’m not saying that there were no challenges, as there were, but on the whole the adults in this community do a wonderful job of creating a relationally rich environment filled with amazing activities, “interventions” and opportunities.

If you work in the child and welfare sector and you ever find yourself in Amarillo Texas – look Cal Farley’s up and see if you can visit – it’s nothing short of impressive and it’s folk are just downright good people who are absolutely and only in this for the best outcomes for kids.

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Kayaking Adventure Therapy Session

 

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Practicing capsizing and rescue and the experience thereof.

 

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Robot built in rocket/robotics/electronics/ computing lab

 

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Pre therapy jigsaw pieces – goals and wishes

 

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Therapy Closure Jigsaw Pieces – outcomes

Sandhill Child Development Center: Authenticity in Relationships

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Del Rio House

I spent the week of May 12 -16 with the staff and residents at Sandhill Child Development Center in Los Lunas New Mexico.  “Sandhill Child Development Center is a residential program for children ages 5 to 13 at admission, who are experiencing significant difficulties functioning in their current home, school or community due to an inability to regulate their emotional states. By repairing a child’s trust in care and adult guidance, Sandhill gives the child the tools necessary to proceed with a healthy and bright future. Sandhill Child Development Center emphasizes a relationally-based clinical approach that is grounded in the Neurosequential Model of Therapeutics (NMT) developed by Bruce Perry, M.D., Ph.D. and The ChildTrauma Academy.” www.sandhillcenter.org  Sandhill takes children from all over the United States.

As one of the ChildTrauma Academy’s initial partner certification sites there was no question about visiting Sandhill.  Having been at the implementation of neurodevelopmentally informed interventions in their residential treatment for some time now, I wanted to see for myself where they were up to and what discoveries they had made.

Sandhill have two homes located on two different sites a short drive from each other in Los Lunas, New Mexico.  The home pictured above and it’s surrounding property align the Rio Grande River and both homes look out onto majestic mountain ranges.  Spending time with Sandhill you can’t help but feel relaxed and like you’ve known these people all your life.  The Zimmerman Family who run the service, exemplify nothing short of authenticity in relationships and with that as their template their recruitment of staff seems to follow suit.  It is clear from Management to Direct Child Care staff that relationships are the core of the healing approach at Sandhill.  Wrap that up with all the staff having a thorough grounding in neurodevelopment theory and you have a program applying all sorts of playful, rhythmic, sensory and somatic interventions with the children staying there.

Interventions include:

  • Individual weekly therapy for the child
  • Family therapy – both face to face during visits and via Skype sessions
  • Parent training sessions
  • Modelling sessions/co-parenting on site
  • EMDR
  • Animal Assisted Interventions – Horses, cats, dogs, chickens and peacocks.  Including day to day care of animals, as well as play and working with the animals therapeutically.
  • Nutrition – provision of a “brain friendly” diet which strives to use many organic and whole foods.
  • Exercise and recreation – including sports, team building, martial arts and other exercise based activities.
  • Service Learning via voluntary interaction in the community – litter/trash clean up on roads & volunteering at the local animal shelter.
  • Neurofeedback
  • Floating
  • Wilderness Adventure Therapy.
  • Daily education program through Del Rio Academy whereby the students are closely monitored from skilled and attuned education staff and given “brain breaks” when needed to help re regulate.  This involves taking the children out of the classroom in small groups and having them engage in exercise such as running laps, bilateral stimulation exercises, walking and talking and much more.
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Romero House

All of this provided on site or as part of the one program!

Sandhill has capacity for up to 30 children and adolescents at any given time and their average length of stay is around 18 months.  While the lists of interventions is broad, it is by no means all of what they do and one of the lovely observations I made was in fact the individual consideration given to each child’s sensory or regulatory need in the moment and matching all sorts of movement, sensory, mindful, relaxation and/or exercise based regulatory activity to them.

As I left Sandhill I reflected to their staff, that you know a program is doing a good job when the clients come up and tell you about themselves, why they are there and what they have learnt and how thankful they are for the experience at Sandhill.  Even more so when this happens in a house full of preadolescent and adolescent boys!

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Del Rio Swimming Pool

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Del Rio Academy onsite at Del Rio Property

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The Bath House: Home to the Float Tank and Neurofeedback

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Sports Court @ Romero (note trampolines in background)

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Romero Sports Court

 

 

 

 

“Heartwaves”

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“I need to be able to keep myself calm, if I can’t do that then how can I send her the heartwaves she needs to regulate, she needs and relies on my calm heartwaves”.
Tammy: Mental Health Liaison for Head Start part of Futures Unlimited , Wellington KS.

In the days of rest and jetlag recovery before my visit with Sumner Mental Health Services and the therapeutic preschool they provide services to at a Futures Unlimited, I had time to think and reflect on the last couple of months, the many consultations I do with our Take Two staff, but also the direct clinical work I do in my own private practice. With time on my hands and minimal demands on me, some of the struggles we have in our work became clearer.

A large part of the initial work in trauma recovery for children isn’t in treating the child themselves, but rather supporting and educating their carers/parents, workers, and teachers. Essentially it has to be about getting these significant relationships in the lives of children, armed and ready to provide the wrap around support and developmental guidance necessary for the child to heal from trauma.

This is often no easy task. Many of the direct care staff, parents, teachers and workers are at the coalface of the worst emotions and behaviours of traumatised children. Carers, teachers, parents sometimes can’t see beyond the behaviour, others less trauma informed may reinforce notions of the issues being purely behavioural. Often by the time these children get to a trauma informed therapeutic service, carers, teachers and workers are tired, worn out, at their wits end in how to manage these kids – some of them even ready to give up, if they haven’t already.

As therapeutic intervention staff, we can often get so child focussed that we charge on in, giving information and education about why the child behaves the way we do – All of it great and accurate information. Then we find ourselves perplexed that these significant adults in the lives of children continue to engage with the child as they did before, or retreat to explaining the behaviours of the child as naughty.

It occurred to me that we often approach this work with the best of intentions and assumptions that we are working with alert and rational adults. I want to be clear here, on a good day that’s exactly what most, if not all, of these adults are – rational, alert and thoughtful about the children they care for. But when you are under the pump, dealing with difficult, challenging and even aggressive and violent behaviour day in and day out, then maintaining a state of alert and rationality is challenging. In fact, these carers, parents and/or teachers may be stressed, angry or reactive in response to their child’s behaviour.

We know that many of the traumatised children we work with have overactive stress responses, these young people due to infant or early childhood exposure to threat, chaos and danger are ‘wired’ for stress. (Remember the brain organises as a function of our experience.) We know that when we move up the arousal continuum, the more stressed, fearful, aroused we become, or in other words as our state changes we have correspondending changes in our behavior. We become increasingly reactive and more likely to engage in fight/flight/freeze responses. We also know that there are changes in our cognitions or more simply, our ability to use the thinking part of our brains. In fact the more we move into a state of arousal, the less likely we are able to problem solve, recall memory, rationalise, reflect and in fact learn.

This arousal continuum is a universal human experience and with this in mind we can be more clearly directed in our treatment planning. Yes we need to get the direct care staff, parents, teachers and the like to a place of understanding their traumatised children, understanding the child’s self regulatory abilities and the reasons for this and then in turn help them in the support of enhanced coping and regulation for the children.

BUT

If we are going to be truly sequential and systemic in our intervention then we have to notice and respect the state of the carers, parents and teachers of the children we work with. Often time the struggle we have in getting these individuals to be able to learn and hold a trauma informed understanding of their kids is because we are less attuned to their state. Like Tammy said, the client she was working with the day I observed her at Sumner Mental Health and Futures Unlimited, needed her to have calm heartwaves to share for co-regulation. In the same way we need our carers, parents and teachers to have more regulated heartwaves and state regulation to hear, learn and hold the messages we have to give.

I came on this fellowship to explore regulatory activities and interventions for infants, children and adolescents, but many of the things I’m going to observe are going to be equally relevant in the wholistic and systemic work in the therapeutic web of a child. What’s more they are essential in order to ensure those caring for and teaching our clients are really able to internalise and reflect on our psychoeducation.

In essence, when necessary, state regulation of those caring for or teaching our infant, child & adolescent clients, in my mind must be one of the primary treatment goals.