integrating trauma -informed staffing & programming...

Integrating TraumaIntegrating Trauma--Informed Staffing & Informed Staffing &

Programming into Residential Systems:Programming into Residential Systems:

Out of the AbyssOut of the Abyss

Hilary Hilary HodgdonHodgdon, Joseph Spinazzola, , Joseph Spinazzola,

Stacey Forrest, & Sean RoseStacey Forrest, & Sean Rose

The Trauma Center, The van The Trauma Center, The van derder KolkKolk Center & The Walden Street SchoolCenter & The Walden Street SchoolBehavioral Health & Trauma, Behavioral Health & Trauma, MeadowridgeMeadowridge Schools, & Connecticut DivisionsSchools, & Connecticut Divisions

Justice Resource InstituteJustice Resource Institute

The Most Vulnerable of All?The Most Vulnerable of All?

� Over 3 million substantiated cases of child maltreatment/neglect exposure, with over 1.3 million exhibited noticeable immediate negative effects (NIS-4, 2010)

� Over 130,000 maltreated children placed in substitute care in 2010 (Children’s Bureau, 2011)

� Residential treatment as “end of the road” for youth “failed out” of less restrictive settings (Rivard, McCorkle, Duncan, Pasquale, Bloom, & Abramovitz, 2004)

� Most severe/pervasive symptoms and difficulties required for residential placement� Trauma-exposed Youth in Residential Treatment in the NCTSN CDS (n = 525 of

total N = 9,942)� Greater prevalence of multiple/chronic trauma

� Greater number of types of trauma exposures (M=5.8 exposures vs. M= 3.6)

� Greater psychological distress across a range of domains including attachment and learning disorders, substance abuse, self-injury and suicidality

� Greater functional impairment including academic and behavior problems, runaway & criminal behavior

� Require more intensive and longer-term intervention (demonstrate similar pattern of response to txt as youth in other placements / txt settings but gains not sufficient by end of typical residential treatment)

• (Briggs, Greeson, Layne, Fairbank, Knoverek, & Pynoos, 2012)

Van Van derder KolkKolk Approach to Comprehensive, Approach to Comprehensive,

TraumaTrauma--Focused Residential Youth Services:Focused Residential Youth Services:

Central TenetsCentral Tenets

Into the AbyssInto the Abyss

�� The context IS the cause IS the cure IS the curseThe context IS the cause IS the cure IS the curse

�� ““Home,Home,”” and and ““FamilyFamily”” as as ““toxictoxic”” constructs for constructs for

many complexly traumatized youth who have many complexly traumatized youth who have

become become ““allergicallergic”” to relationshipsto relationships

�� Residential setting and staff are a more tolerable Residential setting and staff are a more tolerable

alternative for some youth to develop new patterns alternative for some youth to develop new patterns

of attachment (more structure, less intimacy)of attachment (more structure, less intimacy)

�� And yet, both remain fraught with peril for mostAnd yet, both remain fraught with peril for most……

Trauma LensTrauma Lens

�� To be effective, traumaTo be effective, trauma--focused residential services focused residential services

must be embedded within a comprehensive, traumamust be embedded within a comprehensive, trauma--

informed foundationinformed foundation

�� Limitations of behavioral, diagnostic and medical Limitations of behavioral, diagnostic and medical

modelsmodels

�� Other lenses: culture, dissociative parts of selfOther lenses: culture, dissociative parts of self

InterventionistsInterventionists�� Singular teamSingular team

�� Everyone member of the program staff, from Everyone member of the program staff, from Director to janitor, is part of the intervention Director to janitor, is part of the intervention teamteam

�� Work to minimize role distinctions and divides Work to minimize role distinctions and divides between milieu and clinical staffbetween milieu and clinical staff

�� Recognize critical role of milieu staff in youth Recognize critical role of milieu staff in youth recovery, growth or perpetuation of difficultiesrecovery, growth or perpetuation of difficulties

�� Expand the scope: therapeutic mentors, Expand the scope: therapeutic mentors, community based services, state agency reps, etc.community based services, state agency reps, etc.

IntentionalityIntentionality

�� Proactive, planned, collaborative approachProactive, planned, collaborative approach

�� Clinical objectives drivenClinical objectives driven

�� Not Not ““whatwhat”” but but ““why,why,”” ““when,when,”” for for ““whowho””??

�� Responsive not reactiveResponsive not reactive

OpportunityOpportunity

�� Every interaction is a potential therapeutic Every interaction is a potential therapeutic intervention or mishapintervention or mishap

�� Attunement to spontaneous, teachable moments Attunement to spontaneous, teachable moments (whether directly or implicitly through modeling) as (whether directly or implicitly through modeling) as #1 bullet in every staff member#1 bullet in every staff member’’s job descriptions job description

�� A single moment of spontaneous harm done by staff A single moment of spontaneous harm done by staff (whether intentional or inadvertent) can undue weeks (whether intentional or inadvertent) can undue weeks of therapeutic progress of therapeutic progress

�� Seek opportunities for therapeutic repairSeek opportunities for therapeutic repair

ControlControl

�� Paradigm shift from emphasis on maintenance Paradigm shift from emphasis on maintenance

of external controls to building capacity for of external controls to building capacity for

youth internalization of capacity for selfyouth internalization of capacity for self--controlcontrol

�� Mentor not monitorMentor not monitor

�� Cowboy Down, Buddha UpCowboy Down, Buddha Up

�� PRN = Practice Regulation Now!PRN = Practice Regulation Now!

EducationEducation

�� Fostering the social and emotional development of Fostering the social and emotional development of youth should be the primary education focus of traumayouth should be the primary education focus of trauma--informed residential schoolsinformed residential schools

�� Require a paradigmRequire a paradigm--shift from curriculumshift from curriculum--driven driven inflexibilityinflexibility

�� Identify and address traumaIdentify and address trauma--related barriers to learningrelated barriers to learning

�� Increase classroom engagement by integrating clinical Increase classroom engagement by integrating clinical goals into the classroom (e.g., trust and community goals into the classroom (e.g., trust and community building, coping skills, threat detection and building, coping skills, threat detection and differentiation, etc. )differentiation, etc. )

ResiliencyResiliency

�� StrengthStrength--based programmingbased programming

�� Foster youth empowerment, voice and choiceFoster youth empowerment, voice and choice

�� Enhancement of existing competencies and Enhancement of existing competencies and

gradual acquisition of vital capacities and skills that gradual acquisition of vital capacities and skills that

did not develop as result of impaired did not develop as result of impaired caregivingcaregiving

�� Resilience is often tenuous and fragile and should Resilience is often tenuous and fragile and should

be safeguarded and nurtured by residential staffbe safeguarded and nurtured by residential staff

Embodied ExperienceEmbodied Experience

�� Power of transformative actionPower of transformative action

�� Integration of mindIntegration of mind--body interventionsbody interventions

�� Retooling relationship between Retooling relationship between ““toptop--downdown”” and and

““bottombottom--upup”” approachesapproaches

�� Recognizing the limits of cognitive/frontal Recognizing the limits of cognitive/frontal

approaches to resolution of arousal/limbic approaches to resolution of arousal/limbic

based based dysregulationdysregulation

Everyday is HalloweenEveryday is Halloween

�� Children exposed to trauma have learned to Children exposed to trauma have learned to

wear many masks to survive their experiences, wear many masks to survive their experiences,

navigate dangerous, exploitative or navigate dangerous, exploitative or

unpredictable relationships and circumstances unpredictable relationships and circumstances

�� When we get caught up in these presentations, When we get caught up in these presentations,

we lose sight of the vulnerable person behind we lose sight of the vulnerable person behind

these masks who desperately needs our patience, these masks who desperately needs our patience,

our understanding, our help to more adaptive our understanding, our help to more adaptive

ways to safely express themselves and get their ways to safely express themselves and get their

needs metneeds met

The Impossible IS PossibleThe Impossible IS Possible

�� Residential as a Residential as a ““last chancelast chance”” for many youthfor many youth

�� To succumb to their hopelessness and despair, To succumb to their hopelessness and despair, to wash our hands of them, is to hand them a to wash our hands of them, is to hand them a death sentencedeath sentence

�� If we find a way to believe in them despite their If we find a way to believe in them despite their adversities, and next to help them see and adversities, and next to help them see and experience them as we do, we then have an inlet experience them as we do, we then have an inlet retrain the brain, restore the body and begin to retrain the brain, restore the body and begin to reroute the river of their life trajectoriesreroute the river of their life trajectories

Bringing TraumaBringing Trauma--Focused Care to the Focused Care to the

Therapeutic MilieuTherapeutic Milieu

The van The van derder KolkKolk Center, Center, GlenhavenGlenhaven AcademyAcademy--A program of Justice Resource InstituteA program of Justice Resource Institute

�� Est. 2001; 32 total bedsEst. 2001; 32 total beds

�� CoCo--educational program serving educational program serving adolescents ages 12 adolescents ages 12 –– 2222

�� Located in Marlborough, MALocated in Marlborough, MA

�� 766 Approved Private School766 Approved Private School

�� Serving students with complex Serving students with complex trauma, mental illness, and trauma, mental illness, and behavioral strugglesbehavioral struggles

�� Inspired by the cutting edge work Inspired by the cutting edge work of Dr. Bessel van of Dr. Bessel van derder KolkKolk; ; provides individualized, strengthprovides individualized, strength--based, mindbased, mind--body, integrative body, integrative traumatrauma--focused treatmentfocused treatment

�� Serve school districts, state Serve school districts, state agencies, and private referralsagencies, and private referrals

IntroductionIntroduction

�� Program was facing significant challengesProgram was facing significant challenges�� Restraint utilizationRestraint utilization

�� Critical incidentsCritical incidents

�� Staff training and retentionStaff training and retention

�� Strayed from clinical modelStrayed from clinical model

�� Increasingly more challenging referralsIncreasingly more challenging referrals

�� Other examples: Level systems, restrictions, physical plant, Other examples: Level systems, restrictions, physical plant, earning privileges/tripsearning privileges/trips

�� Change was neededChange was needed……

Organizational Change CycleOrganizational Change Cycle

Assessment

Plan for Change

Implementation

Feedback &Evaluation

Sustainability

Putting the Vision into PracticePutting the Vision into Practice

AdministrativeTeam

Clinical

Team

Residential

Team

Educational

Team

Clinical

InterventionMilieu Classroom

Children we Serve


AdministrativeTeam

Clinical

Team

Residential

Team

Educational

Team

Clinical


Children we Serve

Administrative

Team

Clinical

Team

Residential

Team

Educational

Team

Clinical


Children we Serve

Role of the Administrative Team:

• Establishing the Mission and Vision.

• Needs assessment

• Adjusting Policies, Procedures & Allocation of Resources

• Training & Professional Development

• Physical plant

• Hiring, supervision, and scheduling.

• Staff self-care and wellness.

Implementing a Complex Trauma Implementing a Complex Trauma

Intervention FrameworkIntervention Framework

Change is hardChange is hard…….. Leading it is .. Leading it is

harder.harder.

Structuring Change InitiativesStructuring Change Initiatives

�� KotterKotter’’ss

Change Change

Model Model

ExampleExample

CitationCitation



�� Step 1 Step 1 –– Establishing a sense of urgencyEstablishing a sense of urgency –– help others help others

see the need for change, and why any change see the need for change, and why any change

initiatives are importantinitiatives are important

�� MUST be a programMUST be a program--wide initiativewide initiative

�� Why now?Why now?

�� Death by a thousand initiativesDeath by a thousand initiatives

Step 2: Step 2: Creating the guiding coalitionCreating the guiding coalition –– assemble work groups for the assemble work groups for the

purpose of change, provide guidance, empowerment, and supportpurpose of change, provide guidance, empowerment, and support

�� Role of leadershipRole of leadership

�� Administrative TeamAdministrative Team

�� Bringing everything back to the Bringing everything back to the

MissionMission

�� Creating a powerful, cohesive Creating a powerful, cohesive

teamteam

•• Need to trust that those Need to trust that those

people understand and can people understand and can

share the key points of the share the key points of the

modelmodel

�� Who else should be on the team?Who else should be on the team?




Intervention FrameworkIntervention Framework�� Step 3: Step 3: Developing a change visionDeveloping a change vision –– direct the change direct the change

effort, develop strategieseffort, develop strategies�� Start with Mission/Vision Start with Mission/Vision –– Example:Example:

•• Mission: Our mission is to keep kids safe, teach them skills andMission: Our mission is to keep kids safe, teach them skills and build build their selftheir self--esteem to form positive identitiesesteem to form positive identities

•• Vision: Our vision it to become a program where kids, in partnerVision: Our vision it to become a program where kids, in partnership ship with families and communities, can imagine and discover futures with families and communities, can imagine and discover futures beyond their present lives, regardless of their pastsbeyond their present lives, regardless of their pasts

�� Must guide ALL decision making and initiativesMust guide ALL decision making and initiatives

�� Needs Assessment Needs Assessment –– connects back to Mission / Visionconnects back to Mission / Vision•• Action Plan: concrete stepsAction Plan: concrete steps

•• Identifying a Treatment Frame / Approach Identifying a Treatment Frame / Approach –– See the following ARC Info See the following ARC Info slides:slides:


Intervention FrameworkIntervention Framework�� Step 4 Step 4 –– Communicating the vision Communicating the vision –– helping others in the helping others in the

organization to understand and connect with the purpose and organization to understand and connect with the purpose and directiondirection

�� Disseminating the messageDisseminating the message�� Training Training –– BIG commitment!! BIG commitment!!

�� Commitment to extending the information outside of trainings Commitment to extending the information outside of trainings –– how how do you get the information to do you get the information to ““the masses?the masses?””

�� Example:Example:

•• Training modules where staff rotate throughTraining modules where staff rotate through

•• Consultations with trainers and cliniciansConsultations with trainers and clinicians

•• SupervisionSupervision

•• Changes in schedulingChanges in scheduling

•• ProgramProgram--wide staff and student Challenges wide staff and student Challenges –– Make it fun!Make it fun!

�� All program staff must be committed to the modelAll program staff must be committed to the model


Intervention FrameworkIntervention Framework�� Step 5 Step 5 –– Empowering broadEmpowering broad--based action and remove obstacles based action and remove obstacles

–– be willing to change things that are not in like with be willing to change things that are not in like with

the vision, restructuring systemsthe vision, restructuring systems�� Through assessments, will likely find that people or systems in Through assessments, will likely find that people or systems in your program do your program do

not fit with new model not fit with new model –– Need to be willing to train, teach, and support, but also Need to be willing to train, teach, and support, but also to make hard choicesto make hard choices

�� Need to be willing to make changesNeed to be willing to make changes

•• Program Specific Examples: Philosophy of Program Specific Examples: Philosophy of ““they need to earn itthey need to earn it”” vs. vs. ““give give them what they needthem what they need””

�� ASSESSMENTS are keys to changeASSESSMENTS are keys to change

�� Implementing a framework thatImplementing a framework that’’s s ““graygray””

�� Time consuming to implement something newTime consuming to implement something new

�� Resources Resources –– willing to allocate them when neededwilling to allocate them when needed

�� Being willing to take CALCULATED risksBeing willing to take CALCULATED risks



�� Step 6 Step 6 –– Create short term wins Create short term wins –– plan for plan for

visible achievements, and point out visible achievements, and point out

accomplishmentsaccomplishments

�� There are always examples of things that worked, There are always examples of things that worked,

use them to your advantage!use them to your advantage!

�� Make milestones shortMake milestones short--term and achievableterm and achievable

�� Celebrate achievements, give praise and recognitionCelebrate achievements, give praise and recognition

�� Make change fun!Make change fun!



�� Step 7 Step 7 –– Build on the change Build on the change –– build on successes to build on successes to

continue forward momentumcontinue forward momentum�� CommunicationCommunication

•• Look for ways to communicate around the new model while integratLook for ways to communicate around the new model while integrating into ing into ongoing systems, new language and lensongoing systems, new language and lens

•• Then, assess if more communication would be beneficialThen, assess if more communication would be beneficial

�� Ongoing assessments, including use of time and resourcesOngoing assessments, including use of time and resources

•• Proactive communication and planning vs. reactive communication Proactive communication and planning vs. reactive communication and and planningplanning

�� Being proactive is more work!!Being proactive is more work!!

•• Use data to inform practice Use data to inform practice –– share with the masses in an ongoing and share with the masses in an ongoing and structured way structured way –– Knowledge is powerKnowledge is power

�� DonDon’’t get complacent t get complacent –– think next stepsthink next steps

�� Strategic planningStrategic planning



�� Step 8 Step 8 –– Incorporating change into culture Incorporating change into culture ––

anchor the change, link to long term anchor the change, link to long term

organizational successorganizational success�� RealityReality……

•• Making significant programmatic changes is very difficultMaking significant programmatic changes is very difficult

•• ARC (and many other treatment models) are most effective when imARC (and many other treatment models) are most effective when implemented longplemented long--termterm

�� ShortShort--term hurdles can be defeatingterm hurdles can be defeating

�� Not unreasonable to question direction and planNot unreasonable to question direction and plan

�� Sustainability and longevitySustainability and longevity•• Regular review of systemsRegular review of systems

•• Reflecting back to the mission and visionReflecting back to the mission and vision

•• Marking successes while incorporating new goalsMarking successes while incorporating new goals

Complex Trauma Intervention Models Complex Trauma Intervention Models

developed for use with youth Residential developed for use with youth Residential

Service SettingsService Settings

�� Overarching, systemsOverarching, systems--level frameworkslevel frameworks�� Attachment, Regulation & Competency (ARC)Attachment, Regulation & Competency (ARC)

�� Trauma Systems Therapy (TST)Trauma Systems Therapy (TST)

�� Specific Treatment ProtocolsSpecific Treatment Protocols (adapted for use as (adapted for use as

residential milieu frameworks)residential milieu frameworks)

�� Trauma Affect Regulation: Guide for Education & Therapy (TARGET)Trauma Affect Regulation: Guide for Education & Therapy (TARGET)

�� Structured Psychotherapy for Adolescents Responding to Chronic SStructured Psychotherapy for Adolescents Responding to Chronic Stress tress

(SPARCS) (SPARCS)

ARC Intervention ModelARC Intervention Model

Caregiver

Affect

Mgmt.

Attunement Consistent

Response

Routines

and

Rituals

Affect

IdentificationModulation Affect

Expression

Self Dev’t

& Identity

Executive

Functions

Trauma

Experience

Integration

Attachment

Self-

Regulation

Competency


Intervention FrameworkIntervention Framework�� Viewing problems, questions, and decision making through lens Viewing problems, questions, and decision making through lens

of a CTof a CT--Intervention FrameworkIntervention Framework�� Environmental considerations, physical plantEnvironmental considerations, physical plant�� Examples from Attachment, Regulation, Competency ARC) Framework:Examples from Attachment, Regulation, Competency ARC) Framework:

•• Attachment Attachment �� Starting right from interview/intakeStarting right from interview/intake�� Teachers, nurses, etc branching out and connecting with kids in Teachers, nurses, etc branching out and connecting with kids in other waysother ways

•• SelfSelf--RegulationRegulation�� Not reacting to behaviors; looking for causes and assessing Not reacting to behaviors; looking for causes and assessing whatwhat’’s needed to build regulation skillss needed to build regulation skills

�� Making appropriate skills available in different settings (classMaking appropriate skills available in different settings (classes, es, etc)etc)

•• CompetencyCompetency�� Assessing capacity and figuring out how to start increasing Assessing capacity and figuring out how to start increasing capacity through different competenciescapacity through different competencies


AdministrativeTeam

Clinical

Team

Residential

Team

Educational

Team

Clinical


Children we Serve

AdministrativeTeam

Clinical

Team

Residential

Team

Educational

Team

Clinical Intervention

Milieu Classroom

Children we Serve

Role of the Clinical Team:

-Training, supervision and consultation

- Redefining the clinician’s job description

- Identifying, implementing and sustaining trauma specialty interventions

Training, Supervision & Consultation

� Training:

� 2 day ARC training

� Other specialty interventions

� Trauma informed assessment tools

�ARC case consultation every other week

�ARC fidelity tool used to structure supervision

�Active involvement in ongoing training.

Redefining the Clinician’s Role� Intervention is not limited to the

therapy hour.

� Clinician’s as Directors of the

Symphony:

� Case conceptualization

� Trauma informed treatment plan

� Individualized plans for students – link

back to treatment goals.

� On the ground modeling and training

of staff in intervention methods.

Specialty InterventionsSpecialty Interventions

�� Program also adopted specialty interventions that work in Program also adopted specialty interventions that work in conjunction with the ARC Modelconjunction with the ARC Model�� SMARTSMART (Sensory Motor Arousal Regulation Therapy )(Sensory Motor Arousal Regulation Therapy )

�� TraumaTrauma--Sensitive YogaSensitive Yoga (TSY)(TSY)

�� NeurofeedbackNeurofeedback (NFB)(NFB)

�� Do the GoodDo the Good ((DtGDtG) therapeutic sports program) therapeutic sports program

�� How are these followed through on?How are these followed through on?�� Have to commit to the time, training, and resourcesHave to commit to the time, training, and resources

•• Training of staffTraining of staff

•• Supervision of providersSupervision of providers

•• Infusing into milieuInfusing into milieu


AdministrativeTeam

Clinical

Team

Residential

Team

Educational

Team

Clinical


Children we Serve

Administrative

Team

Clinical

Team

Residential

Team

Educational

Team

Clinical


Children we Serve

Role of the Residential Team:

-Redefining the role of direct care / front line staff

- Supervision & debriefing

- Supporting Competency

- Staff professional development

- Throwing out “Behavior Management”

Redefining Roles

The Residential Team:

� Supervision � Provides valuable 1:1 feedback for staff

� Builds rapport between employee and supervisor

� Proactively addresses issues or concerns

� Focuses on professional development versus client symptoms and behaviors

� Debriefing� Offers staff an opportunity to talk through and process events

• Affords staff the option to openly discuss how they’re managing their own self care post incidents or events

• Allows for honest assessment of events or incidents in an effort to avoid future incidents

� Supporting Competency� Understanding the importance of supporting client symptoms and behaviors to

supporting client competencies and identity building

� Throwing out “Behavior Management”� Recognizing that symptoms and behaviors are teachable moments� Awareness of the importance of practicing coping skills and for clients to attain

mastery and independence of these self regulation skills

� Acknowledging the significance of measuring and assessing internal capacity as a way to

treat clients

Administrative

Team

Clinical

Team

Residential

Team

Educational

Team

Clinical


Children we Serve

Role of the Educational Team:

- Supporting development of Executive Functioning

- Consistency & Routines in the Classroom

- Shifting view of education

- Integration of regulation

- Building relationships with kids outside of the classroom

Redefining Roles

The Educational Team

� Consistency & Routines in the Classroom� Recognizing how routine alleviates anxiety

� Minimizes disruptions

� Makes transitions from subject matter or classroom activities smoother

� Shifting view of education� Understanding the need to differentiate instruction in the moment

� Realization that self regulation and coping skills are a critical component to achieve maximum student performance

� Adjust pace according to your assessments over the course of a lesson or a unit

� Integration of regulation� Making coping skills available

� Building in moments to practice coping skills in the classroom proactively

� Building relationships with kids outside of the classroom� Shifting the balance of redirection and positive reinforcement

� Supporting development of Executive Functioning� Creating real life connections to lesson planning and assignments whenever possible

� Establishing moments for students to engage in discussion about real life situations and current events to

reinforce critical thinking skills

A Look BackA Look Back

�� Since fullySince fully--implementing the ARC Model in 2010implementing the ARC Model in 2010……�� Advances:Advances:

•• Restraints have decreased by over 60%Restraints have decreased by over 60%

•• Complete elimination of mechanical restraint and closed door Complete elimination of mechanical restraint and closed door timeoutstimeouts

•• Elimination of seclusionElimination of seclusion

•• Four month average reduction in length of stayFour month average reduction in length of stay

•• Staff retention (including promotions) improved by nearly 30%Staff retention (including promotions) improved by nearly 30%

•• Debriefing of approximately 80% of all major incidentsDebriefing of approximately 80% of all major incidents

�� In progress:In progress:•• Continue to improve staff retention ratesContinue to improve staff retention rates

•• Continue to increase focus on staff selfContinue to increase focus on staff self--care and wellnesscare and wellness

Out of the AbyssOut of the Abyss

integrating trauma -informed staffing & programming...

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