The question is not “What is wrong with you?” …but “What has happened to you?” Sandra Bloom

Trauma informed residential care: The role of the TCI system in meeting developmental needs and improving outcomes for young people in residential careDiana Boswell, Thomas Wright InstituteDavid O’Rafferty, ac.care rural South Australia ACWA 2012 Trauma Informed Residential Care TWI/ac.care

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

ACWA 2012 Trauma Informed Residential Care TWI/ac.care

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

PREMATURE SEXUALISATION 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

Relationships are the agents of change 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 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

Therapeutic Crisis Intervention Edition 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

“We want to raise children whose reasoning brain can triumph over the impulsive 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 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

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

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 ACWA 2012 Trauma Informed Residential Care TWI/ac.care

The question is not “What is wrong with you?” …but “What has happened to you?” Sandra Bloom