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The Salvation Army EastCare – Youth Services

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The Salvation Army EastCare – Youth Services Powered By Docstoc
					   The Salvation Army
EastCare – Youth Services


   Therapeutic Residential
      Program for Early
   Adolescents Living with
     Relational Trauma
  Lothar Wahl B.Soc.Wk. , M.Soc.Wk. by Research
                Project Consultant
    Brief Background to the
     Therapeutic Program

• EastCare and key Senior staff have had a long-
  standing interest in the application of Attachment
  theory to working with „at-risk‟ & „high-risk‟
  adolescents
• This dates back to 1997 when then Regional
  Manager of Youth Services Cheryl Baxter (recent
  Director EastCare) received a DHS study grant to
  visit various residential treatment programs based on
  Attachment theory, in both Canada and the USA
• Attempts to incorporate Attachment theory within the
  various EastCare Youth Services followed over many
  years with no dedicated positions to drive this
    Brief Background to the
     Therapeutic Program

• Meanwhile…current Project Consultant (PC) Lothar
  Wahl completed a Master‟s Degree Research Thesis
  from 2000-2006 examining interventions with
  adolescents placed in residential care, focusing on
  the potential applications of Attachment theory & the
  Neurobiology of Attachment & Trauma (Wahl, 2006)
• End February 2006 – PC employed full-time & „in-
  house‟ to implement a staggered therapeutic
  realignment of all Youth Services programs based
  around Attachment-Trauma theory
    Brief Background to the
     Therapeutic Program

• These include Residential Care, Contingency Units,
  ICMS, CIRC Education Support program, Work,
  Recreation and Education Day program, Leaving
  Care & JJ HIP
• Long-Term goal is therefore a „whole of service‟
  therapeutic realignment that sees all services
  delivered within an Attachment & Trauma framework
• Initial focus is to develop a model for a Therapeutic
  Residential Program (TRP) based on contemporary
  Attachment & Trauma theory
    Brief Background to the
     Therapeutic Program

• PC role is integrated with Youth Services Senior
  Management Team and is available for informal
  consultations to all YS‟s staff
• This integration & availability alongside the focus on
  developing a model for a TRP allows for an
  incremental diffusion of „therapeutic culture‟ across
  YS‟s that is complimentary to the implementation of
  the TRP
       Why a Therapeutic
      Residential Program?

• Recognition that therapeutic interventions are barely
  reaching adolescents in residential care
• We have been aware of this for some time
• „When Care Is Not Enough‟ (Morton et al, 1999)
  - recommendation re establishment of specialised
    residential treatment service to meet the
    therapeutic needs of adolescents with complex
    histories of attachment disruption & trauma
       Why a Therapeutic
      Residential Program?
* Whittaker (2000) – Residential programs in Australia
  suffer from a lack of model development, innovations
  and treatment
• Ainsworth (2001,2003) – Time to move beyond
  ideological rigidity, institutional scandals and the
  impasse about the usefulness and relevance of
  residential programs to „at risk / high risk‟ youth
• Need to build a new generation of powerful, tertiary
  level residential programs that offer „care and
  treatment‟ and consist of a „new practitioner
  workforce‟
• „If you want deeply rooted change, you need to apply
  deeply rooted methods’          (Goldstein, 1994)
       Why a Therapeutic
      Residential Program?

• Prof. Dorothy Scott - Opening Comments @
  CAFWAA Symposium 2003
  - „We gather together in the knowledge that the child
     welfare systems in our country are failing. To move
     forward we need not just a shared vision. We need
     to be visionaries‟.
• Prof. Dorothy Scott – Expert Panel Discussion on
  ABC Radio National 2003
        Why a Therapeutic
       Residential Program?

• Residential Care producing „…a growing cohort of
  young people who don‟t have a capacity to trust…to
  control impulses, who don‟t have a conscience…‟
• Vic. State Coroner‟s findings (2005) (reflecting on the
  suicide of a 16 year old female in Residential Care):
  - a void through which vulnerable adolescents are
  falling with catastrophic results for them, their families
  and the community at large
• Churchill Fellow Report „Reclaiming Residential Care‟
  (Hillan 2006) – Re-affirmed place of Residential Care
       Why a Therapeutic
      Residential Program?

• & emphasised the need for the development of
  therapeutic residential care (TRP) programs centred
  around Attachment and Trauma theory
• There will always be a cohort of clients unsuitable for
  Home Based Care due to its level of intimacy and the
  severity of their attachment and trauma issues
  (Barber et al, 2002; Bath, 1998; Delfabbro et al,
   2001)
• = we need Therapeutic Residential Programs!
      What Is a Therapeutic
      Residential Program?

• „Therapeutic‟ (Oxford Dictionary) – 1. relating to the
  healing of disease. 2. having a good effect on the
  body or mind
• To „heal‟ or have „good effect‟ it is necessary to
  administer a course of treatment that is systematic,
  highly intentional, purposeful and has components or
  properties known to alleviate the core suffering
• During and following the course of treatment, the
  core suffering in the recipient‟s body or mind will have
  been healed or at least profoundly improved
      What Is a Therapeutic
      Residential Program?

• Furthermore, these improvements will be
  experienced as profound to the recipient as well as
  those around them
• Therefore, we consider a TRP is a model of
  intervention that can heal or have profound „good
  effect‟ on the client‟s mind and body
• This is achieved by implementing an approach that-
    : has complete internal consistency & coherence
    : is intentional, deliberate and reflective
    : alleviates the core suffering of severe relational
      trauma
      What Is a Therapeutic
      Residential Program?

• We believe a truly effective TRP will produce
  therapeutic change of „clinical significance‟ (Kazdin,
  2002)
• „Clinical significance refers to the practical value or
  importance of the effect of an intervention, that is,
  whether it makes any „real‟ difference to the patients
  or to others with whom they interact‟
• In this context, a TRP will help to bring about
  improvements that materially affect the client‟s
  functioning
       What Is a Therapeutic
       Residential Program?

• „Clinical significance is important because it is quite
  possible for treatment effects to be statistically
  significant, but not to have impact on most or any of
  the cases in a way that improves their functioning or
  adjustment in daily life‟
• Callister (2005) refers to Raymond Lemay‟s belief
  that the purpose of the whole social work/child
  welfare sector is to „help people lead a good life‟
• That‟s „clinical significance‟ indeed!
      What Is a Therapeutic
      Residential Program?

• TRP with practice integrity will display evidence-
  based „signs and symptoms‟ (Berry, 2005)
• „…Evidence tells us not only what works, but also the
  components (my emphasis) of the intervention that
  need to be in place for it to work‟
• The practical components of our TRP will be covered
  later in this presentation
• The theoretical approach that informs these practical
  components is now outlined…
 What Type of a Therapeutic
   Residential Program?

• Best answered according to the profile, needs &
  sufferings of the intended target group
• = Adolescents who require residential placement due
  to the complexity & severity of their presentation and
  corresponding inability to reside in home based care
• „When Care Is Not Enough‟ (1999) identified a range
  of „co-morbid‟ psychiatric conditions as characterising
  this client group
 What Type of a Therapeutic
   Residential Program?

• We now understand that we have somehow been
  „…missing many children who we cannot fully and
  accurately diagnose (with the current diagnostic
  criteria)‟ and this has „…just crystallised in the last
  few years‟ - Julian Ford, US Child Trauma expert,
  2007
• Previously then, resi clients have received „…a
  hodgepodge of labels for any number of symptoms…‟
  (Moran, 2007)
 What Type of a Therapeutic
   Residential Program?

• A „hodgepodge‟ example from a Mental Health Assessment of
   an adolescent in residential care by a previous Clinician in
   CAMHS
• F 94.1 Reactive Attachment Disorder of Infancy or
         Early Childhood (Disinhibited Type)
  F 41.9 Anxiety Disorder (Not Otherwise Specified)*
  * couldn‟t articulate trauma symptoms/experiences
  F 91.3 Oppositional Defiant Disorder
  F 90.0 Attention Deficit/Hyperactivity Disorder (Combined Type)
  Z 62.4 Neglect of Child
  Z 61.9 Parent-Child Relational Problem
 What Type of a Therapeutic
   Residential Program?

• „Approaching each of these problems piecemeal,
  rather than as expressions of a vast system of
  internal disorganisation, runs the risk of losing sight
  of the forest in favour of one tree‟ - van der Kolk 2007
• This makes poor clinical sense as well as poor
  financial sense
• = Treating the isolated symptoms of severe relational
  trauma is likely to be more costly overall than funding
  programs that deal with the constellation of issues „at
  once‟ (Moran, 2007)
 What Type of a Therapeutic
   Residential Program?

• Theorists from the fields of Attachment, Trauma &
  Neurobiology have conceptualised the variety of
  difficulties many adolescents in residential care
  present with using four mostly interchangeable terms:
  - Cumulative Trauma (Khan, 1964; Schore, 2001)
  - Relational Trauma (Schore, 2001; 2003)
  - Complex Trauma
  - Developmental Trauma        (van der Kolk, 2005)
 What Type of a Therapeutic
   Residential Program?

• Fundamentally, these four terms describe:
   „…the experience of multiple, chronic and prolonged,
   developmentally adverse traumatic events, most often of an
   interpersonal nature and early-life onset‟
   (van der Kolk, 2005)
 * The exposures often occur within the child‟s caregiving system
   and include the various forms of abuse and neglect
 * The perpetrator of abuse or neglect is most often one of the
   primary caregivers
 What Type of a Therapeutic
   Residential Program?

• These primary caregivers can be described as a
  „traumatogenic parent‟ = „…a parent who is likely to
  inflict a high degree of cumulative trauma: sexual or
  physical abuse, emotional cruelty, exposure to adults‟
  promiscuous sexual behaviour or unnecessary
  separation and abandonment‟ (Marrone, 1998)
• There is also a „pathogenic‟ style of parental
  communication = the constant repetition of
  communications that are unsupportive or lacking in
  sensitive responsiveness (Marrone, 1998)
 What Type of a Therapeutic
   Residential Program?

• „Such developmental trauma is relational, usually not
  a singular event but „cumulative‟, a characteristic of
  an impaired attachment relationship‟ (Schore, 2001;
  2003)
• Bruce Perry (1997) describes such a childhood as
  being „incubated in terror‟
• US Trauma experts such as Bessel van der Kolk and
  Julian Ford are leading the campaign for the
  establishment of a new DSM diagnostic category that
  can accurately reflect the above experiences
 What Type of a Therapeutic
   Residential Program?

• US trauma experts propose a category titled
  „Developmental Trauma Disorder‟ (Moran, 2007; van
  der Kolk, 2005)
• The diagnostic criteria proposed for this disorder
  neatly captures the two central themes of Attachment
  & Trauma. It includes:
  Persistently Altered Attributions & Expectancies
      - negative self-attribution
      - distrust of protective caretaker
      - loss of expectancy of protection by others
What Type of a Therapeutic
  Residential Program?

      - loss of trust in social agencies to protect
      - lack of recourse to social justice/retribution
      - inevitability of future victimisation
Triggered Pattern of Repeated Dysregulation in
Response to Trauma Cues
* Dysregulation (high or low) in presence of cues.
  Changes persist and do not return to baseline in the
  following areas
What Type of a Therapeutic
  Residential Program?

  - affective
  - somatic (eg. physiological, motoric, medical)
  - behavioural (eg. re-enactment, cutting)
  - cognitive (eg. thinking that it is happening
    again, confusion,dissociation,depersonalisation)
  - relational (eg. clinging, oppositional, distrustful,
    compliant)
  - self-attribution (eg. self-hate, blame)
 What Type of a Therapeutic
   Residential Program?

• The „Nameless Dread‟
  = „…intense anxiety or anxiety-ridden feelings which
  a person experiences at a subjective level but to
  which they cannot give a name. …this is anxiety or
  pain which has no meaning‟ (Marrone, 1998)
  - this extreme level of anxiety is chronic and derives
  from two basic human needs not being met…
  Safety & Security
What Type of a Therapeutic
  Residential Program?


• In order to address the relational trauma
  that adolescents in residential care
  present with, a model of therapeutic
  residential care that addresses issues of
  disrupted attachment & trauma is
  essential
 Relational Trauma Further
         Explored

• Neurobiology
 - The application of neurobiology to human behaviour
 has been defined as the specialisation of affective
 neuroscience or interpersonal neurobiology (INB)
 (Schore, 2003; Solomon et al, 2003)
 - INB aims to explore how a person‟s
 interpersonal/relationship experiences, especially
 early in life, impact the development of the neural
 pathways involved in attachment and self-regulation
  Relational Trauma Further
          Explored

• The human brain is extremely social in that although
  genes program the maturation of the brain, life and
  relational experiences have a critical level of
  influence in shaping the structure of the brain
  (Siegel, 2003)
• The primary caretaking relationships of infancy and
  childhood determine core neurobiological
  organisation for the human individual (Perry,1997)
  Relational Trauma Further
          Explored

• When infancy & childhood is characterised by ongoing relational
  trauma, a variety of „brain insults‟ occur that cause serious, long-
  term and relatively intractable neurobiological, psychological,
  emotional and behavioural impairments
• These will only be summarised today…
• Prolonged, excessive secretion of the stress hormone cortisol,
  causing:
  - an over-pruning of synapses in the area of the right brain
  related to the modulating and regulating of emotion in response
  to stress
  - damage to the brain stem and limbic structures, significantly
  inhibiting soothing functions at a basic physiological level
  Relational Trauma Further
          Explored

  - that part of the brain (hippocampus) concerned with the
  operation of explicit memory and the development of a sense of
  self in the world, to shrink
• Overuse and over development of the primitive portions of the
  lower brain (brain stem & midbrain) & Consequent
  underdevelopment of the midbrain area (limbic & corticol) above
  the lower brain; predisposing individuals to significant & chronic
  levels of impulsivity, reactivity, dysregulation, aggression, hyper-
  vigilance, hyper-arousal, hypersensitivity, bias towards
  perceiving threat and hostility and a persistent stress-response
  state
  Relational Trauma Further
          Explored

• Due to the brain’s ‘bottom-up’ sequence of development, higher
  brain areas (prefrontal & orbitofrontal cortex) are also
  underdeveloped & impaired which represents a central
  mechanism in the behavioural expression of poor attachment,
  lack of empathy, violence, poor executive planning and control
  of inhibitions & inability to process, contextualise and
  understand life experiences
• = This experience-based, developmental imbalance between
  lower & higher areas of the brain „…predisposes to a host of
  neuro-psychiatric problems…‟ (Perry, 1997)
Relational Trauma Further
        Explored

* Attachment
- The founder of attachment theory, John Bowlby,
contended that attachment theory in psychiatry
represented the equivalent of the study of
immunology in medicine (1969, 1973, 1980)
- „Attachment in its broadest sense is consistently
found to be the most significant factor in assessing
long-term outcomes for children‟ (Calvert et al 2001)
- Bowlby (1969) defined attachment as being strongly
disposed to seek proximity to and contact with, a
specific figure/s and to do so in certain situations
such as being frightened, tired or ill.
  Relational Trauma Further
          Explored

• The establishment of attachment leads to the
  formation of enduring and strong affectional bonds to
  particular others
• Attachment issues apply from „cradle to grave‟
• Attachment behaviour is not in a constant state of
  activation but rather is activated only by certain
  conditions such as hunger, fatigue, illness, distress,
  strangeness, fear or unavailability or
  unresponsiveness of an attachment figure (Bowlby,
  1980)
• There are four attachment types (Ainsworth et al,
  1969; Ainsworth et al, 1978; Main et al 1986) - one
  Relational Trauma Further
          Explored

• Secure Attachment („B‟)

- Secure attachment is present when a person has other people in
   their lives that they consistently approach - especially in periods
   of negative stress - show no fear of them, be highly receptive to
   being cared for by them and display (appropriate) anxiety if
   separated from them

• The internal working model of others is as responsive, loving,
  reliable and capable and of a self that is „good‟, worthy of love,
  care and attention. Also, the world will be internally represented
  as safe, relatively predictable and as presenting many desirable
  opportunities for exploration, creativity and play
  Relational Trauma Further
          Explored

• Insecure Attachments („A‟, „C‟ & „D‟)
   - When a person‟s primary caregiving experience in childhood is
   relationally traumatic, insecure attachment types will develop
   - Insecure attachment is experienced when „conventional‟ and
   „normal‟ attachment-seeking behaviour does not achieve its goal
   of proximity to and felt security with, the desired attachment
   figure and is replaced with maladaptive attachment behaviour
  - (Attachment behaviour refers to any of the various forms of
   behaviour that a person commonly engages in to attain and/or
   maintain a desired proximity to some other differentiated or
   preferred individual)
  * While insecure attachment behaviours are „maladaptive‟, they
   do represent a person‟s best efforts to adapt to a traumatising
   environment, as they are a form of defence aimed at survival
  Relational Trauma Further
          Explored

• Avoidant/Dismissing Attachment Type („A‟)
  - minimises or denies attachment behaviour and affect
  - strong feelings are defensively excluded, distress is denied or
  not communicated and emotional self-containment is
  established
  - this emotional self-containment establishes a „wall‟ around the
  person that protects them and reduces their chances of
  rejection, which they see as more or less inevitable
  - over-regulation of emotions
  - This downplaying of feelings and expressions of distress can
  be seen as a „flight‟ from a display of attachment needs
  Relational Trauma Further
          Explored

• Ambivalent/Preoccupied-Entangled-Enmeshed
  Attachment Style („C‟)
  - maximises their attachment behaviour in order to „break
  through‟ the perceived and/or actual, emotional neglect,
  unavailability and lack of responsiveness of others
  - attachment behaviour is often highly demonstrative,
  demanding, angry, threatening and loud
  - preoccupied with the availability of the other
  - such behaviours are likely to be particularly pronounced at
  times of upset, signs of separation, perceived insensitivity,
  threatened abandonment and emotional unavailability
  - under-regulation of emotions
Relational Trauma Further
        Explored

- This overly strong communication of feelings and expressions
of distress can be seen as a „fight‟ response – demands for
attention and protection
- Avoidant and Ambivalent attachment styles will lead to the
development of an internal working model of others as
insensitive, unavailable, unreliable, inconsistent and/or
incompetent and of a self that is ineffective, unworthy of love,
care and attention and lacking intrinsic value
- In addition, the view of the world that is internalised is one of it
being a dangerous place in which other people are to be treated
with great caution
  Relational Trauma Further
          Explored

• Disorganised/Unresolved Attachment Style („D‟)
  - A person whose attachment behaviour and affect are highly
  disorganised with no consistent approach or strategies to deal
  with their attachment needs
  - Attachment behaviour is often incoherent and disoriented, with
  a confused mix of withdrawal, avoidance, angry approaches,
  controlling behaviour and inertia towards others who are
  generally perceived as frightening, unreachable and
  unpredictable
  - The ongoing state of anxiety and insecurity present is more
  severe and distressing than with the insecure-organised
  patterns (avoidant and ambivalent), since attachment needs are
  not even partially met
Relational Trauma Further
        Explored

- The disorganised/unresolved style is superimposed on a core,
‘best fitting’ organized attachment pattern such as avoidant or
ambivalent
- The disorganisation is only seen where distress, attachment-
related anxieties and traumatic childhood memories intrude into
the present
- This means that when the individual is not immediately caught
up in their fear and distress, an underpinning „organised‟
attachment style operates.
- This disorganised communication of feelings and expressions
of distress can alternate between „fight‟, „flight‟ and „freeze‟
responses.
Relational Trauma Further
        Explored

- In Disorganised attachment, the internal working
model is of a self that is unloved and/or bad and
other people are essentially unavailable, threatening,
frightened or frightening
- The world is internalised as highly unpredictable
and a hyper-vigilance is maintained in order to
defend against ever-impending attacks and profound
threats to self
- „…constitute the hard core of most clinical and
welfare caseloads‟ (Howe et al, 1999)
  Relational Trauma Further
          Explored

• Trauma
  - „…psychological injury caused by some extreme
  emotional assault‟ (Reber, 1995)
  - The experience or witnessing of an event or events
  that involved actual or threatened death or serious
  injury, or a threat to the physical integrity of self or
  others
  - The person‟s response involved intense fear,
  helplessness or horror
  Relational Trauma Further
          Explored

  - All usual coping mechanisms & defences are
  overwhelmed
• The above description of trauma is usually
  associated with the isolated or discrete trauma
  „events‟ we associate with Post-Traumatic Stress
  Disorder (PTSD) (American Psychiatric Association)
• Because trauma experiences are so overwhelming,
  they are not integrated into explicit memory nor the
  understanding of the „self‟
  Relational Trauma Further
          Explored

• However, any similar experience or fragment of the experience
  can have the effect of „bringing back‟ the initial traumatic event
  completely
• It will seem as if past traumas are being re-lived
• This „re-living‟ is caused by exposure to „triggers‟
• The re-living includes:
  - acting or feeling as if the traumatic event were recurring
  - intense physiological reactivity and arousal
  - recurrent and intrusive, distressing recollections
  Relational Trauma Further
          Explored

• Relational, Complex Trauma means there is a chronic
  experiencing or witnessing of traumatic events, as well as a
  pervasive, almost constant „incubation‟ in the feelings of intense
  fear and helplessness
• The experience of complex trauma is so pervasive as it occurs
  within the daily context of primary caregiving relationships
• This means potential „triggers‟ will be far more diverse and
  constant
• Normal sensory and „environmental‟ triggers such as a particular
  smell, taste, sight, sound or tactile experience combine with a
  vast array of „relational‟ triggers such as a particular smile, tone
  of voice, form of physical contact, experience of discipline or a
  caregiver‟s attempt at being nurturing
  Relational Trauma Further
          Explored

• Imagine living in this world every day!!!!
• Then, imagine living in it with a variety of staff who
  are not adequately resourced to provide much of the
  therapeutic care required to facilitate safety, soothing
  & recovery and who by virtue of this inadequacy will
  unintentionally further traumatise and re-wound…
TRP – Some Interventions &
       Techniques

• KEY PRINCIPLES FOR INTERVENTION
• Attachment – the following is largely influenced by
  the work of John Bowlby, Mary Ainsworth, Mary Main
  and the latter day Attachment theorist Daniel Hughes
  (founder of Dyadic Developmental Psychotherapy)
• Trauma – the following is largely influenced by the
  work of Judith Herman, Sandra Bloom & Bessel van
  der Kolk
TRP – Some Interventions &
       Techniques

• Safe and secure-attachment promoting relationships
   are the conduit or ‘funnel’ through which all other
   interventions can best be provided
* „The provision of primary attachment figures is the
   central task of the state as good parent. Unless this is
   achieved the other services offered to the young
   person are unlikely to be effective (my emphasis). It
   is vital that the young person be offered a close
   ongoing relationship with one or more adults (Morton
   et al,1999)
TRP – Some Interventions &
       Techniques

• „To “process” their traumatic experiences, these children first
  need to develop a safe space where they can “look at” their
  traumas without repeating them and making them real once
  again‟ (van der Kolk, 2005)
• This safe space is therapeutic relationships
• Therapeutic interventions must primarily focus on:
  - establishing safety & competence
  - dealing with traumatic re-enactments
  - integration of traumatic material
  - being able to feel „in charge‟ of body & mind
TRP – Some Interventions &
       Techniques

• The beginning point for intervention then, is assisting clients to
  negotiate safe interpersonal attachments
• In this relational context, clients can be helped to realise „…that
  they are repeating early experiences and to find new ways of
  coping by developing new connections between their
  experiences, emotions and physical reactions‟ (van der Kolk,
  2005)
• This will require staff who themselves have a secure adult
  attachment style and strong self-reflective function regarding
  their own relationship history and patterns
• Many staff who work in residential care, due to their own
  troubled histories, do not have these strengths (Hillan, 2006)
TRP – Some Interventions &
       Techniques

• Staff recruitment & selection processes are therefore
  crucial and represent the foundation of the entire
  range of proposed interventions & techniques
• Their own attachment profile will need to be screened
  (covered more later)
• We want staff capable of „keeping PACE‟ (Playful,
  Accepting, Curious and Empathic) in the midst of the
  work (Hughes, 2003)
• Now, some more specific „techniques‟ or tools…
TRP – Some Interventions &
       Techniques

• Key aspects of addressing attachment disruption are:
  - challenging the core beliefs and associated cognitive
  distortions that maintain a destructive internal working model
  - assisting the client to develop a coherent autobiographical
  account of their life, integrating difficult material into an
  otherwise highly fractured sense of self
  - staff „teaching‟ & „role-modelling‟ self-reflection by clearly,
  appropriately & purposefully communicating their own subjective
  experience as well as reflecting that of the client back to them
TRP – Some Interventions &
       Techniques

• Practical tools for direct care staff to address these areas will be
  included in the Therapeutic Service Delivery Manual (TSDM),
  which will feature much new material developed by the PC
• Therapeutic modalities that appear to suggest helpful
  techniques and means by which to hold hold therapeutic
  conversations specifically addressing attachment disruption are:
  - Parallel Parent Child Narrative (e.g. meaning making)
  - Narrative Therapy (e.g. meaning making)
  - Cognitive-Behavioural Therapy (e.g. core beliefs)
  - Motivational Interviewing (e.g. secondary gains)
  - Relationship Management (e.g. process over content)
  - Critical Counselling (e.g. challenging origins of beliefs formed)
TRP – Some Interventions &
       Techniques

• Key aspects of addressing trauma are:
  - establishing basic physical & psychological safety in both the
  physical & relational environment
  - education regarding symptoms occurring on physiological,
  psychological and emotional levels
  - provision of alternative, positive coping strategies
  - exploration of traumatic memories
  - integration of traumatic material
  - reconnection to self, others and world
TRP – Some Interventions &
       Techniques

• Therapeutic modalities that appear to suggest helpful
  techniques and means by which to hold therapeutic
  conversations specifically addressing trauma symptoms are:
  - Psycho-education / Mental health literacy (e.g. physiological &
  neurobiological symptoms)
  - Supportive Psychotherapy (e.g. CSE - coping strategies
  enhancement)
  - Dialectical Behavioural Therapy (e.g. distress tolerance skills)
  - Somatic Psychotherapy (e.g. embodiment of experience)
  - Narrative Therapy (e.g. externalisation)
  - Cognitive-Behavioural Therapy (e.g. using Socratic dialogue to
  counter threat perception)
TRP – Some Interventions &
       Techniques

• „Cautionary Word Heeded‟
  - It is acknowledged that any particular therapeutic
  strategies or techniques developed to address
  relational trauma, must be employed in the context of
  a broader, underpinning therapeutic intent derived
  from an understanding of Dyadic Developmental
  Psychotherapy and also provided by a staff member
  with strong reflective function and a secure adult
  attachment profile
TRP – Some Interventions &
       Techniques

• However, it is also asserted that in order to realise
  and maximise the implementation of a Therapeutic
  Residential Program able to address relational
  trauma, the understanding of an overall, underpinning
  approach is insufficient without practical &
  conversational tools
• Such tools may be usefully derived and developed
  from a range of therapeutic modalities as listed above
        Target Client Group

• Custody to Secretary or Guardianship Orders
• Unable to reside in Home Based care due to its level
  of intimacy
• Effects of attachment disruption & cumulative trauma
  are pervasive, severe and not significantly impacted
  by less therapeutically intentioned relationships
• Attachment and trauma issues „get in the way‟ of
  receiving and benefiting from more „traditional‟
  service responses such as residential care and
  „wraparound‟ approaches
          Target Client Group
• Lack of / poor empathy
• Violent, aggressive and/or impulsive behaviours
• Limited social & problem solving skills
• Poor emotional regulation with little insight
• Heightened threat perception and hyperarousal
• Negative attributional bias regarding the intent of others e.g.
  hostile, threatening
• Risk-taking behaviours
• Substance abuse
• Parental and/or familial mental illness, substance abuse and
  violence
             Program Details

* Two Therapeutic Residential Houses
  - each to have 3 clients aged 12-14.5 years at intake
  - 18 month – 2 year admission with planned exiting to less
  intensive setting (Leaving care focused)
  - one female & one male house; staffing group mixed
  - most of each 24 hour period, a minimum ratio of two staff:
  three clients will be maintained
  - the Program Co-ordinator will supplement these two staff
  during the course of each day
  - overnight staffing arrangements to be finalised; build in
  outreach capacity for clients who have absconded?
                Program Details

    - Case management held through EastCare ICMS (culturally
     aligned to TRP)
•    Each property will have on-site educational, vocational &
     recreational facilities
•    E.g. Dedicated learning space; garage workshop space
     (mechanics, wood, metal); Wet area for art; sporting area
•    Sessional, educational & volunteer staff with specialist skills to
     attend during school hours?
•    Some therapeutic modules presented that aim to provide mental
     health literacy regarding issues such as relationships, mind &
     body, stress responses etc.
•    Content of these modules can be utilised as resourcing
     therapeutic conversations
            Program Details

• Structuring of each day
  - each client will have an Individual Activity Plan (IAP)
  that will „fit‟ with the broader routines of the House as
  well as the Group Activity Plan (GAP)
  - this means clients will have a highly structured
  program across the seven day week that involves
  both individual and group activity
  - these activity plans are seen as indispensable to
  providing a containing, predictable environment as
  well as providing a context for fun and therapeutic
  work with staff
               Program Details

• Referral Process:
  - From DHS (EMR)
  - Based on client needs not Regional demand management
  - Current CAMHS or TT Mental Health Assessment to be
  completed prior to referral by DHS
  - This assessment to provide basis of referral information that
  will include client history, developmental profile & diagnoses etc.
  - Referral panel consisting of Program Manager, Project
  Consultant, Program Co-ordinator + staff representatives from
  DHS PCU & Child Protection, CAMHS and TT
  - Four week decision-making timeline
  - Individual Therapeutic Plan (ITP) developed collaboratively by
  assessing mental health clinician, project consultant and
  program co-ordinator
    Staffing Considerations

• The recruitment & selection processes for staff to be
  employed in the TRP are considered the very
  foundation of the program
• Staff will require three key qualities to be selected:
  - Capacity to conceptualise their work drawing on
  therapeutic frameworks
  - Secure Adult Attachment Profile
  - Strong reflective skills regarding their own
  subjective states and those of others
    Staffing Considerations

• Due to this, applicants will be required to undergo a
  three-stage interview process
• This will include an individual interview in which
  questions will be asked and reflection sought based
  on their own attachment history etc.
• This interview will be based around the material
  included in the Adult Attachment Interview (A.A.I.)
  (Main, 1984)
• There will also be a group interview in which
  applicants will share some of this information with
  others
    Staffing Considerations

• Position descriptions for a Program Co-ordinator and
  other direct care staff with appropriate „therapeutic
  loading‟ are nearing completion
• This process is being assisted by the involvement of
  the Quality Manager within Youth Services
• Direct care staff employed under SACS Award
• We aim to secure staff from a range of disciplines
  including youth work, psychiatric nursing, psychology,
  occupational therapy and social work
    Staffing Considerations

• Some potential recruitment from existing Resi staff,
  others will be new staff to EastCare
• Staff Training
  - comprehensive training intensive with
  homework/workbook activities to consolidate
  understandings, including a residential retreat
  - ongoing „booster‟ sessions each month
• Staff Coaching & Mentoring
  - ongoing and provided by Project Consultant and
  Program Co-ordinator (office and on-site)
   Staffing Considerations

• Staff Supervision (formal)
- Program supervision provided by Program
  Co-ordinator once per fortnight
- Therapeutic supervision provided by Project
  Consultant once per fortnight
• Staff composition = balance of male & female
  staff is regarded as important
 Evaluating Effectiveness &
         Outcomes

• The key indicator of the success of the TRP will be
  deemed to be the „evidence‟ in the client‟s lives of
  outcomes that were earlier defined as „clinically
  significant‟
• Specific process sheets will be developed to record
  improvements in client functioning regarding e.g.
  care-seeking and help-seeking behaviour patterns;
  autobiographical competence and emotional
  regulation skills
 Evaluating Effectiveness &
         Outcomes

• Other data collection points will be established that
  reflect reductions in client disturbance (e.g. incident
  reports, critical incidences and use of Secure Welfare
  Services) by comparison with current residential care
  programs
• Clients will also be provided with some self-report
  questionnaires that relate to their functioning, similar
  to the SDQ (Strengths & Difficulties Questionnaire)
  but „tracking‟ attachment and trauma related issues
  more specifically
 Evaluating Effectiveness &
         Outcomes

• The specific therapeutic components and techniques
  used by staff with clients will be „tracked‟ in order to
  establish the most effective interventions within the
  TRP e.g. Narrative questions regarding an „exception‟
  to people feeling „unavailable‟ as part of disconfirming
  internal working model
• = we‟ll know what has changed, how it changed and
  why it changed
• = building of evidence-base for TRP‟s for adolescents
  living with relational trauma
Snapshot of Achievements
         to Date

* 14 MONTHS OF WORK, YEARS IN THE MAKING!
* Organisational/structural re-development of Youth Services to
 enhance program resources and staff skill levels available to the
 Therapeutic Residential Program e.g. Resi; ICMS
* Progressive „whole of service‟ cultural realignment to
 therapeutic ways of working via e.g. PC participation in decision-
 making processes within Senior Management Team (SMT);
 redevelopment of on-call, case management and case
 presentation practices
* Employment of a full-time Quality Manager to bolster
 operational policies and procedures, which must be strong in
 order for any therapeutic model to be implemented successfully
Snapshot of Achievements
         to Date

* Amendments to Policy & Procedures Manual derived from
  Minimum Standards for Residential Care plus Training in these
  Standards to reflect use of Attachment theory
 * Use of recent and locally produced research (by PC) to glean
  the ideas and experiences „from the field‟ to place alongside
  literature review and overseas experiences, thus ensuring
  applicability to the local context  (Wahl, 2006)
* Included depth interviews with Senior Managers from Child
  Protection, Juvenile Justice, Welfare & Mental Health (range of
  disciplines)
* Development of a comprehensive model for a TRP based
  around an Attachment-Trauma approach
         Issues & Challenges

• Negotiation of broader systemic issues such as the interface
  between the TRP and external service providers e.g. DHS;
  CAMHS; TT; JJ etc.
• Development of unique program will require development of
  tailored & specialised protocols with other organisations
• Major service re-configuration required to convert existing resi
  targets and accommodate new TRP
• Potential need for additional project staff to assist PC to
  implement in a more timely manner
 Regional Thoughts to Date

• Presentation to Acting Manager Protection, Support
  and Juvenile Justice & Manager Placement, Support
  and Family Services occurred recently
• = Extremely well received, v.positive reception
• Discussions established desirability of opening two
  TRP‟s instead of one (total 6 clients)
• Better „critical mass‟ & economies of scale regarding
  purchasing in of various services, additional program
  staff etc.
• Timeline: Open first TRP around August, second
  TRP soon after
 Conclusion



• Questions ????


 (References provided)

				
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