A Call to Children’s Residential Treatment Centers: Please, Please Do Your Own Trauma Work

“Sanctuary is a place of joy and creative innovation, of sympathy and solace, and of transformation.”

- Sandra L. Bloom & Brian Farragher, Restoring Sanctuary

Over the past two decades evidence has mounted regarding the prevalence of adverse childhood experiences (ACES)^1-3, the effect of these experiences on health-status and functional outcomes in adulthood⁴, the impact of trauma on neurodevelopment^5-8, and its disruption of the capacity to feel safe^{5- 10}. Most of the youth in residential treatment centers (RTC) (50%-71%) have been exposed to trauma^{11, 12}. As many as 92% have endured multiple traumatic events¹³. The American Association of Children’s Residential Centers¹⁴ has explicitly acknowledged that “many children in residential treatment manifest complex traumatic stress reactions that […] have been ‘hard wired.”’ And that “these children’s abilities to use cognitive processes or draw accurately upon memory is limited as a result of their traumatic experiences.” Nevertheless, therapeutic measures that rely heavily on cognitive processes (e.g., CBT, TF-CBT) linger as the standard of care in these organizations¹⁵. Even as the term trauma-informed has been integrated into the popular culture, RTCs have been challenged to fully incorporate the systemic changes necessary to provide effective trauma-informed care ^{16, 17} and to recognize trauma-specific clinical interventions which consider a neurodevelopmental perspective^15-17.

Trauma-informed care is more than a set of Guiding Principles hung on a wall to be reviewed at monthly staff meetings¹⁸. It is more than a two-day training that is never fully integrated into the cellular structure of the organization. It is a fundamental change in “an organization or system’s culture, behavior, actions, and responses”¹⁹. It is a holistic approach which requires courage, commitment, and the implementation of an iterative process inviting the opportunity for open, non-judgmental dialogue among stakeholders at all levels, rigorous evaluation, trouble-shooting, and supportive follow-up.

There are several recognized and valid barriers to effective systemic change in RTCs^14-17. One of the most significant, and sorely under-recognized, is the extent of the organization’s own trauma²⁰ – the collective implicit memory that continues to drive old paradigms even after new methods have been introduced. It is difficult, for example, to implement a system which deemphasizes power and control within a typically hierarchical organizational structure. Like the children it serves, an organization’s seemingly intractable behavior is a coping mechanism; it relies on what it knows in order to stay safe – or viable.

Trauma is often processed nonverbally^{5-7, 19, 21, 22}. Persistent fear-states impede the ability to “benefit from social, emotional, and cognitive experiences”^{5-9, 22}. This is not only true of children who have endured developmental trauma, but also of the organizations to which the most critically affected children (and their families) turn for help. In organizations, as in individuals, trauma operates insidiously. It informs written and unwritten policy, attitudes, practices, behavior, and ultimately, the felt sense of safety that lays the groundwork for meaningful change.

Without fully accounting for what is operating beneath the surface, demonstrable, authentic trauma-informed care may be beyond reach²⁰. Despite the best of intentions, it remains a set of guiding principles which are aspirational but not necessarily achievable.

Within a trauma-driven organizational structure, all systems are on high alert. Change is subverted by implicit fear. Most significantly affected are the relationships between the organization and its stakeholders. It seeks to appease those with relatively more power (e.g., accrediting bodies, payors) while marginalizing, intentionally or not, those with less (e.g., employees, families). The organization’s behavior is a fully adaptive response to the larger culture within which it operates. There is a fixed mindset that fails to see trauma (organizational or individual) as a root cause of otherwise inexplicable behavior.

This inflexible mindset carries into the treatment milieu where a child’s behavior is seen, not as adaptive, or as a symptom of what underlies it, or as a means of communicating an unmet need, but as a de novo problem which must be extinguished. Behavior alone is addressed without regard to its origins or functional utility. When treatment is not successful then, at least in some cases, the conclusion is that the child is not working hard enough or is not sufficiently engaged in the therapeutic process.

Trauma obviates the organization’s capacity for the perspective-taking that would lead to deep understanding and openness to change. It is stuck in defensive mode. The organization cannot provide trauma-informed care because it has not done its own trauma work!

I am the parent of a 9-year-old boy who has been in a residential treatment center for 18 months. He is bright, engaging, energetic, compassionate and, as the result of early trauma, he acts out aggressively. He was severely neglected and physically and emotionally abused from the moment of his conception to 23 months of age. At times he is infant-like and wants to be held. At other times he is fearful of predators that no one else can see. He is alternately playful and disinterested, close and detached, empathetic and provoking, silent and rageful. No matter what his internal state, he is a little boy. He has been away from home for a very long time – so long that he has nearly stopped believing in home – and yet he awakens every morning and finds his way through the day in the best way that he can. To say that he is brave is not enough and what would be enough cannot be conveyed with words.

My son has been tried on at least a dozen medications and has been working with a behavioral therapist since his admission. He has amassed six DSM diagnoses. His behavior today is as it was on day one. His trauma has scarcely been addressed. The overarching assessment is that he is not working hard enough, that he is acting out intentionally, that he is not sufficiently engaged in his treatment. He is 9.

In its publication Changing Communities, Changing Lives²³, SAMHSA’s National Center for Trauma Informed Care, refers to trauma-informed services as “a new social movement […] sustained by the emerging hope that things could be different.”

According to innovators Bloom and Farrager²⁰:

The current challenge for everyone in human services is how we unwittingly, and often in the name of science, erect barriers to recovery that prevent self-organizing change in the individual life of clients and in our organizations as well. We must wrestle with the fact that our diagnostic categories often shame clients from the moment the enter care. Our rigid hierarchies frequently prevent participation and innovation when what we actually need are staff members who can exercise almost constant creativity in order not to be drawn into traumatic replays of previous negative life experiences in the lives of the clients we serve. (p.30)

The challenges of becoming an effective trauma-informed organization are considerable for sure. Taken as an opportunity, and not a burden, they present a unique platform for organizational learning, healing, and growth. Among so many other things, the efforts inure to the benefit of a milieu that becomes a sanctuary for healing and where little boys are not subject to blame for unintended treatment outcomes.  

Yes, things could be different.

References

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