Trauma Informed Care in Residential Care Environments

Organizational Leadership

Residential centers, and the staff who work in them, are themselves subjected to overwhelming stress. This is related to vicarious trauma that may occur from working with youth and families who have experienced severe and persistent stress, as well as to demands both from within the organization and from external sources that can result in staff feeling hopeless, blamed, helpless, and fearful. If staff are to respond to children and their families with trauma-informed sensitivity, it is leadership’s responsibility to develop and support a culture that does the same for staff.

Elements leaders are building into the RCH&R culture include:

• Implementing shared governance and collaborative decision-making. Staff who are actively engaged in decision-making that affects the work they do experience influence over the activities of the organization and gain a sense of personal control over their immediate jobs.

• Adopting a treatment philosophy focused on relationships, helping youth and their families maintain calm engaged states, maintaining clear expectations and supports, and allowing choices.

• Engaging Board and staff in affirming organizational values that focus on inclusivity, collaboration, and empathy.

• Providing ongoing and repetitive training regarding the cause and impact of traumatic stress on youth and families, the reality that children’s behavior is likely an outgrowth of traumatic experiences and not simply a manipulative attempt to “get their own way”, and specific interventions that are trauma-informed.

• Ensuring that treatment is family-driven, youth-guided, and culturally and linguistically competent.

• Including family- and peer-support specialists as equal members and advocates on decision-making teams.

• Adopting the mindset that it is critical to listen to and understand the youth’s perspective, and to work collaboratively to resolve differences.

• Utilizing business practices that promote hospitality and sensitivity.

Physical and Relational Environment

The physical environment of a residential facility sends a powerful message. Surroundings that are warm and inviting, and decorated with age, developmentally, and culturally appropriate furnishings convey a sense of belonging and worth. This includes the living environment, offices, waiting rooms, and general areas. The RCH&R has given careful consideration to the many details in its buildings and on its campus that can help youth and families feel welcome and to see their time there as part of a journey to greater health. Sensory rooms and furnishings provide opportunities for youth to learn self-soothing.

Routine maintenance and immediate repair of damage will ensure that the physical environment does not contain unnecessary triggers. Involving staff and youth in upkeep of the physical surroundings and design of refurbishments will help keep the living environment fresh and attuned. Regular walk-through assessments of the environment by staff and youth will attend to factors that may contribute to stress and help create settings that are calming and supportive.

The relational environment is equally critical. It is important that staff adopt the language of collaboration and do not see themselves as agents of control. A trauma-informed mindset assumes that:

• “bad behavior” is a result of unmet needs
• in fact, there is no such thing as a “bad child” youth are doing the best they can.
• If they are not doing well, there is a reason related to how well they are able to think about and process their immediate situation.

When this philosophy pervades the relational environment, coercive interventions and power struggles are reduced. Reminding staff to proactively identify routines and expectations helps the youth develop self-regulation. Similarly, anticipating rather than reacting to behavior helps staff and youth alike enhance their sense of personal responsibility and self-control. Utilizing language that is not negative or diminishing reduces the potential of re-traumatization.

Programming

Several key program strategies come together to create trauma-informed environments:Establish expectations that staff proactively attend to aspects of the daily routine that can be triggers, for example bedtime, room checks, yelling, close physical proximity, school, and bus or van rides. Additionally, draw staff attention to potential individual triggers, such as size differences that may be intimidating, perceptions of power differentials, men, aggression of any form, and family/peer rejection.

• Teach staff interventions that help youth identify and learn how to manage triggers.

• Train staff to identify early warning signs that can signal upset or impending crisis, e.g. restlessness, agitation, pacing, shortness of breath, tightness in the chest, sweating. Emotional first aid at such times will often avert power struggles and behavioral escalations, and help the youth learn to recognize stress and self-soothe.

• Implement sensory integration and sensory modulation opportunities, including exercise, yoga, and other physical activities. These have the effect of helping the individual self-regulate, relate, and reason.

• Avoid point and level systems, which by their nature generate power struggles and are most difficult for the most seriously traumatized youth.*

• Utilize expressive therapies, such as art and music, to enhance self-regulation, competence, and confidence.*

• Employ interventions that ask youth to think through situations and collaborate in solving problems.*

• Offer a rich variety of opportunities for youth to be active and to learn by doing. Activities help youth develop a positive sense of control over their own experience that can generalize to other circumstances. Make activities an explicit cornerstone of the program rather than simply a recreational privilege. Adjust activities in response to behavior based on immediate circumstances and potential safety considerations, rather than merely restricting them.*Teach staff to develop appropriate therapeutic relationships, while supporting and encouraging healthy relationships with family and community peers.

• Involve parents and family members in activities to the greatest extent possible to expand family skill-building opportunities; respond to the trauma for the family with frequent opportunities for youth and families to connect.

• Implement wraparound principles and planning processes, linking residential services with community-based services and supports.

• Focus explicitly on skill building throughout all programming, helping youth name the skills they are developing.

• Minimize or eliminate seclusion and restraint, two interventions found to be the most traumatizing for youth and staff.

Promote trauma-informed practices with system partners.

Individualized Planning and Intervention

For youth who’ve experienced trauma, readiness to do individual trauma work may be compromised by their developmental age and the nature of the complex traumatic stress they may be suffering. It is nonetheless important to develop and implement individualized trauma-informed response plans. Key considerations include:

• Choose from a variety of trauma-informed and evidence supported practices and approaches. The RCH&R has chosen Collaborative Problem Solving as the fundamental interactive approach and will also use other evidence-based models to address specific individual needs.

• Develop a fully individualized assessment of each child and their family, based on an understanding of their history of overwhelming stress and trauma.

• Customize how and when individual work occurs, including: not limiting therapy to office settings; utilizing moment-in-time opportunities; training front line staff to work on specific treatment objectives with the youth; and helping all staff develop a solid understanding of therapeutic relationships and boundaries within their specific roles. Remind staff to implement this understanding in their interventions with each individual youth.

• Focus on helping the youth and families learn the cognitive, emotional, behavioral, coping, self-soothing, and social skills they need at home and in the community.

• Create an individual behavioral support and safety plan for each youth, in a partnership between the staff, family, and youth, written in language that is easy to understand.

• Support the youth and families in identifying youth-chosen specific calming/soothing strategies that the youth can use to manage or minimize stress, such as time away from a stressful situation, going for a walk, yoga, working out, talking to a peer, laying down, listening to peaceful music, etc.