Sunday, August 30, 2015

The Capacity to Think: Why it is so Important and so Difficult in Work with Traumatized Children


I have used the image of Descartes the 17th century French mathematician and philosopher because of his famous line, I think therefore I am.  I am using this quote simply to state that the capacity to think is the distinguishing feature of being human.  This capacity gives us great potential as individuals and a species.  Conversely not being able to think causes great limitations.

It didn’t take me long when I began work (1985) in a therapeutic community for ‘emotionally disturbed’ children, to discover the difficulties I would have in my own thinking.  Out of the ten boys in our home there was one who had earned the reputation of being able to drive everyone ‘round the bend’.  Whenever this 12 year old boy approached me with a manic look on his face, the best I could do was hold my hands behind my back to prevent myself from pushing him away.  Thankfully I was successful in that.  I can’t remember anything else I did or thought but maybe that was an important enough achievement.  This is why we had regular meetings with our supervisors and consultant child psychotherapist to help us think about the children. 

It seems obvious that not being able to think is a major and common difficulty.  However, the huge numbers of people who have suffered trauma, especially complex trauma during childhood are often misunderstood.  Their difficulty in thinking is unacknowledged and they are held responsible for their ‘thoughtless’ actions.  Trauma causes many problems in thinking.  For example, difficulty in linking cause and effect, inability to make appropriate decisions and plans, the misreading of people’s feelings and intentions.

“Trauma results in a fundamental reorganization of the way mind and body manage perceptions. It changes not only how we think and what we think about, but also our very capacity to think.” (van der Kolk, 2014, p.21)

Despite the importance of thinking in child development, cultures have evolved where thinking is often relegated.  Sometimes with good reason. For instance, if we need a working population that is going to sit by a conveyor belt all day long, obedience and conformity might be more useful qualities than thinking.  Schools and parents might be encouraged to foster this culture: learning by rote; repeat after me; do as I say; tests based on memory.  However, in today’s complex world it seems that helping children develop the capacity to think should be the main goal of education, at home and school.

Real learning needs the opportunity to work things out for oneself.  Clifford-Poston in her book ‘The Secrets of Successful Parenting’ asks,

What does a child need in order to learn?
·                A secure base from which to venture into the world.
·                Permission to be curious.


If curiosity and safety are central to learning, Einstein clearly did not think much of his education.  He said that ‘It is a miracle that curiosity survives formal education’.  He also added, ‘The value of a college education is not the learning of many facts but the training of the mind to think’.  As safety and curiosity are so important to learning, it is evident how disadvantaged a traumatized child can become.  Curiosity and imagination can feel dangerous to such a child.  A child who is constantly on guard can’t relax into being curious. Simply being curious may also have been a precursor to abusive experiences.  Imagination, which can be a retreat may also be too risky as it leads to re-experiencing traumatic events.

The very nature of trauma means that the experience is overwhelming.  Trauma is a profound emotional shock.  The brain and body go into survival mode.  During infancy, severe neglect can also be included as a trauma.  When trauma happens out of the blue, such as a car accident, the people involved are likely to recover in time. When a child experiences multiple traumas, the traumatized state is likely to become permanent.  The expectation isn’t recovery and a return to normal.  Trauma has become the ‘normal’ and the child is constantly on the alert for the next terrifying event. Usually, what helps someone to recover from trauma is one’s own internal resources and support from others.  Where a child not only experiences trauma but has little support the impact is multiplied.  Where those who are supposed to protect and nurture the child actually inflict the trauma, the impact is unthinkable.

What makes complex childhood trauma so devastating is that it also happens at a time before the ‘thinking brain’ has fully developed.  This part of the brain, located in the cortex is often referred to as the executive function. 

“Executive functions are processes that support many everyday activities, including planning, flexible thinking, focused attention and behavioural inhibition, and show continued development into early adulthood.” (Knapp and Morton, 2013, p.1) 

Of course the executive function in an integrated person is also connected to the feeling, emotional part of the brain.  Good decision making for example, relies on the thinking and feeling parts of the brain working together in an integrated way. 

A child who is traumatized early in life, often has an underdeveloped capacity to think.  The brain develops according to experience.  For a child to develop thought he needs to experience the care of a thoughtful caregiver. 

"It is almost a truism that children learn to think by being thought about; that an infant’s essential learning about him or herself takes place in the encounter of one mind with another from the very moment of birth.  (Waddell, 2004, p.22)

The kind of thinking Waddell is describing is both conscious and unconscious.  It relies upon emotional attunement.  The ‘good enough’ parent is responding repeatedly to the infant, often without being fully aware of the detail and mirroring that is taking place.  Without this the child’s development is severely hampered. Lyons-Ruth (2003) found that maternal disengagement and misattunement during the first two years of life was strikingly linked to dissociative symptoms of their children in early adulthood.  She concluded that infants who are not truly seen and known by their mothers are at high risk to grow into adolescents who are unable to know and see (van der Kolk, 2014, p.121).  In other words they will have difficulties in thinking.

However, in the absence of serious trauma a little thought and attunement may go a long way.  We must also remember the child’s innate tendency towards growth and resilience.  Wilfred Bion (1962) made the important point that the infant’s first thoughts would happen in response to the gap created by absence, i.e. by thinking about the mother who is not there.  This means that there is also a process of development that happens outside of direct interaction between a child and caregiver, but within the context of a secure base (Bowlby, 1969).  This has something in common with Winnicott’s (1958) concept of the ‘capacity to be alone’.  This ability to manage and even enjoy the sense of being alone, paradoxically as Winnicott points out, initially relies on the presence of another.  The idea is that in the presence of a safe and reliable other, it is possible to develop a sense of one’s own direction and thought.

A child who has suffered complex trauma is likely to both, not be able to think and to actively stop any thinking that might be possible.  The child’s thoughts can also become a source of terror as they link her back to the trauma.  This may happen persistently through, flashbacks, nightmares, and physical sensations, such as panic and anxiety.  To survive this exhausting onslaught the child’s brain/body system may shut out both thoughts and feelings. 

“…they focus their energy on not thinking about what has happened and not feeling the residue of terror and panic in their bodies.” (van der Kolk, 2014, p.133) 

This happens purely as a primitive survival response.  However, though feelings and thoughts may be blocked out of consciousness, the child’s body continues to register the huge stress that he is under (van der Kolk, 2014).  It isn’t hard to see how this scenario is going to lead to a pile-up of secondary adversities for the child.   Such as, 

·           Difficulty living in the present.
·           Inability to use opportunities for nurture and learning.
·           Problems in relating to anyone, including getting on with peers.
·           Poor health due to unhealthy routines, problems with eating and sleeping.

The difficulty goes on and on in a relentless cycle.  This is why helping such a child is so demanding.  The earlier the difficulty started, the more severe and the longer it has gone on for, the harder it is.  This is one of the reasons for the appalling fact that some 10 year olds or even younger children have lived in 30 or more failed placements. 

So, what are the key elements in enabling recovery to happen?



Safety is the starting point.  The child must actually be safe and reach the point where he feels safe.  This in itself might take a year or longer and with plenty of ups and downs along the way.  One reason while a settled and consistent placement is so important.  To achieve this those working with the child must be able to think, individually and together.  Thinking in this context means to be able to receive and notice everything that is going on with the aim of making some sense out of it.  It means being able to hold bewildering realities, strong emotions, contradictory possibilities and to think rather than react.  However, this is likely to be difficult for many reasons (Tomlinson, 2005), 
  • The child is likely to behave in a manner that is hugely demanding, challenging and confusing, which is physically and mentally exhausting.  Thinking is hard when we are tired and anxious.
  • Moving from a thoughtful to reactive state can happen very quickly.
  • The child will do things that are extremely difficult to understand.
  • The ‘normal’ response may not only not work it may make things worse. 
  • Understanding is required to see what lays beneath the behaviour.  The helpful response may be counterintuitive.
  • As soon as you think you’ve worked something out something else will contradict it.
  • When we do think about a child, he may do everything possible to stop us.
  • The child has stopped thinking because it leads to no good in his world.  Therefore our thoughts are perceived as a threat and something that may link him back to trauma.
  • A traumatized child may associate adults thinking about him with adults abusing him.  Ordinary caring thoughtfulness may be completely alien.
  • The child may attack and reject our thinking in a hostile way.  This may also be a form of testing to see if we will give up or retaliate.
It can be seen how thinking and understanding the child is essential on many levels.  It could be argued that the child will not be able to think about himself until the adults working with and looking after him can.  For the child’s disassociated and unintegrated experiences to become integrated, someone else must be able to bear and hold those ‘bits’ of experience together.  The reality that others can do this helps the child sense that her experiences may be possible to survive.  Surviving the child’s attempts to destroy the thoughtful care being provided offers the hope that the worst she has experienced can be survived.  And therefore that maybe she can also be survived. 

This challenging work will impact on those directly involved with the child and also anyone else who is involved, such as supervisors and managers.  It is crucial to maintain an environment where thinking can take place.  As soon as this goes there is likely to be another failure. It sounds clear, but the problem is that we are always on the edge of finding our own way out of the difficulty.  Those involved have to face very painful and sometimes shocking realities.  One way of getting out of this, is by adopting similar survival strategies to the child.  Cut off from our thoughts and feelings.  Distract ourselves from thinking.  Focus on other things and close down the opportunities for thoughtfulness.  If this happens temporarily to one person, others can step in and support.  It is a serious problem only if it becomes the norm within the culture.

The symptoms of such a culture include, 
  • A lack of openness and a focus on control.
  • A move towards a closed system, based on secrecy and denial, which are the typical dynamics of sexual abuse.
  • A dismissal of thoughtful insights, which might be labelled as indulgent, or ‘letting the child get away with it’.
  • Frequent cancellation of all meetings, which offer an opportunity to think about the child.
  • Quick reactive responses to situations.
  • A lot of doing and ‘busyness’.
  • A tendency to blame and a lack of empathy. 
As with the traumatized child this begins to look like a traumatized environment. It isn’t long before the secondary adversities of this also begin to pile up, causing far more extreme symptoms. 


The capacity to think is central to ordinary child development.  Complex childhood trauma greatly compromises this.  To help a child recover from trauma and to resume ordinary development, an intervention based on thoughtfulness is essential.  To provide this is extremely challenging both on an individual and collective level.  We may give up and also adopt a defensive response, which is likely to cause a failure.  To prevent this from happening we have to be constantly working together on the difficulty.  However much thinking is required cannot be prescribed.  It has to be enough to match the difficulty that is involved. 

In a strong culture based on these principles it is more likely that not only can we survive but also offer traumatized children and young people the hope of recovery. 

References

Bion, W. R. (1962) Learning from Experience.  London:  Karnac Books/Heinemann
Bowlby, J. (1969) Attachment, London: Hogarth Press

Clifford-Poston, A. (2001) The Secrets of Successful Parenting: Understand What Your Child’s Behaviour is Really Telling You, Oxford: How To Books

Knapp, K. and Morton, J.B. (2013) Brain Development and Executive Functioning, published online January 2013, http://www.child-encyclopedia.com/Pages/PDF/Knapp-MortonANGxp1.pdf

Lyons-Ruth, K. (2003) The Two-Person Construction of Defenses: Disorganized Attachment Strategies, Unintegrated mental States, and Hostile/Helpless Relational Processes, in, Journal of Infant, Child, and Adolescent Psychotherapy, 2 (2003): 105

Tomlinson, P.  (2004)  Therapeutic Approaches in Work with Traumatized Children and Young People:  Theory and Practice, London and Philadelphia:  Jessica Kingsley Publishers

Tomlinson, P. (2005)   The Capacity to Think:  Why it is Important and what Makes it Difficult in Work with Traumatized Children, Therapeutic Communities: The International Journal for Therapeutic and Supportive Organizations,  26(1):41-53

Van der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Viking: New York

Waddell, M.  (2004) Attachment Anxiety, Young Minds Magazine 72 September /October.  London:  Young Minds

Winnicott, D.W. (1958) The Capacity to be Alone, in, International Journal of Psycho-Analysis, 39: 416-420

Wednesday, August 12, 2015

The Leadership of Organizations Providing Services for Traumatized Young People

If a leader needs people who can think about difficult problems it is no use simply telling them what to do

“The leader of the organization is often between a rock and a hard place.  Like Janus, the Roman God of gateways, sitting on the boundary of the organization with one eye looking out and one looking in – both views can seem equally challenging and hopeless.” (Barton, Gonzalez and Tomlinson, 2011)

Rudy Gonzalez, Executive Director at the Lighthouse Institute asked me if I would write this blog on leadership (http://goo.gl/eoadFw).  For over 20 years, Lighthouse who are based in Melbourne have provided a service for young people who have experienced homelessness.  This in itself is an achievement of leadership.  I feel privileged to be asked to write on the subject and it didn’t take me long to realize I could only scratch the service.  I will mention some important aspects, but leave out much more.  Even so, this blog will be longer than usual! 

Services for traumatized young people, as well as adults are fraught with difficulty.  Partly as a consequence of this their history is one of controversy, sometimes including cases of abuse and scandal.  We know that preventing the re-enactment of trauma is a challenge.  It is a sad fact that just as in a family, where those who are supposed to protect and nurture children can end up abusing and traumatizing them, the same can also apply to organizations who are supposed to help the traumatized child. 

Therefore there has been a strong need over recent decades to try and discover what works and what doesn’t (see Clough et al., 2006).  Can we identify the factors that are most likely to correlate with positive compared with negative outcomes?  The UK has had numerous Government initiated investigations into the ‘Care System’ for children and young people. Often these have been reactive, following the exposure of child abuse.  The Warner Report in the 1990s identified two factors that correlated with positive outcomes for children in residential care.  These are having a coherent philosophy of care and strong leadership. 

Given the challenge of leadership in such organizations and the identification of its importance, it is surprising how scarce the writing on it is.  Although, I may have missed a few publications I can think of very little.  There are many publications on the subject of work with traumatized young people.  Some of these have excellent sections on leadership, but there are few specifically about leadership.  Adrian Ward’s recent book, which I refer to later is an exception.  In the wider world, leadership must be one of the most written about subjects.  I believe that leaders of organizations who serve traumatized young people, would be very well placed to contribute.   There could be little else that is so complex and challenging, and such rich ground for learning about leadership.

From the start of my career in 1985 in an English Therapeutic Community (The Cotswold Community) for emotionally disturbed boys I soon learnt the importance of leadership.  At a basic level, effective leadership could mean the difference between chaos and an appropriate level of stability.  The difference between the two could mean: getting children to bed and asleep by 10pm, compared with 3am; having a satisfying day with young people compared with being physically assaulted and injured; feeling supported and understood, compared with feeling isolated and misunderstood or not even valued.

We had homes with 10 boys in each, a staff group of 5 and worked 60-70 hours per week.  Each home manager reported to a senior management team of 4 people.  I guess that on average 50% of home managers didn’t last more than 1-2 years.  Leaders had to be resilient and create a sense of safety for the staff team and young people.  From its beginning in the late 1960s this community had consultancy from the Tavistock Institute of Human Relations.  The ‘Open Systems’ theory developed at the Institute had an emphasis on issues related to role, responsibility and authority, and how these related to the primary task.  This helped me to realize that the way a leader worked was as important as what might appear to be successful short term results.  Short-term results can be achieved in ways that are not always helpful in the long-term.

For example, in any organization that works with traumatized young people there will be an inevitable desire for a day without too much drama.   The kind of difficulties experienced in these organizations can be extremely anxiety provoking with high levels of risk.  However, preventing the drama can be achieved in ways that are not congruent with the primary task.  Some leaders do create control that feels safe.  However, they might do it in a way that is based on the power of their personality and which creates dependency.  Everything seems fine as long as they are present.  The dependency on the ‘powerful’ leader might stifle the development of the staff team and more importantly the recovery of the young people. 

Short term gains can be sacrificed for long term ones.  I used to wonder how a leader should be evaluated in terms of effectiveness.  I came to the conclusion that while what appeared to be success in the short term, it was also important to look at what happened after the leader had gone.  Had the leader established a way of working that could be sustained after his/her departure?  Had the leader created a culture in which new leaders emerge?  For the personality driven leader, a collapse after his/her departure can actually be gratifying.  It may feel like confirmation of how good and indispensable he/she was.  Some organizational cultures encourage a focus on the short-term and only reward leaders on that basis.  Therefore there may be little to encourage a leader to take the risk of devolving responsibility in others. 

 Recently a colleague recommended a book on leadership - Turn the Ship Around! A True Story of Turning Followers into Leaders, by L. David Marquet (2012). While Marquet talks of running a nuclear submarine the essence of his story is remarkably relevant to leadership in the organizations I am talking about.

In some ways, his challenging messages are even the more powerful, because no-one can doubt the risk of operating a nuclear submarine, during a war, with over 100 people on board.  Yet Marquet says things, such as,

“Our greatest struggle is within ourselves. Whatever sense we have of thinking we know something is a barrier to continued learning.” (p.1)

“Resist the urge to provide solutions…..despite the time it would have taken, I should have let my officers figure things out.” (p.91)

and,

“When I, as the captain, would ‘think out loud,’ I was in essence imparting important context and experience to my subordinates.  I was also modelling that lack of certainty is strength and certainty is arrogance.” (p.106)

This reminds me of the concept of Negative Capability coined by the poet John Keats back in 1817.  Keats described negative capability as the art of remaining in doubt “without any irritable reaching after fact and reason” and “the willingness to embrace uncertainty, live with mystery, and make peace with ambiguity”.

The British psychoanalyst Wilfred Bion elaborated on this, describing negative capability as the ability to put aside preconceptions and certainties, and tolerate the pain and confusion of not knowing. Bion also knew about leadership in challenging circumstances.  By the age of 21 he had been promoted to Captain of a tank section fighting in World War 1.

More recently the child psychotherapist and psychoanalyst Adam Phillips (2013) in discussing parenting has said,

".....that the parents, the authorities, are at their most dangerous when they believe too militantly that they know what they are doing."

So, the thoughts of a poet in the early 1800s, which have been embraced by the world of psychoanalysis also provide an effective principle in the leadership of a nuclear submarine.  In all of these cases ‘not knowing’ doesn’t mean doing nothing.  It means acting when we have given time and thought to the problem.  ‘Being with’ the problem is in itself doing something.  Where possible it also means involving others.  It also means being clear about people’s competence so we have a realistic sense of what can be asked of them and when we need to ‘take charge’.  As Marquet (p.128) states, ‘control without competence is chaos’.  However, when we jump quickly into action with a sense of certainty it may well be that we have defended ourselves against the real difficulties involved.  Not only is there a significant risk of mistakes, but we have also deprived others of an opportunity to contribute.  Marquet explains,

“How many times do issues that require decisions come up on short notice? If this is happening a lot, you have a reactive organization locked in a downward spiral. When issues aren’t foreseen, the team doesn’t get time to think about them; a quick decision by the boss is required, which doesn’t train the team and so on. No one has to actually think through the issue,” (p.92) 

Steve Covey who writes the forward for Marquet’s excellent book, states,

“We are in the middle of one of the most profound shifts in human history, where the primary work of mankind is moving from the Industrial Age of ‘control’ to the Knowledge Worker Age of "release." As Albert Einstein said, ‘The significant prob­lems we face cannot be solved at the same level of thinking we were at when we created them.’ They certainly won't be solved by one person; even, and especially, the one ‘at the top.’” (p.xxi)

This approach to leadership means a shift from a top-down leadership-follower to a less hierarchical leader-leader model.  This is also reminiscent of what has been described in the world of therapeutic communities as a ‘flattened hierarchy’.  This approach can greatly encourage the development of authority and responsibility throughout the organization and most importantly in the young people.  Menzies Lyth explained (1985, p.239),

“It is in general good management practice to delegate tasks and responsibilities to the lowest level at which they can be competently carried out and to the point at which decision-making is most effective.  This is of particular importance in children’s institutions, since such delegation downwards increases the opportunity for staff to behave in an effective and authoritative way, to demonstrate capacity for carrying responsibility for themselves and their tasks and to make realistic decisions, all of which are aspects of a good model.”

About 15 years into my career I studied for an MA in Therapeutic Child Care.  Adrian Ward was the course leader and he along with his team provided a model of leadership through the way they ran the course.  The training was experiential and we learnt from this as much as from anything we were ‘taught’.  All of our days at the University began and ended with a reflective group meeting.  Ward (1999) has referred to this as the ‘matching principle’. The mode of training must match or reflect the mode of practice.  The way the course was provided matched key elements of what we needed to provide traumatized children.  The same can be argued to apply to leadership.  If a leader needs people who can think about difficult problems it is no use simply telling them what to do.

The leader of a service for traumatized children is not just someone who will help the organization achieve results.  Unlike many other businesses, industries and professions the way that he/she does this is of direct relevance to the service user.  Traumatized young people have suffered a kind of authority that has been central to their difficulties.  Those in positions of authority and power, instead of looking after them, in many cases abused, neglected and exploited them. 

The leader represents an authority figure with specific meaning to traumatized young people as a parental figure.  The way the leader does things, will set the tone for the culture of the organization.  Even if the young people don’t experience much of the leader directly, they will experience him/her indirectly through the culture.  Traumatized young people, like all traumatized people have experienced a loss of control and sense of helplessness.  Therefore leadership needs to be sensitive to these issues and encouraging of a culture that promotes self-control and choice.  Trauma also often involves the violation of personal boundaries.  Therefore, attention to and respect of boundaries is especially important.  Trauma causes mistrust, so establishing trust is important.  Denial and ‘turning a blind eye’ are often the defensive responses to trauma, so it is important to pay attention, listen and hear.  All of this can only happen within the context of meaningful relationships.  It could be argued that the way leadership is exercised provides young people a template for healthy relationships.

To conclude by tying a few threads together.  Adrian Ward (2014) who I mentioned earlier, published a book on leadership last year.  The well-respected researcher and author on residential care, James Anglin, in his recommendation of the book, called it an ‘Instant Classic’.  As the title suggests, Ward’s book has an emphasis on relationships.  Childhood trauma takes place within a relational context and one of the central elements is attachment difficulties.  There is a vicious circle.  The lack of attachment makes a child more vulnerable to trauma and trauma causes attachment difficulty. Therefore the culture of an organization for traumatized young people must be one where relationships are central.  This is why the culture needs to be both Attachment and Trauma Informed.  The leader in this context becomes a role model for the culture of relationships within the organization.  This will influence the way everyone relates to each other, including the relationships with and between the young people.       

As with Marquet in ‘Turn the Ship Around!’, Ward also urges that rather than being a problem fixer and someone with the answers, the effective leader works alongside others to find solutions.  It is not that a leader shouldn’t have solutions, but he/she should resist the urge to jump quickly into that role.  While the leader is ultimately ‘The Leader’ this approach will also bring out the leadership qualities in others including the young people.

References

Barton, S., Gonzalez, R. and Tomlinson, P. (2011) Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for Practice, Jessica Kingsley Publishers

Clough, R., Bullock, R. and Ward, A. (2006) What Works in Residential Child Care, London: NCERCC and National Children’s Bureau

Covey, S. (2012) Foreword, in Marquet, L.D. (2012) Turn the Ship Around! A True Story of Turning Leaders into Followers, Penguin Group: New York, USA

Menzies Lyth, I. (1985) The Development of the Self in Children in Institutions, in Containing Anxiety in Institutions: Selected Essays Vol. 1.  London: Free Association Books (1988)

Phillips, A. (2013) The Magical Act of a Desperate Person: Adam Phillips on Tantrums, London Review of Books, Vol 35, No 5, 7 March 2013, p.19-20,  http://goo.gl/y5xHWL


Ward, A. (1999) The ‘Matching Principle': Designing for Process in Professional Education, in Social Work Education, 18 (2) 161 – 170  

Ward, A. (2014) Leadership in Residential Child Care: A Relationship-Based Approach, Norwich: Smokehouse Press

Warner/Dept. of Health (1992) Choosing with Care: Warner Report - The Report of the Committee of Inquiry into the Selection, Development and Management of Staff in Children's Homes, London Stationery Office


The Lighthouse Institute - http://lighthouseinstitute.org.au/