INFORMING, EDUCATING, EMPOWERING FAMILIES 617-236-7210 | www.fcsn.org | fcsninfo@fcsn.org

Residential Education: Working with Students Who Have Experienced Complex Developmental Trauma

Maureen McGettigan, LICSW Clinical Director Southeast Campus The Home for Little Wanderers

Acknowledgements • All work in congregate care is done by a team. I appreciate the work of the current and past members

of our clinical team, Julie Cusack, LMHC, Rachel Herman, LICSW, Chris Wong, LMHC, Morgan Thompson, LICSW, Caitlin Tobias, LICSW, Liz Gillott, LICSW, Dawn DiMartino, LCSW, Alla Abramov, LCSW, Beck Rothberg, LCSW, Tara Whooley, LCSW and Emily Murray, LCSW.

• I want to acknowledge the stellar work of the educational staff with whom I have worked over the years, particularly Mike Nelson, Adam Marto, Karson Motta, Shannon Sullivan, Susan Mackoul, Sharon Basso and Brenda Burke, from whom I have learned a great deal.

• The hardest work in residential program is done by the direct care staff who are the unsung heroes in any program. Thank you to the many past and present members of our milieu staff who have taught me everything I know about congregate care. A few of the many superlative staff I have worked with are Eric Ohlson, Kevin Laudermilk, Matt Marrano, Mike Lepara, Elyse Morin, Deb Sheehan, Allison Callahan, John Ryll, Mark Haskell, Carlos Antunes, and Caitlin Tobias.

• I began my work in the field of trauma after reading a book by Bessel van der Kolk in 1990. I owe my passion in the field to him and to the team with whom I worked at the Trauma Clinic.

Complex Trauma

The traumatic stress field has adopted the term “complex trauma” to describe the experience of multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early life onset.

van der Kolk, 2005

Areas of Functioning Impacted by Exposure to Complex Trauma

• Attachment • Biology • Affect Regulation • Dissociation • Behavioral Control • Cognition • Self-Concept Cook et al 2005

Attachment

• Problems with boundaries • Distrust and suspiciousness • Social isolation • Interpersonal difficulties • Difficulty attuning to other people’s emotional states • Difficulty with perspective taking

Biology

• Sensorimotor developmental problems • Analgesia • Problems with coordination, balance, body tone • Somatization • Increased medical problems across a wide span of areas and

issues

Affect Regulation

• Difficulty with emotional self-regulation • Difficulty with labeling and expressing feelings • Problems knowing and describing internal states • Difficulty communicating wishes and needs

Dissociation

• Distinct alterations in states of consciousness • Amnesia • Depersonalization and derealization • Two or more distinct states of consciousness • Impaired memory for state-based events

Behavioral Control • Poor modulation of impulses • Self-destructive behavior • Aggression toward others • Pathological self-soothing behaviors • Sleep disturbances • Eating disorders • Substance abuse • Excessive compliance • Oppositional behavior • Difficulty understanding and complying with rules • Reenactment of trauma in behavior or play

Cognition • Difficulties in attention regulation and executive functioning • Lack of sustained curiosity • Problems with processing novel information • Problems focusing on and completing tasks • Problems with object constancy • Difficulty planning and anticipating • Problems understanding responsibility • Learning difficulties • Problems with language development • Problems with orientation in time and space

Self-Concept

• Lack of a continuous, predictable sense of self • Poor sense of separateness • Disturbances of body image • Low self-esteem • Shame and guilt

Components of Residential Congregate Treatment

• Education • Clinical Services • Milieu Treatment • Ancillary Services

Therapeutic Crisis Intervention

Goals of TCI Preventing crises from occurring De-escalating potential crises Managing acute crises effectively Reducing injuries to children and staff Learning constructive ways to handle stressful situations Developing a learning circle within the organization

Cornell University, 1979

TCI

At TCI’s core lies the principle that successful resolution of the child’s crisis depends on the environment’s (the organization) and the individual’s (the care worker) therapeutic and developmentally appropriate response.

TCI teaches and support workers at all levels of the organization to:

– Assess children’s aggressive behaviors as expressions of needs – Monitor their own levels of hyperarousal

– Use non-coercive, non-aggressive environmental and behavioral strategies

that deescalate the crisis and that lead to the child’s own emotional self-regulation and growth

– Use physical interventions only as a safety intervention that contains the child’s acute aggression and crisis

TCI Stress Model of Crisis

• Baseline or Pre-Crisis • Triggering Event • Escalation Phase • Outburst Crisis • Recovery

TCI Stress Model of Crisis

Behavior Support Techniques

• Manage the Environment • Prompting • Directive Statements • Hurdle Help • Redirection • Caring Statement • Proximity • Planned Ignoring and Positive Attention

Life Space Interview

• Isolate the conversation • Elicit the young person’s point of view • Summarize what the young person has said • Connect the young person’s feelings to the behaviors • Alternative behaviors are discussed • Practice new behaviors • Enter back into the group

Typical Day

• Wake up/Morning ADLs • Off to school • In school • Returning from school • Afternoon activities • Dinner • Evening Activities • Bedtimes

Classroom: Science

Elective: Woodshop

Peace Pond Entrance

Peace Pond

Elective: Culinary

Elective: Equine Science

Therapeutic Horseback Riding

Weekends and Vacations

• First shift • Second Shift • Third Shift

Winter

Summer Programming

• Summer school • Summer activities

Garden

Fishing Dock

Swimming Dock

How it works together

• Treatment Goals • Behavior Support Plans • Multi-Disciplinary Team

Challenges in Congregate Care Settings

• Additional Exposure • Distance from Family and Community • Staffing Inconsistencies • Availability of Resources

Factors that Contribute to Successful Outcomes

• Teamwork • Rituals and Routines • Creativity • Solution Focused Goals • Sense of Mastery

Maureen McGettigan, LICSW mmcgettigan@thehome.org

INFORMING, EDUCATING, EMPOWERING FAMILIES 617-236-7210 | www.fcsn.org | fcsninfo@fcsn.org

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