The development of a trauma-informed therapeutic milieu—the unique social environment of youth living in residential facilities—utilizing the TST approach has many positive features, both theoretical and practical. Although TST was originally created as an outpatient and home-based treatment model, providers in several residential settings quickly saw its utility for their programs and worked with the developers to adapt and implement TST to their settings. Over the years, there have been several key features of the adaptation of TST to residential care settings. We describe the most important of these next.
The creation of a common language of care
TST helps to create a common language as well as shared goals and values to which all staff members, youth, and families are exposed. For instance, staff members and families are taught to understand that what is often referred to as a youth demonstrating “bad”, “difficult”, or “conduct disordered” behavior is actually a youth in a dysregulated state who is reacting either to reminders of traumatic events or significant environmental stressors. Creating a context in which this kind of shared mutual understanding exists helps to change the very nature of the therapeutic milieu that, in turn, creates the opportunity for outcomes that can truly bring about lasting and meaningful change both in the individual and larger system. As discussed above, a process is conducted whereby frequent ratings of both the youth and the social environment are made. This creates a shared language for all providers, professional and non-professional, which greatly facilitates the integration of care.
One of the most important elements of this common language is a shared approach to assessment and treatment planning which results in the team’s capacity to use clinical data to hone in on a small number of “priority problems” that define what all residential care services are meant to treat. Once the priority problems are defined, strategies are developed for how each service of the residential care setting (e.g. clinical, milieu, education) addresses the child’s priority problems.
One of the primary assessment tools for identifying priority problems is called the “moment by moment assessment”. This assessment tool is meant to explore episodes in which the child has become dysregulated and to look for patterns of contextual stimulation and emotional and behavioral responses. Priority problems are defined as follows: patterns of links between specific environmental signals and dysregulated emotional or behavioral responses. As youth usually enter residential care for significant problems regulating emotion and behavior, the moment by moment assessment helps providers understand how there are often specific regularities in the social context and emotional experience of the episodes that bring the child in to care.
A focus on the social environment of the residential milieu
One important adaptation that has been made to TST for use in residential treatment is the definition of the social environment. When TST was originally developed, the stability of the caregiving environment as well as the larger system of care (e.g., social service agencies, outpatient therapy providers, schools, etc.) was the main focus of assessment. What was not specifically addressed was the fact that youth in residential treatment live within a unique social environment that may itself play a significant role in contributing to traumatic triggers/reminders or significant stressors and thus to the dysregulation of the youth. As an example, a residential program in Westchester County, NY, implementing TST, revised the assessment process to specifically evaluate whether the treatment team (defined as direct care and clinical staff) within the therapeutic milieu is meeting the youth’s emotional needs.
Specifically, two types of potential distress or threat were identified for assessment in the milieu. The clearest example is a violation of boundaries. If a staff member verbally or physically threatens or is physically or sexually abusive to a resident, the milieu environment is clearly threatening. Such violations would likely have a negative impact on the entire milieu, in addition to the specific youth being subjected to them, which would thus require immediate administrative intervention. A potentially more subtle and yet more pervasive form of distress within the therapeutic milieu comes in the form of violations of “team integrity”. Because residential staff members are, in essence, the youth’s immediate caregivers during residential treatment, the functioning of the team as a surrogate family system can have a profound impact on the youth’s functioning. If a team does not have good systems for communication among members or if team members do not consistently uphold residence expectations (e.g., morning staff allowing youth to have “seconds” at breakfast, but evening staff not allowing second helpings for dinner even though the administrative rule is that these must always be allowed), the milieu environment is distressed.
Another example would be staff members openly discussing their feelings about other staff or the youth. If such conversations take place in the youth’s presence, a more subtle boundary may be violated and the youth may be reminded of dysfunction within her/his primary family system, which may lead to dysregulated emotions and/or behavior. Such violations of team integrity, although often without malicious intent, are ubiquitous within congregate care settings, and are a critical factor to be considered in the care of traumatized youth. Staff members providing care in residential settings are at risk for contributing to the types of environmental distress discussed because of the prevalence of trauma histories in people who tend to seek out such roles in child serving organizations (Bloom and Farragher 2010).
Assessing for distress or threat within the therapeutic milieu of residential programs is one of the most important innovations of TST. Residential-based TST teams now have a system and format for regularly discussing the functioning of the team and ascertaining whether individual team members (or the team as a whole) are effecting a distressed or threatening environment. This process allows the team to develop solutions and proactively identify and address problems in a more productive manner. Adhering to the TST principle of insist on accountability, particularly your own, the team cannot avoid addressing such issues. As an example, a TST team would determine that it is contributing to a distressed environment if the team allowed a given youth to have phone conversations with his mother, even when the team is cognizant that the mother always and openly blames him for child protective services being called and continuously refuses to let him return home. In such a case, the team is not acting to protect the youth by monitoring or suspending calls until the team intervenes with the mother, not providing support to the youth, and not meeting the youth’s needs. Hence, the team is central to creating a distressed milieu environment for the youth. Once such an assessment is conducted, efforts can be made to find ways to make the milieu more stable.
Family involvement in treatment is an essential component of assessing and addressing the child’s social environment. While rating the social environment, for example, the team considers whether the youth’s caregiver(s) has been able to adequately meet the youth’s emotional needs (i.e., prevent the child from becoming dysregulated or help her/him sufficiently if dysregulation does indeed occur). For many youth in residential treatment, this question is clearly a relevant one as the youth may have phone contact or visits with the caregiver(s). A caregiver who fails to provide agreed-upon calls or visits is rated as not meeting the needs of the youth, thus the environment is considered to be distressed.
If, however, a caregiver does call and/or visit as planned, the environment may still be rated as being less-than-stable. For example, if a caregiver does call, but says something upsetting to the youth during the conversation, the environment may be rated as distressed. If a youth while on a home visit is exposed to violence or not provided with adequate food, for example, the home environment may be rated as threatening.
Residential staff using TST has been trained to engage caregivers by utilizing the TST “Ready-Set-Go” module. This process involves aligning with caregivers by helping them identify and communicate what is most important in their lives: in TST terminology, their life goals and “major source(s) of pain.” This strategy allows the clinician to form a treatment alliance with the caregiver based on the caregiver’s own priorities rather than priorities imposed by the clinician. The clinician is trained to elicit the priorities of both the caregiver and youth and to consequently develop a treatment plan that is equally based on their input as well as the assessment conducted by the residential TST team.
TST as a vehicle to integrate care
Historically, treatment within residential settings has often followed a “private practice” model wherein each individual clinician provides therapy according to her/his own approach based on her/his own training and experience. While such a model may lead to positive outcomes, this approach does not allow a residential program to provide treatment to all youth based on an agreed-upon clinical model in which all clinicians have been trained. In contrast, TST is a systems-based treatment that can provide a framework agency-wide and across all staff. Although TST is fully documented in a published manual (Saxe et al. 2007), the model is not a “one size fits all” intervention. Rather, TST is a flexible, systemic approach to treatment planning based on frequent reviews of relevant data. As previously mentioned, TST is also an organizational model for systems change.
The decision to adopt and implement a system-wide approach to conceptualizing and implementing trauma-focused, evidence-based practice such as TST requires a commitment from agency leadership to make changes throughout every level of the organization. Part of these changes comes in the form of trainings that typically are directed at social workers, psychologists, and psychiatrists, but not the direct care staff. Such differential training can facilitate splits or exacerbate already-existing splits between the clinical and direct care staff, which unfortunately often contribute to creating a distressed or threatening environment for the youth.
The direct care staff members are the adults who spend the most time with the youth. They are the ones on the “front lines” who most likely intervene when the youth become dysregulated and thus in many ways are in most need of training and support. TST emphasizes the importance of creating a TST team of which direct care staff are a crucial component. The team approach makes clear the need for training to reach all levels of the team while also emphasizing the importance of contributions of all team members. For example, when assessing a youth’s present emotional state, the clinician may state that the youth appeared regulated in the most recent session whereas a night staff member might report that the youth cries quietly in bed each night—an important clinical observation that might not come to light without that staff member’s input being specifically sought out and valued in a TST team meeting.
A frequent barrier cited in many residential programs is the difficulty of freeing up direct care staff for training and participation in team meetings as these team members are responsible for constantly supervising the youth. This obstacle requires administrators to be creative in creating opportunities for training and for scheduling team meetings. In some cases, financial issues are involved, such as paying overtime to allow staff to come in for training or meetings when they are not scheduled to work. One agency that has successfully adapted and implemented TST in a residential facility solved this dilemma by integrating training into already-existing meetings. This agency observed that once the TST concepts and language became a greater part of daily interactions, meetings, and internal processes, the trainings consequently became more integrated into the milieu itself. Examples of this diffusion of innovation include direct care staff being overheard and observed using the TST concepts in their daily work, such as referring to a youth in crisis as “dysregulated” rather than as “acting up” or “being bad” as might have been the case in the past and examining the milieu to determine the environmental triggers/stressors that might be eliciting the youth’s distress.
Other important organizational innovations that may help with successful implementation of TST in residential programs include, but are not limited to, hiring a full-time staff member as a TST coordinator; redefining the role of the lead clinician (e.g., psychologist, social worker) within the milieu to become the TST team leader; creating increased time for treatment planning meetings; and changing job descriptions and performance evaluations to align with TST benchmarks (e.g., adherence to the “10 TST Principles”). Perhaps most important is a relentless focus on examining possible factors within the team and the milieu that may be impacting the overall environment, thus contributing to a distressed or threatening environment for all youth. For example, if a significant change has occurred (e.g., a staff member no longer working at the agency) but the youth have not been adequately informed or given the opportunity to process their reactions to this event, the environment may be distressed for all youth and for staff as well. In such a case, an account of the organization’s present functioning may be needed to determine how organizational factors may be affecting both staff members and youth. To that end, tools have been developed to assess the functioning of the residential team/milieu (Appendix B).
In order to best illustrate how TST can be applied in residential care settings we provide the following case example:
“Deshaun” is a 15-year-old boy placed in residential care through the New York City child welfare administration. Deshaun had been removed from his biological mother’s custody because of allegations of abuse and neglect, and parental rights have been terminated for both parents. He had several failed foster home placements, and at the time of placement in a residential program had no viable discharge resource. Deshaun had a long history of episodes of severe aggression and had twice been hospitalized for suicide attempts, both of which involved efforts to hang himself and occurred around the time of needing to change foster homes. The current admission to residential care was arranged following an outpatient family session when he expressed suicidal thoughts when his foster mother informed him she asked that he transfer foster homes because “I can’t take care of you any more”.
Deshaun had a very difficult time adjusting to the residential care setting. His first weeks were marked by non-compliance with program rules, yelling at others, destroying property, and of most concern, making serious suicidal gestures. The team engaged in a careful process of “moment by moment assessment”: exploring his most concerning outbursts and noticing a significant pattern. As described above, this type of assessment is a critical process of information gathering within TST in order to identify priority problems, namely, patterns of connections between specific environmental signals and dysregulated emotional or behavioral responses. What were these patterns in Deshaun’s case?
The team noted that Deshaun’s patterns of suicidal ideation and behavior prior to admission were usually in the context of a transition between foster placements and hypothesized that in a child with such a history of abuse and neglect, the context of being informed about a change in placement may have lead to feelings of abandonment. These feelings, the team surmised, may be the driver of the suicidal behavior. With this hypothesis, the team began to gather data about the episodes of suicidal ideation and behavior expressed since admission. A direct care staff member noted a pattern that Deshaun has become particularly suicidal on Friday afternoons and noted that this was a time of particular difficulty because many of Deshaun’s peers would leave the milieu to go on weekend home visits beginning on Friday afternoon. Another direct care staff recalled several conversations with Deshaun on Friday afternoons when he would express resentment that the peers “had a home to go to…unlike me”.
The team then decided to gather information about Deshaun’s experience on Friday afternoon and, indeed, determined that the experience of others leaving the unit to be with family on Friday afternoons led to feelings of abandonment and aloneness which prompted suicidal behavior. This experience was highly consistent with the context of Deshaun’s suicide attempts prior to admission. The team then constructed a treatment plan for Deshaun, based on this priority problem. The team, knowing that weekends are particularly difficult for him as he sees other residents going on home visits, put into place a plan in which extra staffing was arranged specifically for Deshaun starting on Friday afternoons. This consisted of a staff member with whom he had a good relationship spending time with him doing a pleasurable activity, during the time the other youth were leaving for home visits.
The team also made sure his weekends were tightly scheduled, to keep him busy and engaged in activities he liked. A treatment plan that proactively inserted experiences of caring relationships at precisely the times when he was most likely to feel alone and abandoned, was instrumental in diminishing his urge to harm himself. Further, the treatment plan integrated emotional regulation skills sessions to help Deshaun have increased capacity to manage the emotion of loss and abandonment so that he had options other than to feel suicidal. Accordingly, this intervention approach addressed both components of the trauma system:
The child’s limited capacity to regulate emotion when experiencing signals suggesting loss and abandonment by building emotional regulation skills in the face of these signals; and
The social environment’s limited capacity for helping the child to regulate emotion and to protect the child from triggering stimuli by organizing care around Deshaun’s most vulnerable moments (when he is reminded of loss and abandonment).
As Deshaun began to have greater capacity to regulate emotion when reminded of loss and abandonment, and these signals became less ubiquitous in his social environment, his suicidality dramatically reduced, he became much more engaged in the program, and he required much less intensive staffing. Simultaneously, the team focused on the “Services Advocacy” treatment module of TST, designed to address his lack of a stable plan for his future. While his permanency plan was adoption, there was no viable discharge plan for him, which in itself represented a significant signal of abandonment for Deshaun. Therefore, the team actively engaged in developing a discharge plan for him, including him in the process. This required legal advocacy with a child welfare attorney as well. As Deshaun became more aware of the team’s efforts to help him move on to the next level of care, he was able to use his newfound emotional coping skills to tolerate the process of waiting for this to occur.