Trauma-informed behavior analysis, Part 4: On terms (Is “trauma” behavioral?)

This article is the fourth installment in a series on trauma-informed behavior analysis, by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

Is “trauma” a behavioral term?

“Trauma” is a buzzword lately. As several people recently noted on behavior analytic forums, it seems as though schools and other entities are requiring “trauma-informed care” from people tasked with providing behavioral interventions, yet it isn’t clear whether trauma actually presents as anything different than the reinforcement history, or a client’s past, that would be explored routinely in any old behavior assessment.

On a recent facebook post in a behavior analytic group, one person posted, “Trauma”, “trauma-informed”, etc, is [just] the new buzzword to get grant funding and sell product”. Another poster chimed in, “Trauma? What’s the behaviors [sic] of concern? What’s the function?” This seems to imply that if we know the current function of behavior, what more do we need to know? It suggests that the resulting treatment path is likely to be no different than that for a “typically developing child” of the same age and an apparently similar behavioral repertoire.

The implication in the social media posts above seems to be, “what’s the big deal?” In other words, trauma is thought of as some in the behavior analysis community as simply another sexy concept that is meant to sell and sound good, rather than being something critical to appreciate (and to suggest differential treatment based on its presence or absence).

As a behavior analyst who has treated children and adults exposed to serious and adverse childhood experiences, I have come to appreciate that the current function is NOT the only important thing to know before treating someone’s challenging behavior patterns, or helping an adoptive parent cope with challenges a mental health therapist might call “reactive attachment”.

So what’s a BCBA to do? Continue reading

What does hope sound like?

What does hope look like?

The behavioral doctor sat between house calls in her car with amazed tears streaming down her face.

Was this viral story true?bird.jpg

Intuitively, she knew that it must be, for she instantly recognized the chubby little face she saw on the screen. She suddenly recalled the clear little voice asking for “music!”, and a couple of weeks later, “music, please!”. She remembered when his list of words included about five. She recalled singing songs (“Way up in the sky, the little birds fly….”) to a toddler who had needed early intervention desperately.

But the story she read on facebook was also hard to believe, because this young man wrote so confidently and was about to graduate. He also sang so beautifully, as links posted by his mother—and his scholarships to prestigious programs—confirmed. It had been at least 15 years since she saw the toddler’s face, or said “do this” and prompted him to carefully stack one block on top of the other, painstakingly teaching play skills that other children seemed to learn so naturally. At the time she had worked for an early intervention program, providing or supervising up to 7 hours per day of behavior therapy to children whose tantrums often overwhelmed and injured their parents, teachers and skilled therapists—but communicated their wants and needs before they had words. And at the time, she did not know that behavior analysis would become her fulfilling career and that she would go on to study neuroscience and learn how the brain really does change with the hundreds and in some cases, thousands of hours of careful social input that certified behavior analysts are trained to provide.

But this was definitely the same little guy, except he was all grown up. Continue reading

Trauma-Informed Behavior Analysis, Part 3: Is It Ethical For Behavior Analysts to Treat “Trauma”?

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This is Part 3 in a series of how behavior analysts approach “trauma”, by Teresa Camille Kolu, Ph.D., BCBA-D.

Is It Ethical For Behavior Analysts to Treat “Trauma”?

Meaningful answers often depend on asking an appropriate question.

Since this “yes-or-no” question is not the least bit appropriate for many of us to answer “yes” to without more information, let’s start by refining our question.

Under what conditions would it be appropriate for a behavior analyst to treat someone whose behaviors relate to their adverse childhood experiences?

The question above is one way of asking the question, and your team might think of others. It also may help to check out Tuesday’s upcoming article on Behavioral Terminology Related to “Trauma”.

I’ve certainly seen some inappropriate, well-meaning, and harmful treatment of behavior when the children and people involved have been through adverse childhood (or other) experiences.

Part of my concern is that young behavior analysts may have come from a program that did not cover adequately the experimental basis of our field, including schedule effects or concepts like the molecular or molar view of behavior.

I think young behavior analysts who are smart and curious can get these things; they need to have better exposure in their classes (and online course sequences toward certification paths aren’t likely to bring this exposure) or groups (so ask your friendly local or skype article CEU club if you’d like to read an article like this one on the paradigm shift from the molecular to molar view in behavior analysis). This is why a supportive verbal community of reinforcement is so critical for developing behavior analysts (more on that later elsewhere on this site).

(Not sure how to look up pdf’s of articles? An easy way is to first look at the online journal list (for example, for JABA or JEAB) and first enter your search terms, then when you find the article, go to the journal’s archive and click on the issue where the article was published, and download the pdf. This works for all archived JABA and archived JEAB issues through 2012.)

That was fun; let’s get back to the scary stuff: inappropriate, well-meaning, and harmful treatment of behavior.

Sometimes an inexperienced behavior analyst treats only the “local function”, such as treating a behavior in your classroom that seems like it’s related to attention with pure extinction (e.g., without conducting a complete and appropriate functional assessment). This might seem appropriate without more information, but in clients with “trauma backgrounds” or exposure to serious past (or hidden and ongoing) childhood adverse experiences (such as disruptions in primary caregiving and exposure to abuse and neglect), this course of treatment may lead to further harmful escalation, or serious risks and side effects. There are other possibly more appropriate options such as differential reinforcement without extinction, or the preventative schedule approach I mentioned in a previous article. At the least we need to base decisions on better information.

In a classroom where I observed a child who had been through a series of terrible and neglectful situations, when his behavior was placed on attention extinction, he virtually lost all advocacy skills (e.g., stopped manding for help or showing his distress), was being abused by others and never reported it, and started hiding his self-injury which became more and more severe. These were some of the risks involved of using a procedure without evaluating the possible side effects given the child’s repertoire and the reinforcement available for his appropriate skills, and without collaborating with others who had access to the child’s history and current home situation (Compliance Code 2.03b).

The teacher was using the procedure recommended by a behavior analyst, but the BCBA did not know about the child’s history or home life (and did not ask). As I’ve said before, I am NOT asking anyone to stop a function-based approach!- but to demand the information you need to understand the larger context for behavior.

So what’s a behavior analyst to do?

I typically try to think first of ethics (asking, “should I be doing this?”) before diving into strategies (“what should I be doing?”). Here are some ethical considerations:

  1. Is this in my boundary of competence and based on my education, training, and supervised experience?

See Compliance Code 1.02a). If not, it’s a good idea to first seek continuing study, training, supervision and consultation (see Compliance Code 1.02b). I think the skill of reaching out to obtain supervision and mentorship when appropriate (e.g., accepting clients appropriately) may be an important behavior cusp critical to the future repertoires of behavior analysts trying to practice ethically.

  1. I think of ethical behavior analysis as practicing within my boundaries, yet at the same time as growing my boundaries of competence so that next year I will have expanded them and will be able to take a client I said no to this year.

Dr. LeBlanc and colleagues have an article on expanding the consumer base for behavior analytic services that is available for a CEU.

  1. Consider ethics and your own experience and resources carefully, before you begin treating trauma or accepting any kind of trauma-related client.

See 1 and 2 above, and remember not to give advice that stands in for services (e.g., 1.05a). Our responsibility is always to do no harm, and at times the side effects of inappropriate treatment may be riskier than doing nothing (2.09c). It is important to develop a relationship with a mentor who has been there and can assist you to apply new information to an exquisitely sensitive set of problems and clients. If not, arrange for appropriate consultation and referrals (2.03).

  1. All this goes for supervisors too:

Just like we should be careful before we accept a client for treatment, we accept a supervisee who is treating in a sensitive area only after considering our own defined area of competence (5.01). How will we communicate about and report risks (7.02) if we are not experienced enough to recognize and communicate about the risks of our own treatment (2.09)? Agencies may be under particular pressure to accept clients when there is funding, but there are serious risks of doing this too early or without appropriate in-house supervision.

  1. Be prepared for extensive collaboration:

I’ve talked to supervisors who have taken on trauma cases without completing assessments of risks and side effects (2.09c) or collaborating with other therapists the child is concurrently seeing, and this means they are already in danger of not being able to review and appraise effects of other treatments that might impact the goals of the program (2.09d).

Why do you need mentorship, education and experience under supervision first?

This is partly because after you accept a client (e.g., 2.01) whose service needs are consistent with your education and training, experience, resources and policies, your responsibilities are to everyone effected by your behavior analytic services. For example, once I started treating clients affected by trauma, I also found myself treating foster families’ other children to deal with the abuse the affected child talked about, the primary caregiver who used to be on drugs and was trying to demonstrate she could follow a plan and get her children back, and the social workers and other team members who didn’t understand schedule effects and were making placement decisions without data on behavior.

In an upcoming article we discuss some treatment approaches and how we can improve our supervision of BCBA’s treating these serious concerns. But first, next Tuesday covers some behavioral ways of talking about “trauma”. Stay tuned!

And as ever, this information is not a substitute for mentorship or supervision. This is intended for use in supporting behavior analysts to reach out to their own networks and supervisors and mentors, growing their boundaries of competence in an ethical and responsible way.

May we all keep expanding our repertoires.

 

Ethical Friday presents: The power of a Worst Case Scenario

Picture the worst that could happen.

Can you even imagine it?

And if you’re a seasoned therapist or behavior analyst, how do you communicate about this with your students and supervisees, who almost certainly can’t really go there?

If you’re like many of us, you don’t know what you don’t know. Suppose a client wants to gift your staff a gourmet coffee gift card, or a mother wants to step out quickly to get her dry cleaning. “It’s a five minute drive, I’ll just be a second”, she calls, as you work with her child in an upstairs therapy room. “No problem”, you start to call… but your ethics bone starts to tingle. Surely you’re over-reacting. What, if  anything, could go wrong?

When the worst case scenario relates to our vulnerable clients affected by trauma, the consequences may be even more dire– and yet, those who haven’t faced the possibilities may not recognize the dangers.

Should I accept this client in foster care with severe challenging behavior and a history of abuse although I have never treated similar cases? Should my agency supervise our new BCBA to take on a new trauma case (we have funding, after all) when we haven’t experienced this situation?Danger sign

For those of us tasked with supervising and teaching others, or working with families, we can help students, supervisors or parents picture the worst case scenarios so they can better prepare for, predict, and prevent dangerous outcomes. The Compliance code helps give guidance and rules that we follow, but for those of us who have NOT encountered situations that make us keenly aware of the reasons for these, some of the code items may seem “nit-picky” or unreasonable, and may be disregarded in a dangerous way.

To support our own cases and our supervisees where it counts, we must have a wealth of experience, stellar training that exposed us to a variety of worst case outcomes and possibilities and some solutions, or a great imagination- and a few good teaching and documentation tools.

I get a new wake up call every semester I teach ethics students about the origins of Behavior Analysis’ Ethics Code, which was spurred in part by atrocious, life changing and widespread abuses by those doing “behavior modification” in recent decades.

When I ask “what do you think? Could those things ever happen here?”, Continue reading

Trauma-informed behavior analysis, Part 2: Arranging a supportive behavioral environment

(Continued from Part 1 of Trauma-informed behavior analysis series by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)

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Part 2, Engineering Supportive Environments

On arranging the environment

What does it mean to arrange the environment in a preventative way? This means to think about everything someone needs, and how they get it or communicate that they need it. After we consider this piece, we see holes in the behavioral environment.

If these holes go unfilled, the person will likely do whatever they need to do to fill them, often in a way that is ultimately unproductive and painful for themselves or others.

In a way, everyone is doing the best they can, all the time.

So in considering what someone needs in advance, we can find ways to plug in something helpful where it is needed, in a preventative way. This means that before someone needs something, an observant caregiver or friend may recognize the need is coming, and begin to set up the surroundings so that need is being filled. Before someone falls in the well, we fill up the well with concrete and make it so that they cannot fall in — even if they step right on top of it. For example 1 in Part 1, the client who was left alone in the dark is given preventative repertoire building, and taught skills that help her to cope each night with the coming darkness. Her caregivers are taught new repertoires, learning to announce their presence and ask her permission before entering; to problem solve with her instead of forcing the next event on her; and to check in in a preventative way to see if she needs anything, instead of responding with force when something is already going wrong. Eventually, she learns to ask for help before it gets to a crisis, to soothe herself to sleep instead of showing agitation leading to support going to bed, and to problem solve by herself when about to face a known triggering event. Continue reading

Resource Wednesday: How do you document risks?

Many behavior analysis supervisees, students, and even young Board Certified Behavior Analysts (BCBA’s) have not yet obtained proficiency communicating with their clients and agencies about risk assessments, and may even lack the experience or training to use or document them in their own practice. Yet, a risk assessment is required by our Compliance Code (for example, see related items 2.09 c and d, or items 4.06-4.07), and the need for this skill is evident in the Task List (see C-01, C-02, and C-03).

As a consultant and an instructor for a university’s course sequence toward certification in Behavior Analysis, I use the Bailey and Burch text on ethics as a resource both for my students and for my practice. Several editions of this text mention and describe a Risk Assessment Tool which is not only necessary and required, but can also be a powerful decision making tool for teams, supervisors, agencies, and even families. When services are discontinued after barriers to service have been repeatedly encountered, supervisors and the court systems value evidence that the behavior analyst documented and discussed the risks and barriers with a family or team. Also, lives might be saved by considering the short and long-term risks before moving forward with an intervention that is at best, inappropriate, and at worst, dangerous. Risk assessments can facilitate otherwise difficult conversations about risks (or benefits) to a client, family, team, agency, system, or even a consultant’s reputation and credentials.

So what tools do YOU use, and what are those used by your team? Kolu and Winn (2017) presented tools for our work, based on something developed in our consulting practices. First a Risk versus benefit flowchart helps walk a supervisor, team, agency or family through a sequence of questions. Then the Risk Assessment Tool helps keep track of the answers, and can be used to facilitate a discussion with families and teams. When making a tough decision, it helps to ask about the short- and long-term risks of doing “the current option” or doing “something else”, and weigh these against the potential benefits. Should my family pull our child out of a school where he is not really benefiting from education but has immense social interaction opportunities? Should I stay with this employer billing in a confusing and possibly unethical way, or start my own practice? What should I consider when approached by a long-distance supervision client whose client caseload doesn’t really match my skillset?

And as the Compliance Code makes clear, we should be continuously asking, what is the best treatment recommendation, given the possible options, the current environment, resources, and the risks and benefits?

With these questions and more, a risk versus benefit assessment can be extremely informative, helpful, and may even be required. Know the requirements, and then assess, document and communicate about the risks. It might just save your credibility one day when you are called to testify. (We all think it won’t happen to us, until it happens to us.)

Need a tool to document your risk versus benefit results? Download this Risk Assessment Tool and let us know your suggestions or what kinds of decisions you use it for.

Email us if you’d like a word version of the form that you can use to fill in with your team or agency. And if you’d like to share, let us know what YOU use to document risks.

Self Injury in the General Population: Will I hurt myself today?

Will I hurt myself today… Or do something (F.A.B.) instead?

Time for a Trauma Tuesday post. But this one is not what you think.

By this time, most people have heard the notion that those who have been hurt may be more at risk to hurt others.

In my work with clients who have been through childhood abuse, mistreatment and neglect, I often see the tragic pattern they try to stop, often failing because of a lack of resources, or knowledge about what to do differently.

And on our caseloads with clients with autism or developmental disabilities, we frequently treat another kind of pain, the kind that a person produces for themselves and often related to the challenging environments in which our clients live, or a lack of skill in expressing one’s needs. In our field, hurting oneself is known as “self-injury” or SIB (self-injurious behavior).

However, this post is not about treating SIB in our clients, although there are many resources for doing this, and your friendly local behavior analyst can do a functional behavior assessment to determine where to start, before making an individualized plan.

This post is about something else that is common, yet hidden.

Recently in a women’s empowerment group for supposedly “neurotypical” people, a behavior analyst was stunned when 75 percent of hands went up as the question was asked, “how many of us have actually hurt ourselves, or do this on a regular basis?”

Today, my question for us is, what about the pain all around us? What about self injury in the general population? Continue reading

Trauma-informed behavior analysis

Part 1: Trauma-informed Behavior Analysis: Beyond the immediate “function”chalk_child playing (2)

(Also see Part 2 coming later this week, on Engineering Supportive Environments)

What is trauma-informed care? Should we provide it as behavior analysts?

For any given behavior analyst, perhaps we already think of a good functional behavior assessment as “trauma-informed”. This is because a comprehensive assessment would necessarily take into account the kinds of information that makes an assessment or treatment trauma-informed.

For example, an assessment is required to take into account someone’s history before treatment recommendations are made. But how much history do we review? What are the guidelines for what to consider? When, and how consistently, are these guidelines followed?

How much history is enough?

Some assessors (or agencies) write only a few lines or a paragraph about “previous history” or “previous treatments” without fully understanding their impact, or learning more about what happened and how it contributed to current functioning. This may happen because there is not funding or hours available to look into these variables. In some cases it occurs because the records are not available to the agency conducting the assessment. This is frequent in a case in which much of the client’s family history is unknown, or when a school psychologist or behavior specialist is doing a behavioral assessment for educational purposes but doesn’t have access to (or time to find) the information.

What happens when we don’t consider history? Continue reading

New blog series: Treating trauma from a behavior analytic perspective

A new series on trauma and behavior analysis  

By Dr. Teresa Camille Kolu, Ph.D., BCBA-D

chalk_teddy (2)Behavior analysts are tasked with doing no harm. Like other professionals who adhere to a rigorous code of ethics, they are responsible for working only in their defined areas of competence, while seeking supervision and training in other areas as appropriate if needed to grow their expertise.

A new training is available from Dr. Kolu on the ethical and behavioral treatment of cases related to “trauma” (e.g., adverse childhood experiences or variables related to early disrupted caregiving). See some of the learning objectives below, check out our related blog series, and contact us today if we can support your team.

SAFE-T model Continue reading

Thanks: To a scientific grandfather I never met, and other mentors

This past week, a great man of science passed away unexpectedly. In a loss profound within the behavior neuroscience community, we miss Howard Eichenbaum. This scientist was known for his prolific work on the hippocampus, a seahorse-shaped structure shared by animals from rodents to people, and taught us much about the brain’s role in memory, learning, and emotion. One of his graduate students, Timothy Otto, became one of my own graduate mentors.

For several years until a decade ago, I spent time in his Rutgers laboratory. I learned from, studied under, and published with Dr. Otto; his criticism helped strengthen my work, hone my behavioral observation expertise first watered at UNT, and illuminate skillset cracks that I continue to work to fill.

Perhaps good mentors hope we follow in their footsteps. I think great mentors foresee that often, we will not, and still encourage us to forge a unique path—or to find the “path that has heart”. From the vantage point of my private practice serving adults with dementia, developmental disabilities or autism, and children affected by Rett syndrome, asperger’s, or foster care, I realize now how great a loss it might seem to have one’s student (although I was not all that promising) leap from the academic tower—and fall right out of the neurotree.

Yet although we are no longer tethered, we remain invisibly connected. Today my work touches some of the most vulnerable populations and is informed in a way it could not have been except for those laboratory days.

When I support foster families who raise babies exposed in utero to drugs of abuse Continue reading