A Pediatric OT's Screed on Trauma Informed Care (2015) - Three years later: Have we made progress?

Maybe some.

A couple years ago I wrote this 'screed' on trauma informed care (TIC) models.  My concerns at the time were related to the lack of direct intervention that was promoted as part of this model - and that it appeared that some OTs were adopting a social work approach to the issue.

Last night there was an #OTalk2Us twitter conversation about these models; I was not able to participate but I have been studying the conversation.  I think that this is a good opportunity to see if we are progressing ideas on TIC to be more occupational therapy directed and intervention-focused.

It was good to see more conversation around the areas of occupational therapy assessment and intervention.  I think that we still need some direct conversation about how this problem gets addressed from an intervention perspective.  In my local experience, most of the conversation around TIC models is still oriented toward 'awareness' and is being driven by systems-level consultants.  I also don't see enough progress about creating methodologies for addressing mental health concerns within the IEP context and I don't see that school-based practitioners are even talking about mental health concerns.  I also don't see enough progress with re-professionalizing residential mental health care teams.

I think that we still have a long way to go in order to address these concerns.

Below was my concern in 2015.  We are making some progress, but not nearly enough.  Also, read this for additional background: http://abctherapeutics.blogspot.com/2015/02/the-american-occupational-therapy.html

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I would like to express my opinions on 'Trauma informed care' models.  The model is actually more of an organizational structure that seeks to increase sensitivity around the trauma that people (children) experience.  By being more informed about that trauma we can modify our own practices and responses so that care environments are more 'safe' for all people.

That sounds noble from a theoretical perspective, but I am a person who likes to see things in action.  I like to see lives change more than I am interested in seeing my wallet get fat from systems consultation.  We need to choose our models carefully and thoughtfully.

In a March 2015 webcast that was reportedly moderated by AOTA it was clearly stated that the presenters who were supporting the model don't provide care themselves.  Rather, they 'broker' services and make sure that all involved people are 'speaking the same language' so that 'access and disparity problems can be addressed.'   That sounds like social work to me, but with the way we change the definition of  practice every 5 years maybe I am mistaken.

The direct care that was mentioned consisted of a single 30 second slide out of an hour long presentation.  The rest of the time was spent discussing ancillary issues with the model.  It was unclear if these services were supposed to be a part of an IEP, or if they were supposed to be provided by private clinicians who were 'brokered' into the school setting.  Maybe it is both.  What was clear, however, was that 'services are provided in schools because this is where the children live and this is where the important people in their lives are.'  That is a nearly direct quote from one of the presenters.

What seems to escape the presenter is that if school is where children are living and if that is where the important people in their lives are that the problem probably needs to be solved with a stick much bigger than being 'sensitized' to the issue.

The trauma informed care consultant  talks to teachers, apparently, and helps them understand that children who have emotional and behavioral problems are merely 'responding to perceived injustices.'  So, since we can't control the children and their past experiences, teachers should have lunch once a week with aggrieved children so they feel 'safer.'  Other people can do things like find housing for the children, get substance abuse counseling for the parents, and training the parents to stop beating the children.  Those were the actual recommendations.  Oh, and then there was that little 30 second slide about working with the child.

I actually care about people, and I believe that these kinds of models are examples of how professionals 'give up.'  We don't want to really dedicate the energy and resources to addressing the real problems, so instead we will just become 'sensitive' to how bad things are.  This is Public Health on steroids - a model where we know we can't address the root cause of things so instead we do our best to tuck in the ragged edges of the problem so that it LOOKS neat and clean from a flyover at 35,000 feet.  We can't stop drug abuse, so we will just give clean needles and methadone to addicts.  We can't stop STDs and teen pregnancy, so we just hand out condoms to 8th graders.  In this webcast we can't stop 'Henry's' drunk father from beating him, so we will just learn to be more 'sensitive' to his problems and pretend to care by eating lunch with him once a week.

Worst of all, then we will all meet in our professional societies and back-pat each other and give each other awards for who gets the biggest grant that shows how much they care and how many programs we have consulted to.

This infuriates me, and I hope it will infuriate more people when they actually stop to think about it. 
The needs of people will be met by MEETING THE NEEDS OF PEOPLE.  That means actually working with them directly, and dedicating more than a 30 second slide to the direct care aspects of our programs.  That means actually discussing the specific mechanics of how to make these things happen and not just acting as 'system consultants' so we can tell OTHER people what they should be doing.

I spend some of my time working in pediatric mental health care systems.  I am actually hesitant to even call them that.  They are residential schools where the IEPs can't address the mental health problems because the home school districts that create the documents don't know how to intersect 'mental health' with 'educational relevance.'  That leaves the programs with a worthless IEP that talks a lot about reading and math but talks very little about addressing the mental health problems.

These systems are in desperate need of professionals, particularly in educational contexts beyond early elementary school.  In the last ten years I decided to take on these challenges and in two separate Counties I have actually had to ESTABLISH OT in middle and high schools in these residential settings.  OT was not even being offered as a service to these children.  I can assure you, however, that both of these programs were extraordinarily well versed in 'Trauma informed care' models.  I guess no one thought to 'broker' in OT as a service.  If we continue to identify ourselves as systems-level consultants I don't suspect much will change.

The problems that I run into in these contexts are very real.  Professionals are hard to find - and instead these programs are staffed (on the residential side) by high school grads and college students who mean well but know virtually nothing, except that they need to be more 'sensitive.'  Care is 'brokered' by people with generic human service degrees who use these low-paying jobs as a stepping stone or temporary stop-gap until they can find a better paying job.  Last week I actually had a case worker give a family a surgical scrub brush because they 'heard' that it might stop a child's aggressive behaviors.  That child had 29 documented 'take-downs' last week alone - apparently having lunch once a week and handing the mother a scrub brush isn't helping.

Here is the solution:

1. Stop adopting social work models of trauma informed care.  We are occupational therapists and we do our best work when we address the needs of people.  We are not providing a 'unique' service by pretending to be systems level trainers and consultants.

2. Train OTs to expand their school-based efforts beyond handwriting concerns for pre-K to 2nd graders.  Meeting those needs are fine, but we do TOO MUCH of that and NOT ENOUGH of addressing other problems.  With the large number of therapists working in schools, do we really need the vast majority of them working in the early elementary years only?

3. Promote private practice models to get community practitioners into schools to address mental health needs that are not always readily understood by education staff

4. Promote occupation-based direct care treatment models that address the underlying skill deficits that exist and also respect the environmental challenges that need to be considered.  Our OB/MOHO/PEO models are all extraordinarily well suited to framing these issues and directing treatment.

5. Be more critical.  Our status quo is not good enough, and we need more people engaged in finding better solutions.  I am getting hoarse, and I am certain that there are people who are tired of hearing it from me.  Please engage.

Comments

Sarah Austin said…
This is a powerful post and I think that it is worth pointing folks toward Tina Champaign who is working HARD to provide OTs with hands on interventions to address these issues using tools that are deeply rooted in OT Practice.
Alison, OT said…
Your timing is impeccable! I have so many mental health kids on my case load in a public school. I have transitioned back to our roots and started to do more crafts and activities that are client based or purposeful. It is amazing how well kids respond to basic tactile activities and crafts. I tried to do an interest checklist with one of my students only to find myself completely outdated. The kids are not exactly playing the games we did. They play a lot of video games. A lot of my kids want to come to OT just to "get the lead out" or as a break. I tried to start a pediatric mental health based interest group as a way to get more treatment activities, mentorship, and overall background training through my state association but I did not get enough interest of participation. I can't be the only school based OT dealing with this problem. The Zones of Regulation curriculum is a nice way for school based OTs to learn about their students' self-regulation skills. This has been a helpful program for many of my kids. Even with the Zones program, I always ask myself what else I can do to help. What courses should I take that would better prepare me to help the kids?
Hi Alison - I encourage you to stay on your current path - attending to the broad physical and cognitive and social needs of the child and how they are impacting educational participation. Too often OTs are having their approach dictated by the reimbursement system or by the practice setting itself -

Don't be discouraged if you have not been able to get a lot of interest from colleagues yet - just keep at it and continue talking about the broad impact that OT can have - and then just keep walking the walk. Your outcomes will speak volumes. Over time you will find like minded people, and they will find you, and then things will build from there.

Stay current with your theory. Make sure that your approaches are evidence-based, but also make sure that you continue to embed those approaches within an occupation-based framework - and don't fall prey to letting others dictate your practice! In the past month I have been told that mental health OT was not OT, and that treating a child who had a lower extremity difficulty was not OT. Push back! When children have ANY problem that limits their occupational performance, OT can help.

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