Moving from Faith to Facts in the Message of Our Work

Lorraine E. Fox, Ph.D.

In these days of “Outcome Based Funding” and “Evidence-Based Practice”, those of us working with wounded, discouraged, demoralized, and vulnerable young people are challenged to find a way to talk concretely about our work and the results of our work.

We know what our task is, and that is to engage with children, young people and families in ways that lead to healing and better lives for those who have been abused and neglected, as well as for those who have hurt them.  And one of the evidence-based facts of abuse is that many, if not most, of adults who hurt children were children who were hurt.  This would make the basic principles of intervention the same for both the children and their families.

If you are actively engaged in either reading or contributing to the discussions on CYC-online you will know that child and youth care workers love to share what they think and have no shortage of ideas.  Thinking something, however, doesn’t make it true, and our ideas don’t necessarily make for a profession.

Sometimes we try to use different words to give our ideas more credibility.  Have you noticed how often people use the word “believe” when they want to make sure you pay close attention to their point?  Instead of “I think you’re wrong Frank”, it’s, “You know, Frank, I don’t believe you are correct”.  Or, “you know Margaret, I believe you will find….”  So what’s the difference between think and believe?  Exactly.  There is no difference.  Except that we like to use the word believe to try to convince someone that we are right about what we are thinking.

Of course everyone likes to be right. We search for words to make us appear correct in our thinking.  How many times have you heard someone say, “I am convinced” blah-blah-blah, or “it is my conviction”.  Again, a conviction is just a thought or an idea.

Of course, there’s nothing wrong with thinking.  On the other hand, people have been known to think some strange things.

How many of you have heard someone say “I happen to know”……and follow it up with something you disagree with?

Faith has been defined as the ability to believe in things for which there is no proof.  So in order to gain professional recognition we must definitely move beyond just faith and commit ourselves to practice based on proven truths.  Facts can be checked and proven. But something can be “true” without being factual, and that’s a good thing. A line from a novel or a fairy tale or a song can be true, without being factual.  Sometimes truth is easier to come by than facts.

You know how the kids are always telling us we don’t know anything.  Well, we do know some things. So let’s talk together about what we as a profession actually do know – not believe – to be true about our work.  I give you:

A DOZEN TRUTHS DISCOVERED OVER THE DECADES AND CENTURIES OF CHILD AND YOUTH CARE WORK. TRUE WHETHER YOU WANT TO BELIEVE THEM OR NOT

Truth #1: Systems theory principles of change turn out to be true. Faster is slower, and the easy way out usually leads back in.

Those with the money to fund our work with kids and families don’t want long, drawn out interventions.  They want a quick fix so we can discharge clients as quickly as possible.  Sometimes, to keep the money coming, we have colluded in a wish, hope, fantasy that we can create an approach, a program, a gimmick, a motivation strategy that would be easier on us and faster on the outcomes – incentives, points, levels, rewards, punishments – and we’ve convinced ourselves that these will work.  But we must face the facts, the evidence that a lot of our ideas up until now about what helps kids, have proven to not help kids.  

We have spent decades looking for a quick fix, but programs don’t make kids sick, and programs don’t make them well.  The truth is that kids get their hearts and minds broken from faulty relationships, not from faulty programs at home, and programs built around anything other than curative relationships will fail.  And building relationships with betrayed, hurt, demoralized children is a long, slow, tedious, laborious task.

Let me just rattle off almost 30 years of follow-up studies on the outcomes of substitute care for abused and neglected children and youth:

Follow up studies on kids leaving substitute care are unfortunately very consistent in their findings.  Studies done by Casey Family Programs, Courtney, The Los Angeles Times, The Pew Charitable Trust, Youth Today, Child Law Practice and the Department of Health and Human Services reveal that following discharge from our programs our kids:

• Make up the majority of juveniles arrested on prostitution charges
• End up incarcerated at a rate of one in four to one in five
• Become homeless at a rate of 20 to 33%
• Fail to complete high school in far larger numbers than youth in their own homes
• Continue to show evidence of mental health problems and post-traumatic stress disorder after discharge
• Are frequently unemployed and if employed have low wages
• Have significant health problems
• Get pregnant at a significantly higher rate than peers

Doctors who change the medicine they give their patients when new and better medicines are found are admired, not criticized. The medicine we have been using has not been working. This is a fact we have to face.

Trauma Informed Care, now a mandated training in many places, is a recognition that we should never stop trying to find approaches that are best, or at least better, for our kids and families.  It is also recognition of the degree of harm caused by child maltreatment.

We can’t use a crisis intervention model for treating trauma.  The truth is, children and families traumatized by poverty, community violence, domestic violence, addiction, and abuse cannot be treated in short term, get ‘em in get ‘em out models.  We have not failed and the clients have not failed when we are not given the time required to repair the mental and emotional injuries we are called on to treat.

Truth #2: When the mind is sick the symptoms are behavioral

We are not behavior interventionists, we are behavior detectives.  

There are so many reasons for kids to behave in certain ways.  We have workshops on strategies for dealing with oppositional behavior and we discover that there are at least seven very different reasons why a kid might be oppositional.

Learning to distinguish between the unwilling, the unable, and the unwilling because they are unable is no walk in the park.  Punishing the behavior will not give us the information.  Only a relationship in which sufficient trust is built to have open and honest sharing of what is in the hearts and minds of our clients will tell us what we need to know before making a “plan” to help them.

Let’s face it, some kids are just “brats” and are temperamentally difficult, which many parents have to struggle with.  However brats, while annoying, do not generally end up in child welfare.

In the child welfare population we discover a boatload of possible causes for oppositional behavior:

• Response to controlling abuse
• Symptom of PTSD published in the DSM
• Symptom of neglect and lack of parenting
• Result of pre-natal exposure to drugs and alcohol
• Evidence of a learning disability
• Result of multiple placements where exposure to a multiplicity of different rules render them too confused to remember where they are now and what they’re supposed to do
• Evidence of an attachment or conduct disorder

It’s not the behavior we are out to treat, but the cause of the behavior.  This truth is very unpopular because it implies that a behavior intervention is likely to be more difficult than we would like, requiring that we find the cause before attempting a cure.

Truth #3: One size does not fit all.  

We have learned that treatment of the mind and heart must be tailored to the individual, just as is true in the treatment of other disorders of the body. Sometimes I think we forget that the brain is a body part.  

One size does not fit all is why senior citizens such as myself have to carry around a list of every medicine they take, because if something happens they can’t just give me something without knowing what else is in my system.  It is why even when you younger people sprain your ankle the doctor is pulling out the family history form before they will tape up you ankle.  What does my father’s heart condition have to do with treating your ankle, you say?

Everything, they think.  I’m not treating your ankle; I’m treating you.

A medicine that will help one person will kill another. An intervention that will help one kid – room time to calm down for a kid with ADHD and contagion problems who can settle when removed from the stimulation – can cause a despondent, rejected, kid to commit suicide if put in a room alone.  We can’t have a program that gives the same medicine to every kid and expect healing for all.

Truth #4: We know that treatment is done by individuals, not by programs.

I want to take a minute to have a private conversation with all of you out there who have been referred to as “fluff balls”.  You know who you are and the rest of the team does too.  You have been called weak, naïve, a pushover, and who knows what all because you have taken the kid’s side.  You don’t yell at a kid that they are “off program”!  You have advocated for a softer approach.  You have tried to steer away from punishment and toward discipline; from harshness to help.  When a consequence has been called for you have decided that the appropriate consequence is a session with you at the kitchen table, going over what happened, what went wrong, and what could be different next time.  And after your heartfelt discussion with the young person who would have chosen to clean the toilets rather than talk to you, one of your colleges said “yeah yeah I know you talked to him/her – but what is their consequence?”  Why do we feel the need to do something harsh or hurtful to think that a young person has received a consequence?  According to the dictionary, a consequence is “that which naturally follows”.  Why can’t engaging in a teaching interaction be something that follows a poor choice?

There are still some among us who believe that a therapeutic intervention with a young person who has already lost everything – their innocence, their dignity, their families, neighborhood, school, pets, siblings, favorite pillow – the way to help them is to take something else away from them.  That’s right; this kid will shape up when they lose something. You can believe this if you want, but giving is the cure for loss, not more loss.  And so we give them ourselves.

Truth #5: We know that our work is too complicated to be done by any one person.  We know that proficient teamwork is as important as any other skill.

Just as in a family where parents work harmoniously together on behalf of their children, Teamwork has been proven to be a key ingredient in an environment that promotes healing.  And isn’t this annoying!  Why do I have to work things out with her, or him – my colleague with whom I disagree so often???  We’re here for the kids, aren’t we?  Why can’t I just work things out with them and just try to avoid my teammate who I find so frustrating?  After all, I didn’t even choose to have him/her on the team; s/he was just assigned to me.

We talk ourselves into believing that we either don’t have the time to put into developing a competent team or we don’t want to spend the money. You can believe that the kids are more important than the team, but you will be wrong.  Couples whose only relationship is with the kids and who don’t spend time collaborating on how to raise their children are not competent parents.  A truth is that the time and money you will spend on the cost of poorly functioning teams wreaking havoc on the unit and in the lives of clients far outweighs the cost of putting the effort into helping us get on the same page, work out our differences, manage our conflicts, and get consistency in our approach.

Truth #6: There are limits to what can be accomplished with training.

Unhappily, licensing bodies often respond to troubles in programs by mandating more training.  As a professional trainer I am certainly all for training.  But training fixes two problems only:  deficits in knowledge; deficits in skill.  No other problems will be fixed with training.  Attitude problems do not get fixed with training. Unmanaged conflict between colleagues does not get fixed with training.  Lack of consistency in responses, causing anxiety and confusion with kids does not get fixed with training.  The truth is that most problems do not get fixed with training.  

Most problems get solved with competent supervision and competent teamwork.  Sometimes we have to be willing to have “courageous conversations” not just with clients but with each other for the sake of fixing what isn’t working on our team.

Truth #7: It is a truth that although we are here for the kids, treatment can only happen when we Care for the Caregivers as well as the Cared For

There is a mountain of evidence about the stress caused by caring for traumatized and demoralized individuals and families.  There are demonstrated “costs” in terms of compassion fatigue, secondary traumatic stress, and vicarious traumatization.  A program that does not put as much effort into taking care of the staff as it does into caring for the kids is putting both the staff and the clients at risk.
Compassion is one of the oldest proven medicines for the heart around.  All religions teach it.  Unfortunately, the root of the word is the word passion, and passion is exhausting.  The truth is, the Caregiver needs as much care as the client.

Truth #8: There is no manual!
It’s not that we haven’t read the book; it’s that the book doesn’t exist.  There is no book that has the answers to each of our most challenging problems and there never will be.

It isn’t possible to write a book about every person alive.  That’s what it would take to give us the key to the puzzle that is an individual client.

Your supervisor does not have the manual that will make your job easier.  It’s not in a drawer, or cabinet, or library, so we have learned to stop looking everywhere for the answers.  We have found it to be true that we waste time hoping someone else – some teacher, some expert, some author - will give us the key, the answer, the correct path to healing.

Rather, the time should be spent getting to know the secrets locked securely in the mind and heart of your client.  Only by getting to know them do you stand a chance of figuring out how to motivate them, or what new approach to try. Only by putting the time in to get to know them can we convince them to take a chance on a relationship with you, and to trust you enough to be vulnerable and hold onto your hand, while they find new ways to cope with the challenges that overwhelm them.  It is as important to read your clients as it is to read books.

Truth #9: It is true that doing something that isn’t working longer and more often will not make it work.

Sometimes interventions don’t work because although we believe them to be effective they are silly because we don’t take the time to think them through.

Some of my personal favorites:

• Time out.  Why would you put an emotionally disturbed child with learning disabilities, FASD, ADHD, PTSD and who knows what other handicaps on a chair or in a room alone and tell them to think?  Really?  Do we expect that they will magically mature or overcome their cognitive difficulties, while they stare at a clock for however many minutes we assign them?  And what is their problem with time anyway, since all they do is sit there and watch time go by?  Now, time out with two chairs, with us sitting next to them to help with problem solving, so that they can respond differently, might be good idea.  But in my experience, children are most often sitting alone.  Not only not bright; but not helpful.
• Early bed time for bedtime problems.  The literature on Post-traumatic stress disorder makes it clear that in two out of three categories of symptoms – Re-experiencing and Arousal – there will be sleep disturbances.  Children who experience difficulty with going to bed or sleeping are not demonstrating “behavior problems” but well documented symptoms of mental harm.  They avoid bed to avoid their repetitive nightmares.  They avoid bed to avoid remembering how creepy it was to go to bed and wonder if or when someone would be coming in to join them in bed and hurt them.  They avoid bed because they have learned that harm to their mother often came when the violent perpetrator thought they were asleep. So going to sleep was abandoning your mother.  Or, they go to bed, but their symptoms of hypervigilance keep them from being able to settle down.  They hear every noise, sometimes even the clock ticking.  High levels of cortisol in their systems, similar to veterans returning from war, keep them awake and restless.
  
  And what do we decide would be a “therapeutic” (healing) intervention?  More time in bed.  Don’t you sometimes have to wonder what is wrong with us?
  
  Building in bedtime routines and practices – something relaxing to drink before bed; a night light; soft music; something cuddly to hold; promises to check on them frequently – would make a lot more sense than putting them in a situation they already have trouble handling well for a longer period of time.  Or at least not yelling at them, when they pop up frequently to check the environment, to reassure themselves that they are safe.
• Grounding runaways.  Young people who run away do not have problems with leaving; they have problems returning.  How do we help them learn to return when we decide to keep them from leaving?  Just saying.
• I challenge you to examine the interventions you are using to see if, in a futile effort to gain some compliance, you are disempowering yourself by repeating something that is not working because you have built in a standard response that does not allow for truly therapeutic responses to non-compliance.
• One of our truths is that creativity is your friend.  If something isn’t working, try something else.  Build into your program permission to step out of the program if it will allow you and a young person to figure something out that will be more helpful than what is in the handbook.  Quirky people often respond to quirky interventions.  And quirky workers can think of them!

Truth #10: Sometimes you just have to laugh.

A wonderful truth for us is that silliness is an evidence-based professional intervention strategy, both for us as workers and for the kids and families as clients.

No baby has to be taught to laugh. All people start out laughing, but some stop as their world turns grim and frightening.  It is a great gift to give laughter back to someone who has lost it.

Not everyone has to be funny.  Some of you are funny; others are of good humor and appreciate funny.  Both work.  

Stress produces an increase in a body chemical referred to as the “stress hormone” or cortisol.

Cortisol is a steroid like substance that carries with it the same risks that accompany the risks from taking too many steroids, one of which is an increase in aggression.

Sometimes we do this without even realizing how scientific we’re being.  Think of how often you have experienced a challenging interaction that was truly awful and unnerving, only to retell the story later in with humor and exaggeration with colleagues, making it hilarious rather than frightful.  Sometimes we fall all over ourselves trying to get our story in while others share their misadventures and get everyone laughing.  Believe it or not, this is a professional, evidence-based practice.

Stress is not the event, but our perception of it.

Humor gives us perceptual flexibility or cognitive control.

Laughter changes your body chemistry. Laughing causes the release of Endorphins and enkephalins – secretions with morphine like molecules, which is a natural tranquilizer and a built in pain killer.  Endorphins have been shown to combat and decrease the amount of cortisol – the stress hormone – in our systems.  

So, along with the other tools in our stress management repertoire, we have learned to include humor.

And it turns out that you can remind your supervisor next time you are reprimanded for being too silly in the workplace that laughter is an evidence-based practice for coping with stress.  And stress is a fact of our work.

Truth #11. There’s a limit to what we can do.

There’s a reason that child abuse and neglect are crimes, and the reason is that maltreatment forever changes a child, and they can never be as they were intended to be.

It is very hard to sort out the reasons for our very modest success with some kids and our complete lack of success with others.  How much of the blame are we to take and how much belongs to those who hurt our kids before we met them.  If someone steals your car you can either get your car back or get another car.  If someone steals your childhood you can never get it back.  And we can never give it back.

The truth is that we have to recognize our limitations.  We do what we can.  Like many soldiers coming back from war our young people have traumatic brain injuries.  The majority of their wounds are invisible.  We see the symptoms and we see the pain, but the prescription to alleviate their suffering is often illusive.

Embedded in this truth is another:  There is no program that wants the kids you don’t want.
Don’t give up on a kid because working with them is too hard.  Nobody else wants them either, and moving them will cause more pain as they deal with another rejection.

People say that kids are “not appropriate for our program”.  But are they appropriate for a relationship with someone who will give them what they deserve.

Truth #12: A key principle of our evidence-based practice is that child and youth care work does require faith.

An accepted reality of child development is that cause and effect are not related closely in time.  

Issues of “displacement”, “transference” and all of the other psychological and behavioral issues that come regularly into the relationships between direct service workers and wounded children and adults, resulting in extreme stress and the constant need to self-monitor and employ our strategies of “professional distance” are the result of maltreatment suffered much earlier than any particular day and time.  The mind is a repository of everything that it has experienced, and harmful inputs in early years can cause harmful outputs decades later.

On the other hand, many of you have had the experience of being surprised, maybe even with your own children, to have found that the good stuff you put in there while they were growing up, really did “take”.  Parenting is often frustrating because it often appears that children are rejecting the input from their parents and parents worry that they are not being effective at raising healthy children.  And then to their amazement, that child you were so worried about becomes an adult to be proud of.

In the same way, it is not possible to “measure”, in an academic sense, the results of the seeds planted by child and youth care workers.  Often it seems that nothing is taking hold and all of our efforts at establishing the kind of relationship that can provide a balm for trauma and pain are being rebuffed.  But, the truth is, you never know.  

I believe that more often than not you will not be there to hear yourself being quoted, or see the anger being properly managed, or watch the formerly hard and harsh young person now hugging and showing love to their child, the way you showed it to them.  

A truth of our work is that we just have to believe that we are doing the right thing, and trust that we planted enough seeds and gave them enough water that someday the seeds will take root and produce the beauty that was hidden by the pain.  

So we love them, we take them back time after time and give them chance after chance.  I believe that most of our kids are doing the best that they can, given everything, so we do the best that we can and we have faith.

Conclusion

The truth is that we have to get paid for our efforts, not for our outcomes.  The outcomes of what we do are not possible to measure because the exact impacts of the emotional injuries are hard to measure, in any scientific sense, and because the results of our work may not become apparent immediately.  

The problem in explaining our work is that many of our truths seem counter-intuitive or go against generations of so-called wisdom.  Responding to an aggressive child with tenderness seems like the wrong response. But we know better.  That’s why we come to conferences where we can talk to other CYC’s who “get it”.

Once we clarify the truths of our profession we are then tasked with the difficulty of explaining these truths to those who have trouble believing them. So let’s keep working on learning how to articulate our own wisdom, the sources of our information, and the bases for our convictions.

We are not told that the truth will make us happy, but we are told that it will set us free.  The truth is we are engaged in work requiring love and labor!  The results of harm cannot be accurately measured, nor can the results of love.  I hope these truths of our profession will provide freedom from the judgment of others, who would like our work to be easier than it is, and who demand outcomes we cannot provide in the time we are given.

Editor’s Note: For more on CYC pioneer and legend Lorraine Fox, see the Fall 2015 issue of the ACYCP newsletter here