Page 1
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 1
THE ATTACHMENT, SELF-REGULATIONAND COMPETENCY
(ARC) MODEL
DelphineCollin-Vézina,PhDDirector, Centre for Research on Children and FamiliesNicolas Steinmetz and Gilles Julien Chair in Social Pediatrics in CommunityTier II Canada Research Chair in Child WelfareAssociate Professor, School of Social Work & Associate Member, Department of PediatricsMcGill University
Page 2
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 2
Youth in Out-of-Home Care
• DatafromtheNationalSurveyonChildandAdolescentWell-Beingshowedthat43%ofteenagersinout-of-homecarereportedatleastonementalhealthproblem:depression,anxiety,substanceabuse,suicidality,ADHD(1)
• Among9,942childrenandyouthinresidentialcaresettings(meanage10.4)(2)– 92%ofyouthreportedatleast2traumaticevents.– 80%wereratedashavingbehaviourproblems,70%had
attachmentissues,65%hadacademicdifficulties,and42%hadsubstanceuseproblems.
– Asthenumberoftraumasincreased,functionalimpairmentincreased.
(1) Heneghan etal.,2013(2) Briggsetal.,2012
Page 3
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 3
Youth in Residential Care: A Quebec Study
Collin-Vézina etal,2011
N=5322.6
26.430.2
20.8
Age
14
15
16
17
45
55
Gender
Girls
Boys
17
18.9
39.6
20.8
RacialGroup
Aboriginalor1stNationsBlack
WhiteorEuropeanOther
Youth in Residential Care: A Quebec Study
62%
68%
38%
55%
59%
ChildhoodTraumaQuestionnaire
TypeofAbuse
Noneorminimal
Lowtomoderate
Moderatetosevere
Severetoextreme
Physicalabuse 38% 19% 9% 34%
Emotionalabuse 32% 26% 9% 32%
Sexualabuse 62%(none) 6% 9% 23%
Physicalneglect 45% 15% 15% 25%
Emotionalneglect 41.5% 24.5% 17% 17%
Page 4
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 4
Youth in Residential Care: A Quebec Study
Compoundedmaltreatment:• 83% ofthesamplereportedatleastoneformofmaltreatment.
• 76%oftheyouthreportedMULTIPLE(2orMORE)forms ofmaltreatment.
• 64%oftheyouthreported3formsofmaltreatment.• 40%oftheyouthreported4formsofmaltreatment.• 19% ofthesampleexperiencedALL5TYPESofchildmaltreatment.
Youth in Residential Care: A Quebec Study
However,thereasonsthese53youthweretakenintochildprotectioncare(3sub-sections)werepoorlyreflectiveofthetraumasexperienced:
• 83,0%behaviourproblems• 26,4%neglect• 5,7%sexualabuse,• 5,7%abandonment• <5%emotionalabuse• <5%physicalabuse
Milne&Collin-Vézina,2014
Page 5
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 5
Adolescent male whois…
Aggressive to peopleDeceitfulNot receptive to feedbackEasily frustratedBelittling Quick to anger
A young personwho is suffering
Page 6
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 6
NTCSN: Principles of Trauma-Informed Care
NCTSNChildWelfareCommittee,2012
PartnerwithOtherAgenciesandSystems
MaximizePhysicalandEmotionalSafety
IdentifyChildandFamily’strauma-
RelatedNeeds
EnhanceChildWell-Beingand
Resilience
EnhanceFamilyWell-BeingandResilience
EnhanceStaffWell-Beingand
Resilience
PartnerwithChildandFamily
BroaderChild-ServingSystem
ChildWelfareSystem
Family
Child
Page 7
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 7
ARC: A Systemic Approach to Trauma
Blaustein &Kinniburgh,2010
Ofthehandfuloftrauma-informedinterventions,toourknowledge,onlyonepresentsamulti-systemicdesignthatallowsforimplementationamongdirect-carestaff.
Targetsthe3coreresiliencydomains:
A AttachmentR RegulationC Competency
ARC: A Systemic Approach to Trauma
• Evidence- andpractice-informedtreatment• Groundedintraumatheory,attachment,andchild
development.• Asawhole,thesetheorieshighlighttheimportanceof:
– Workingwiththeyouth-in-context,– Recognizingthattheyouth’scurrentadaptiveresponsesare
linkedtohistoricalexperiences,– Promotinginterventionwithintheimmediateenvironment–
whetherprimarycaregiversortreatmentsystems– tosupporttheyouth’sgrowthanddevelopment.
• RecognizedasapromisingpracticebytheNCTSNandSAMHSA
Page 8
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 8
THE ATTACHMENT, SELF-REGULATIONAND COMPETENCY
(ARC) MODEL
ARC: A Systemic Approach to Trauma
Trauma-impacted CHILD
Flexibleapplicationaccording theinterventioncontext:Individual,family,andgrouptherapy;children,parents,milieux
Page 9
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 9
The ARC Model
Competency
Self-Regulation
Attachment
ARC: A Systemic Approach
Attachment
Routines&Rituals
CaregiverAffect
Management
Attunement
ConsistentResponse
Self-Regulation
Identification
Modulation
Expression
Competency
ExecutiveFunctioning
Identity
TraumaIntegration
Page 10
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 10
Conceptual Model: The Impact of ARC
Offeringacommonvisionof
trauma(knowledge).
Offeringasetofconcretetoolstousewithtrauma-impactedyouth(Know-how).
Enhancecaregiverand
professionalself-efficacy.
Diminishnegativeinteractionswith
youth.
Decreaseproblembehavioursandmentalhealth
difficultiesforyouth.Increaseyouth’ssense
ofsafetyinrelationships,emotionregulationcapacitiesandcompetencies.
Offeringspaceandopportunitiesforreflectiveprofessionalpractice
(« savoir-être »).
Research – Current Implementation in Quebec
Page 11
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 11
ARC – Foster Care
• Sensitizationprogramforfosterparents– Objective:promoteplacementstability
• DevelopedincollaborationwithCISSSLanaudière;nowimplementedalsoatCIUSSSCentre-sud del’Île deMontréal.
• 7 cohortsoffosterparentsattwoinstitutionssinceFall2013
• Format:– 12weekly2.5hourmeetingsonthe10ARCblocs– 2individualmeetingswithapsycho-educatorassignedtothe
ARCgroupwithoptionalin-homesupport– Regionalandprovincialpracticecommunities
ARC – Foster Care
0
5
10
15
20
25
TotalDifficultiesScoreEmotionalDifficultiesBehaviourProblemsHyperactivityRelationalProblems
PrePost
* * **
n =36foster parents
*
Strengths andDifficulties Questionnaire(SDQ)Pre- andPost- at12week interval
Page 12
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 12
ARC – Foster Care
n =36foster parents
Strengths andDifficulties Questionnaire(SDQ)Pre- andPost- at12week interval
11%
8%
81%
TotalDifficulties (pre)
Average
Slightlyhigh
High
VeryHigh
22%
17%
61%
3%
TotalDifficulties (post)
ARC – Group Homes and Residential Care
• Trainingforeducatorsandclinicalsupportstaff– Objective:reduceuseofrestraintsanddeveloptrauma-
informedprofessionalpractices(beliefs,attitudes,behaviours)• 8unitstrainedsinceDecember2014
– CIUSSSCentre-sud del’Île deMontréal,CISSSOutaouais,CISSSLanaudière,CIUSSSCapitale-Nationale,CIUSSSOuest-de-l’Île deMontréal,CISSSMauricie-Centre-du-Québec
• Format:– 1.5dayoftrainingforeducatorsandclinicalsupportstaff– 1additionalfulldayoftrainingforclinicalsupportstaff– Minimumsixmonthlyclinicalconsultation/integrationmeetings– SuggestedARCactivities
Page 13
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 13
ARC – Juvenile Justice
• Trainingforeducatorsandclinicalsupportstaff– Objective:reduceuseofrestraintsanddeveloptrauma-
informedprofessionalpractices(beliefs,attitudes,behaviours)
• CurrentlyinprogramdevelopmentphaseinpartnershipwithCIUSSSCentre-sud del’Île deMontréal.
• Format:– 1.5dayoftrainingforeducatorsandclinicalsupportstaff– 1additionalfulldayoftrainingforclinicalsupportstaff– Monthlyclinicalconsultation/integrationmeetings(permanent)– SuggestedARCactivities
Page 14
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 14
Building Block 1:Routines and Rituals
Attachment
Attachment
Routines&Rituals
CaregiverAffect
Management
Attunement
ConsistentResponse
Self-Regulation
Identification
Modulation
Expression
Competency
ExecutiveFunctioning
Identity
TraumaIntegration
Knowledge: General Considerations
• Traumaisoftenassociatedwithunpredictability,chaos,andlossofcontrol.
• Youthmaybereactivetochangeandtransitions,andmayhavedevelopedrigidityintheirattemptstocontrolthemselves,others,andtheenvironment.
• Consistentroutinesandpredictabilityarehelpfultodecreaseinsecurityandvulnerability.
• Energycanshiftfrom‘survival’tohealthydevelopment.
Page 15
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 15
Know-To: Intervention Tips
• Individualintervention– Beingpredictable(calendar,schedule)
• FamilyIntervention– Adaptingexpectations– Targetingkeymoments(morning,homework,
bedtime)• SystemicIntervention
– Avoiddisruptionsinroutines– Anticipatedifficultmoments– Createrituals– Improvecommunicationwithinteamsandbetween
systems
‘Savoir-être’: Challenges
• Adaptingexpectationstotheyouth’scurrentcapacities(e.g.,homework,hygiene,etc.).
• Acceptingthatroutinesthatworkwellforotheryouth,orforthesameyouthinthepast,mayneedtobechanged.
• Findingbalancebetweenfamilyorgrouproutinesandpersonalizedroutinesforeachyouth.
• Lighteningheavyroutines,makingroomforflexibilityin“military”styleroutines,oralternately,helpingdisorganizedadultstoestablishandsustainroutines.
• Creating“roundtables”withallpartners,takingamoremoderateapproach.
Page 16
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 16
Examples from the ARC Manual
Building Block 2:Caregiver Affect Management
Attachment
Attachment
Routines&Rituals
CaregiverAffect
Management
Attunement
ConsistentResponse
Self-Regulation
Identification
Modulation
Expression
Competency
ExecutiveFunctioning
Identity
TraumaIntegration
Page 17
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 17
Knowledge: General Considerations
• Youthvigilance:traumatizedyouthcaninterpretcaregiveremotionsindichotomies(safetyvs.danger,approvalvs.disapproval,andacceptancevs.rejection)• Trauma-impactedyouthhaveextremelysensitiveantennae
todetectthreats,butoftenmakeinaccurateinterpretations• Caregiversmustconstantlymodulatetheirownemotions
inordertohelpyouthlearntomodulatetheirs• Workingwithyouthwhohaveexcessivebehaviours has
anemotionalandcognitiveimpactoncaregivers(reducedsenseofself-efficacy,angerandblametowardsthechild,shuttingdown,overreacting,overlypermissive).
Know-To: Intervention Tips
• FamilyIntervention– Well-beingactivities(e.g.,identifying5strategiesto
helpyoufeelbetter)– Supportandhelp– Therapy
• SystemicIntervention:workerself-careandcultivatingasupportiveworkculture– Individualorgroupsupervisioncanbeusedto
normalizestrongreactionsandoffersupport– Ongoingtraininganddiscussions– Workloadandwork-lifebalance– Reflectionspacesaboutvicarioustrauma,
compassionfatigue,burnout…
Page 18
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 18
‘Savoir-être’: Challenges
• Recognizingandvalidatingthatourownchallenges,asworkers,arenumerous(overwork,reform…).
• Establishingatrustingrelationshipwiththefamilyortheteamisessentialbeforethisblockcanbeaddressed(recognizethevalueoftheirwork,normalize,validate,findsolutions,etc.);highlightstrengthswhilecreatingmoreandmorespacetodiscussmistakesandmissedopportunities.
• Inanorganizationalcontext,theteamleader/manager’sroleisvitaltocreateaclimateoftrustandopenness;themanager’sfullparticipationisessential.
• Acceptingthatdevelopingareflexiveanddeliberatepracticeisalongprocess.
• Linkreflectionsanddiscussiontoconcreteaction
Examples from the ARC Manual
Page 19
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 19
Examples from the ARC Manual
Block 6: Modulation
Self-Regulation
Attachment
Routines&Rituals
CaregiverAffect
Management
Attunement
ConsistentResponse
Self-Regulation
Identification
Modulation
Expression
Competency
ExecutiveFunctioning
Identity
TraumaIntegration
Page 20
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 20
Knowledge: General Considerations
• Trauma-impactedyouthhavealimitedawarenessoftheirpsychologicalstates,eitherbecausethecompetencieswereneveracquired,orbecausethetraumadeconstructedpreviouslyacquiredcompetencies.
• Low-toleranceforemotions;emotionsthemselvescometofeelthreatening
• Difficultywith:– Differentiatingone’sownemotionalstates– Decodingotherpeople’semotionsandcues– Communicatingemotionsinanappropriateway– Usingeffectivemodulationstrategiestomanageintense
and/orpainfulemotionalstates
Know-To: Intervention Tips
• IndividualIntervention– Learningandpracticingmodulationstrategies
(breathing,imagery,progressiverelaxation,stressballs)
– Listeningtomusic,drawing,writing,etc.• GroupIntervention
– Socialcircus,dance,theatre,choir,etc.– Yoga,meditation– Trampolineandotherrhythmicactivities– Sportsandotherphysicalactivities
• Systemic Intervention– Ensuringthatyouthhaveeasyaccesstomodulation
toolsandstrategiesatalltimes
Page 21
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 21
‘Savoir-être’: Challenges
• Whenin“dangermode”ordealingwithtriggers,childrenarelessabletouselanguagetocommunicatetheirexperience.Modulationisanecessaryfirststepbeforeattemptingtohelpthemidentifyorcommunicatewhatishappening
• Usingresourcesinadeliberateandintentionalway,basedontherapeuticobjectives,ratherthaninamechanisticway
• Ensuringthattheactivitiesandstrategieschosencorrespondtotheyouth’sdevelopmentallevel(asopposedtochronologicalage)
• Usingactivitiesasopportunitiestogettoknowandunderstandthechildratherthanasanobjectiveitself(e.g.,ifachildrefusestoansweraquestionorelaborate).
Examples from the ARC Manual
Page 22
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 22
Examples from the ARC Manual
Building Block 9:Identity
Competency
Attachment
Routines&Rituals
CaregiverAffect
Management
Attunement
ConsistentResponse
Self-Regulation
Identification
Modulation
Expression
Competency
ExecutiveFunctioning
Identity
TraumaIntegration
Page 23
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 23
Knowledge: General Considerations
• Traumatizedchildreninternalizenegativeexperiencesandseethemselvesasunlovable,unworthy,helpless,ordamaged.
• Traumatizedchildrenmayrelyondissociativecopingmethods(fragmentationanddisconnectionfromtheirexperiences,multiplesensesofself).– Difficultyintegratingacoherentsenseofselfacrossexperiencesandaffectivestates.
• Traumatizedchildrenoftencurtailexplorationtofeelsafe,relyinginsteadonrigidcontrolandrepetition.
Know-To: Intervention Tips
UniqueSelf
Develop anawarenessofone’sindividualcharacteristics.Listenforandreflectstatementsthatsupportthis.
“Aboutme”books,personalcollages, creativeexpression,hobbies,otheractivities.
PositiveSelf
Abilitytotune into,name,andownpositiveattributesofself.Considerrelativesuccess,smallvictories,redefinesuccess.
Makealistofpositiveattributes,wallofsuccess,superheroselfactivities,otherartisticactivities.
CoherentSelf
Abilitytointegratemultiple aspectsofselfacrossexperiencesandaffectivestates. Notice andnormalizefragmentationwhileworkingtocreatecoherence.
Concrete timelineactivities,“Myhistory”book,aspectsoftheself(artistic)
FutureSelf Abilitytoenvisionpossibilities,selfinthefuture,waystobecomethatself.Set goals,makelinksbetweencurrentactivities andfuture goals.
Activitiesthatprojectthechild5,10,20yearintothefuture,annextothe“myhistorybook”
Page 24
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 24
‘Savoir-être’: Challenges
• Suchreflectionsonidentity,pastandfutureselves,etc.,cannotbedoneinameaningfulwayunlessthechildhasasenseofsecurity(Attachmentblocks)andareasonabletoregulateaffect(Regulationblocs).
• Canbedoneataveryconcretelevelifneeded(e.g.,foodsIlike,etc.)
• Creativeandartisticactivitiesshouldbepartoftheprogramingastheyofferanalternativetolanguage-basedreflections
Intervention: examples of activities
IdentityMasks CoatofArms
TotemPole
Page 25
Workshop April2017
Formationsurletraumaetlemodèle d’intervention ARC 25
ALL QUESTIONS CAN BEADDRESSED TO
DELPHINE COLLIN-VÉZINA:delphine.collin-vé[email protected]
Thank you for your attention & participation!