FRAMEWORK (WORKPLACE CURRICULUM) FOR THE DEVELOPMENT OF A THERAPEUTIC MODEL - PATRICK TOMLINSON (2025)

Date added: 25/01/25

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A RESEARCH-INFORMED AND EVIDENCE-BASED MODEL - CREATE YOUR ORGANIZATION’S UNIQUE THERAPEUTIC MODEL FOR TRAUMATIZED CHILDREN AND YOUNG PEOPLE

INTRODUCTION
The development of a model is a complex task. This document aims to provide a structure for working together on this task so that the work can be managed step by step. The process can be adapted according to need. The document is divided into three parts,
 
1. Leadership and Management
2. Organizational Culture
3. Practice
 
The three parts can be considered as the whole system. This is a whole-system approach to a therapeutic model. There is research evidence to suggest that this approach is most effective in delivering positive outcomes for service users. Kezelman and Stavropoulos (2012, p.16) in their research on trauma services link the organizational context and the recovery process,
Both administrative and clinical experience suggests that attributes of the system `as a whole’ have a very significant impact on the implementation and potentially the effectiveness of any services offered.
The development project is broken down into 22 key areas of work. Under each of them, there is a summary of why it is relevant to the model.  In some organizations, some of the areas of work may not be so relevant and there may be others that need adding.  The language may also need adapting. There are bullet points at the end of each section highlighting the specific tasks that need to be completed in creating the model for that section.  
 
If the three parts of a model are not effectively integrated the effectiveness of the work is likely to be undermined and not congruent with the ‘best interests of the child’ (Anglin, 2002). The steps/sections of each part are a way of organizing the project. All the ’22 Steps’ cover vital areas of a therapeutic model. Key elements of practice supported by research and experience over many decades are all included. (see, Tomlinson, 2019).
 
The clear organization of the 22 Steps, also provides a focus for different aspects of the model and who might be involved in the development of the different areas.  There is an overlap between the parts so there is no clear rule as to who might be involved in working on the different parts.  This is a matter to be decided by the Leadership of the organization in consultation with others.
 
There is an introduction to each of the 22 sections to explain why that area is relevant to the development of a model.  The aim is to provide a general orientation for the work that will take place.  It is not meant to be prescriptive, but just to provide a framework from which a model can be developed.      
 
Whilst the document follows a chronological process, some things may need to be skipped and come back to once other parts have been completed.  Many areas that will come under the model will already be in place.  Once the model is defined, current organizational structures, processes, practices, and policies will need to be reviewed and where necessary (and possible) adapted to the model.   
 
Clough et al. (2006, p.64) in their major research on studies into what works in residential care outline what must be included in an effective model, 
We repeat the core areas for consideration:
• ensuring goals are in harmony
• establishing the structure of the home
• establishing clear and coherent leadership
• establishing well-articulated objectives, consistent throughout the organization
• staff feel that they have significant responsibility for life within the home.
 
... The fundamental requirement for an effective service is that different types of goals are as congruent as possible. However, this abstract state needs to be underpinned by sound professional knowledge, appropriate processes, and the good practice that the research studies have identified.
 
WHY HAVE A THERAPEUTIC MODEL? 
For several decades it has been recognized that it is important in trauma-based services to have a well-articulated therapeutic model.  Along with leadership, this has been identified as a key factor in well-run organizations (see, Tomlinson, 2019). 
 
Having a model and strong leadership are associated with positive outcomes for children and young people. Conversely, not having a clear model, ethos, or philosophy is often a factor in poor outcomes, bad practices, and negative outcomes. One of the key benefits of having a model is that it should improve safety and reduce risk. It is a positive protective factor (see, Wardhaugh and Wilding, 1993, Tomlinson, 2019). 
 
Recent research from neurobiology, trauma, and the conditions necessary for recovery have affirmed the value of the consistency brought about by a clear therapeutic approach. This is so clear now that in many parts of the world, it is becoming a requirement that organizations in this field have a therapeutic model. In some cases, children will no longer be placed with organizations that do not have one.
 
Having a model is important but not a guarantee of positive outcomes. It must be delivered in the context of good leadership and become embedded in the culture. All aspects of the organization must be congruent (Anglin, 2002, 2004) and aligned with it. This includes leadership, management, organization policies, and procedures, as well as any kind of therapy that is used in working with children. This is referred to as a ‘whole system’ model and has been evidenced to be most effective (Kezelman and Stavropoulos, 2012, p.16). 
 
BENEFITS OF HAVING A MODEL
These are the key benefits, 
 
1. A clear model framework increases safety and reduces risk. 
2. An articulated model clarifies the task and reduces confusion. This leads to a higher level of congruence, with improved outcomes for all stakeholders. A model creates a shared language and processes, which helps integrate different professional disciplines.
3. It is highly beneficial for organizations to understand trauma and how to respond to it. This is becoming trauma-informed. 
4. Greater consistency and quality of professional and organizational development.  Improved performance, funding, and cost-efficiency.  
5. The development work is a helpful way of reviewing the organization’s culture and practice. 
6. The work involved will be a positive experience of team building - creating a shared vision, values, and commitment.  The involvement of the organization in the creation process will lead to a high level of engagement and ownership.
7. A high-quality model will further consolidate the organization’s position – in terms of being a high-caliber service provider, attracting referrals, funding, and good-quality staff.  
8. Holding a conference, and publishing papers/a book all help to establish the organization as a leading authority in the field. 
9. In some countries having an articulated therapeutic model is becoming a regulatory requirement, influencing the placement of children. Therefore, not having a model could jeopardize an organization’s future. 
 
The first of the above benefits, improving safety and reducing risk is critical. It has been known in the field of trauma work since the 19th century that nothing can be done until a level of safety is established. Kezelman and Stavropoulos (2012, p.71) state, 
The three phases of treatment (which date to the work of Janet in the late nineteenth century, and which current research findings endorse) are broadly described as follows:
(1) Safety and stabilisation
(2) Processing
(3) Integration202
Decades of research have culminated more recently in meta-studies of the research. There has been a convergence and collaboration between experts in many countries. A consensus statement from 32 experts from 12 nations, based on extensive research about the key principles of Therapeutic Residential Care confirmed that safety is the number one principle out of the 5 they identified (Whittaker et al., 2016, p.96),
1. Do no harm – Safety First
We are acutely mindful that the first principle undergirding therapeutic residential care must be ‘primum non nocere’: to first, do no harm. Thus, our strong consensus is that ‘Safety First’ be the guiding principle in the design and implementation of all TRC programs.
As discussed earlier Wardhaugh and Wilding (1993) have powerfully highlighted the risks involved in not having a clear model. 
 
PHASE 1 - CREATING A ‘HOME-GROWN’ MODEL 
This document outlines the areas of a framework or workplace curriculum (Billett, 2005) for developing a therapeutic model.  The framework is designed as an active, learning and development process. The areas covered by the framework are based on the evidence and research as to what is important to children in residential care and other care settings, and what helps them to achieve positive outcomes in their lives. 
 
A framework such as this provides a way of assisting an organization to create and articulate its model. In recent years this has been referred to as creating a home-grown model. The only other way to have a model is to import and license one from somewhere else. James (2017, p,7) highlights some of the benefits of creating a home-grown model rather than importing one,
It is believed that instead agencies use “home-grown” milieu-based models, which have developed over time and thus have validity within the context of an agency’s history and environmental context. These may be informed by existing models, may meet the agency’s needs for providing a general framework for their services and are, at minimum, sufficiently cogent to meet requirements for licensing and accreditation.
Referring to research on residential care James (p.7-8) continues,
In the already mentioned Special Issue on residential care in the Journal of Emotional and Behavioral Disorders, Lee and McMillen (2017) recommended the development, specification and careful evaluation of “home-grown” programs as a viable alternative for residential care agencies that cannot or do not want to shift to one of the existing evidence-based program models but want to develop an overall evidence-based approach to their program.
And (p.12),
Lee and McMillen’s recent article opened the possibility of different avenues toward evidence-based practice that may be more fitting for the residential care context than the transportation of ‘packaged models’ into agencies. These avenues should be explored.
The aim of creating a therapeutic model is to significantly improve outcomes for the service users, the organization, and all stakeholders. This is achieved through the change process, which is model development. 
 
It usually takes one year to work through the framework and produce a model written in a document. The model is then ready for the implementation process. As variables are involved, such as how long the organization has been established, the size of the organization, whether there is a working model (if not fully articulated), the resources available, and other contextual matters, the model process could take longer or less than a year. A Pre-Model Assessment will help to clarify these issues and readiness for model development. 
 
The key reason why a year is usually needed is not because of how long it takes to gather information or write anything but because of the need for time to process such a significant change. Inclusivity is also vitally important at all levels of the organization. Without time to properly review, reflect, and consider the meaning of change there is not likely to be strong ownership and commitment to the model produced. The aim is for as many people as possible to digest the meaning of the model, and its implications for their role, and identify with it. Ideally, to see some of their influence and contribution to it (see, Tomlinson, 2021a, 2021b, 2022).
 
 
PHASE 2 - MODEL IMPLEMENTATION
After creating a model document and approving this stage as complete the next stage is implementation. The implementation phase can also be expected to take up to a year. A key part of this phase is to test the model in practice and tweak parts of it wherever necessary. 
 
With the 22 sections completed a training programme can now be created based on the model. Organizational policies, practices, and procedures will also need to be reviewed to ensure that they are aligned with the model. Finally, an outcomes measurement process will need to be in place or developed to ascertain whether the aims of the model are being achieved. The fidelity of the model is in its implementation. As Duppong Hurley et al. (2017) state, 
Treatment fidelity refers to the extent to which treatment and care is implemented as intended. This includes adherence to, and implementation of, the key aspects and components of treatment design, and the delivery of treatment through skilled and appropriately trained professionals.
Oranga Tamiriki (2020, p.9) concur,
Where treatment was delivered as intended, children and young people in TRC exhibited lower rates of internalising and externalising behaviours while in care. 
 
PHASE 3 – MODEL ESTABLISHMENT AND ONGOING DEVELOPMENT
This phase is about fully establishing the model in the culture and practice of the organization. Where everyone whatever their role, understands the model, is committed to it, and the way they work is aligned with the model. To some extent, this is always a work in progress and things never remain static. For example, things may become stagnant and go backward. 
 
The context of the work and external factors is always changing so the model must adapt and evolve. Additionally, we should not view any model as the finished article but as a process of continuous learning and development. Research and experience may lead us to question parts of the model and to discover new insights.
 
Therefore, it is essential to put in place a way of managing the ongoing process of change. For example, there needs to be a way of agreeing whether proposed changes and additions to the model are aligned or not. Changes might include new training events, new procedures and processes, new approaches to an aspect of the model, and changes to policies. If these processes are not managed consistently there is a high risk that there will soon be contradictory and incongruent practices sliding into the unmanaged space. 
 
Continuous development and creative thinking should be encouraged but there must be a way of managing it. A simple solution is to establish a Model Committee made up of technical and operational representatives whose task is to review and recommend proposed changes. This could be done on a 3 or 6-month basis. All stakeholders can be encouraged to submit proposals for review. Any significant changes in the organization, including changes to the model, could then be submitted to senior management for approval and signing off. 
 
 
THE ROLE OF THE EXTERNAL CONSULTANT/CO-CREATOR
Patrick Tomlinson has been involved in developing therapeutic models for over 25 years. Since its inception in 2008, Patrick Tomlinson Associates has provided a Therapeutic Model Development service. The core value of creativity has been central to the work and that is why organizations are assisted to create their unique model which they have complete ownership of. This is done through a process of collaboration and co-creation.
 
Fourteen therapeutic models have been created in several countries and three are in progress (England, Ireland, Northern Ireland, Portugal, and Australia). Some of the models have achieved national and international recognition. For example, Thoburn and Ainsworth (2015, p.45) state in the book, Therapeutic Residential Care for Children: Developing Evidence-Based International Practice, 
In Australia, the most clearly articulated model of Therapeutic Residential Care is that offered by the Lighthouse Foundation (Ainsworth 2012; Barton, Gonzales and Tomlinson 2012) that owes much to the Cotswold Community in the UK. 
The models have been for a wide variety of organizations, covering residential care, children and family services, education, foster care, and community services. The models have all been articulated in a model document. The size of the model documents has varied from 5,000 to 70,000 words. They are tailored according to need and the smaller documents can be built upon in the future.  
 
The models that have been co-created have been in organizations that vary in size and complexity. For example, start-up organizations to well-established organizations with hundreds and in one case thousands of staff. And organizations that provide one service, such as residential care, and others that provide several services. In general, having an external consultant can act as a form of emotional containment, which enables the staff within the organisation to think more clearly and identify their solutions. The consultant/co-creator provides several areas of support,
 
1. Vast experience which enables understanding of the model development process and potential challenges involved.
2. The consultant aims to ensure that the way of working together models the model. For example, if reflective practice is an important part of the model it must also be an important part of the model development work.
3. Model Development is a significant process of organizational change. The external consultant provides a form of containment that enables, understanding, differences and resistance to be worked through, and internalization of the model’s meaning.
4. As there is a process of change for the organization this means that the people involved also need to develop. The mentoring provided by the consultant supports this. 
5. Research-informed material is provided from an extensive library to underpin the validity of the model.
6. The writing process is supported by review and feedback, editing, and adding material as needed. 
 
Wilson (2003, p.232) states that the benefit of the role of external consultant,
… is his or her particular specialism and external perspective. The consultant has a unique relationship to the organisation, being invoked from outside, rather than employed from within.
The organizational consultant Eric Miller (1989, p. xviii) emphasized the value of the external consultant when working on a major change project, 
Change, even when intellectually people see it as necessary and desirable, always arouses anxiety. It is part of my task as a consultant to contain some of that anxiety so that members of the client system are not crippled by it.
Whitwell (1998) describes the value of the more removed perspective as helping those inside the organization be more able to see the wood through the trees, or as Miller (p. xvii) explains, 
I have to stand back far enough far enough to discover alternative ways of looking at a situation, ways that may be less accessible to those who are caught up in it. 
Wilson (p.221) elaborates further on this point,
The essential value of consultation is that it exists ‘outside’, or rather, ‘on the edge’ of an organisation. As Silveira (1991) puts it, the consultant in a residential institution is ‘the nonresident crossing the boundary every time he visits, looking in and looking out’. The strength of his or her contribution resides in being slightly at odds with the organisation: a part of and yet apart from the living goings-on of the organisation. This is the very element that the organisation needs because of temporary or prolonged moments of blindness that occur, inherent in its involvement with its own working. The directors, trustees and management may lose sight of their mission or strategy and become over-embroiled in their practice. The consultant offers, from a special place of difference, something relatively uncompromised or cloyed by institutional pressures – a bird’s eye view, without as it were, having too much institutional wool being pulled over it.
This is a key reason why the model development process can be significantly aided by having an external consultant/co-creator. Once the model development task is complete and by the end of the model implementation phase, Miller (xviii) explains,
My task is then to become redundant. The intervention will be successful if clients have transformed the dependence on me into fuller exercise of their own authority and competence. 
In the beginning, the consultant will work with the organization to agree upon how they will work together. This is influenced by the size of the organization, the resources available, the organization's stage of development, and how much of a model may already be in place. A pre-model assessment can help to establish the reality of these factors. 
 
MODEL PARTS AND SECTIONS
 
PART 1 - LEADERSHIP AND MANAGEMENT
1.1 THE PRIMARY TASK (MISSION) AND CORE VALUES
1.2 THE ORGANIZATION’S VISION AND CULTURE
1.3 LEADERSHIP
1.4 THE LANGUAGE OF THE ORGANIZATION
1.5 BOUNDARY MANAGEMENT 
1.6 TRAUMA RE-ENACTMENT AND ITS IMPACT ON THE ORGANIZATION
1.7 INDEPENDENT CONSULTANCY AND MONITORING
1.8 DEMANDS OF THE WORK AND STAFF SUPPORT 
1.9 MANAGING CHANGE
 
PART 2 - ORGANIZATIONAL CULTURE
2.10 THE IMPORTANCE OF BOUNDARIES
2.11 THE RELATIONSHIP BETWEEN THE ORGANIZATION AND THERAPEUTIC TASK
2.12 THE NATURE OF AUTHORITY
2.13 THE ORGANIZATION AND COMMUNITY
2.14 CREATING A SENSE OF COMMUNITY 
2.15 ORGANIZATION AS ‘FAMILY’
2.16 GROUP PROCESSES
 
PART 3 - PRACTICE
3.17 OUTCOMES
3.18 THE IMPORTANCE OF THEORY 
3.19 THE THERAPEUTIC APPROACH
This section will be extensive and will include how the following (this is not a complete list as there may be other areas to add)
3.20 CHILD SAFETY
3.21 THE ‘HOME’ MEETING
3.22 PROMOTING RESPONSIBLE CHILDREN (EMPOWERMENT PROCESSES) 

For each Section, 1.1 - 3.22 there is an explanation at the beginning. This outlines what the section is about and why it is included. At the end of each section are TASKS to complete. These are key tasks that must be completed and implemented so that the organization has a working model.

PART 1 - LEADERSHIP AND MANAGEMENT
 
1.1 THE PRIMARY TASK (MISSION) AND CORE VALUES
Given the challenging nature of the work, organizations that work with traumatized children must be clear about their primary task.  The primary task is the task the organization must perform over and above everything else – the reason for its existence.  For example, - is the primary task may be, to safely contain children or to enable them to recover from their experiences?  Clarity on this makes a significant difference to all matters of the organization’s activity.  The precise definition of the ‘primary task’ is essential and constant vigilance is needed to stay ‘on task’, faced with the ever-present challenges involved in the work.  
 
As well as having a clearly defined task, the approach to the task or methods and tools used also need clarifying.  
 
The therapeutic approach in all its details, the resources used, and how they are applied and organized, should give the best possible fit with the primary task.  Both the ‘clinical’ approaches used in working with children and the way the whole organization works are relevant to the task.  The organizational culture needs to support and facilitate the work with the children in a complementary way.  A theoretical understanding of what is being ‘treated’ - and with what ‘aim’ - is necessary, so that theory can be applied to practice. 
 
Processes and therapeutic approaches, however sophisticated will be of limited value unless they are embedded within a culture that reflects their core aims and values.  
 
TASKS: THE FOLLOWING NEED TO BE DEFINED
• The organization’s primary task (mission).
• The organization’s core values, which will underpin the primary task.
• The type of children who are suitable for this task and how they will be selected.
• The methods that will be used in the work.
• The resources that are needed, how many carers, managers, directors, consultants, buildings, vehicles, etc.
• How the resources are organized to support the primary task.
 
1.2 THE ORGANIZATION’S VISION AND CULTURE
The leaders in the organization will hold the organization’s vision and will articulate this inside and outside of the organization.  Without a strong vision, it is unlikely that the work will be sustainable.  Khaleelee (2004, p.271) argued that one of the central aspects of leadership is,  
… the capacity of the leader to keep steadfastly to his or her long-term vision whilst containing the anxiety of followers during the implementation phases of that vision.  
A strong vision can provide a sense of purpose and commitment for everyone, which can inspire, motivate, and make sense of why we are all doing this work.  The vision must be something that everyone can relate to and believe in.  Therefore, the leader needs to have the utmost belief and conviction in the vision.  
 
Strong Culture
There is a wealth of literature exploring organizational culture that highlights the importance of having a strong culture in an organization. A strong culture is said to exist when staff respond to situations because of their alignment with organizational values. In these environments, strong cultures help organizations operate like well-oiled machines (Janis, 1982).  An important element of a strong culture is consistency. As such, traditions, rituals, systems, and processes are necessary for organizations to maintain a strong culture that can survive the test of time. 
 
Conversely, when an organization has a weak culture with little alignment with organizational values, often control is exercised through rigid bureaucratic systems. These organizations often have high levels of turnover and interpersonal conflict between staff (Janis, 1982). Consistency in the care of the children provides predictability, which in turn helps provide a sense of safety. Processes throughout the organization also need to offer consistency and predictability.
 
TASKS
• Define the organization’s vision and how it will be communicated within and outside of the organization.
• Clarify the general type of systems that are necessary to support the appropriate culture, e.g., bureaucratic, hierarchical, flattened hierarchy, processes for involvement and consultation, etc.
• Clarify what kind of traditions and events would be positive to establish within the organization, e.g., regular seasonal events such as celebrations, weekly or monthly meetings for all staff, get-togethers, events for children from different homes, newsletters, etc.
 
1.3 LEADERSHIP
The organization’s leader is ultimately responsible for the environment within which the work with traumatized children takes place.  The leader will have to contend with difficulties such as the way trauma becomes re-enacted within the organization, the difficulty in maintaining appropriate boundaries and containing anxiety.  
 
Not only is the leader dealing with these internal issues but also managing the boundary of the whole organization with the outside world.  Often the political, societal, and economic climate that which the work takes place is ambivalent, if not directly hostile.  This happens on different levels, which can be conscious or unconscious.  
 
Organizations that work with traumatized children are a painful reminder of the reality that child abuse and neglect happen in families.  The reality of what has happened to the children is often denied.  The organization is held responsible for managing its behaviour and is often expected to do this with inadequate resources.  Farragher and Yanosy (2005, p.99) summarized some of the challenges involved, 
Residential centers provide 24-hour care, 365 days a year to traumatized children. These settings are very intense, highly volatile, often unpredictable and exceedingly complex environments.  Things can go very wrong, very fast.  At the same time, the high cost of residential care makes these centers a constant target for funding cuts and cost control efforts.  Many are located in communities that are less than thrilled about having such troublesome neighbors.  
Having stated the difficult side of things, which is often the reality facing the leader – there are also positive dynamics both inside and outside the organization that the effective leader will identify and use for the benefit of the task.  For example, the concern and guilt that might be felt about child neglect and abuse can mobilize reparative drives in individuals, groups, organizations, and communities.  
 
Within the organization, there will also be much goodwill and commitment towards working with the children.  The children have resilience and the capacity to recover from trauma.  Enabling children to recover is immensely satisfying.  The leader of the organization is in both a potentially painful and privileged position.  As Van der Kolk and McFarlane (2007, p.573) have claimed, 
This struggle to transcend the effects of trauma is among the noblest aspects of human history.
Managing the powerful dynamics involved in working with traumatized children requires the leader to have mature, emotionally intelligent qualities that help maintain a realistic and balanced approach.  
 
The leader can come to represent the good ‘maternal’ provider who will nourish and take care of everyone, or the ‘abuser’ who is the cause of everyone’s pain.  This can happen in a way that mirrors the dynamics of a relationship with a traumatized child, or an infant.  The ‘maternal’ caregiver is idealized as ‘good’ until he or she fails the child in some way and then the caregiver is suddenly all things ‘bad’.  The leader needs to be highly aware of these potential dynamics and his/her vulnerability to the projections involved.  
 
The leader needs to be sensitive to the emotional climate of the organization but not so much so that he or she is easily overwhelmed.  Therefore, the leader needs the right balance between being ‘thick’ or ‘thin’ skinned, or in other words emotionally defended and undefended (Khaleelee and Tomlinson, 1997).  
 
The emotional intelligence of the leader is now regarded to be one of the primary requisites of leadership in general.  This is even more so, for a leader of an organization working with traumatized children, where the emotional intelligence of the whole organization is vital to the recovery process.  
 
One of the key tasks of leadership is to create conditions within the organization that facilitate the growth of leadership throughout the whole organization.  At all levels in the organization, appropriate delegation of authority and empowerment can lead to the development of responsibility and ownership.  This is especially important for the children who may be perceived as and feel themselves to be powerless victims.  Menzies Lyth (1985, p.239) explained,
It is in general good management practice to delegate tasks and responsibilities to the lowest level at which they can be competently carried out and to the point at which decision-making is most effective.  This is of particular importance in children’s institutions, since such delegation downwards increases the opportunity for staff to behave in an effective and authoritative way, to demonstrate capacity for carrying responsibility for themselves and their tasks and to make realistic decisions, all of which are aspects of a good model. 
The way the whole organization works creates a model that is internalized by the children.  The children are highly sensitive to everything that is happening around them and they will often exhibit behaviour that reflects what is happening at the management or organizational level.  The leader of the organization, in the way she relates to others, and takes and delegates responsibility - provides a role model for the nature of all relationships within the organization.  
 
Given the complexity of leading an organization that works with traumatized children, the powerful dynamics and emotionality of the work it is also important to consider the processes available to the leader to think about and develop his/her role concerning the task.     
 
TASKS
• Clarify the role and functions of the organization’s leader(s).
• Define the necessary skills, personal qualities, experience, and qualifications required.  The leader and other senior managers will need to have significant experience in therapeutic care for traumatized children.
• Define the process for appointing suitable senior personnel.
• Clarify the structure of accountability concerning the leader’s role, e.g., the leader’s autonomy and exactly who he/she is accountable to. 
• Clarify the processes available to support the leader’s role, e.g., coaching, role consultation, training, etc.  
 
1.4 THE LANGUAGE OF THE ORGANIZATION
The children’s trauma will have an impact on everyone in the organization, both directly and indirectly and everyone will have an emotional response to this.  In the same way, everyone’s response will have an impact on the children, directly or indirectly.  The organization provides a therapeutic milieu, which is about recovery from trauma.  Therefore, the organization needs to have a shared language and understanding related to trauma. The language of the organization needs to be embedded within a trauma-informed culture.  
 
The organization needs to have a clear understanding of child development, trauma, and recovery. There are theoretical variations on these themes.  Therefore, a consensus on the core theoretical foundations, organizational beliefs, and therapeutic approaches needs to be agreed upon.  Once the underpinning theory has been mapped out, it needs to be converted into a straightforward language that is understandable to everyone.  This can then be incorporated into training, daily interactions, supervision, and other processes.
 
TASKS
• Clarify the language that will be used in the organization to describe the work that is taking place and to communicate within the organization.
• Set up processes that may be necessary to develop this, for example, workshops and training sessions for everyone who works in the organization.
 
1.5 THE BOUNDARY MANAGEMENT OF AN OPEN SYSTEM
The ‘boundary manager’ or system of boundary management is placed on the boundary of the organization.  From this position, both the inside and outside are observed and the relationship between the two can be regulated appropriately. 
 
It is particularly critical in organizations that work with traumatized children that the boundary of the whole organization is effectively managed.  If the boundary is too permeable too much information and activity will come into the organization, potentially leading children, and workers to feel unprotected and overwhelmed.  If the boundary is too rigid and impermeable the organization will tend to become closed and starved of valuable inputs from the outside world.  Both dynamics reflect the nature of trauma and abuse environments and can become re-enacted within the organization.  
 
For example, in an abusive environment, there may be a complete lack of appropriate protective boundaries.  Alternatively, there may be very rigid boundaries to create an environment of secrecy where the outside world is kept out.  The way the boundary of the organization is managed will set a template for the way internal boundaries are managed - between departments or ‘sub-systems’, and between people, including the direct work with children.  
 
The appropriate management of boundaries creates an environment that potentially contains the emotional turmoil involved in the work with children.  Boundary management is a central task of leadership, management, and therapeutic work concerning personal/professional boundaries.  Effective boundary management also has a positive effect on the development of identity,
It gives a stronger sense of belonging to what is inside, of there being something comprehensible to identify with, of there being ‘my place’, or ‘our place’, where ‘I’ belong and where ‘we’ belong together (Menzies Lyth, 1985, p.245).
Children who have been severely traumatized in their early years are in many ways like infants and need their relationship with the outside world to be carefully managed.  Too much outside world and they can feel engulfed, too little and they are the centre of the universe!  They need buffering from the outside world and the outside world from them.  
 
TASKS: THE FOLLOWING NEEDS TO BE CLARIFIED
• The role of boundary management in the whole organization.
• The containing membranes between the outside of the organization and the child.
• The processes for children and staff joining and leaving the organization.
• The procedures for external people, professionals, regulatory authorities, children’s families, etc. to come into the organization.
 
1.6 TRAUMA RE-ENACTMENT AND ITS IMPACT ON THE ORGANIZATION
Traumatic events – and chronic stress – can produce a similar impact on organizations.  Without intending to do so, without recognizing that it has happened, entire systems can become “trauma–organized”.  A traumatized organization, like a traumatized person, tends to repeat patterns of behaviour in a way that prevents learning, growing, and changing (Bentovim, 1992).  And like individual trauma survivors, systems find it very difficult to see their own patterns.  They resist the pain it takes to grow and change, to thaw their frozen parts and reclaim movement.  (Bloom, 2005, p.63)
For the organization to be effective in its work of enabling traumatized children to recover, it needs to be especially aware of how trauma tends to be re-enacted.  Traumatized children will try to create re-enactments of their experiences for various reasons.  One simple reason is to create something familiar and therefore re-assuring in some way even though the consequences can be destructive.  
 
These children are especially fearful of change.  Even though we are trying to provide a healthy environment for them, it is new and unfamiliar, and therefore potentially threatening.  A traumatized child may feel that a return to a chaotic and abusive environment is inevitable, so rather than wait for it to happen they take control and try to provoke it to make things feel more predictable.  On the other hand, if the child can identify the new environment as potentially positive and hopeful, this will then raise anxieties about being let down and rejected.  The child will challenge, test, and attack the new environment to see how reliable and trustworthy it is.  
 
Another, more benign reason the children will create re-enactments is as an attempt to resolve their specific traumatic experiences.  A child who has been traumatized may feel compelled to continuously act out the trauma with those around him, in an attempt to find a better outcome.  The child may not be able to put his experience into words or to play in a way that can work things out symbolically.  Particularly, when the trauma occurred at a pre-verbal stage of development, he may only be able to act things out in a very literal way.  
 
Whilst we need to be careful not to get caught up in a re-enactment to the point that we take on and act out a negative role, to some degree it is inevitable that we do get ‘caught up’.  This is due to the unconscious and powerful processes at work.  The important thing is that we maintain the capacity to observe ourselves and reflect on the positions we find ourselves in.  In this way, we can gain insights into the roles we are unconsciously being asked by a child to take on and how this is related to their past experiences.  When we are unable to do this directly in a situation with a child, this becomes a crucial feature of supervision.  As Ruch (2010, p.35) argued, 
 
What makes it complicated is that because these patterns develop unconsciously, we are not likely to be aware of them as they are happening, although we may be able to make them more ‘visible’ through later reflection or supervision – which is one reason why supervision is important.  
 
Trauma-informed theories on working with traumatized children can be seen to have an emphasis in the following descending order – the impact of trauma on the children, the impact through vicarious trauma on those who work with them, and finally the impact on the organization that provides the service.  Farragher and Yanosy (2005, p.94) highlighted the potential implications of this, 
It is our assumption that readers have had at least some orientation to trauma theory and the impact trauma has on children.  What might be less common knowledge, however, is the impact trauma has on every level of the organization and why organizations that fail to grapple with this issue do so at their own peril. 
The difficulties facing the organization can often be underestimated.  As a result, the organization may fail to put in place the measures and processes, described above, that are necessary to support and sustain the work.  
 
TASKS
• Develop an understanding of trauma re-enactment, relevant papers, and books.
• Set up relevant training to ensure this is fully understood by the senior staff.
• Define the processes that will be put in place within the organization to help prevent trauma re-enactment.
 
1.7 INDEPENDENT CONSULTANCY AND MONITORING
Many organizations carrying out therapeutic work with traumatized children use external consultancy.  The external consultant is not an employee of the organization, but an independent person who is not involved with the organization on a day-to-day basis.  
 
As stated earlier, the nature of the therapeutic task is extremely challenging and there are powerful processes to manage if the organization is to stay on task.  The external consultant can: observe what appears to be happening within the organization; ask questions to clarify things; offer a view on problems that may be arising; and suggest potential solutions. Having a consultant in this role can also act as a form of emotional containment, which enables the staff within the organization to think more clearly and identify their solutions.  
 
Within an organization that provides therapeutic care to traumatized children, there are two potentially valuable areas of consultancy.  One is clinical and the other is organizational consultancy.  The clinical consultancy is for those working directly with the child.  This provides a much-needed thinking space and can be a great help in dealing with the emotional impact of the work.  The consultant’s experience also helps to identify specific issues related to trauma, the children’s behaviour, and appropriate therapeutic approaches.  
 
Organizational consultancy is to help look at the organization as a system and how it is performing concerning the primary task.  As we have discussed, traumatized children and the work involved will have an impact on the whole organization.  Therefore, it is useful to have a space to step back and look at what is happening with an experienced consultant who is looking in from the outside.  This type of consultancy is always potentially useful, but especially so, during periods of major change when the internal anxieties can be especially difficult to understand and manage.
Independent Monitoring
 
For similar reasons, it can also be very helpful for the organization to establish a system of independent monitoring.  For the reasons described it can be very difficult to maintain consistent standards in working with traumatized children.  At times, it can also be difficult for those directly involved to objectively evaluate standards of work.  
 
It is essential for clarity of the therapeutic task to have clearly defined standards of work and to have ways of measuring whether the standards are being met.  An independent person who understands the nature of the work is appointed to visit the organization periodically (e.g., once per month); to look at what is going on; inspect various practices, and provide a report on their findings.  
 
The processes of both independent consultancy and monitoring can help to enable the organization to stay on task and protect it from becoming trauma-organized.  
 
TASKS: THE FOLLOWING NEEDS TO BE DEFINED
• The role of independent consultancy and monitoring and how it will be used.
• The skills and experience that will be required in these roles.
• The processes for appointing suitable people.
 
1.8 DEMANDS OF THE WORK AND STAFF SUPPORT 
Working with traumatized children can be highly rewarding and very demanding.  Whether the demands involved lead to rewarding benefits for the children and those who work with them will largely depend upon how the demands are managed, thought about, and responded to.  
 
Continuity of Care
The continuity of care provides carers with an opportunity to continuously role model and engage in positive therapeutic relationships with children. It also provides an opportunity for repetition of responses and interactions, which is vital in the recovery process.  When conflict happens, children and carers are required to take a relationship-focused approach to manage it. 
 
Role Modelling
Living in a home with children means that many facets of a carer’s personality are used and exposed in the work.  Children experience the carer as a human being with strengths and weaknesses. Through the way they deal with conflict and the way they face challenges, carers become role models, for what healthy relationships should look like.  
 
Carers are required to continually be mindful of the way they present to children; and continually reflect on all their interactions; their thoughts, emotions, and experiences.  Essentially, carers are required to be “switched on” when in the presence of children. In a role where much of their time is spent in the presence of children, this level of active awareness is very demanding.
 
Physical and Emotional Wellbeing
As the research on trauma shows, we recognize that our physical and emotional states are entirely interconnected.  
 
In the care sector, it is common for workers to experience stress-related health concerns. We know that there can be high rates of leave due to illness, and vicarious trauma and that there is often a high turnover of staff.  We are also aware that in a program that focuses on long-term care, the emotional and physical wellbeing of care staff is vital for a therapeutic care program to be effective.  The organization needs to be aware of this and ensure that systems are developed to support the wellbeing of care workers.
 
The role of the senior team in these circumstances is very similar to the role of a carer in caring for children. The senior team, in some ways, is the carer of the carers, or the container of the containers, they must be attuned to the needs of the carers.  The success of a therapeutic care program relies on the psychological wellness (Prilleltensky and Nelson, 2000) of the carers. 
 
Therapeutic Supervision – Working with Feelings
In working with traumatized children, strong feelings inevitably get aroused.  This is partly, because of what an emotionally disturbed child does to us and partly because of what they remind us of in our childhoods, which we may have found painful.  The genuine difficulty, risk, and pain experienced by all involved create a strong potential for avoidance of the main issue and failure in therapeutic work.  
 
It is essential that whatever feelings a person is carrying can be talked about and explored.  If we cannot explore the feelings we have, then rather than be understood in a way that can lead to change for ourselves and the children, the feelings are likely to be re-enacted in repetitive scenarios that don't change anything. As well as supervision specialized training is also necessary. As Whitwell (2010) said, 
Love by itself is not enough.  Many carers will intuitively do the right thing without knowing why.  Unless carers receive training to help make sense of behaviours which are symptoms of the underlying emotional disturbance (panic rages, disruption, no guilt, splitting), they will burn out.
TASKS   
• Clarify the role and job descriptions of carers and other staff who work with the children.
• Define the skills, personal qualities, experience, and qualifications required.
• Define the systems that will be put in place to support those working with children, such as supervision, training, consultancy, on-call support, etc.
 
1.9 MANAGING CHANGE
Managing change is one of the central tasks of leadership.  Organizations that work with traumatized children, where stability is so important are faced with the challenge of managing necessary change and adaptation.  This must be done in a way that doesn’t fundamentally rock the boat so much, that anxieties become uncontained.  Traumatized children are fearful of change, as it means the environment becomes unpredictable and potentially harmful.  They are hyper-vigilant and constantly scan the environment for signs of change, including the emotional states of the adults looking after them.  Therefore, if a carer or team is aware of forthcoming changes that are causing some anxiety, the children will often pick this up unconsciously before they are told about it.  
 
The most difficult type of change for carers and children is a sudden change that leaves little time for processing the implications.  This can have a similar quality to some of the children’s traumatic experiences, where they felt helpless and out of control.  Traumatized children need to gain a sense of control and mastery over their lives.  Therefore, even if the change is not their own choice having some say and involvement in the process can help reduce the sense of helplessness.  
 
Bloom (2005) has talked about the importance of involving as many members of the organization as possible in the process of management.  Increasingly, children are consulted and involved in organizational processes.  If this is managed appropriately it can have great benefits, for the children, their carers, and the organization.  This requires leaders to develop a flattened hierarchy within the organization and to devolve decision-making as far as appropriate.  Bloom (2005, p.69) claimed that, 
Experience has taught that courageous leadership is always the key to system change and without it, substantial change is unlikely to occur.  This change process is frightening for people in leadership positions and they rightfully perceive significant risk in opening themselves up to criticism, in levelling hierarchies and sharing legitimate power.  The gains are substantial, but a leader only finds that out after learning how to tolerate the anxiety and uncertainty that inevitably accompanies real change.
The process of change will inevitably lead to differences in opinion and potential conflict.  However, the differences can often be vital to getting a full picture and improving the likelihood of successful implementation.  By having an open dialogue there is the opportunity for details to be considered and for potential problems to be identified.  Also, the level of resistance can be gauged, indicating further work that may be necessary.  
 
TASKS
• Clarify a process for how change will be managed in the organization.  This should include, the key principles, processes for consultation, decision-making, implementation, review, etc.
 
PART 2 - ORGANIZATIONAL CULTURE
 
2.10 THE IMPORTANCE OF BOUNDARIES
To support the therapeutic task the whole organization will need to be clear about its boundaries.  The larger and more complex the organization the more challenging this is.  The whole boundary system of the organization will be experienced and internalized by everyone in the organization, including the children.  The clearer the boundaries are between different roles and departments, the less confused everyone will be and more able to maintain clear and appropriate boundaries in working with children.  A clear structure of authority where it is understood exactly who is responsible for what is especially important.  
 
The organizational culture and structure need to be compatible with the therapeutic task.  Miller (1993, p.4) described how effective management of the ‘holding environment’, (taken from Winnicott’s (1990) idea of what a mother provides for her infant) of an organization can promote psychological security for its staff.  Talking about organizations whose task is to provide care, he states, that there is,
… the need for a match between the holding environment that staff have to provide for their clients or patients and the holding environment that organizations and management provide for them.
For example, a management structure that allows little autonomy and responsibility in the staff is not likely to encourage the growth of autonomy and responsibility in the children.  Boundaries are established around and within a home that gives individuals an appropriate amount of space within which to negotiate and make choices.  
 
Organizations that work with traumatized children can expect considerable difficulty in maintaining effective boundary management.  There are several reasons for this.  The work involves significant levels of anxiety that will impact those working directly with children and the whole organization.  
 
Maintaining clear boundaries is especially difficult when people are anxious and where boundaries are being continuously tested.  Thinking becomes difficult and management can become reactive and too rigid or on the other hand too permissive due to fear of negative reactions.  In many ways, the dynamics of abuse, denial, and secrecy, can infiltrate the whole organization. There is always the danger that organizations can become closed systems much like those in which family abuse occurs.  
 
When we are working with children traumatized by abuse, and particularly sexual abuse, being clear about things is often responded to as if it is abusive.  This can lead to collusion as a way of avoiding the anxiety involved.  The concept of ‘tough love’ can also be challenging for the organization to manage.  On the one hand, providing care for some of society’s most ill-treated and vulnerable children, but on the other also needing to be very firm and resilient in the work with children.  Many people come into the work wanting to provide love and care for the children and find themselves being reacted to as if they are being hurtful and abusive.   
 
For the worker to be supported in thinking about and understanding the difficult feelings we have described, there must be specifically designed forums for this purpose.  The forums, which can include supervision, team meetings, consultancy, and training, will need to be clear in terms of boundaries and tasks.  They will need to be reliable and consistent.  In working with children who present such challenges to our: emotions; thinking; and ability to hold boundaries; and where staff must deal with high levels of uncertainty, it is helpful that the key structures for staff support are reliable and predictable. This helps create a sense of security.  
 
In the cultural context, it is mainly about ensuring the culture reflects clear and respectful boundaries. What are the cultural norms about behaviour? Is the culture respectful and informed on the subject of appropriate boundaries? It is a bit formal and informal. So, on the one hand, it is important within the culture for people to have a clear sense of each other's roles, responsibilities, authority, etc., and also how to behave with young people so that anyone regardless of role always behaves sensitively and appropriately. But also, the informal bit - how do people talk to each other, interact, etc.? 
 
Issues of gender, sexuality, ethnicity, disability, race, etc. come into it. What is allowed implicitly as well as explicitly in the culture – what is appropriate? Are there expectations for every employee and also board members, etc. matters such as dress, and language? The whole organization must be trauma-informed so that the cultural understanding and implementation of boundaries are aligned with the primary task. 
 
TASKS
• Set up a process for clarifying the boundaries between systems within the organization, who should be involved, etc.
• Clarify the boundaries between systems within the organization, for example, between the home and senior management team, and between the finance department and the home.
• Clarify who is responsible for managing each boundary. For example, who is managing the home boundary, and who is managing the senior management team boundary?  Once this is clear, it also becomes clear who should be talking to whom about an issue between the home and senior management.
• Draw and agree on an Organization Chart.
• Define a pattern of meetings to review/reflect on work done and plan forward. 
 
2.11 THE RELATIONSHIP BETWEEN THE ORGANIZATION AND THERAPEUTIC TASK
Menzies Lyth (1979, p.234) drew our attention to the difficulty of management in those institutions that care for people and possibly aim to help them change - collectively known as the ‘humane institutions’.  She claims that the management of these institutions, 
… calls for an unusual degree of management skill from people who do not easily see themselves as managers.  
Management and the Therapeutic Task
As well as establishing appropriate processes and structures, the management of the organization is also about creating and leading a culture that runs through the organization.  One that influences the way everyone thinks and works together on a day-to-day basis.  Processes and therapeutic approaches, however sophisticated will be of limited value unless they are embedded within a culture that reflects their core aims and values.  Within this culture, thoughtfulness and communication are central.  
The culture must be an open one, where within appropriate boundaries communication and thinking are encouraged rather than censured or dismissed.  (Tomlinson, 2005, p.51)  
For open communication to take place, boundaries need to be clear, consistent, and reliable.  There are two key reasons for this - clear boundaries enable everyone to know, 
 
• Where they stand, how things work, and what is expected.  This reduces anxiety and distraction and enables everyone to focus on the therapeutic work at hand. 
• The appropriate place to communicate about various issues and concerns.  
 
Clarity of purpose and task can reduce anxiety and provide emotional security.  There needs to be opportunities for anxieties and concerns to be communicated.  It is important to provide reliable meeting spaces for team members to work through the emotionality of the work. 
 
For the organization to stay on task, clear management and leadership are essential.  Achieving the appropriate level of clarity is one of the biggest challenges for organizations working with traumatized children.  There is a danger that management and therapy are perceived to conflict, rather than two complementary aspects of the therapeutic environment for children.  Children, who have been traumatized from an early age, need an environment that is well-managed and emotionally contained.  
 
Management includes safety, boundaries, and all aspects of the organizational structure.  Without these conditions, traumatized children will not be able to make use of therapeutic work.  
 
In a well-run organization, both business and care are compatible and integral to the task of the organization.  The way this is managed and getting the balance right potentially serves as an excellent role model for children who in the future will need to make the best of things within the reality of limited resources.   
 
A culture where those responsible for managing children’s homes are given responsibility for managing budgets and taking responsibility for their own decisions can help prevent this split from developing.  As far as possible, the running of the home should reflect a typical family situation, with carers having the same kind of responsibility that parents have.  It is also vital that those responsible for the business management of the organization understand the challenges of managing a home. 
 
Keeping the management of the organization on task and boundaries clear is by its very nature hugely difficult.  
 
TASKS
• Clarify the organization’s management systems: who is responsible for what; who is accountable/responsible to whom; how responsibility is delegated; and how communication will take place.
• Define all meetings that take place in the organization, including the frequency and duration of the meeting, who is involved, who chairs the meeting, and the task of the meeting, etc.
 
2.12 THE NATURE OF AUTHORITY
To manage the systems and their boundaries effectively, the organization beginning with its leader needs to know what its authority is and then exercise it appropriately in line with the therapeutic task.  With authority comes the requirement to take responsibility and to be held accountable.  If authority is fudged, no one knows who is responsible for what, and holding anyone accountable for anything is impossible.  
 
It is immediately clear how this issue is directly relevant to the development of children, whose relationship with authority is often immature, negative, and distorted by their experiences.  The way the leader exercises her authority provides a role model for the whole organization and is central to the therapeutic task.  Menzies Lyth (1985, p.242) argued, 
It seems a fault in many children’s institutions that they do not handle authority effectively.  There may be too much permissiveness, people being allowed or encouraged to follow their own bent without sufficient accountability, guidance or discipline.  If this does not work (and it frequently does not, leading to excessive acting out by both staff and children) it may be replaced in time by an excessively rigid and punitive regime.  Both are detrimental to child development.  The ‘superego’ of the institution needs to be authoritative and responsible, though not authoritarian; firm and kindly, but not sloppily permissive.    
TASKS
• Clarify the key principles related to the appropriate nature of authority within the organization.
 
2.13 THE ORGANIZATION AND COMMUNITY
Abuse and neglect suffered by children occur within the context of a social environment.  Though they may have suffered abuse primarily from a parent, the fact that no one within the family, the extended family, or the wider community prevented it, means the child will have experienced the whole environment to have failed them.  As a result, they will not only be fearful of any individual’s capacity to take care of and protect them but also of the whole environment around them.  This means that the whole organization, as in a healthy family and community needs to be attuned to the needs of the children and the role everyone plays in supporting their development.  
 
For instance, a child may be settling into a new home and getting to know the carers.  As things progress, the child is likely to challenge and test those closest to him.  Therefore, the team working with the child are all involved in responding to this, to ensure that any developing attachments for the child take place within a safe and emotionally containing environment.  The child will test the team’s capacity to work in a safe, effective, and reliable way.  Traumatized children are familiar with chaotic, fragmented, and conflict-ridden environments and they will try to recreate this dynamic amongst the team.  
 
The reality of working with this behaviour is hugely challenging on an emotional level for everyone on the team.  There is a strong likelihood that team members begin to take on aspects of the role the child has given them.  Therefore, the care team’s work must be understood and supported by the whole organization.  This may happen in the form of supervision, consultancy, training, and practical support.  
 
The team will need supervisory help both on an individual and group level, on making sense of the children’s behaviour; training which helps to make links about the impact of trauma on child development, as well as on the therapeutic approach; and practical support to help keep on top of things in general.  
 
TASKS
• Clarify the key principles related to the concept of the organization as a community.
 
2.14 CREATING A SENSE OF COMMUNITY 
It Takes a Village to Raise a Child – African Proverb
Traumatized children are often forgotten children. Due to the abuse and neglect that they have experienced, the number of broken placements, and the transient nature of their existence, they do not feel a sense of belonging to a community. We know that having a sense of belonging to a community is an essential element in human wellbeing. 
 
Historically, promoting a sense of community in the widest sense of the word, for the children in its care has been a challenge for organizations that provide care for traumatized children.  Theoretical underpinnings and organizational systems must support and enable meaningful community building for the children. By this, we mean both the internal and external communities.  Programs that have a focus on individual therapeutic approaches can forget the importance of community in the recovery process.  
 
As discussed earlier, child abuse occurs within a family environment and therefore in the wider community context.  Therefore, the therapeutic task must address the need for a positive sense of community.  In the future, the children will also need to live interdependently as part of a community. The child’s ability to transition into an autonomous adult and be able to provide for themselves and their family in the future will partly rely on their ability to be part of a community. 
 
TASKS: THE FOLLOWING NEED CLARIFYING AND DEFINING
• How the organization will work as a community.
• How the different parts of the organization will work together as a whole concerning the therapeutic task. 
• How the organization relates to the external local community.
 
2.15 ORGANIZATION AS FAMILY
In a therapeutic community that also acts as if it were an extended family to the children, all operations and relationships within the organization need to be attuned to the therapeutic task. All members of the organization from the board to the carers need to role model a healthy sense of family. This is referred to as organizational parenting.  All systems and relationships have a therapeutic purpose and promote a sense of family for the child. The children are supported to have appropriate relationships with different members of the organization; much like the village that it takes to raise a child, the organization becomes the village. Children in this environment develop a variety of relationships.  A circle of care that helps them internalize a more positive view of family and community.
 
TASKS
• Clarify in detail how different parts of the organization and how specific roles will be related directly to children.  
• For example, will there be community events and celebrations, which everyone attends?  
• Will children from different homes have contact with each other?
 
2.16 GROUP PROCESSES
By their nature, therapeutic care organizations involve group living, often smaller groups within a larger group.  Therefore, children within these communities can relate to a small group, like a family unit, and a larger group as in an extended family.  
 
There are many opportunities in the daily life of such a setting for spontaneous therapeutic opportunities.  For example, a positive experience between a child and a carer, between children, and between a child and someone in the community.  Where all staff in the community are attuned to the needs of children, difficulties that arise also provide the opportunity for something to be worked through.  This might be a new and constructive experience for the child.  Perry and Szalavitz (2006, p.231) emphasized the importance of community in enabling children to recover from trauma, 
What maltreated and traumatized children most need is a healthy community to buffer the pain, distress and loss caused by their earlier trauma.  What works to heal them is anything that increases the number and quality of a child’s relationships. 
and 
Brain development is use-dependent: you use it or you lose it.  If we don’t give children time to learn how to be with others, to connect, to deal with conflict and to negotiate complex social hierarchies, those areas of their brains will be underdeveloped.  As Hrdy stated: ‘One of the things we know about empathy is that the potential is expressed only under certain rearing conditions’.  If you don’t provide these conditions through a caring, vibrant social network, it won’t fully emerge (ibid, p.239).
It is possible in an organization that has several small homes (or foster homes), perhaps spread over a geographical region, to create a sense of community.  This can be done by establishing different networks within the community that bring people together.  For example, children’s forums, staff support groups, community events, sports days, etc.  Hills (2005, p.120) talking about, Integrated Services Programme (ISP), a foster care organization said, 
This model [does] not aim to set up a therapeutic community but rather create a therapeutic network operating for the child within a community-based, non-institutional setting.  It [seeks] to maximize the possibilities for positive change by harnessing the transformative potential of both collaborative practice and the fostering relationship...
Diamond (2003, p.5) also explained how the concept of the group has been developed at the Mulberry Bush, a therapeutic school for children, 
Within the new formulation, all the component parts of the school (group living, education, family team, art and psychotherapy, ancillary and maintenance staff) work interactively to create the totality of the ‘organization as therapist’ rather than the dependency on the individualized relationship. In this way, the therapeutic school can adopt the model of the therapeutic community for children.
Therapeutic communities have traditionally used formal group meetings as part of the therapeutic process.  These processes are an opportunity for everyone involved to establish their sense of self by making their unique contribution.  For everyone to reflect on what is happening for themselves, for others, and for the whole group.  This enables the members of the group to learn about their feelings, thoughts, and relationships and to consider this alongside other people’s experiences.  
 
A well-run group provides a form of emotional containment where anxieties, conflicts, and difficulties can be thought about and understood.  The group meeting also provides the opportunity to observe the group dynamic and where it is helpful to intervene in a way that disrupts destructive dynamics that may be developing.  For example, difficulties within the group may be projected onto one person who could then become a scapegoat for the group’s difficulties.  At a more basic level, the group enables communication to take place and for people to feel connected to each other.  
 
TASKS
• Clarify the group processes that might be useful to take place within the organization.
• Clarify the task of each process, who should be involved, how responsibilities are organized, where the process takes place, frequency, and duration.
 
 
PART 3 - PRACTICE
 
3.17 OUTCOMES
Once the primary task is defined and the category of children identified, it is then very important to define the outcomes that will be aimed for.  Work with traumatized children is complex and it is, therefore, possible that the approaches adopted might not work.  Progress might also be variable.  For example, some children take one step forward and then two back.  Others might seem to be stuck for a long period and then suddenly seem to move forward.  Therefore, it is important to keep an open mind on any evaluation.  Regular assessment can be an essential tool in thinking together as a team about a child, considering how they are getting on, what seems to be working or not, etc.  
 
Despite the unpredictable nature of progress in the short term, if a program is effective, it should be possible to identify generally positive outcomes for groups of children in the long term.  By defining clear and achievable outcomes at the beginning, expectations can also be set realistically.  Clarity of outcomes will also help to ensure that the best methods and resources are used to achieve the outcomes.
 
TASKS
• Define the outcomes that will be aimed for in the work with children.
• Define how progress towards the outcomes will be assessed, what assessment tools will be used, who will use them, and how often.
• Define a process, such as an individual care plan that will ensure children’s needs are consistently met based on the assessment.
• Clarify how children’s progress will be documented and reported internally and externally.
 
3.18 THE IMPORTANCE OF THEORY
A ‘trauma-informed approach is best suited to organizations that provide therapeutic care for traumatized children.  This approach is evidence-informed and influences all aspects of the work,
• the work with individual children
• the work in groups
• the way we organize the home environment and daily routine
• the way we run our organization and work together
• and our relationship with the wider community 
 
Bloom (2005, p.67) defined a trauma-informed organization as one, 
……that heals from its own past history of chronic stress and trauma and rejects the notion of inevitable crisis is an organization that is able to contain the emotional turmoil so characteristic of working with traumatized individuals without becoming “trauma-organized” itself.  
Tomlinson (2004, p.17) argues, 
There is no simple solution to recovery from trauma. It cannot be prescribed but needs an environment where it is safe to think about the trauma, experience feelings about it, and make reliable provision to heal it. This type of environment has been referred to as a ’holding environment’.
Children need a secure environment, where they know what to expect and what is expected of them (Perry and Szalavitz, 2006).  In the same way, a theory can provide a consistent way of doing things which enables a team of people from different backgrounds and experiences, to work together.  In this sense, the theory can provide a form of containment, which helps professionals to think about their work, especially when things become overwhelming and difficult to make sense of. Bloom (2005, p.56) pointed out the potential risks where there is not a clear and consistent theoretical approach, 
The staff often work at cross-purposes without even recognising that their conflicts are due to conflicts in basic theoretical models and instead attribute the problems to the resistance of the children or personality conflicts among the staff. 
Emphasising the need for a trauma-informed approach she continues (ibid) to advise that, 
An approach to childcare that takes into account the impact of overwhelming stress on child development is particularly important since it has been established that a large proportion of a residential treatment population have a history of exposure to violence, abuse and neglect. 
A trauma-informed approach will include different theoretical perspectives.  Kezelman and Stavropoulos (2012, p.76) argue the benefit of this, 
While effective treatment of complex trauma needs to address several key dimensions (i.e., irrespective of the particular approach used) the current literature also advises of the need for knowledge of more than one modality.
Theories from the following fields are particularly useful, others may be added.  
3.19 THE THERAPEUTIC APPROACH
Shonkoff and Phillips (2000, p.10) state,
Interventions that work are rarely simple, inexpensive, or easy to implement. 
And (p.119), 
Designing appropriate, individualized interventions for young children who are displaying early deficits in organizational, planning, and attention-related capacities depends on understanding the processes that underlie their development and manifestation. 
Fahlberg (1990, p.51) emphasized the importance of a theoretical base in therapeutic care, 
The most important task of treatment must be clearly and succinctly stated. Specific problems and dynamics vary from child to child, but a philosophy of treatment must clearly identify the category of problems that are most essential for the programme to confront if successful treatment is to occur. 
Without a clearly defined approach underpinned by validated theory, it is difficult for staff to be trained to a level that enables them to provide consistent, coherent, and appropriate care.  
 
It is crucial in the therapeutic care of traumatized children that the whole organization and every activity within it are aligned with the therapeutic task. For this to happen there must be a theory of ‘true’ child development, of trauma and the impact it has on true development, and of organizational systems and dynamics.   In addition, these theories need to be compatible so that they complement each other, and the nature of the organization enhances and supports the individual work and attachments that take place within it.  Confirming the importance of this, Canham (1998, p.69) argued, 
...the whole way the organization functions is the basis for the possibility of an introjective identification. 
In other words, the children will internalize not only the relationships they are most directly involved with but also the way the whole organization functions.  
 
The first step is the referral process, where the child’s social worker identifies the potentially suitable placement.  For this stage to be effective there needs to be clarity about the nature of the child’s needs and the therapeutic service being offered.  Any confusion at this point can cause great difficulties once the placement has started.  
 
TASKS
• Define the therapeutic approach in detail and the relevant theory.
• Clarify how the therapeutic approach will be applied to achieve the desired outcomes.
This section will be extensive and will include how the following (this is not a complete list as there may be other areas to add)
 
3.20 CHILD SAFETY
From a child safety perspective, all members of the community must be aware of and support the values of the organization. An organization that is fractured, and where negative behaviours and serious relationship conflict exist, could potentially place the children at risk. 
 
An organization that promotes awareness through trauma-informed processes across all departments becomes less vulnerable to trauma re-enactment. The organization needs to be consistent and emotionally intelligent, and the children need to experience the adults’ role modelling this too.  
 
Traumatized children often have major anxieties about their ‘omnipotence’ and their destructiveness.  It is common for these children to project their past experiences onto others, particularly parental figures.  These projections can be positive and negative, seeing the carer as good or bad.  It can often be difficult to differentiate between reality and fantasy for the child, which can be very hard when investigating allegations of abuse.
 
The organization needs to have clear policies on child protection and complaints procedures to support this work.
 
TASKS
• Define clear policies and procedures within the organization to support high standards of work, which protect children.
• Ensure that policies regarding children’s safety are thorough, such as the child protection and complaints policies.
• Clarify how all staff members will be trained and supported concerning the therapeutic task.
 
3.21 THE ‘HOME’ MEETING
The home meeting is a process that is commonly used across therapeutic communities and may have different names - house meetings, children’s meetings, etc. The purpose and structure may be different depending on the organization and the therapeutic task.  
 
The home meeting is a process aimed at enabling and encouraging children to become more confident in expressing themselves and listening to and respecting the rights of others. It is a process that assists children in developing solution-orientated approaches, including conflict resolution and creative problem-solving skills, rather than remaining in the role of a victim with a sense of powerlessness. It is also an opportunity for carers and other team members to provide positive role modelling in the form of effective emotional regulation and pro-social behaviours to the children.  
 
When children have input into how their life is managed, they feel that they have a sense of control over their environment, and as such their positive self-esteem develops. When they feel that their opinion is as important as anyone else’s it enables them to also value other’s opinions and points of view.  
 
TASKS
• Define the process for ‘Home’ Meetings, including the task, frequency, and duration, who will be involved, who chairs, how decisions will be made, etc. 
 
3.22 PROMOTING RESPONSIBLE CHILDREN (EMPOWERMENT PROCESSES)
Hannon et al (2010, p.97) state the importance of listening to and involving children in the decision-making process, 
If we are to prioritise looked-after children’s and young people’s emotional wellbeing, they must be able to influence decisions that affect them. 
• It is important to children’s self-esteem and confidence to have their opinions respected, particularly if they have previously suffered abuse or neglect, as it can help them to feel like ‘active agents’ as opposed to being ‘the powerless victims of the whims of adults’.
• Being helped to participate in decisions can build children’s resilience and sense of agency, preparing them to take control of their lives when they reach independence.
 
The rights of children must be at the forefront of what we do as an organization. All organizational policies and processes need to be aligned with the rights of children. For example, 
 
• To live in a safe and caring home, where I can learn and grow.
• To have a say and to be an active participant in my care.
• To express any concerns, for my physical and emotional safety, to my carer and/or the care team.
• To be allowed to be a child and be treated with respect.
• To be provided with information.
• To know that information about me will only be shared to help care for me.
• To have a carer and a care team who is there for me.
• To have fun and do activities that I enjoy.
• To have my cultural beliefs respected.
 
At the same time, if a child is to accept rights in a meaningful way, they also need to learn that with rights come responsibilities.  So, if a child has a right to be listened to, they also have a responsibility to listen to others.   As it is a right to not be physically hurt, they also have a responsibility not to hurt others.  
 
There must be clear rules and expectations relating to children’s behaviour.  Rules should generally be related to non-negotiable matters related to safety and well-being, e.g., no one should be hurt and other things that are not permissible.  Expectations are the desirable aspects of daily living – such as attending meetings, school, mealtimes, etc. and the way we expect to live together, such as treating each other with respect.  The aim is to enable children to move towards expectations as they grow and develop.
 
TASKS
• Define the Rights and Responsibilities of Children.
• Define the Rules of the Home and Organization (e.g. Code of Conduct).
• Define the expectations in daily living.
• Clarify how children’s challenging behaviour will be worked with, including any consequences that may be used.
• Clarify the process for involving children in their day-to-day life and the wider organization.
 
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