Trauma-informed behavior analysis helps trusted teams make informed care decisions
Our past experiences play an important role in shaping our habits, our behaviors, and how we interact with the world. How do we consider our past when making meaningful changes today? How can we involve the people we trust to help us recognize and overcome traumatic experiences?
We sat down with Dr. Camille Kolu, BCBA-D, of Cusp Emergence to learn from her expertise in trauma-informed behavior analysis. Dr. Kolu shared her views on what it means to make meaningful changes in someone’s life, how to to be mindful of a person’s past when helping them make decisions for their futures, and why collaboration is always valuable.
Can you please describe the concept of trauma-informed behavior analysis, and the importance of this approach for the people you support?
Sure! I think that for an agency or provider to want to be trauma-informed is to acknowledge that the people we serve have backgrounds that are important, and need to impact treatment, in specific and sensitive ways.
This seems intuitive to many of us in the mental health or behavioral health care fields, and applied behavior analysis is a related field in which we apply the science of behavior to help people change their lives in ways that are meaningful and socially significant for them. So to me it seems like a natural combination, to want my practice of behavior analysis to be trauma-informed- it is another way that I can try my best to “do no harm”.
As natural as it sounds, though, you might be surprised that it can be difficult to find providers who have received education and experiences on how trauma affects behavior. The field of behavior analysis has established a strong ethics code requiring us to practice only within our boundaries of competence and to look closely at the risks of our procedures with clients and families before we implement them. We have a long tradition of using “functional behavior assessment” before we intervene to change a behavior. Sometimes a person is using a behavior because it’s the only thing that works to meet his needs, or it’s communicating pain or his desires. If a behavior analyst does not know much about our client’s past or what they went through, we might look too closely at how the behavior is “paying off” in the moment, focusing on the immediate consequences it’s having—such as what we see when a child begins to hurt other kids whenever a teacher walks away. Perhaps his aggression makes adults come running, and we could say it’s paying off for the child in the form of “attention”. But what if he was neglected as a baby? What if someone close to him left him without food or abused him with other siblings? Do those things matter? A behavior analyst should say “yes”! Our early environments and experiences can make a big difference in the behaviors and skills we learn to use later, and they also make a difference in the kinds of things or people we want to approach or avoid later in life. So one perspective is that a well-trained behavior analyst is already using an approach that is trauma-informed.
But most of us behavior analysts were not trained this way; for instance, we haven’t been exposed to the studies on ACES or how adverse childhood experiences affect nearly everything, from our physical to mental health throughout life. Most of us don’t learn to recognize the signs of trauma so before training and experience in this specific area, we may not do a great job of acknowledging and documenting these histories, or the risks that they carry. Trauma-informed behavior analysis is a phrase I’m using to make all of this – including the recognition of the significance of traumatic experiences, the documentation of the risks, the richer collaboration of teams that it requires—more intentional and individualized for the people I serve.
How would you teach a newcomer to trauma-informed care to recognize the signs of trauma, anxiety, and fear?
Well, one of the 7 qualities of applied behavior analysis that must be present for it to qualify as real ABA, is that we look at things that are “behavioral”. So I’m interested in how a person says and does; or how a person with anxiety or fear shows that. With anxiety, maybe I’m looking at how a child freezes up around a certain person, how she starts looking from side to side and stops reading her book, how her breathing changes, how her heart rate changes. With fear and anxiety, maybe I’m looking at how she stops in her tracks when her former caregiver walks in the room, how she stops playing with toys in a variety of creative ways and starts repeating the same sequence over and over, or how she suddenly has a toilet accident in that moment when the door opens even if she just went to the potty a few minutes ago.
Signs of trauma may include some of the things I’ve mentioned above, or they may include behavioral differences and changes. For example, a child might use several behaviors that are usually not part of childhood or respond differently to people or stimulation. Maybe someone has an unusual pain response, shakes, screams or hides when certain sounds or smells are present or regresses in skills that were developmentally on-track before a traumatic event. Sometimes their eating, sleeping, playing, talking, or toileting habits are interrupted. In my line of work I do not make diagnoses of trauma, but as you stated, we can teach others to recognize possible signs. For any health team, differential diagnosis is extremely important, because there’s no one change that would necessarily signal trauma- some of my clients with a genetic disorder or other challenges may smear feces or eat out of the garbage, or use aggressive behavior with siblings, without any trauma-related experiences in their past at all. Our ethical compliance code emphasizes the importance of ruling out medical needs or complications before treatment is provided so that we do not make things worse by acting on our assumptions. One of the things we can do as providers learn to recognize and document patterns in a person’s development and growth that are typical for them, so we can notice when something changes. A trauma-informed care provider might notice when development was progressing normally but stops, or when a child is doing well and then has visited with a person from their past who was there when the abuse occurred. The child might suddenly seem to use uncharacteristic behavior the hours or days after the visit. We teach team members to be thoughtful about the decisions surrounding the person’s care and support, considering why these behaviors are changing from a larger perspective. When appropriate, this consideration can help inform decisions about changing medications, providers, foster parents, educational environments or living circumstances, and potentially protect clients from knee-jerk changes that might occur in their already chaotic environments if the context was not considered.
What are some tools you use to empower the people you work with to overcome the challenges caused by trauma?
Several tools I use in trauma-informed supports are similar to what I would use in other kinds of cases, although I use them a little differently. I use the FBA, or functional behavior assessment, to help teams understand the meaning behind challenging behaviors and to appreciate the possible influences of aversive or adverse experiences in the person’s past or current environments. Similarly, I use a variety of risk versus benefit tools to document options that are available to the person and their team, and help work through the potential outcomes of each, looking at both the short term risks and benefits, and those that are far in the future. I use collaborative documents and tools to help facilitate team communication so that members of the team (like community members, hospital and educational staff, and even law enforcement and legal professionals) can stay informed about how their interactions impact a client and that person’s behavior and future.
On the individual level, we have a huge science behind us if we are behavior analysts using our science in a trauma-informed way. For a child who needs the social skills they didn’t learn in their neglectful youth, we can teach these powerful skills. For a child who is not responding appropriately to positive teaching in her new home or school, we can teach caregivers and educators how to provide the kind of attention that doesn’t overwhelm a child who has just gotten out of a devastating neglectful situation. We often use a tools like “time in” or “noncontingent reinforcement”, which are just ways of saying that we can teach families and educators how to do things that are preventative, helping the client to adjust to a predictable and stable environment for the first time. And for a person who never learned to communicate pain because their initial attempts were punished or ignored, we can teach empowering advocacy and communication skills. I have seen this done even late in adulthood. It’s never too late to make the therapeutic environment more trauma-informed!
As a behavior analyst, how do you measure progress for the people you support?
When I talk to a caregiver or client, one question I ask is “how would this situation look different if things were better for you?. I want to know what the person is not able to do and enjoy in their life or their family that they would like to, or that they were able to do before the problem started. Sometimes the answers are obvious because there are missing skills- perhaps a client is not talking or toileting or sleeping or playing with peers. In these cases, we can teach the missing skills, but we must do it in a trauma-informed way because maybe the person knows how to do these things, they are just doing something else instead.
Behavior analysts get to the nitty-gritty data to measure progress: if you need help 20 times today but only ask for it once, that’s a pretty low rate; if you hit your head on a cabinet 5 times a day and each time causes damage, that’s too much! I want to measure your effective use of skills and increase that rate to a level that is meaningful for you and YOUR life, and I also need to measure and reduce how many times you are doing things that are hurting you. The actual numbers will depend on the individual and what is meaningful for them! We call this the “socially significant” threshold in behavior analysis. If I help you change your behavior but it’s not enough to make a real difference in your life, we aren’t doing enough.
How do you use data to understand the people you support; and how do you use data to help diverse care teams understand the people you support?
Earlier I mentioned we might take data on the skills that need to be increased, or the things that are happening that are interfering with someone’s quality of life. But another type of data is when we use it to show the relationships between different aspects of the environment and a behavior. For example, suppose I am a client who has been through trauma and I have been trying to injure myself for a few years. Now suppose my behavior is tracked for a couple of years by my team and I, and suddenly my analyst realizes that my self-injury and suicidal attempts get worse every year around the holidays and that this escalation starts around September. Now my team has a lot more to go on in learning how to help me get better! They know more about when they need to be even more preventative, and they know to investigate the relationship between my behavioral health and the holidays or time of year. Sometimes it’s meaningful for us to take data on the timing of changes that occur in someone’s life. For instance, I might take data on someone’s challenging behavior, and draw lines on the graph every time a medication is added or removed, or a dose goes up or down. Or I could collect data that shows me how a client’s court-ordered visits with his biologically family members are affecting his behaviors or use of skills. As I discussed earlier, we are not making diagnoses in my line of work, and we are not making decisions that should be made by a team- but data on these relationships can be really helpful to show a team how the recommendations they are considering might help or facilitate or impede someone’s success.
Another great kind of data is when we use it as feedback, showing a person a visual of how they are getting better at using their new coping skills, or to help them predict when things are about to get difficult so that they can reach out to their teams or families for more support.
Can you speak to the importance of family involvement in therapy? What about the importance of a team approach in complex cases that require multiple therapists?
The importance of family or team involvement cannot be overstated! Of course, the more members of a team are added, the more crucial communication becomes, but I have generally found that the more people invested in a person’s life, the better the treatment outcomes. This is true if I am able to do a good job, as a trauma-informed therapist, of facilitating team coordination and collaboration. If the family is not brought into treatment, then we are probably missing a huge piece of the picture, and not meeting the full spectrum of needs in the case. It isn’t enough merely to change behavior, it needs to be done in the contexts where it is meaningful for the person. For example, if I teach a skill in an office and the person never uses it at home, I have done nothing helpful.
Besides making the process work, there is another reason we need to involve the entire family. On many of my cases, the family has endured multigenerational trauma; there may be several generations of family members who carry the damage from sustaining decades of difficult experiences. We can share trauma with our children if we parent in the same ways that our caregivers failed to meet our needs when we were young; or a family who has been through war and poverty, or death and displacement, may not have the resources to provide their children what they need. We can look at the client’s relationship with members of the family from all the connected generations, individualizing our treatment to help each one to heal and interact in ways that they really value. One of my clients had grandparents who enjoyed learning positive ways to interact with their grandchildren; the client’s mother learned skills to support her daughter as a single mother in ways her own mom had not been able because she was using drugs at the time, and the client herself learned parenting skills that her mother had not had when she was homeless and raising the client years ago. The young children themselves learned ways to communicate their wants and needs in ways their single mother could respond to appropriately and supportively, so that ultimately, four generations were brought from broken to a family together, in the family-focused trauma-informed treatment.
Sometimes a client lacks family but has a team of possible involved community members. If we do not involve the entire team, we lack valuable perspectives, missing out on the expertise of members who may know the client or case details much more intimately than we do. On the other hand, rich team involvement empowers us to engineer a potent collaboration, with people who are all informed on common goals that benefit a client, participating on multiple levels that sustain their ability to support the client’s experience. This approach may take more systems level support—but in my experience, it has always been worthwhile.
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