Being the Instrument of Change : Staff Experiences in Developing Trauma-informed Practice in a Norwegian Child Welfare Residential Care Unit
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The overall aim of this project is to contribute to the development of interventions that benefit children and adolescents in residential care. Research shows that this is a particularly vulnerable population, typically with histories of detrimental care and traumatic experiences, and which is institutionalised as an additional burden. Many of them display severe emotional, interpersonal, and behavioural problems. Meeting their needs in a residential care setting is challenging, and there has been a general call for models of care that can encompass the complexity of their life histories and problems and the institutional context. Along with the growing understanding of the effects of developmental trauma, trauma-informed practice (TIP) has emerged as a theoretical framework guiding residential treatment and care. TIP was introduced in Norway around 2010 and has since become widespread, especially in child welfare settings. TIP is a theoretical framework or model, rather than a standardised or operationalised method, that must be operationalised within each concrete context. In Norway, TIP has mainly been based on the Three Pillars Model advanced by the Australian psychologist Howard Bath. The objective of this project was to gain information on how Bath’s TIP model was operationalised and experienced by staff at a child welfare institution for adolescents in Buskerud County, Norway. The institution was among the first in Norway to start operating in accordance with a TIP framework, starting with the implementation of Bath’s Three Pillars model in 2014. The regional resource centre on violence, traumatic stress, and suicide prevention in southern Norway (RVTS-south) facilitated the implementation process. The qualitative research project this thesis is based upon was initiated as part of this process. In the project, the following main research question was explored: how do staff in a residential care unit in Norway transform the TIP framework into practice, and how do they experience and reflect upon this practice? The project comprised three studies examining the research question from different angles with a qualitative phenomenological research methodology. Over the course of six years, a total of 27 individual in-depth interviews were conducted with 19 informants. Data were analysed in accordance with the principles of thematic analysis, thematic network analysis, and narrative inquiry. The findings of the three studies are presented in three separate papers. The focus of the first study (presented in Paper I) was how the TIP framework of Howard Bath was translated into concrete practices. Using thematic network analysis of data from interviews with all 19 informants, we identified three global themes: self-awareness, including self-reflection, other-regulation, and authenticity; intended actions, including building strength, building mentalisation skills, providing staff availability, setting safe limits, and collaborating with youth; and organisational and cultural practices, including having a commonly shared mindset, stability and routines, and cultural safety. We suggest that the described practices, in general, reflect shared ideas across TIP models and resonate with informants' training. However, some practices also seemed to be influenced by other, and perhaps partly conflicting perspectives. In particular, the results indicate confusion and the need for clarification regarding the roles of authenticity and boundary setting within TIP. The second study (presented in Paper II) focused on prerequisites for staff members’ capacity to maintain an emotionally regulated state when faced with disruptive emotional and behavioural expressions. Providing other-regulation through one’s own emotional state is considered a core element of TIP. Using thematic analysis of data from interviews with 15 of the informants, we found that informants experienced their self-regulation capacity as depending on critical self-reflection, self-acceptance, being part of a regulating work environment, and having a trustworthy theoretical model to be guided by. The findings point to the importance of organisational cultures and procedures that encourage critical self-reflection and self-acceptance, which promote self-compassion and shame-resilience, and where investments are made to ensure staff identification with the chosen model of care. The third study (presented in Paper III) explored informants’ experiences with situations and interactions that could potentially threaten their capacity to maintain an emotionally regulated state. Data from interviews with eight of the informants were analysed using narrative inquiry, with an interest in how informants made sense of their experiences. We identified three major narrative themes: Are we doing the right things?, My childhood issues surfaced, and Missing togetherness with trusted others. The themes reflect that situations and interactions were seen as particularly challenging due to their complexity and confusing character, their potential to trigger painful childhood memories, and their potential to evoke fear of disconnection from colleagues. Findings were discussed in terms of what strain working within a TIP framework may imply for staff members – a strain that we suggest should be acknowledged and addressed at an organisational and structural level. An overarching interpretation is that informants, in their ways of practicing TIP, experienced themselves as ‘the instruments of change’. They engaged in a reflexive self-scrutinising endeavour, where they tended to attribute successes and failures in interactions with residents to factors within themselves. Although informants were generally in favour of working in accordance with TIP principles, the results revealed that working this way comes at a cost and may be deeply personally and emotionally challenging. Findings of the project point to the importance of acknowledging these costs and of establishing cultural and organisational practices that enable staff to endure the strain they face as the 'instruments of change'. This may include a particular focus on the management of shame by working with self-compassion, for example, by applying standardised procedures developed for this purpose. To be able to face potentially dysregulating situations on a day-to-day basis, based on the project findings, the work environment should entail a culture of other-regulation, wherein cultural safety, transparency, and collegial support are emphasised. In addition, to be able to invest so much of themselves in their work, both personally and emotionally, staff would need an understanding of why they are doing it and confidence in the productivity of the approach. Additionally, based on project results, it is recommended that services practising or implementing TIP clarify to the greatest possible extent what TIP is and what it is not, including a clarification of what is unique or generic to the model. Clarifying the role of authenticity and boundary setting within TIP might be of particular importance.
Består avPaper I: Steinkopf, H., Nordanger, D., Stige, B., and Milde, A.M. (2020): How do staff in residential care transform Trauma-informed principles into practice? A qualitative study from a Norwegian child welfare context. Nordic Social Work Research. The article is not available in BORA due to publisher restrictions. The published version is available at: https://doi.org/10.1080/2156857X.2020.1857821
Paper II: Steinkopf, H., Nordanger, D., Halvorsen A., Stige, B. and Milde, A. M. (2021): Prerequisites for maintaining an emotionally regulated state in social work with traumatized adolescents: A qualitative study among social workers in a Norwegian residential care unit. Residential Treatment for Children and Youth, 38(4): 346-361. The article is not available in BORA due to publisher restrictions. The published version is available at: https://doi.org/10.1080/0886571X.2020.1814937
Paper III: Steinkopf, H., Nordanger, D., Stige, B., and Milde, A.M. (2021): Experiences of becoming emotionally dysregulated. A qualitative study among staff in youth residential care. Child and Youth Services. The article is available in the thesis file. The article is also available at: https://doi.org/10.1080/0145935X.2021.1918541