TRAUMA-RESPONSIVE ENGAGEMENT AND TREATMENT (TREAT): THE NEW YORK MODEL

This article will outline a conceptual framework for Trauma-Responsive Engagement and Treatment (TREAT), which can be implemented as a model for organizational and programmatic transformation in a juvenile justice system. The proposed TREAT framework is designed to create juvenile justice programming that is not only trauma-informed, but is actually trauma-responsive with respect to all of the members of its community. That is, TREAT staff identify and respond to the outcomes of traumatic experiences in order to help people recover. They work to increase emotional and behavioral self-regulation of participants and help them to achieve self-identified goals. The article will discuss the evolution of this model in the context of recent and historical forces that have fueled juvenile justice reform efforts nationwide. The article will also describe how systemic changes in reaction to those forces should include a clear understanding of, and response to, the impacts of trauma on youth, staff, and systems, and will emphasize that true systemic transformation requires a model which engages, motivates, and benefits all members of a juvenile justice service delivery system—staff and youth alike.

moving services when appropriate to youth's home communities, and broadening service need assessment and delivery to include family and community supports and to treat complex mental health problems. To accomplish these things, they are attempting to change both practice and culture. Internal and external changes to juvenile justice systems, even when movement is in a positive and healthy direction, create stress on the system and on the people within it. The creation and maintenance of a safe, healthy environment for both youth and staff are critical for such expansive, inclusive changes to be successful and sustained.

Trauma-Responsive Engagement and Treatment
Trauma-Responsive Engagement and Treatment (TREAT) is offered as a strength-based, trauma-responsive model. It addresses the service delivery environment as a whole, offering change in both practice and culture. It emphasizes the engagement and safety of every member of the juvenile justice service delivery system community: youth, family members, and staff.
TREAT uses three interdependent foundational concepts to provide the basis for positive growth and development of all of the members of the program community. Each of the three concepts (safety, skills, engagement) is fundamentally reliant upon the other two, and a successful implementation of TREAT relies on an understanding and commitment to each of them.

Safety
The first foundational concept is safety. In order for youth to grow or develop in a positive and healthy way, they must first feel safe. In the absence of safety, psychological and physical defenses prevent individuals from connecting to one another and from being able to practice new behaviors and strategies for dealing with problems in healthier ways. TREAT uses a program for trauma-informed organizational change that broadens the conceptualization of safety to include psychological and physical safety (Bloom, 2003(Bloom, , 2005Bloom & Sreedhar, 2008). The creation and maintenance of a safe environment requires an understanding of how the experience of trauma can impair youth's personal experience of safety even in an outwardly "safe" environment, and cause unsafe feelings. Thus, trauma can lead to unhealthy outcomes for them and for others around them.
Understanding trauma and its impacts on emotions and behaviors can create a framework from which both youth and staff behavior might better be understood. A trauma-informed program includes the idea that individuals are not presumed to be oppositional, defiant, or delinquent, and unexpected, disruptive, or even dangerous behaviors are considered through the lens of trauma to provide an understanding of behavior prior to responding. Other important trauma-informed principles include the idea that people are supported when they struggle, even when their struggles are disruptive and the idea that consequences are fair, not solely punitive, and are tied to restoring safety to the community.
Trauma-informed programming helps staff understand the impact of trauma on human development, their own and their charges'. It also provides a useful context in which to consider current youth behavior in light of formative and often traumatic experiences. Psychobiological theories and research show how behaviors that might appear impulsive or aggressive can be understood as an effort by a traumatized person to maintain their experience of safety, for example, a startled response or an impulsive pushing away. Helpful concepts include reactivity; overresponse to seemingly benign or minimal stimulus; reenactment, emotional and behavioral dysregulation triggered by reminders of previous trauma; and triggering, provocation to action and reaction via restimulation of traumas. These assist staff in understanding the youth whom they serve and the behaviors and emotions that are not otherwise expectable or predictable. For example, someone comes up unexpectedly and quickly behind a youth who responds with a curse-laden verbal barrage and a haymaker swing of their fist toward the other person. The youth might have once been considered impulsive, aggressive, or violent. While the outward behavior might be characterized that way, that limited understanding of behavior will likely lead to a very narrow, inaccurate, and ineffective type of intervention, namely, to treat the impulsivity or the aggression. If one also considers a history of trauma, the intervention possibilities expand significantly when the behavior is viewed as an attempt to create and maintain safety. In addition, the former interpretation of behavior quickly leads to the presumption of volition and subsequent hypotheses about defiance and authority issues, usually resulting in power struggles between staff and youth. The latter, trauma-informed interpretation allows staff to avoid a power struggle around presumed compliance, to be non-judgmental about the behavior, and to try to understand the youth as a whole person in the context of their unique experience of the world.
Staff are also challenged to apply their understanding of trauma to themselves and their colleagues with the same compassion and understanding required when working with the youth in their care, for example, to understand how a coworker disappeared during the exact times of a late night youth group disturbance and reappeared right after it was resolved. Without trauma-informed training, staff often personalize, misinterpret, and imbue defiance and oppositionality into the behavior of traumatized youth, and they can also misinterpret and respond negatively to the trauma-reactive behavior of their peers.
In the TREAT model, safety is not solely equal to the absence of violence or aggression, which is necessary for safety. Safety also includes the ability to think, experience, and express genuine affect without hurting others, engage others without violating boundaries, be vulnerable without fearfulness, be empowered without abusiveness, and be present and functional while able to manage difficult emotions such as anxiety and fearfulness.
Previously, many systems of care in juvenile justice care settings have relied on achieving safety via the exertion of authority and ultimately physical superiority. That is, safety is obtained by being more physically powerful and therefore in control of the environment and of the youth in it. Behavior management strategies that use authority in this way simply isolate and suppress problem behaviors and are typically only effective in specific settings, which means the results are not generalizable. So a youth who complies with expectations in a residential program but who is under the threat of physical intervention is unlikely to have learned a new positive skill to substitute for a problem behavior and is unlikely to maintain compliance once the threat of physical intervention is removed. TREAT is designed to dispel the illusion that anyone actually controls anyone else. An important goal of any well-designed rehabilitation program is the promotion of the emotional and behavioral self-regulation of those in care. Self-regulation is the most effective and long-lasting means of achieving safety and the broadest, and perhaps most valuable, therapeutic goal: successful transition of youth to the community and toward future successes, regardless of the setting in which youth may find themselves.
The TREAT model is based on safety via relationships. Staff communicate clear structure and facilitate appropriate consequences in the context of their engagement of youth. Consequences are framed and understood as learning opportunities, and staff strive to use the reinforcement of new, healthy, skillful behaviors whenever possible and in preference to the punishment of negative behaviors, which only suppresses them. This strategy both empowers and engages individuals who form communities of individuals who live, work, and grow together in residential facilities in units or cottages.

Skill Acquisition (Skills)
The second foundational concept of TREAT is skill acquisition, or simply skills. In order to increase self-awareness and self-understanding, to manage the emotional and behavioral dysregulation that can result from trauma experiences, and to deal with people effectively and safely, individuals need skills. Ultimately, the self-regulation of emotions and behaviors empowers individuals to actively work toward self-determined goals. TREAT includes a cognitive behavioral skillsbuilding and reinforcement treatment program, delivered in group and individual formats, to enhance the skill sets of youth and staff with respect to interpersonal effectiveness, distress tolerance, emotion regulation, and mindfulness (Linehan, , 2000Trupin, Stewart, Beach, & Boesky, 2002). Groups are delivered by trained staff who are the primary caretakers for youth. Thus, as direct care staff develop healthy, goal-focused relationships with youth, they also learn and use the same skills they train and reinforce in youth.
A strength-based assessment of youth assets, skills, and abilities, and thoughtful development of the youth and family's self-identified goals form the basis for the identification of the particular skills that will be offered, taught, and reinforced. Although all youth may learn many skills, the youth's individualized plans identify the particular skills expected to help particular youth reach their goals.

A Strength-Based Approach to Assessment
In the historical model for juvenile justice service delivery, assessments were typically deficit-focused. That is, they identified problems, limitations, vulnerabilities, and challenges to the youth in care and their families. While these issues cannot be ignored, the TREAT model is designed so that change cannot occur successfully if the support system does not identify the strengths and resources that youth and families already have and must then use to build new and refined competencies and skills. Staff accept that they cannot build on a deficit or a limitation and therefore must focus on identifying assets and strengths for the youth and their family members. Historical assessments often focused in a narrow and limited fashion on the changes that the youth needed to make, regardless of other systemic factors and variables. The TREAT model expands the assessment to include family members and other resources for the youth so that their contributions can be accumulated in service of the youth and family goals.
As mentioned, assessment in the TREAT model starts with an evaluation of strengths, assets, and resources but does not ignore challenges or vulnerabilities. The latter issues become apparent when the youth's goals and aspirations are considered in light of their skills and abilities. The areas that require supports, services, and interventions become apparent when the support team considers how they will assist the youth in getting from their current situation to their stated goals. The gaps become apparent and then become the targets of the plan that will match the needed services, supports, and interventions with the existing skills to overcome the challenges and vulnerabilities and to accomplish the youth's goals.
This concept is taken even further in TREAT. An implementation goal is to use valuable concepts at a systemwide level. An informal motto of the TREAT program is, "If it (i.e., process, system, concept, assumption, strategy) is good for youth in care, it is good for staff as well." As such, staff supervision, referred to as coaching, is strength-focused in the TREAT system. Staff strengths are identified, their goals for their performance and career path are developed between them and their supervisors, and they actively engage supervisors in plans for professional development. Like the youth assessment component, staff challenges or deficiencies are not ignored, but become clear through a feedback discussion of strengths and goals.

A Motivational Approach to Goal Setting
In the TREAT model, goal development is youth-and family-centered. The TREAT system is designed to meet youth and their families where they are and help take them where they want to go. Historically, care systems assessed youth from an outside-in perspective and then, based on expert opinions, wrote plans for (rather than with) them. Unfortunately, one result of this strategy was that the staff owned the goals and the plan. That is, the staff identified the goals, and when the youth did not follow the plan toward the staff-identified goals and was confronted by staff, they could simply, and accurately, abdicate responsibility. After all, it was not their goal or plan to begin with. Another problematic result for goal-setting in this manner was the routine matching of available program services to youth regardless of their individual interests or other practical considerations. So, if the program had a greenhouse, the kids got horticulture as part of their plan. Many youth in juvenile justice systems in various jurisdictions over the years have received certificates in small engine repair or cosmetology without the youth having any identified career interests or ongoing motivations in those areas. Prescribed goals and services, even when offered with the best of intentions, often failed to motivate youth and families to do the hard work of self-reflection, skills-learning and practice, and other challenging self-change tasks.
Even when care systems staff did ask youth for their self-generated goals, they were often quick to dismiss the goal if it was thought to be unrealistic or somehow impractical or unattainable. Staff might ask for a back-up goal which youth accurately translated as a vote of no-confidence-a statement of the expectation for failure. In the TREAT model, staff strive to work with any goal, noncriminal, nonantisocial, or non-self-abusive. Goal-setting can be a challenge with youth involved in juvenile justice care; it is not typically a practiced skill for this population. The youth in juvenile justice care often have a well-documented history of failures in various settings and of giving up in the face of obstacles or negative feedback.
They often learn early in their development not to set goals, not to dream, and when they do, they are told that their dreams are impossible. In the TREAT system, staff recognize that good outcomes can be obtained even if the ultimate goals are not reached. The emphasis is on engaging youth in a motivated process of positive growth and change with less emphasis on the ultimate outcomes. Staff strive to find youth motivation for positive gains: to engage youth in positive change, regardless of an outcome that may not be apparent or even measurable for many years. So, a youth in care who wants to be president of the United States would have to graduate from high school, learn leadership skills, learn negotiation skills, have good interpersonal skills including anger management, deal with substance abuse issues if present, accept feedback, work well with others to solve problems, and learn how to take responsibility. The list of health-promoting steps toward that goal can also go on and on. If youth achieve even a few from the list, they have obviously benefitted regardless of whether or not they ever actually become president.
Thus, a thoughtful analysis of the youth and family's self-identified aspirations and goals, when considered in light of an assessment of their strengths, assets, obstacles, and challenges, illuminates the plan for supports, services, and interventions. If done well, such a plan uses the motivation of the youth to drive their engagement with supports, services, and interventions, leading to healthy growth and development.
An important goal for all youth in care is not just to leave a residential facility, not just to go home, but rather to learn how to live a life: how to self-assess strengths and weaknesses, how to identify obstacles, how to identify supports and resources, how to engage others successfully to find ways to meet their needs, how to learn the process of goal setting, and how to accomplish their goals. In the TREAT model, this process is referred to as effective independence and is considered a crucial life skill. Youth learn the fundamental skill of living life purposefully, setting goals, working toward their attainment, doing what they are capable of on their own, identifying and engaging helpful others when assistance is needed, accepting the help that is offered, assessing their progress and modifying their strategies for achieving goals as needed, and repeating the process as goals are attained or change over time.

Engagement
The third foundational concept is engagement. The creation of community is crucial to the success of the TREAT model. Community is formed among individuals who understand the importance of safety and the impact of trauma on themselves and on others, and who have a developed a repertoire of skills to use in the face of stress and trauma reactivation. They have made a commitment to safety and to support their fellow community members. People are both accountable and responsible for their behavior and are supported, not judged, when they struggle. Multidisciplinary teams of staff, family members, and each youth comprise a support team whose function is to assist the youth and family in achieving self-identified goals. Each member of the team brings skills and expertise to bear in supporting the advancement of youth goals.
Engagement of others and the creation of healthy and non-abusive relationships provide a healing intervention for those who have been traumatized, but these are often among the most difficult treatment tasks for them to do. Survivors of trauma need to learn that past experiences are not 100% predictable of future experiences and that not all interpersonal interactions are or will be hurtful. Understandably, it can be terrifying to push beyond the fear born of their own experiences and based on chronic and repeated negative outcomes of relationships and interactions with others.
In the TREAT model, teams of providers are developed to create and maintain consistency in relationships. Youth can develop predictable, healthy connections to trained staff who rely on each other to support youth in their day-to-day progress. So, once unit staffing is established, staff do not work on other units, except briefly in emergency situations, but remain consistent for youth in care and their peers. In this way, consistency and predictability can help counteract the posttraumatic expectation and experience of chaos and unpredictability in people and environments.

TREAT Engagement: Training with Youth and Staff Together
Another opportunity for the creation of community among the youth and staff in the program is during training. In the TREAT model, education on trauma and training in skills-building are offered to staff and youth together. This sends a clear and important message, especially around the learning about trauma: This material is so important that we are going to learn it together. Staff and youth learn the didactic material together, staff can model by asking clarifying questions, and each group gets to hear the other's perceptions of the new programs and material, and can discuss how the ideas will be used on their units. It is powerful to engage youth in this process together, as they can both witness and experience how people grow, learn, and challenge themselves in healthy ways. Also, TREAT staff are trained in the components of the overall model. Administrators, maintenance staff, teachers, cooks, nurses, and secretaries are trained and expected to understand and utilize the principles of TREAT in their individual roles in the program and in support of others and the youth who are in care. The expectation is that changes in program philosophy and practice as described here will occur at all levels of the system and to the benefit of all of its members.
When individuals are engaged in healthy relationships and can understand and be sensitive to each other's histories, they can address issues and maintain accountability without judgment. That is, understanding the origin of a behavior, , flipping over every desk in a classroom following a trauma trigger, is help-ful to frame an adaptive response, such as helping youth ground themselves to counteract a flashback. However, it does not change its impact on others, such as other youth fleeing the classroom, people feeling unsafe, disrupting the learning, and halting the program. The actors are still responsible for their actions and for the outcomes of their actions. They are responsible to people to whom they are connected, so the resolution must include a repair, in addition to any punitive consequences. The repair is needed to address the impact of their actions on the relationships that they need to continue to grow and develop in healthy ways. It may include an apology, a task, such as fixing something that was broken, or some way of making it right to others. When problematic behavior is identified as an obstacle to self-identified goals and an impediment to healthy relationships, the youth can learn to accept responsibility to themselves and to others. This creates empowerment and supports self-regulation as the connections between actions and outcomes are continually identified and made clearer. Staff do not need to invoke facility rules, when the actual issue is that youth are interfering with their own progress toward their own goals. Staff who use this conceptualization can avoid power struggles and conflict with youth.
The obstacles to successful attainment of even simple goals, for example, successfully completing aftercare or probation, for youth involved with juvenile justice can be numerous. Therefore engagement must include as broad a network of supporters for an individual youth as can be identified. TREAT is designed to promote engagement of family resources, community resources, and others whom the youth and family might identify as supportive members of their team. Skills and strategies learned in a residential setting can often be challenging to implement in a community setting and require out-of-agency supports. TREAT teams are using video and audio conferencing technology and in-person meetings wherever possible to engage others in support of the youth in care.

Discussion and Implications
Historical approaches to service delivery to youth in juvenile justice care often used deficit-focused assessments of youth, authoritarian strategies to manage problem behavior that ultimately relied on physical power and force, and behavioral systems that were more geared toward punishing in order to suppress problem behaviors than in developing and reinforcing skillful, positive behaviors. Outcomes were quite limited, and staff found themselves dealing with high levels of violence, poor staff morale, high rates of injuries to youth and staff, and high recidivism rates. Many factors have combined to create a fundamental change in the philosophies and strategies that underlie juvenile justice service delivery. Youth who remain in juvenile justice care following the shrinking of juvenile justice service delivery systems present significant challenges to providers because youth in care often have individual and family challenges, limited internal and external resources, and significant trauma histories.
TREAT is a trauma-responsive model offered as a plan for the delivery of services to youth in juvenile justice care that creates both individual change and cultural change. Modifications to juvenile justice service delivery systems need to be based on the creation and maintenance of a safe environment for the youth in care and the staff who serve them. Using a trauma-informed program component, TREAT is designed to engage all of the members of the service delivery community in the process of establishing and maintaining a safe environment. It is understood that all of the members of the community, youth and staff alike, are potentially impacted by their personal trauma histories, and they are joined in the common goals of being safe and responsible to each other for their shared environment.
When TREAT's foundational concepts are integrated and implemented concurrently, the resulting programs can engage in both procedural and cultural change. Safety in the milieu is supported through the use of clear expectations and consequences, reinforcement of skillful and healthy behaviors, and the relationships among community members. Crucial to the implementation of TREAT is the notion that everyone in the environment is engaged using the same principles, and they are expected to use the same skills to manage their own emotions and behavior. Staff have different roles in working with youth and facilitating program and youth goals, but they are afforded the same supportive, nonjudgmental environment as the youth in their care. TREAT entails systems in the past that maintained safety primarily through external force to become systems that use supportive relationships as the foundation for safe and healthy growth and development.
Historically, and in currently corrections-based juvenile justice programming, emotional dysregulation or behavioral noncompliance is commonly assumed to be the result of delinquency or open defiance. This hypothesis on youth behavior presumes volition on the part of the youth. It also invites a personalized characterization of youth behavior by the staff member, which frequently leads to negative affect or the reflexive use of control-focused strategies to facilitate behavioral compliance. The personalization of conflict is typically evident in both directions of the interaction between youth in care and facility staff. Also inherent in such systems is the use of authoritarian power as a means to attempt to gain behavioral compliance. This combination of factors consistently leads to unnecessarily personalized power struggles between youth and staff, often resulting in and perpetuating escalated emotional and behavioral dysregulation in youth. Too frequently, the end result of this interaction is the use of physical interventions on the part of staff, which have understandably become increasingly intolerable in consideration of the physical and emotional damage that results. When staff understand and can implement, or even consider, a trauma-based explanation for dysregulated emotions or behavior, they have the opportunity to respond to youth in ways that maintain connection and engagement, reestablish safety, and do not lead to the power struggles which have often led to physical conflict. In the TREAT system, staff are taught to understand the impact of trauma on development, recognize the indicators of trauma histories in youth, and identify the current emotional and behavioral consequences of trauma experiences in youth. Following such training, a primary hypothesis to explain emotional dysregulation or behavioral noncompliance by youth could posit a link to the youth's trauma history via a more immediate cue or trigger in the environment. While the staff do not ignore the personal responsibility of the youth or abdicate the role of authority in response to youth behavior, the trauma-responsive hypothesis opens several avenues for staff intervention, none of which include the personalized power struggle described previously. Staff who do not presume intentionality do not personalize the problematic interaction. Staff who are able to see the functional goal of trauma-triggered behavioral dysregulation, often to gain safety in a situation which is perceived by the youth as unsafe, can intervene using relationship-and skills-based interventions. Rather than meet the youth head on in a struggle for behavioral control, the staff can join the youth side-by-side and work toward a common objective of emotional and behavioral self-regulation in the service of youth-identified goals. The TREAT model includes the creation and maintenance of a trauma-informed milieu in conjunction with empirically validated skills-based treatment modalities and an effective behavioral reinforcement system as a means to address emotional and behavioral issues in a juvenile justice residential setting. This combination moves TREAT from a trauma-informed to a trauma-responsive program.
The foundational principles of the TREAT model, which includes safety, skills, and engagement, are interdependent. Safety cannot be achieved without the use of skills in the context of interpersonal relationships of engagement. Skills cannot be learned without the experience of safety and the willingness to try new skills, and without the engaged support by teaching and reinforcement of others. Engagement between individuals cannot occur if they do not feel safe and do not have the skills to interact without hurting each other.

Conclusion
TREAT provides a model for programmatic and cultural change in juvenile justice residential programs. It is designed and implemented in a way that is sensitive to the trauma of everyone in the environment, recognizes that safety is the foundation of treatment, and benefits both staff and youth. The foundational concepts and program components of the TREAT model may also be applied to outpatient or community-based programs to create systems which are strengthfocused, safe, and trauma-responsive.