Sunday, November 29, 2009

How to Help Malina

I was doing a recent training when Martha, a therapist asked me: "Pat, I know you say not to blame the kids for their behaviors. However I am a firm believer in the kids needing to take responsibility for what they do. So what do you do when a kid just will not take responsibility for what she did and keeps blaming others?"

When I asked her for further clarification, the situation got worse, in my mind. Martha told me that a fifteen year old girl named Malina was on a plan that she had to earn her weekend pass with her mother by maintaining good behavior in school. Last week, Malina had a major outburst in school, tipping over tables and completely disrupting the classroom. So, she lost her pass. When Martha attempted to talk with her about this incident, Malina would not admit that it was her own behavior that caused the pass to be withdrawn. She blamed her therapist, her teachers, everyone else.

What’s wrong with this (very common) picture?

1. I don’t think I said that "we should not blame the kids for their behaviors." I actually do not think that blame is a useful concept here. I think we should help the kids understand their behaviors, and teach them the skills they need to act in new, more helpful ways.

2. I do not believe that children should have to earn their home passes. If the home situation and the child are safe, they should go. The ties between the child and her family are essential for both recovery and the child’s future. We should do everything possible to enhance them, and nothing to interfere. If the child is actually unsafe (such as suicidal) the family should be welcome at the agency and, when possible, transportation provided for them. Home passes should not be part of a reward system.

3. Okay, so Malina was on this plan, and she blew it. What are we asking of her when we ask her to "take responsibility for her behavior"? We are asking her to admit that she did the one thing she did not want to do, and in the process disappointed herself and her family once again. We are in her mind asking her to admit she is a no good, worthless person who will never change. How can she possibly be able to do this?

4. Why do we even think that "taking responsibility" is such a good idea? I guess it is because we feel a person needs to admit something before they can change it and as long as they are blaming others they will not try to change themselves. There is of course some truth to this. Yet, there are many gentle, face saving ways to discuss an incident and the factors that contributed to it.
Most importantly- what will help Malina to stop turning tables over when she gets upset? Not mere increases in motivation. The "earn your home pass" plan is designed to make Malina want to behave better. And I’m sure it did, I’m sure she wanted to earn the pass. But the problem is, she does not know how. She is not able to be different yet.

5. So what can we do? We can look carefully at the incident in school, with Malina in any way she can participate. Not in a blaming way- let’s discuss this and get you to admit you were wrong. Instead, to understand what happened. What upset Malina? Where did the incident start? What did she first feel? What were the warning signs that she was getting upset? What alternatives did she have then? What help could we have given her at that point? This discussion is a search for better understanding, looking for patterns. It is a path to interventions both we and Malina can do to avert a meltdown next time. Was Malina frustrated by work she didn’t understand? Did another girl make fun of her? Was she agitated because she hadn’t heard from her mother in several days? No- these are not excuses for her behavior. They help us understand the skills she needs to handle such events in the future without making things worse. What can we do to make it easier for Malina to ask the teacher when she needs help? What skills and sense of self worth does Malina need to withstand peer teasing, and how can we help her build them? How can we teach Malina techniques (such as the ones we know and use daily) to get through anxious situations? These are things she has never learned in her disrupted upbringing, and we are here to teach them to her.

This thinking will actually bring us forward in our treatment. Making her earn her home pass undermines the only fragile support she has and increases her anxiety. Forcing Malina to admit that what she did was wrong will leave her feeling more shamed, more stupid, and in fact more likely to do the same thing again. Working with her to determine why she acted this way, and to teach her other alternatives, will (after many repetitions) create real and lasting change.

Sunday, November 22, 2009

A Parable: Symptoms are Adaptations

Once upon a time a man named John decided to go for a kayak ride in a near by river. Unfortunately, he greatly underestimated the strength of the current, and shortly after he set out he capsized, He was tumbling down the river, being injured as he banged into rocks, when he spotted a large log near him. With considerable effort, John was able to grab the log, and he held on to it for dear life. Clinging to the log, John continued to be swept down the river. He still crashed against things but with the log he was able to keep his head above water and survive. Finally, the current ejected John and the log into the middle of a large, tranquil pond. The log got caught on a rock in the middle of the pond.

There were some people on the beach at the edge of the pond, and they saw John out in the middle. The called out to him: "Hello! You are safe now! It is not very far to shore! Just swim over here- the water is calm, it’s not that deep, you will be fine!"
But John could not let go of the log.


Why is John clinging to the log when he is so close to safety?

What will the people have to do if they truly want to help John?


They will have to swim out to him, and they will have to give him something like a life preserver to replace his log.


In what ways are you swimming out to your clients?

What life preservers are you giving them?

Monday, November 16, 2009

Playing the Victim

Overheard at a Risking Connection® training: "Well, you know Jeff. He just likes to play the victim."

What is wrong with talking this way?
How do we understand this behavior?
What can we do about it?

What is wrong with talking this way? Why did I cringe when I heard it? It is because of the blaming quality- the statement that Jeff likes to play the victim, as though it is a deliberate choice he makes every day among the many delightful possibilities open to him. Although minor in itself, it leads to an annoyance with the boy, a frustration that he doesn’t see how much better his life would be if he would just stop this.

How do we understand this behavior? When asked to describe Jeff further, the staff member said that he constantly uses his past abuse as an excuse for not trying or for failing. He also picks on other kids (instigates, to use a residential favorite word) and then blames them for whatever fight begins. So why would a kid do that? It is because he sees absolutely no possibility of success through competence. In other words, he has no confidence at all that he could succeed on the basis of his talents and natural skills. He has had no experience of being loved or appreciated for who he is. All the goodies of life and of relationships have come to him in the context of his problems, of reparations for his abuse, of sympathy for being picked on. That is the only way he knows to engage others.

So, what can we do about it? The road to change is through helping Jeff experience other types of competence and success. And this will be difficult, as he will be afraid to try things and will quickly revert to his old standby methods that have worked so well. But with patience staff can support him into positive experiences, achievements, maybe even triumphs. These must include positive interactions with peers, fun, play, every day social back and forth. He doesn’t know how to do this, staff must teach and model. It will take many repetitions for Jeff to believe that people like him for other reasons than his problems.

When Jeff experiences the possibility of competence and fun, we will notice that he "likes" to play the victim much less.

Sunday, November 08, 2009

Victor and Vicarious Traumatization

Victor is eight years old and in residential treatment. He was born to a teen aged mother with a severe trauma history. He has moved around a lot, several foster homes, treatment programs, back and forth to his mother. One difficulty has been that his mother always distrusts his caretakers and forms combative relationships with them. So it is hard for Victor to trust, because he loves his mother deeply. He has a low IQ and sensory issues. He cannot read.

Victor has developed one solid coping mechanism. When ever he is confused, ashamed, sad, upset or fearful, he becomes aggressive. He curses, attacks, spits, etc. He has got this down to a science- because he feels confused, afraid and ashamed often.

Luckily Victor also has a lovable side. Staff care about him a lot. They speak of him with affection and amusement. They go far out of their way to help him feel safe and comfortable.

Victor’s mother has moved to Mississippi, where she has relatives. The long inter-state compact process has been completed, and a plan arranged in which Victor will go to a foster home in Mississippi. In fact, one was located for him. The plan was that he would go there with his state worker for a long weekend, return and say his good byes, and go there to live. Victor was scared, and very excited about being closer to his mother.

Victor was going to be picked up at 5:00 a.m. At 10:00 p.m. the night before, the foster mother called the unit and cancelled the visit, mentioning a "family emergency". Later it turned out that she had not been told any information about the severity of Victor’s problems, and now that she knew more, she was not prepared to take him.

Since then, Victor has fallen apart, and the frequency and intensity of his aggression has increased.

This is why we get vicarious traumatization. Its not just that we read or hear the children’s histories, or that we sit with them and feel their pain from the past- although that would certainly be enough. It is also that we go through with them the terrible things that continue to happen in the present- the many ways the adults (including, at times, ourselves) are not able to provide safe, long lasting homes.

And we have to acknowledge that much as they love Victor, staff were in some ways looking forward to his discharge. It would be a relief not to be spit on, hit or bitten as often. Treaters totally understand why he is falling apart. And, it can be exhausting to deal with the depths of his despair. Especially when we do not ourselves see where there is hope for his future. Not to mention that it can be tiring just to hold a strong wiry little boy over and over again.

But here he still is. And there is as yet no alternative plan. And to give this boy safety, to stick with him, to be there as he survives all this, is certainly the most important thing we could be doing in the world.

So how can we bear it? The most important thing is to talk about it. We have to share all our complex feelings with each other. We have to be free to say that at times we get tired of him, just as we are free to say that our hearts hurt with his pain. Staff have to be commended over and over again for the difficult, repetitive, unending acts of caring they provide. Of course, we continue to advocate that the system give Victor what every child should have.

And we turn to each other with tears in our eyes, make a joke, take a break, have a meal, and return to Victor, and continue the heartbreaking work that will save his life.

Sunday, November 01, 2009

Marcus, Take Two

Thank you to everyone who participated- and please, continue to add your thoughts!

If we keep in the front of our minds the idea that symptoms are adaptations, we must wonder what doing the drawings and sharing them with his peers is accomplishing for Marcus. I can think of several possible theories, such as giving him power, expressing his pain, giving him one area in which he is in control and can have an effect on others.

Also, the drawings express a part of Marcus, however disturbing they are. If we just try to ban them, we are giving Marcus a message that we are turning away from his pain, and that we do not want to see, share or accept all of who he is and what he has experienced.

I do not feel that taking drawing supplies away from Marcus will help at all. For one thing, we won’t win on this one. There are many more pencils and pieces of paper in the world than we can ever confiscate. But more importantly, that is a response that tries to eliminate his behavior and not to understand it.

We need to take seriously the effect the drawings have on the other kids, the staff and especially the therapist. This is something we have to discuss as a team and make deliberate plans to give ourselves the stamina to take this on. For example, the therapist may wish to include a male staff at first when she talks with Marcus about the drawings.

Then, as noted by one of the comments, I think we should explore the pictures with Marcus, and not in a judgmental way. What is happening? What are the characters thinking and feeling? What is likely to happen next? The therapist can express her thoughts: "Really? I think the woman might be scared and angry." But all discussion should be from a very centered, calm place- tell me more. Explain how it feels. What does it remind you of?

These discussions should include NO MENTION OF THE NEED TO CHANGE. They are entirely exploratory.

Meanwhile, staff can talk with the other kids about how sometimes when people have had painful lives they draw painful drawings. Encourage the kids not to react, but just bring staff into the conversation if Marcus shows them a picture. Of course, Marcus’ showing them around would decrease if he got less reaction. Then staff would handle it matter-of-factly: you know, Marcus, better to save these for therapy- I’ll give this one to your therapist and you can talk it over with her.

Another area of treatment could be to offer Marcus other opportunities to have power and control, using his drawing. Could he draw some posters for an upcoming agency event (subject to review of course). Can he draw a picture for the unit illustrating some positive message, and can staff get it framed and hang it up? You get the idea.

Marcus has been hurt repeatedly over his life time. He has found a way to both express his pain and get strong reactions from others. His behavior will not change quickly. We must understand that the way that we feel in looking at these pictures is the way that he often feels in his life. And we must support each other in doing the long hard work it will take for Marcus to develop a new, kinder view of life’s possibilities.

Let’s continue this discussion- click on "leave a comment" to share your thoughts.