Sunday, June 20, 2010

Dilemmas of Trauma Informed Care

Our difficulties in treating Mario exemplify some of the key dilemmas of trauma informed care.

Let me introduce you to Mario. He is twelve years old. He experienced severe early abuse including repeated violense both between his parents and directed towards his siblings and him, and has lost his entire family. He has been ejected from three foster homes. His IQ is low average, and his mother may have used substances during her pregnancy with him. He has been in residential treatment for a year and three months.

During the first few months of Mario’s placement, he destroyed a lot of expensive property at the agency. He trashed the gym, broke windows, destroyed a part of the school, and more. After each event he was deeply ashamed and further confirmed in his sense of himself as a horrible bad boy. He would hide under the furniture and refuse to talk with anyone. When he was not upset, he could describe some strategies he could use when something went wrong. But when something did go wrong, and it was often something very small, his emotions would well up and completely take over his mind. A staff member says that he has to wait ten minutes before going to dinner. Mario becomes overwhelmed with a sense of total hopelessness. He knows he will never eat again. His mind becomes muddled and he is unable to think. He is plunged back into his basic reality in which his needs are never met, no one can be trusted, and he has to fight for anything he gets. So he reacts- he throws something, breaks something, threatens someone. Anyone around him would be bewildered. What happened? Waiting ten minutes is no big deal. They try to explain this to Mario but he literally does not hear them. Mario’s pain gets worse and he tries to express and escape it by increasingly aggressive actions. Finally, he is contained and the storm passes. Afterwards, he feels worse than ever.

Elliot is Mario’s team mate (child care worker with a special relationship with and responsibility for Mario.) Elliot is a caring young man, and he sees Mario’s shame and pain. He works hard to form a relationship with Mario and not to give up on him no matter what he does. When Mario is calm, he and Elliot have some great times together. Elliot is proud that he is able to connect with this difficult child, and thinks that their relationship may be part of the reason that Mario has gone a month with no major episodes. Yet, yesterday Mario got into a minor argument with a peer that rapidly escalated into violence. When Elliot tried to intervene and get Mario to take a walk with him, Mario looked at him blankly and said: "I don’t know you. You don’t know me." Elliot felt hurt.

Over all Mario’s behavior improved, his property destruction decreased, and his episodes became further apart. The treatment team members were proud of what they had accomplished, and Mario himself was feeling more hopeful. So he was referred to a therapeutic foster home and began to visit a family. Almost immediately the aggression returned. After several episodes the family withdrew from consideration.

Now, Mario appears to be regressing. He has become aggressive towards people instead of just property. He has had several major, dangerous high-end events. He was hospitalized, and did well in the hospital. Staff felt hopeful and lifted all his restrictions when he came back. As one person described it: "We gave him a blank slate and he smashed that slate into pieces." Staff have noticed that he acts worse when there are fewer staff on duty, or when the shift workers are all female. Shortly after coming back Mario went on an agency trip to a baseball game. On the way back he got into such a major unstoppable fight that several policemen and supervisors needed to intervene. At this point, the team is investigating transferring Mario to a longer term hospital program.

It is always painful when we are not successful in our treatment of a child. When we have been working with relationships, with our hearts open, it can feel personally distressing. We doubt ourselves and wonder if there is more we could do. We feel hopeless for this child, and perhaps less hopeful about our work in general. In short, we feel much the way the child feels.

So how do we react to our pain? And how do we understand what is happening with Mario? It is easy to begin seeing Mario’s behavior as intentional: "he waits until staff are vulnerable and attacks." It is natural to think punishment would help: "he needs to go somewhere where he will get serious consequences for his behaviors. We are being too nice to him. He needs to understand that in the real world he cannot get away with these sorts of actions." It feels like Mario is uncaring: "We don’t have a relationship. When he is upset he does not even know me. He never seems to consider the needs and feelings of anyone else." A common reaction is to retreat, to treat Mario with distant politeness, and stay emotionally closed. It is natural to feel angry, betrayed, sad and hopeless.

Mario may need to be in the hospital. In a hospital adults can physically keep him and others safe using tools residential does not have (high staff ratio, locked doors, etc.) He probably did well in the hospital because right now he needs the feeling of safety that a hospital provides.

Yet I think it is important to re-consider what is going on here, no matter what the outcome. Here are some points for thought:

Mario is not deliberately planning his aggressive outbursts. When he says he is going to try some strategies, he means it at the time (just as I mean it when I say I am starting a new diet on Monday). When he is connecting with adults, he is not planning to trick them. When the chemicals in his muddled brain are calm, he can enjoy other people and plan a different future.

Mario is not looking for times when staff are vulnerable due to less people or all females on the shift. It is possible that at these times he feels less containment and safety, and thus more anxious and more vulnerable to over-reaction when something goes wrong.

I do not think that punishment will help Mario change this behavior. Of course punishment will make him feel worse and more shameful. Yet will it be a deterrent? I do not think that Mario would have access to an awareness of consequences when he is agitated. If he did remember them, he would not care or might feel that they would be just what he deserved. I honestly do not feel that when his brain chemicals are raging he can think to himself: if I do this, I will be in trouble so I shouldn’t do it. Unfortunately I do not think he can even remember: if I do this, Elliot will be disappointed. Instead he already feels that he is totally in trouble and already feels that Elliot is disappointed, or couldn’t possibly be trusted to like him. So what is there to lose?

I also think we overlook the role of stimulation, even from positive events. Staff were being caring and compassionate when they decided to bring Mario on the trip. However, it is possible that the excitement of the trip, although a pleasant experience, was too much for Mario. Keeping his world small and predictable might work out better.

What does Mario need? He needs to be kept safe so that he can experience positive relationships over a long period of time. He needs to learn and practice concrete steps he can take when he first starts to feel upset- and the first step is to realize when he is getting upset. He needs experiences of success and positive action. And he needs some hope- some pathway towards growing up outside an institution, some adults who will love him and stay with him.

These are all things that are very hard for our system to provide. And the pain of this situation leads Elliot to wonder: "Is there any hope for Mario? Are there some kids who never change, and who are destined to spend their lives in jail?"

Can a twelve year old be hopeless? That is a crucial question for us all.

1 comment:

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