For four weeks or so I am going to right about the dark side of RICH- by which I mean the difficult and complex aspects of creating RICH relationships. These are the areas where we struggle, stumble, and sometimes become less than helpful to our clients and each other. Let’s look at each part of RICH and discover what is hard about it and how we can overcome the challenges.
This second week I will focus on Information.
This might seem like the easiest one- just give our clients information. Tell them things. But I would like to explore four areas of complexity: collaborative treatment including the use of medications; sharing information with the team; psycho-education about trauma; and information and heartbreak.
Collaborative Teatment Including the Use of Medications: When working with trauma survivors it is essential to be collaborative. They have had so much experience of things being done to them, and of having no control, and they are exquisitely sensitive to such treatment. Also, trauma survivors have not had a chance to develop a voice, learn to speak up for themselves and advocate effectively. In treatment settings, especially with children, we tend to repeat the same dynamic. We make the decisions and when a child tries to object we call that “resistance” and respond with a punishment or at the least disapproval.
One area in which this happens is in the use of medications. We all (I hope) do discuss with a client why we are suggesting a certain med, what the benefits could be, and what the side effects are. We often give them and their families an information sheet. Yet do we truly respect any hesitation or objection the client has to the medication?
Did you know that even accounting for race, social situation, and other variables foster children receive 2-3 times as many medications as other children? I understand it this way: children handle stress and achieve emotional regulation through strong relationships. Connection is the antidote to stress. If a child does not have the strong connections to help her regulate, medication is used instead.
Back to information. It is important to REALLY be collaborative about medication with the child If the child refuses to take her medications she should NEVER be punished (or consequenced) for this choice. It may be an appropriate decision not to take her on a long trip if staff is concerned about her safety and the safety of those around her. But if a child does not want to take her medication, the therapist will be talking with her trying to understand her reality and what the meds mean to her. Why does she not want to take the red pill when she will take the others? Because it has a bitter taste, because her friend told her it was poison, because ever since that one started she can’t sleep. The therapist will get important information and in working with the psychiatrist perhaps something better can be found. And in collaborating with the child the therapist will be developing self awareness as they together monitor how she feels and acts. So, information about medications is not just giving the client a fact sheet. It is a truly collaborative exploration of the suggested meds and the client’s valid needs and wants.
Sharing Information with the Team: I believe that in a residential treatment center or hospital or any congregate care setting, the line of confidentiality should be around the Team, not just around the individual therapist. Some therapists have difficulty with this belief. In our theory, everyone who interacts with the child and family is a treater and contributes to healing. Therefore, they all have to know what is going on. They need to know the child’s discharge plan and destination and what their goals are. They also need to know what is currently happening in the child’s life. In my consulting I have encountered situations in which the full time child care workers have no idea about either the child’s history or their discharge plan. In some situations, such as when the child is disclosing sexual abuse, she may not want everyone on the team to know about it. Her therapist will create with her a phrase that the therapist can tell the team, such as “Nina is talking about some difficult things from her past right now, so she needs some extra support.” The therapist will help Nina to expand the circle when/if she feels ready. But in general, the team is all there to treat the child, and all need to know what is happening. This policy should be clearly explained to the child and family (and documented) when they are admitted. In order to gather this information and discuss its significance, the child care worker must be able to spend time in Treatment Team to learn about the client and understand their reactions.
Psycho-education about Trauma: How many of you in your programs are teaching the biology and psychology of trauma to the children and their families? Even younger children can learn something about their brain and body and why they act the way they do. This knowledge can be extremely important to our children. It helps them feel less crazy. When they learn that the body reacts a certain way to stress, and the same thing happens to soldiers, and policemen, and the workers in the program, it combats that conviction that their crazy behavior is their own fault. I will never forget Colleen, who when reading The Courage to Heal (Bass and Davis, Morrow, 2008) said: “This is me! In a book!” For her it was so normalizing to know that others understood her.
Of course, there is my Blub book on “A Kid’s View of Trauma”. This book uses the Risking Connectionâ concepts to explain trauma to kids, including how they can heal. It can be found at www.blurb.com. Some trauma-specific treatments, like TARGET, also explain the biology of trauma.
Another part of this is the parents. As we know most of them are also trauma survivors, and many have never worked on their issues. When we do psycho-education with them to help them understand their child, many parents immediately relate this information to themselves. Like Mrs. Jennings they say: “I wish I had had this information years ago!”
Information and Heartbreak: When we form caring relationships with children in the child welfare system, we are constantly dealing with heartbreak- the child’s, and hence our own. We often struggle with when to tell the child disturbing information. At what point do we tell Marvin that the foster family he is visiting is beginning to have doubts that they can take him? When does the DCF worker tell Melissa that her mother has dropped out of the drug treatment program? Or does she tell her at all?
I have seen people, especially state social workers, be so reluctant to tell a child bad news (you are not going home) that she hedges and leaves the child with an unwarranted sense of hope. This prevents the child from being able to explore new alternatives.
One are in which we struggle with imparting information is when a beloved staff is leaving. How long in advance should we tell the children? Some feel we should wait until the last minute to tell the kids, as otherwise they will get upset and have melt downs. Yet, if we do not give them time to process this departure, we will be repeating their past trauma in which people came and went without explanation.
In all these situations we have to tell the child in a straight way what is happening, and be prepared for some appropriate emotions of despair and hopelessness. If we can stay with the child through their reactions, and witness and empathize with the painful situation they are in, they will eventually, if reluctantly, be able to move on to the next plan. Their reactions are not inconveniences for us. They are the child’s legitimate protest against an unfair world.
What other dilemmas around Information can you thinkof? I didn’t even get to sharing personal information. Click on “comment” and share your information dilemmas.