Sunday, March 31, 2013

A Small Thought About Band-aids

Jason came up to me in the main hall and started talking about a client in our day school, Marvin. Marvin had been diagnosed with autism. It was clear that Jason was very committed to Marvin and wanted what was best for him.  Together they had developed many tools that helped Marvin stay calm as he moved throughout his day. They included such items as a fidget ball which Marvin kept in his pocket and a weighted vest which Marvin could wear when agitated. Marvin reported feeling calmer when he wore the vest.
But Jason was very uneasy about Marvin’s use of these items. He was concerned about what would happen when Marvin returned to public school. When he used these items the other kids would tease him, he would not have any friends, and he would be miserable. Jason was thinking of taking away the items now so that Marvin could learn to do without them.

Later as I helped my husband to apply a Band-Aid to his cut thumb, I reflected on the idea of a band aid. When we apply a bandage to a cut, we do not worry about the person’s reliance on a bandage. Even if it is a big cut and a big bandage. Or a plaster cast. We do not assume they will need this bandage for life and other people will make fun of them. We realize that the body has a powerful innate healing capacity. All we need to do is provide an environment in which the injured part will not receive further jury and thus will heal. We know that as soon as the cut is mended, the broken bone re-connected the person will reject the band aid and the cast on their own.
When you think of it, it is pretty miraculous that skin knits back together; that bones reconnect and are even stronger than previously; that internal organs return to healthy functioning. I have read that a lot of medicine is providing a safe, supportive environment in which the body can heal itself.

So maybe that is a large part of what we do in treatment. We try to avoid hurting our clients further, and we offer safety and support that promotes healing.
Of course in medicine we cannot cure everything. The person may have a scar. Some need prosthetics. Again, we don’t worry about people’s reactions in the future. If the patient needs the aide, medical personnel will teach him how to use it most effectively.

So Jason doesn’t have to worry about taking the supportive tools away from Marvin. When he doesn’t need them, he will drop them himself. The urge to be grown up and normal will prevail. And it he continues to need some help when he goes to school, work with him on how to use it discretely.  
And he may get teased. Most kids do at some point. But maybe we will have taught him tricks not to over react. And the memory of Jason, who cared about him, will give him the strength and hope to keep moving forward.

Sunday, March 17, 2013

The Tragedy of Inadequate Resources

All over the country the child welfare system at every level is reinventing itself to provide trauma informed care. At State agencies, at non-profit treatment providers, at the foster care level, in schools, in outpatient therapy, good caring people are working hard to understand behavior through a trauma lens and to offer treatment that is more relationship-based and collaborative, less punitive and inflexible. Much training is being offered, including by us, on viewing symptoms as adaptations; understanding that the child is doing the best they can; and offering youth safe and caring relationships in which to heal. The same principles are being applied to parents, and there is increased awareness of how their early trauma experiences interfere with their parenting. Utilizing the information from the ACEs study we have learned the societal cost of early childhood adverse experiences, and thus the importance of early and skillful intervention.
Yet I am increasingly aware of a central tragedy at the heart of our attempts to reform. For our children who have been damaged at an early age through a combination of neglect, abuse, trauma and attachment disruptions, the best treatment skills in the world are useless if the children have to keep moving around.

Recently I was doing a training in another state at a residential facility and I was asked to consult on a girl they were struggling with. Tabitha is thirteen years old and her placement at this facility is her 29th. She has been kicked out of day care, foster homes, treatment facilities, and schools. Currently the facility that she is in is considering kicking her out because she keeps attacking the other youth and seriously hurting them. With the resources they have, they are unable to keep the other kids safe while Tabitha is there.
We have done this to Tabitha, we in the child welfare service delivery system. Sure, the damage started when her bio family, overwhelmed with their own trauma, poverty and despair, abused her. But she was removed from them at the age of two. Since then, we have been unable to create a home with enough support and safety that Tabitha could have time to heal. By moving her around we have eventually taught her that people are expendable, that relationships cause pain, and that it is important to be tough so that no one can hurt you.

We know that Tabitha will increasingly cost the taxpayers money, in addition to the considerable amount we have spent on her already. Whether that money be incarceration, drug treatment, medical care for stress-related illness, placement of her children-to-be, etc. etc. it will be spent. And at the same time we will not be reaping the benefit to society that Tabitha could have provided if she had been given time and consistency in one safe place. Furthermore, we lose whatever talents and contributions Tabitha could have added to the world.
Yet all of this money is from different pots authorized by different people counted in different systems. So there is no way to look at this situation and say: spend money now and save it later. It is not that we are choosing not to spend enough money on Tabitha throughout her lifetime. It is that our inability to spend enough money early enough results in our wasting ever increasing amounts of money on short term ineffectual attempts at change.

Tabitha needs love to heal.
She cannot heal if she keeps moving from caretaker to caretaker.

She cannot heal if she keeps getting her worst opinions of herself confirmed by being kicked out of places.
She cannot heal in six week bursts of treatment.

She needs containment and safety to get her through the worst part of learning to manage her feelings, calm her biology, rebuild her brain, develop connections, learn skills to manage feelings, and discover some worth in herself. She needs resources to keep her and others safe until she learns to do it herself.
In order to help Tabitha heal, the adults around her need sufficient resources so that they do not become injured and exhausted. Only if they are well cared for will they be able to see beneath Tabitha’s seeming uncaring aggression to the scared child within. In addition, the adults around Tabitha need training in order to understand why she is acting the ways she does; to understand it is not about them personally; and to give them a road map for healing. This will help them have the stamina to stay engaged with her. And the adults have to understand that it is safety, connection and pleasure that will help Tabitha, not restrictions and punishments.

In the mean time, the agency where Tabitha is currently placed is doing their best. They have been given an additional five hours a week of staffing for her. They are trying to make safety plans. And they are validating her experiences and helping her understand her feelings and learn skills to manage them. Hopefully, they will make some progress.
Or, because of inadequately funding, limited options, and exhausted treaters Tabitha will succeed in once again seriously hurting one of her peers. And the facility will have no choice but to ask the state to remove her. And Tabitha will leave for her 30th placement, where ever that might be, and the next bunch of people who seem kind but really will not stick by her.

And we will continue to support her ever increasing needs.