Terri has had many people in and out of her life and many changing circumstances. Her mother has been her one constant, and her mother has gone through a lot of hardship throughout Terri’s childhood years. Somehow Terri missed whatever it takes to consolidate a sense of who you are.
Furthermore, Terri is caught in the dilemma that is so familiar within our population. She has learned that the infallible way to engage with others is to have problems. She has trouble figuring out how to be a good friend. She misses cues and doesn’t quite know when to get closer or when to move away. But, she can always get someone’s attention by baiting them, saying whatever will most upset them. She feels lost and empty inside, and has no ability to remember that people care about her when they are not physically present. So when adults are not with her or even are paying attention to someone else, she feel bereft. That’s okay- she has a surefire way of getting them back. Scream. Cut herself. Become agitated. Stand in the middle of a busy road. Adults tend to drift away and become less available, but they always have to engage when you become unsafe.
So you have someone with no central core and a longstanding pattern of engaging people through problems. At this time Terri is so vulnerable to people in the world that would take advantage of her desperate need for love. What do you do? How can treaters help to build a person?
Two overlapping fairly difficult treatment activities will be helpful. The first is to concentrate a lot of effort on helping Terri create who she is. This involves activities such as:
- Create a Me Book with all sorts of categories, such as my favorite color, favorite TV show, singers I like, singers I do not like, etc. etc. Terri could use cut outs from magazines or drawings, some words (less emphasis on words).
- Every day staff should ask Terri what she liked in her day, what she didn’t. What did she have for lunch? How was it? This should largely replace any questions about how her behavior was.
- Every time anyone does something with Terri, they can discuss it with her. At a movie, which character did she like? Why did they do what they did? Would she have done the same thing? If she is reading a book, relate it to what she thinks, feels, would do. Terri will not have much patience for these discussions but in short bursts she could be engaged in them.
- Whenever possible give Terri choices and comment on her choices.” So, you chose these clothes, you like bright colors.”
- Comment on any strengths or skills you see. Not just or even particularly coping skills- more things like “you bake good cupcakes”.
- Engage Terri in helping staff to do work. Coach her to persist despite minor obstacles that arise.
- Coach and support Terri to sustain her effort when something is hard, and point out the positive results.
- Have posters in her room of “Things Terri Likes” and “Things Terri Does Not Like” and have her keep adding pictures from magazines.
The theme of this series is to help Terri move her self-definition away from a girl with severe psychiatric problems and define herself as an ordinary girl.
The second part of the approach is to tell Terri that we understand she has learned that the best way to connect with people is to have problems, but that this is not true. We are going to help her learn other ways to connect that are more fun. So to do this we are going to be less interested in her problems and more interested in the rest of her life.
How do we carry this out? When Terri goes into her emotional escalations, staff and her family of course have to interact with her and keep her safe. However, they should do so in as non-emotional, uninvolved, and routine way as they possibly can. The trick here is not to be punitive, judgmental or mean. You have to try to come from a stance that: we understand you have to do this, you are doing the best you can right now, we hope you can learn better ways but meanwhile we will keep you safe and look forward to when you are calm and we can have fun together.
It is essential that this non-involved, non-emotional approach to problems be paired with an extremely involved, very attached availability when Terri is not having problems. If Terri is available to play a game, have fun, do work, just talk, go for a walk, talk about her day, that is when staff and her family should be very interested, connected and involved. If the talk turns to psychiatric problems, the adults should be more distant and try to change the subject. The adult should be very interested and available to discuss normal teen age problems, like how do you know if a boy likes you? Or how much make up should I wear? The adult should encourage talk about Terri’s experiences and her reactions to them.
It will also be helpful if Terri engages in rhythmic activities with an engaged adult. Dr. Bruce Perry’s work has shown us that these sort of activities help organize the brain and its ability to manage the body. These could include walking with someone, dance, music, drumming, petting animals, throwing a ball back and forth, jump rope, hand clapping games, etc. Doing fun physical activities with a connected adult will also be the best way to change Terri’s deepest assumptions about adults, that they are not there.
This work is hard, and the adults doing it need a lot of sustenance and support. Yet Terri will only have a chance of a life worth living if she develops a sense of who she is. With time and repetition the adults who care about her can help her strengthen her inner core.