Rituals of Passage

In Risking Connection© training we read a letter from a woman who grew up in the child welfare system in the 19950s. She was asked by her therapist, Dr. Kay Saakvitne, (one of the RC authors) what she would want people who worked in that system to know. In her letter she speaks eloquently of the lack of continuity when one is moved from place to place. It is very hard to develop a secure sense of self when there is no coherent narrative of ones life, no pictures, no one to remember the various parts. People appear and disappear. They each say something different about who you are.

This letter makes me think about all the ways we create that narrative for our own kids: we tell them the story of how Mommy and Daddy met, of their birth. We describe their ancestors and say they resemble Aunt Jane. We say "all members of the… family always…" We remind our teenagers of embarrassing things they did when they were kids. When the kids are 57 they are still expected to display the characteristics that were assigned them at age 5.

The author of the letter implores us to ask our clients about their pasts in conversational ways, to help them construct their story. When possible, create a life book with pictures and mementos. When they have to move, explain why, give them time to prepare, and relate the new place to the old- for example, point out both places on a map.

What can we do to help the child put her time with us into her story? One residential (Sunrise, Kentucky) reported some interesting rituals. One is to create a memory box for a child when they arrive. During their stay put in souvenirs, mementos, pictures. When they leave, add messages from staff and kids and send it with them. Another site described a ritual in which they buy the child a necklace. They pass the necklace around to each child and staff, and each states a wish which they are attaching to the necklace to go with the child.

What hello and goodbye rituals does your program do? How do you create a sense of meaning and continuity for your kids during these crucial times of passage?

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.

Book Review: Denial

Denial: A Memoir of Terror

Jessica Stern

Publisher: Ecco (June 22, 2010)

I was asked to review Denial: A Memoir of Terror by the staff of its author, and I am glad I had the opportunity to do so. The author of this book is an expert on terrorism and a national security advisor. In Denial she relates her experience that when she was 15, she and her sister, a year younger, were forcibly raped in their home at gunpoint by an unknown intruder. Years later when the police reopened the case in 2006, Stern was compelled to confront the devastating experience and research the rapist’s background. In the course of doing so, she learned more about her family and herself.

For me, the most valuable part of this book was experiencing from the inside, through Stern’s clear writing, what the after-effects of trauma actually feel like. The various trauma experiences interact with other aspects of her family history to produce both strength and blind spots. At times the book was a bit confusing, as the narrator moves between experiences of the rape, experiences within her family, and present life. However, I came to feel that this reflected what it felt like to her: all these aspects creating confusing and inexplicable symptoms that were very hard to recognize or sort through. In reading the book you experience how assumptions about the world that are formed in trauma become unquestioned reality. These assumptions then influence ones’ actions in life such that they are confirmed again and again.

Stern describes vividly the various subtle and more obvious symptoms she developed as a result of her trauma. The reader can experience the intensity and confusion these symptoms cause.

Another strong theme of the book is the failure of the community within the family and outside it to support these two girls. It is astonishing how little help they got, how they were not believed, and how the case was allowed to go unsolved for so long. Stern demonstrates the unwillingness of the community to face the presence of evil in its midst. Years later, a policeman does develop an interest in solving the case and succeeds in doing so. But in the mean time the rapist has harmed many more girls. The function of denial for the individual, the family and the community is demonstrated clearly.

I would recommend this book. It gives us a rare opportunity to experience from the inside the complexity of multiple layers of traumatic experiences and how they affect relationships with family, friends and partners; influence job choice and performance; and infiltrate every part of life. In addition it clearly demonstrates the function and danger of denial.

Ah, Young Love

In your treatment program how do staff respond to romantic relationships between the youth? Do you forbid them, in the interest of preventing distractions from treatment? Do you set limits, and what are they- no sex? No holding hands? Do you respond differently to a homosexual couple that live on the same unit than you do to a heterosexual one? Do you facilitate normative teenage activities such as dates to the movies? Anyone who treats adolescents has had to struggle with these and many more questions. And the relationships are often fraught with drama, anger, broken hearts, agitation and obsession. In addition, parents, social workers, licensing and accreditation bodies are watching and have strong- and differing- ideas about what you should do.
Sally and Mark are in love. Or at least they were this morning- this afternoon, as they return from school they are angry and agitated. Rosita just told Sally that she saw Mark talking with Leticia in school. Three other girls have told her that Mark said he thinks Leticia is cute. But Kendra said that Mark told her that he only cares about Sally. The girls will not get ready for the planned softball game- they are gathered in clumps discussing this. And it’s even worse because Sally and Leticia were good friends. Now Leticia is in her room with the door closed and Sally and several of her other new friends are considering ways to kill her.

Meanwhile, on the Boy’s Unit Mark is desolate. He is in bed with the covers over his head. He refuses to do his homework or attend activity. He knows that Sally is going to break up with him and he cannot live without her. He doesn’t even like Leticia! He sticks his head out and begs his roommate Devon to call the Girl’s Unit and convince Sally that this is all a big mistake. When staff say that it is not phone time Devon becomes belligerent and insists that this is an emergency.

What’s a staff to do? All this relationship stuff is getting in the way of treatment. It is paralyzing the entire program. It is so over dramatic and messy.

I would suggest that all the drama and mess IS the treatment. First of all, of course, this is normal teen age behavior. We cannot keep kids in treatment programs for several of their teen age years and not allow them to have teen age relationships. So much is learned in these relationships, so much practiced. If we forbid them (as if we could- they just go underground) our kids will be behind and incapacitated in one more way. Isn’t it better to let them experiment in the relative safety of our programs?

What is going on here? What needs are being met? What can be learned?

Can we assist Sally and Mark in direct communication? Instead of relying on the highly unreliable assistance of all their messengers, can they take the risk to talk to each other about whether Mark wants to break up with Sally and go out with Leticia?

What about the other kids? All of them are feeling important and excited by their roles in the drama. That’s okay. We don’t really need to go outside to play softball. Maybe we should pull the girls together and have a group about relationships- a very respectful and real group. How do you know if you can trust someone? How do girls keep on being friends when boys enter the picture? How do you decide who to believe? What are you looking for in a boyfriend? Etc. These topics are central to all teenagers and they are great to discuss in groups- many important issues come up. For example, in one group I talked with girls about who they can trust and I was saddened by how certain they were that there was no one, especially no boy that could ever be trusted. In another group, one girl had called another a slut. So we wrote on a white board all the characteristics they considered slutty, and had a great discussion of whether they wanted to be slutty and in what ways they were or were not presenting themselves that way. The trick is for the adults to be real, hold to their own values, but remain curious and respectful about the kids’ thoughts and values.

Maybe one of the male staff could go in and talk to Mark about women- you can’t live with them, you can’t live without them. He could talk man-to-man about how to show a woman she can trust you, or about whatever topics emerge. Neither our boys nor our girls have known very many good men, and they desperately need to know that it is possible to be strong and kind at the same time. Another staff might talk to Devon about what a good friend he is and how he can best support Mark.

We have to have limits. One is: no sex with anyone in the program. But if we can facilitate normal teen age things, it will be so helpful to them. For example: could staff take Sally and Mark to the movies (after they recover from this setback) and sit one or two rows behind them? We also have to make sure we are equally respectful to homosexual couples, despite the added complexity of sharing living quarters.

We cannot forbid romantic relationships. We do not need to see them as a distraction from the real work. There is nothing more real or important to a teen ager than their romances. And I have seen youth grow and change because of love, start to have more confidence because someone cares about them, learn how to share themselves more directly and experience the joys of being understood. I have also seen heartbreak, despair and regression. But I’ve seen all these in my adult friends as well. This is what life is all about- and we can use every piece of the emotional upheaval as an opportunity for growth.