Terri is one of those kids who seems empty. She does not
have an internal solid self that is continuous between moments. If she is with
Sonia, she develops an accent. If she is with Janaia, she likes hip hop music;
if she is with Courtney she likes Justin Beiber. She tells swears at her team
mate Vanessa and tells her that she hates her one moment, and the next she says
she loves Vanessa and wants a hug. She is at the mercy of her emotions. A small
disappointment occurs and the feelings sweep over her, getting bigger and more
extreme by the moment. She has no ability to modulate her feelings, instead the
tide rises and swells until, suddenly, it breaks and Terri is completely fine.
She has goals- in fact many, contradictory goals- but she has absolutely no
ability to hang onto them or use them in the face of any obstacles.
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.
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