Case-of-the-Week:Survival-in-the-Moment August 18, 2009
Posted by glsaxe in Uncategorized.trackback
Last weeks case involved the tragic and true story about a girl who almost died related to child abuse and neglect. The case illustrated the problems that occur when the assessment process is not integrated across the services system and , as a number of commentators noted, when the TST Principle “Align with Reality” is not vigorously adhered to.
This weeks case illustrates a number of important principles in the assessment process, particularly how we gather data around “Survival-in-the-Moment” states. Please think about the case of Nelson. What pieces of information are most important in the assessment process? How may this information guide his care? What are the likely consequences for Nelson and his family if these critical facts are missed?
This case takes place in a residential treatment setting. I am particularly interested in comments from people who work in structured settings (residential programs, inpatient units, schools, shelters). I’m of course interested in any comment, question, or argument. The more responses the better for our building of this TST Virtual Community.
Nelson
You are working with Nelson, an 11 year old boy admitted to the Residential program where you work. Nelson has a history of physical and sexual abuse from his babysitter for about one year, beginning when he was 7 years old. The abuse stopped after his mother came home early and heard the abuse occurring in Nelson’s bedroom. Criminal charges were pressed. The babysitter was recently sent to prison after a trial that involved Nelson’s testimony. Over the last year, Nelson’s behavior has been increasingly out of control. He has physically assaulted classmates and his 7 year old sister. A neighbor’s pet cat was found dead in the woods near Nelson’s home and his mother presumes that Nelson killed the animal. Nelson vehemently denies harming the cat. Nelson’s mother has reported decreasing ability to control Nelson’s behavior. He has been suspended for more than 15 days this school year because of his agitated and aggressive behavior in class. He will fail the sixth grade this year as he has not completed assigned work. Nelson has always been described as a very bright child. Nelson has been receiving weekly psychotherapy in the last year for ‘anger and aggression’. He has also been treated for Attention Deficit Hyperactivity Disorder with Ritalin. His mother does not believe the therapy or the medications have helped.
Over the past two weeks in the residential program, Nelson has not settled in well. He continues to appear agitated and angry in the milieu, repeating that he does not belong “in this prison’. At times he can be quite engagable. He is clearly very verbal, smart, and imaginative. He loves chess and basketball and is talented at both. He is a fierce competitor. You have had two or three sessions with Nelson where you really enjoyed his talent and charm and imagined a great future for him.
Nelson has had four or five episodes of extreme aggression since his admission. During one of these episodes he struck a male staff member in the head with a chair. The staff member developed a concussion from this assault. Nelson threw a lamp at another staff member a few days ago that barely missed his head. These episodes appear ‘out of the blue’. They don’t seem to have any precipitants. When asked, staff members report that the episodes may follow times where “He doesn’t get what he wants”. One staff member reported at a team meeting “You can’t set a limit on this kid, he has to have his way all the time or else he loses it”. He is perceived by most staff members as angry, entitled, unpredictable, and very hostile.
Nelson lives with his mother and his seven year old sister. His father has been in prison for the last four years for armed robbery. Nelson was very close to his father and was extremely upset when he was imprisoned. His mother reported that he hardly talked for a month after his father “was taken away”. Whenever you ask Nelson about his father, he says that he does not ‘want to talk about it’.
The TST Book
The first thing I would want to do is to establish a team to make sure we are including the perspective of the family, and so that the staff see we are taking action to to stabilize the situation, and that this acton includes their input. Based on input from all team members, including Nelson, his family, and the staff, we would then determine a “priority problem.’ Nelson’s current behavior is that of aggressor, which obscures his role as victim. It is important that all team members understand how his current behavior is shaped by what has happened to him.The team needs to dteremine whether Nelson’s aggressvie actions are occuring while in a dysregulated state. Based on the information provided, a likely priority problem would be something like “Signals of deprivaton and not being protected by adults, such as not getting what he wants in the moment, or adults not creating adequate strucutre and limits, lead to feelings of fear and anger, which lead to behavioral dysregulation as evidenced by physically attacking adults.” Solutions to this priority problem would need to address: a) emotion regulation skill building to help Nelson better cope with stressors, and b) environmental stabilization: the residential staff need to look at what in the milieu may be contributing to a distressed or threatening environment for Nelson, which may lead to his aggressive actions, which are likely occuring in a dysregulated state. Perhaps creating more clear expectations and structure for Nelson would help him to feel that he is being treated farily, and he may thus be less likely to become dysregulated. Also, treatment needs to take into account his identification with his father, and the feeling that he is imprisoned as his father is. If the therapeutic miliieu were more infused with “signals of care,” and interventions developed that build on his strengths, it might feel less like a prison to him, and create an environment where he can begin to particiate in treatment.
For TST this is a relatively straight forward case. The compliucation is intensity rather than the complex interaction of different service systems as in last week’s case. The occurrence of trauma is not in doubt, its relationship to violent survival-in-the moment episodes fairly clear, and the concrete correspondence of room-abuser to room/cottage-staff is suggestive of a cat hair that is built into residential care. Dynamically the onset of the abuse at the very time Nelson lost his “beloved” father is probably an imprtant factor.
But the first principle of TST that I would invoke in this case is “take care of the team”. Two weeks into his admission and Nelson has already knocked out a child care staff. The very first thing that needs to be done is to address the anxiety and morale of child care staff. If this is not done, staff will find a way, intentionally or unintentionally, to “get rid of” the menace, possibly not before someone else, including Nelson, is hurt. He may require hospitalization, or some other form of respite, or at least 1:1 staff coverage, to give cottage staff time to recover and organize an informed staffing plan that will provide safety for everyone.
It is encouraging that Nelson feels quite safe with some people some of the time and has a variety of strengths. In terms of resilience, the question is how to remove the barriers to these strengths. In terms of cat hairs, the search is on–through moment-by-moment assessment of both Nelson and staff–for the very concrete/fragmented aspects of daily events–place, time of day, tone of voice, physical appearance, how limits are explained, nature of consequences, etc–
that convey menace. With Nelson, this search is probably best carried out in those places and by those people Nelson experiences as safe.
I’m not the sharpest microchip on the Internet – but for the life of me I cannot find find a way to contact you guys to ask about training. Where is it hidden?