Therapy Behind Enemy Lines

Working as a wraparound therapist in one of the harshest milieus any could ever encounter is a struggle most would equate to that of Sisyphus, the poor Greek wretch doomed by Zeus to roll a large stone up a hill only to have it fall back down moments before reaching the top, then forced to begin again, each time unsuccessful, but rolling for all eternity. I have more recently likened it to battlefield therapy, much like military medics administering care in the heart of the warzone, amidst artillery and death. We run out, bullets zipping overhead, into dangerous neighborhoods and torn communities and homes, and try to provide treatment to crumbling soldiers on the precipice of total collapse. How can efficient care be given and progress be made in such a tumultuous state of affairs? How can we make a difference?

Most times clients are referred to wraparound for some traumatic event, or a string of events that have contributed to some degree of emotional or psychological unrest. This is where treatment begins, on the frontlines, addressing the core issue, tying the bandages on and attempting to alleviate the symptoms, fostering some sliver of healing.  Back in the trenches, you try to wrap the family in a splint, giving them a support to lean on as you repair the damage of their broken structure and disinfect the festering wounds in the system in order to facilitate the healing in your client. Soon, you see improvement, softening scar tissue, subsiding sepsis, recovery.

Then, BOOM! Before you know it you are rocked from the mild relief of progress and the small infrastructure you’ve built from ground zero shakes, rocks, then crumbles. Tragedy strikes the family, the client, or the community, and it sends shockwaves through the souls you’ve worked so hard to strengthen. The bomb drops in many forms in the ghetto, but most times it’s usually violence. One bomb dropped not too long ago was a nuclear warhead of sorts. A client and her family, not one I had worked with, lost a sibling, lost a child to gang violence. The family was understandably temporarily demolished; the client thrown back from the blast to a state of regression. But, as nuclear warheads do, the radiation soared through the community, a poison seeping into homes like the black plague. One of my clients was considerably close to the deceased, which brought a surge of trauma as we had been processing the loss of her brother to gang violence that had taken place so many years ago. Another client who had lost her godfather to violence in the hood was distant cousins with the deceased. Progress made in many camps was transgressed and had to be quickly addressed to avoid utter devastation.

The common diagnosis soldiers leave the battlefield with is Post-Traumatic Stress Disorder, but what I’ve come to find is in treating these clients, PTSD is hardly appropriate as the key word in the preceding phrase is “leave.” One must leave the battlefield, or rather be removed from the trauma in order to have post-traumatic stress. So many of these clients are still exposed to that trauma daily; the focus of one client’s treatment was directed towards minimizing a preoccupation with death and fears of dying prematurely. As we gradually made progress, he found himself staring down the barrel of a gun when a young gang member approached him and threatened his life, which sent him stumbling back. Months later after more work, he found himself faced with another gun when two young thugs woofed at him on the streets in a brief attempt to intimidate. Days later he was held at gun point by local law enforcement during a case of mistaken identity when they were patrolling for a young suspect in the area. Likewise, we work with Commercially Sexually Exploited Children (CSECs) or human trafficking victims. In the safety of group homes or jail where they usually end up, most CSEC clients are more protected. Returned to their homes and communities where they were recruited into the life, they stew in traumatic stress as the circumstances that drove them from their homes and into the streets are still ever present, and their pimps lurk behind every dark corner just blocks away, waiting to snatch them up for service again.

If you think such occurrences are possible in any client’s life, you’re right. Any one of your clients may be faced with tragedy during their journey on the couch, one that may be entirely unrelated to past events, current disruptions, whatever they have sought your services for, but one that could dissemble the work you have achieved together in a matter of minutes. However, if you think the possibility of such occurrences is proportionate to all clients of all demographics, you are sorely mistaken. Living in certain climates, such as that of the ghetto, places one at a significantly higher risk of experiencing some alternate trauma in the bog of their original trauma. And sometimes the bomb being dropped is not trauma at all, but another obstacle that prevents the client and the family from progressing up the hierarchical pyramid of self-actualization, such as the loss of food stamps, the cessation of unemployment benefits, the rejection of SSI, eviction, the loss of Medi-Cal, which again, is more prominent in the ghetto. Many times the clock of progress is set back when the focus becomes survival rather than mental and emotional well-being. Without basic needs such as food and shelter, safety and security, health and happiness fade into the darkness as a luxury, not a necessity.

Working in such an environment has its impact on the clinician as well, for you sustain every blow delivered to the clients and families you work with. When bandaging a leg, your patient gets shot in the shoulder, and a slug may nick you in the cheek. Rolling your rock, frustration is a close friend as every step forward you take, you risk stepping on a land mine and every benchmark you achieve may not even exist tomorrow. After you retreat from the frontlines for the day and take a few breaths back at the base, you find yourself wondering if the battle will ever end for them. And you wonder how much more of the madness you can bear yourself.

However in spite of so many setbacks and so many struggles, there is notable progress in these cases. It would be a fantastic dream to hope for perfection and a euphoric utopia, but at times, reaching functionality is the zenith of success in these families. Instilling resilience in the face of adversity rather than expecting that the adversity would dissipate, fostering strength and self-efficacy necessary in battle rather than driving away the dark forces of inevitable war, and planting seeds of hope and dreams in a field of cold, stony debris is what keeps these people going. It allows them to rise out of the trenches, if only for a moment, to enjoy the quiet of the early morning hours before the resounding trumpet resonates through the bunkers, to feel the warmth of the new day’s sun on their face before it is reddened with smoke, and to fight another day. And it is this that keeps you going. I often have to remind myself that this is not typical therapy. Far removed from the safety of a stationary clinic in a middle class neighborhood, the experience is both harrowing and invaluable. Should we survive it, we will have been prepared for any feat in the future of our careers.

Keep Calm and Carry On

Self care when you’re a therapist is important, nay, critical to being successful in a career where you take on the burdens of others throughout the week and shoulder the weight of their woes. In graduate school, there are several brief mentions on discovering your own methods and devices for preserving your strength, emotional well-being, and sanity, but as I’m coming to find in my career, it was hardly enough.

As my career has progressed and I have skipped from one population to the next, I am finding that self-care is not just a recommendation passed down by clinical supervisors and professors, it is a necessity that needs to be fulfilled. And where I work, the severity of the cases we deal with, I believe, supercede what most clinicians will encounter in their lifetime. Most of our children find themselves on the cusp of lock down, either teetering towards being hospitalized or incarcerated, or freshly released from such facilities and attempting to re-integrate back into the general population. They have experienced severe neglect and abuse, are emotionally and psychologically disturbed, some are psychotic, others are delinquents, and a handful are human trafficking victims. They come to you as a therapist and divulge their deepest darkest secrets, detail their experiences of abuse, rage against the world, and look to you for guidance, support, and sometimes even safety and security.

Such a responsibility has been a load I’ve struggled to maintain. Never one to cope with large amounts of stress appropriately, I’ve slipped down the dark road of infinite bitchiness, biting the heads off of my loved ones and prompting my mother to inform me I was “no fun to be around anymore”. I spent nights crying, stressed to the max, just trying to breathe my way through it. But breathing doesn’t suffice when faced with such catastrophes. One incident that drove me to the very brink found a client committing an unmentionable act against another human being, triggering not only an overwhelming amount of anger and grief as I attempted in vain to manage my counter-transference, but touching on my personal experiences and eliciting a cold apathetic response I never wanted to have for any client. My prescription for self-care? A bottle of wine and three tear-filled hours as my stomach churned and tied itself in knots. Later, I tried music, exercising, writing, and more crying, to no avail. A more recent incident had me set in an office, listening to explicit details of sexual abuse as a client recounted her childhood trauma, an experience no one had tried to protect her from and no one tried to stop, though they undoubtedly knew it was occurring. And I left the session devastated.

Some people enlist family and friends for a support system, an ear one can ramble to, a shoulder one can cry on, someone to hold until the nerves quiet. I have found these are short in supply. I don’t discuss my job with my parents too much, given that my father didn’t want me to take this job and my mother can only take so much of my stories. Most people listen to my work days and cringe with a pained look on their face that simply tells me “their stomach is too weak for this”, and I silence myself. Many friends are therapists, however when socializing on a relaxing weekend, one runs the risk of becoming Debbie Downer if they arrive to simply vent and cry about work. Many co-workers, though incredibly supportive, have their own trysts to face and can hardly manage the burden of my grief along with theirs. I finally got myself a therapist, and worked through many struggles, and she also gave me amazing advice I have been trying desperately to implement. It is okay to say no.

Given the difficulties of my job, spending several hours a day with incredibly difficult people, I need my weekends. I need time to recharge my batteries and time to quiet my own nerves. Generally I can manage with one day off, and leave the other for chores, errands, and social events. Other times I need both days depending on how my week has gone, otherwise I know I will be utterly useless for the next week, finding myself on the verge of a breakdown or a panic attack. Adding to my anxiety-ridden, stress-plagued emotional state is my full-fledged status as an introvert. Shying away from too many people, too much noise, and too much activity, I require quiet time to myself with minimal stimuli where I can escape into the recesses of my mind, be alone with my thoughts, wherever they will take me, and avoid the trials and tribulations of the real world. This much needed solitude affords me the calm I seek in order to recuperate. Hence, when people plot and plan various activities and parties on the weekends, as much as I want to be there, sometimes I just can’t. Loud music, hustling bustling crowds of people, and putting on a facade to socialize takes more energy than I can give. And really, sometimes it is a facade. To put on a smile, greet friends, family, and strangers with laughter and a hug is occasionally nothing more than a mask you don, because the reality is you’ve spent the week listening to children talk about being beaten and raped, being neglected and unloved, having their bodies sold for money and drugs, watching friends and family be killed in the hood, or slowly realizing that the odds in their lives are stacked against them. And somehow, you’re expected to put that away, bury it in the paperwork and leave it on the progress notes, go out on the weekends and celebrate as though everything is right in the universe. At times, it simply can’t be done.

However, when I get that invitation in the mail for this and that, I feel an obligation to agree. Maybe it will be fun, I tell myself, or maybe that week won’t be so bad at work and I can enjoy myself. Maybe wine will be provided and I’ll sip a glass in the corner, count that as making an appearance, and sneak out early. If I don’t go, I’ll feel guilty, I don’t want them to be mad at me, I don’t want to neglect the relationships in my life, I don’t want to isolate myself. So, at times I’ve agreed to attend events, and find myself cracking, breaking, even shattering later because that crucial battery charging time was never given. My therapist pushed me to exercise my right to say no. Will the world end if you don’t attend? she would ask, and of course, it would continue on as it always had. Will people be angry if you don’t go? And of course, the answer was yes, and I would face the criticism of those who simply could not understand the struggle of the profession I have chosen, adding to my guilt for refusing the invitation. But does it matter? It’s a work in progress but I am slowly realizing in the end, I need to be okay, at whatever costs.

I love my job, I have always wanted to leave a positive impact in the world and help people. That doesn’t mean that such a journey is a walk in the park. It is an expedition with pitfalls, mountains to climb, storms to brave, and treacherous paths to trek. The job of a therapist is such an important one, the job of a therapist to emotionally and psychologically disturbed children and teens is tantamount to securing the future, an attempt to heal festering wounds and rebuild the crumbling ruins of tomorrow’s society (yeah it’s that important, so can we get a freakin’ raise?). As much as I struggle, I can’t see myself retreating from the front lines just yet, I can’t leave my kids, the fallen soldiers, to die in the battlefield. As big of a pain in the ass some of these kids can be, I care about them, I just need my Me time on the weekends. Likewise, we all need to find what works for us in order to provide the best quality care we can to our clients. Maybe a crazy party is just what you need. Not me, but to each his own.

Répondez, s'il vous plaît? Sorry, my kids went cray-cray this week, see you next time. Apologies, with regret, much love, best wishes. And if you can’t handle that, pucker up and kiss it. Your approval is neither desired nor required.

Wraparound Therapy

As I had mentioned previously, I was on the hunt for a new job to continue my experience as a therapist, and I was being directed down the familiar but at times desolate path towards adolescents again. So ironically enough, with an almost prophetic twist, I have landed in the very treatment approach I had discussed in my blog back in November: the multi-systemic therapy model Richard Mendel had cited in his book, and it seems, theoretically, nothing else can match the caliber of its design in treating these kids.

I have been working in a Wraparound program for nearly seven months. The program consists of a few different facets, several different powers that be and each case goes through a very intricate process reaching into every corner of each case, leaving no stone un-turned. Typically, a referral is received from the county Department of Mental Health, filtered down to them from the Department of Children and Family Services or the Probation Department for juveniles. Once a referral is received, it is assigned to a wrap team and a therapist. The wrap team usually consists of three individuals: a facilitator, a parent partner, and a child family specialist. The facilitator is the overall supervisor of the team and conducts weekly meetings with the family to address needs, improvements, and to monitor the overall progress of the case. The parent partner provides support to the parents of the client and coaches them through parenting skills, connects them to classes and resources, and assists them in dealing with their child. They also provide support in parental needs such as finding jobs, finding financial resources, and taking care of themselves medically and otherwise. The child family specialist acts a mentor to the client, engaging them in positive exchanges and provides support and guidance through every day trials and tribulations, as well as larger difficulties. The therapist, a separate entity from the team, collaborates with them as they provide specialized mental health services to the client. The therapist is also considered the SFPR, or the single fixed point of responsibility, managing the treatment approach of the client and the family. If necessary, following an assessment, a Therapeutic Behavior Specialist coach may come on to provide strictly behavioral therapy to address the client’s maladaptive behaviors.

Unlike most therapeutic services, the wrap team and the mental health team provide services within the community, either in the client’s home, in the school, or out and about in the neighborhoods. There is no laboratory, no sterile clinical office; free will is unbridled, and with the help of the therapist, the client must learn to operate in their natural environments. And, unique from the clinic approach of treatment, given that so many of their problems stem from that environment, the wrap team addresses root causes such as family dysfunction, negative influences in the community, and other environmental factors that may impede treatment. Drawing from Maslow’s Hierarchy of Needs, if the family is lower SES (all are in the service provider area we cover), and the family’s basic needs of food and shelter are not met, the team is able to request flex funds to cover necessary bills (electricity, water, food). Helping the family meet the basic needs will ultimately help the family ascend to the next block on the pyramid by reducing the strain on the family unit and allowing them to focus on treatment. We can also use funds to connect the kids to clubs or activities to keep them out of trouble, such as organized sports, classes, and social events. We’ve even sent families out to a nice dinner who couldn’t typically afford it so they might spend quality time together and foster stronger relational ties.

Given the pitfalls of group homes and treatment facilities I had addressed in my earlier blog, it would seem that this approach is damn near infallible, impenetrable, and practically perfect in every way (yes, if Miss Mary Poppins were an LMFT, this would be her approach). But alas, nothing is perfect, and multi-systemic therapy has it’s short-comings as well. First off, nearly all referrals given to the agency are court-ordered services, either by DCFS or Probation court. Unfortunately we are a voluntary service, which means we cannot force clients or their families to participate, and with most court-ordered clients, resistance is inevitable. Many times we track families like the English on a fox hunt, making several calls, surprise visits at the home, and mailing letters, to no avail. Our only defense is to inform the families that a report will be made to the social worker or the PO and we close out. Whatever comes later will come, but it no longer concerns us. Other times, we have the half-assed participants, people who agree to meet, but don’t necessary complete any interventions, follow up on any recommendations, or follow through with any expectations. Or, once in a great while, we have families who take advantage of every service offered in hopes of helping their child. And we get every type in between. Every case is unique in their circumstances.

As previously mentioned, all of our families are struggling financially, and we provide assistance to basic utilities and bills, as well as clothing and food for the client and their siblings, and word travels fast. Most families come to that question “what can you guys do about my bills?” or “what else can you help me with, like with money?” It’s quite easy to take advantage of this aspect of services and it’s a lifestyle most kids are adapting to in planning their futures, seeking out government assistance rather than pursing goals and ambitions.

Wraparound services are not for the meek or faint of heart. Children who generally qualify for wraparound are not simple cases of mild depression or disobedience. Most cases have heightened severity, some to a degree most clinicians will never be faced with in the length of their careers. Referrals and case histories are littered with tales of woe and horror above and beyond basic cases of neglect and abuse, sadness and despair. I have had to begin my own personal therapy to cope with the cases I take in, and it’s a wonder therapists can survive in such a field, let alone thrive. My future in this career is well armored with a harrowing experience in the trenches that has prepared me for any feat I will face in the years to come.

Another factor of wraparound is safety. Leaving the confines of a protected and public clinic, we clinicians venture out into the concrete jungles of projects, ghettos, and crime infested cities. It is not uncommon to see gang members patrolling their territory, crack heads pan-handling for their next hit, expansive homeless camps of tents, used rugs and curtains, towels and sleeping bags, and police. Violence is not in short supply in the hood. During one session where I was playing baseball with a client in the grass area of a project, I observed an individual across the street, stepping out of his apartment, stuffing two nickel plated 9 millimeter guns into the waistband of his boxers. I quickly decided it was time to go inside. We are constantly faced with balancing personal safety with obligation to our clients. Sometimes our obligations leave us no choice. Much to my clinical supervisor’s apprehension, I transported a client in my car who had a green light on him (meaning he was marked by a gang to be killed) because I couldn’t bear the guilt if something had happened to him walking home after I left him on a distant but safer street corner. Sometimes we go into the community because we know we need to. Other times we have had to suspend services because safety concerns prevented us from visiting that area or that family.

The most difficult aspect of wraparound is the intimacy of the service. In stark contrast to clinic-based services where you see a client (and maybe the parent, if it’s a child) for one hour a week on a couch, in wraparound you are immersed in the home and the lives of the client and their family. You go beyond the one dimension perspective you develop in the office and see their entire world and every thing it in. You can’t help but become attached to the family, and when they struggle, you struggle. When they hurt, you hurt. When they experience a loss, you lose. One family (not mine) lost their teenage son to gang violence. Though the son was just the sibling of a client and not receiving direct services, the loss was overwhelming for the treatment team on the case. One of my families was left battered by fate who dealt them one devastating blow after another, and the team felt every impact with them. You return home feeling worn and emotionally bruised.

So why when an approach seems so riddled with complications would one continue? Because even though we have some families resistant to services, we have others just begging for help and willing to do whatever it takes to help their children and rebuild their homes. Because even though we have families who take advantage of good intentions, we have some families who only ask for financial help when they truly need it, and who are generally hard working people just struggling in a recession. Because even though we worry for our safety, someone has to go to the battlefield to save the fallen, otherwise they’ll never be able to crawl out to save their own skins. Because if we can survive this, we can survive anything. And because as clinicians, it is our jobs to, at times, disregard what was drilled into our skulls about cold and calculated professional conduct, cross the boundaries, and just share the pain and suffering with our clients. Because, in spite of flaws beyond the model’s control, wraparound is the best answer and probably the only answer we have.

At times, I don’t know how to continue with my job. At times, I go home and break down crying and rip the heads of my loved ones off for no good reason. At times, I admittedly just want to come home, crawl under the covers of my bed and never come back out. At times, I can’t wait to go to work because I love my co-workers and they support me and make me laugh when I need to get through it. At times, I can’t wait to see my kids. At times, I get to take my kids to the park or the beach and I love being out in the fresh air. At times, I see a genuine smile on my kid’s face, or hear genuine laughter, and I know this is where I need to be right now. Maybe not forever, but right now, in this moment, with the ups, downs, and way below downs, it’s what’s right.

Spare the Rod or Spare the World?

Originally Published: 7/4/12:
To spank or not to spank? This has been a long debated topic for years as political correctness, child psychology, and big brother government have crept into your home in the last generation or two, leaving parents scratching their heads in determining the best approach for disciplining their children. A recent study has come out, echoing the findings of studies before it, stating that spanking can lead to a multitude of issues for your children, including anger management problems, increased aggression, low self-esteem, mental illnesses, and a general distrust of their parents and any others they will eventually develop future relationships with. But how detrimental is spanking?

A recent study published in the Journal of Pediatrics claims that individuals who were “physically punished” as children have been shown to be more likely to suffer from mood disorders, anxiety, substance abuse, and personality disorders. Previous studies have also claimed that these individuals are more likely to “hit their spouse and/or children and engage in violent and criminal behaviors”. Any parent reading the laundry list of risks would probably be subject to a panic attack and immediately ban any form of corporal punishment, or as they say, “physical punishment" in their homes. But what is “physical punishment”?

The article lists physical punishment as “slapping, hitting, pushing, and shoving”, the operational definition of which, it would appear, goes beyond the traditional swat on the butt most of us were probably used to growing up. In fact, many previous studies seemed to have difficulty defining physical punishment and drawing the distinction between general spanking and certifiable child abuse. Even famed child psychologist Diana Bamrind (the queen of parenting styles) cited the faulty methodology in these studies by noting that one study in particular grouped general spanking disciplinary styles with physical contact that left bruises, welts, and even drew blood. Mixed and melted together, the harsher forms of discipline (child abuse) overshadowed simple spanking on the rear-end, and the results demonstrated severe adverse effects in the overall sample population. However, given that the general public comes to learn of these studies through mass media (CNN, Time magazine), sources which glaze over the details, they are never given the full account of the study, its faults and short comings, operational definitions, or the demographics of the sample population used. Once traditional spanking was taken into account and those children who were merely swatted on the butt were examined alone, they were found to be no more maladjusted than other children who were not spanked.

Parents today and of generations past frequently argue that they were spanked as children and they grew up just fine. Many of us did. A good whooping put the fear of God into us and we never committed the same crime twice. Well, sometimes we did. That was all part of the learning process and well, let’s face it, just being thick-headed. But is spanking effective? Studies that have been able to cipher through the muck of abuse and spanking have shown that while spanking is not detrimental to children’s well being, it is no more beneficial than children who are disciplined in other ways, such as using positive and negative reinforcers and punishment. However, I think it is fair to argue that parenting and disciplinary styles are not a one-size fits all, and various approaches need to be tested to find the most effective intervention for your own child. Some children respond well to token economies for rewards and doing chores on a Saturday afternoon when they’ve misbehaved. Others require a more forceful intervention to leave a lasting impression. That is not to say that spanking should be a knee-jerk reaction, utilized for every slip up and misstep, but it may be necessary to employ it once in awhile. It is a parents’ choice to find what method works for them.

Unfortunately the government doesn’t necessarily agree, and studies like this only pave the way to allow the government to tighten its grip on our individual freedoms. As the lines of child abuse and discipline grow significantly more blurred, social services have been putting in more footwork to prevent parents from lifting a finger against their children, claiming child endangerment. As the disciplinary action has been criminalized, more and more people who continue to spank are doing so behind closed doors, too afraid to react to poor behaviors in public for fear of some by-stander reporting them to DCFS. Should parents feel reluctant to intervene, glancing over their shoulders before dealing with an unruly child as they see fit? One could never know how to react as society polarizes.

As previously mentioned, many people were spanked and found no significant harm in it. Others have taken today’s studies and their findings and agree spanking is wrong and reflects poorly on parents. But let’s be real here, most of us have heard that screaming crying child in the store, tantrums and all because they could not get the toy they wanted. Many of us curse that parent for doing absolutely nothing: allowing the child to continue screaming or giving in, gently trying to soothe them when all we really want to say is “what that kid needs is a good whooping”. Others have seen spanking and tsked the parent for being too aggressive. What constitutes good parenting anymore? No one seems to know, so why not leave each to their own? Just spare the world of your crazy brat!

Now let me clarify my position once more. I have been spanked, I have been abused. I have worked with kids who needed to be spanked, I have worked with kids who have been abused. I have spanked my nephew, I would not call that abuse. I find the two disciplines to be mutually exclusive. Thus I am not advocating for parents to beat their children, nor am I ruling the idea of physical contact out entirely. Any “intervention” that leaves a bruise or a welt I am completely against. Any physical contact that lands anywhere but on the butt I am not okay with. A slap, a swat, a flick has no place anywhere else. A spanking completed with anything but a hand is unacceptable in my book. Many people from the older generation are used to the tangibles approach: the use of a switch, a belt, a shoe, even some I’ve spoken to have listed extension cords. Everyone remembers paddles, my dad came from a generation where even teachers could spank in school and his mother gave verbal permission for them to do so. Again, not acceptable for me. But trust, if you are on one, you will get one in my house. During a recent discussion with a woman I met, I argued that my nephew would be spanked for "deliberate disobedience", explaining for example, that if he made a mistake and broke a rule such as running into the street accidentally, he would be disciplined other ways. However, a factual event found my nephew standing on the curb and me standing behind him repeatedly telling him not to go in the street. He thought it over for minutes, glancing back and forth between me and the road before taking a flying leap into the streets. He was spanked. The woman argued that I had challenged him by telling him not to go into the streets, thereby inviting the disobedience and the spanking was unjustified. Yeah, I challenged him not to become roadkill. Next time I'll be sure to sit him down over a nice cup of cocoa, hand him a toy so his feelings aren't hurt, and explain to him gently why he's in a body cast.

We all need to learn to take these studies at face value and use them as a supplemental guide, not our holy book of parenting. We all need to acknowledge the difference between a spanking and abuse, and recognize in ourselves when we might be crossing that line. We all need to remain open to other techniques and styles that may prove just as if not more effective, and keep our options open. And we all need to keep in mind that at the end of the day, if your child is a brat, what you’re doing is not working. A swat on the butt will not bring out the next Charles Manson in your child, but avoiding one won’t breed the next Ghandi either. Whatever you do to put the fear of God in your child, remember, at least you’re not throwing them out of Eden and condemning every female after them to excruciating child birth and making them wear clothes and...well I guess the clothes thing had to happen...all I’m saying is the summer’s getting hot. Yeah. Just do what you gotta do to keep your kid from screaming in Target and ruining my peaceful shopping experience, please and thanks.

The Cold, Callous Child: Sociopath in Training

Originally Published: 6/26/12:
To act without emotion, without a sense of empathy, with little concern for the pain one causes another and even an almost obscene enjoyment of harmful acts. These are symptoms usually reserved to describe most individuals with sociopathy today, also known as Antisocial Personality Disorder. As with most personality disorders, there are age requirements and limits to meet the criteria for diagnosis, and with APD, one must be at least 18. So what happens before 18? It has been shown through most studies that those who qualify for APD as adults presented with symptoms of Conduct Disorder as children. Both are categorized with symptoms of criminal behavior: harm to others, theft and property damage, serious rule violations, deception and defiance. But one key symptom seemed to have been left out of Conduct Disorder that presents in APD: lack of remorse. While most children with Conduct engage in maladaptive behaviors, there is usually resulting remorse or regret, even if it’s simply the fear or disdain of the punishment that inevitably follows. Additionally, studies have demonstrated that most children eventually grow out of such behaviors by the age of 21 rather than progress to the more chilling diagnosis of APD. However, aside from Conduct Disorder, there is no other diagnosis that can accurately diagnose children presenting with possible Antisocial tendencies. But is that to say it doesn’t exist? Can children be sociopaths and should we diagnose them at such young ages?

In my line of work as a therapist working with severely disturbed children, I have handed out many diagnoses of Conduct Disorder and all kids have had similar symptoms as well as similar origins. Most are given this disorder due to serious rule violations (truancy from school or running away from home), deceitfulness (lying about where they are going), theft (stealing from family or local stores), and other negative activities such as drug use, gang activity, etc. One last category included in the diagnosis is of course harm to other people or harm to animals. In nearly all my cases, harm to others has included fighting with peers at school; in rare cases, it was fighting with staff at their school or group homes. All were impulsive acts, poorly thought out, all fueled by anger or pain, and while some did not openly express remorse toward their victims, there was an element of emotional response: anger for being caught and punished or blame toward the victim for upsetting them (typical to avoid self-blame and thus remorse).

In Antisocial Personality Disorder, aggression and acts of violence towards others are rarely impulsive. These behaviors are usually planned and carefully calculated. A premeditated act, there is no crime of passion or rage, just cold, undeserved punishment against some defenseless victim. A good example of such would be Timothy McVeigh, who for months plotted a terrorist attack against the Alfred P. Murrah Federal Building in Oklahoma City. He had no particular victims in mind, no one who upset him other than the US Government. McVeigh detonated a car bomb which caused over $500 million in damage and killed 168 people. When he learned there was a daycare in the building, he wrote the lives of 19 children off as “collateral damage”. He remained calm and collected throughout his arrest, questioning, trial and death. In the remaining years of his life before being executed, he never expressed remorse for his actions.

While it is difficult to imagine a child as cold-hearted as McVeigh, to assume that such characteristics arise purely in adulthood is absurd. Signs and symptoms present themselves early in life. Ted Bundy had such an incident when he was 5, where he stood by his aunt’s bed while she slept. When she awoke, she found him with a devilish grin, watching intently. As she became more alert and aware of her surroundings, she found that she was surrounded by a collection of knives laid on the bed, points directed inward toward her. The book “Children Who Kill" also gives several accounts of disturbed children engaging in acts of cold murder and torture far beyond typical problem children. And I have had the unfortunate business in my 21 months of work as a therapist to come across two such kids.

Both were six years old. My first was much harder to diagnosis: he presented with a mosaic of symptoms, bits and pieces of disorders never quite coming together to conclusively provide one concrete diagnosis. His symptoms ranged from possible autism, Aspergers, or developmental delay, Conduct Disorder or Oppositional Defiance, anxiety, depression, or bipolar disorder. He was moody, most times without antecedent, which would throw him into fits of rage that would last for several hours, or an abundance of depression, triggering crying fits for days. He also presented with a remarkable ability to control his emotions and behaviors, having fits and tantrums at home but not any issues at school. Even in a brief exchange during therapy, while I was explaining that therapy was a safe place to talk about our thoughts and feelings, he angrily retorted “I KNOW!" Taken slightly aback by this abrupt outburst, I calmly addressed it, asking why he felt so frustrated. His physique changed in the flash of a moment: his hunched shoulders sloped, his furrowed brow relaxed, his expression almost angelic, and he sat back and cooly responded “Nothing, I’m fine”, as if he had been caught with his hand in the cookie jar and tried to cover the evidence. He acted aggressively towards his younger brother, 3, whom he would drag around the house from room to room on their tile floors by a small limb, or whom he would calmly walk up to him and without warning scream inches from his face and frighten him to tears. Previous therapists could not pinpoint a disorder, and my task was no easier. While my supervisor pushed for Conduct, at the time to me a conduct disorder diagnosis was a life sentence on a dark road to sociopathy. He was given a provisional diagnosis of conduct, but it wasn’t until 8 months later that I was no longer given an option. A call from his frightened mother informed me that he had killed a duck at the local park, and she believed it was intentional. While somewhat fantastic, she relayed the tale of woe, that he, a pitcher for his local little league with a strong arm, had collected a pinecone, approached a duck by the riverbank, and threw the pinecone full force at the duck’s head. The duck began seizing, no doubt from a hemmorhage, and flopped over in the water, dead. Mom reported he did not seem phased by the incident and did not show remorse. When I later asked him what his intent was, he stated he “wanted to see what would happen”. He later confided that he had the option between the duck and a turtle that was also in the water, but noting the turtle’s protective shell, he stated “I knew if I hit the turtle, nothing would happen, he would just swim away, so I threw it at the duck”. Chilled by this calculated thought process, I reluctantly listed Conduct Disorder on his file.

My most recent case, I cannot go into detail with given that the case is still open, however he presents with a less complex case, nearly no mood lability or developmental delay but similar symptoms of disturbances which resulted in the death of an animal. Both children we exceptionally bright, both came from families with histories of significant mental health issues.

What has become apparent is that in comparison to my typical conduct cases, these children are in a class all their own. While Conduct Disorder has been generally considered the childhood APD, the connection between Conduct and Antisocial Personality Disorder is built on nothing more than a mere resemblance of one another. As previously stated, APD lacks the crucial component of humanity: empathy and care for one another, regret and remorse for our own behaviors, which is not necessarily reflected in CD. But even if the DSM could create a more appropriate diagnosis for children presenting with sociopathy, would the field allow it? Much like my reluctance to diagnose a 6 year old with such a dismal label, many others would most likely be just as apprehensive to diagnose a child with a damning sociopathy label. But as with my dilemma, my concern for labeling a patient and my hesitation to do so did not bring that duck back to life, and it did not make my patient’s difficulties disappear. If anything, it only delayed receiving more appropriate treatment. While labels can be hurtful, refusing to diagnose for fear of social stigma can be far more detrimental and as a therapist it is ethically unsound.

Dan Waschbusch, a researcher at Florida International University, has continued his study in children presenting with similar symptomology as my cases, and even one child named Michael was an almost exact replicate of my first kid with moody lability, hysterical outbursts, calculated aggression and violence toward his siblings and amazing mood control. Waschbusch described the condition as “Callously Unemotional Children”, and began a research camp where many children with the same affliction were sent to be observed and treated. The level of manipulation was immeasurable and bringing these children together could have been a recipe for disaster. Many children ended up worse, some remained the same, few improved, though Washbusch maintains that early intervention and intensive treatment could drastically improve the chances of these children growing into productive members of society. I am not so sure that I agree at this point and time, as an effective treatment cannot have been developed yet; typical behavioral interventions are probably ineffective as a simple system of rewards and consequences mean little to children who struggle with apathy. Certain medicinal interventions have been ruled out such as Ritalin, which would decrease any impulsivity the child suffered from and allow them more time and mental clarity to plan and coordinate more intricate attacks. In residential or treatment facilities they would be grouped with other children either with the same symptoms which they could pair with and learn from, or in facilities with children of different diagnoses they could dominate or harm. But no one wants to write any case off as being hopeless or untreatable and we have to try, at the very least to intervene when it might still make a difference.

It is impossible to claim that Antisocial tendencies don’t exist in children, and it has been demonstrated that it is inappropriate to lump preliminary APD into the Conduct Disorder category. On the other side of the scales lies the concern of wrongly diagnosing a child. What needs to be developed is not only an appropriate diagnosis and supporting criteria, but diagnostic tools to assist in accurately recognizing this disorder in children. Only when that path is paved can we begin to explore and create more effective treatments and help these kids before it’s too late.

Troubled Teens and Jaded Juveniles: Failing Our Kids Part 2

Originally Published: 11/14/11:

The ominous situation most juvenile delinquents find themselves in is that no better than the punishments typically reserved for adults. Though some may think that Juvenile Hall is a playground for the young offenders of today, the nature of the environment is unfortunately exact to the nature of prison. There is an element of survival, a hierarchy one must navigate through in the social construct of federal and state reprimand. To prove oneself, through acts of structural defiance, acts of loyalty, and further criminal behaviors, is to guarantee one’s protection. Other times watching and learning the inner workings of the placement assists the convict in manipulating the system to best meet their needs. And such behaviors are hardly limited to imprisonment.

As an alternative, in order to provide juvenile offenders with a better opportunity for self-improvement and successful reintegration into society, many convicted delinquents are sent to behavioral treatment facilities, high level group homes, and work camps. Through tightly structured days, afforded slightly more intervention and support than that found at the Hall, these facilities were ideal compared to the juvenile prison. But it was far from perfect, and here, the kids are expected to grow and fall on the right path. But what really are the odds?

One event I noticed on occasion both in my work with the teen girls at the BT facility and working with the male juvenile delinquents at their facility was that at times, teens are misplaced for one reason or another, a decision that compromises their future. With the boys, I found one young man placed in the facility for a very minimal offense (stealing a bike and truancy from school), though the rap sheet of his peers typically included robbery, grand theft, drug dealing, assault with a deadly weapon, and in one case, manslaughter. Though we were a level 12 facility for the girls with specific behavioral criteria for admission, some girls were merely placed with us because extraneous circumstances left them with no better placement. They had mild behavioral issues, usually depression, but significant medical issues such as diabetes or epilepsy, conditions far too risky for a level 10 or 8 home. Therefore they were placed with us, though we were no medical center either.

When it came to the young man, achieving protected status in the dormitory of 24 other delinquents became his priority. A typical 13 year old, he was well-mannered, polite, seeming to be of middle-class status, and terrified of his new surroundings. When a fight began to ensue between his roommates, he did what he believed to be the right thing, alerted the staff member on duty. Unfortunately for him, in this society, he was now labeled a snitch, and became a target. After one beat-down, he quickly began what Jane Goodall would refer to as displaying in the chimp community, proving his worth by showing off his machismo. He began to break rules, disrespect staff, and fight with other clients to climb the social ladder. After proving himself, he was accepted into the protective circle of the thug society and was deemed a pain in the ass by staff throughout the facility. After a confrontation between him and other peers took place, fearful that he would be moved to the Hall, he ran away from the facility in the dead of night and I never heard of him again.

With the girls, while there were several instances of behavior changes to graft a niche into the group home society, one behavior I typically observed was the modification to get one’s needs met. This is where the key element of the Social Learning Theory, first presented by Albert Bandura, comes into play in these environments. Individuals observe behaviors others engage in, note the pay off of the behavior (are they punished or do they receive some kind of reward) and in turn imitate the behavior themselves.

When girls were placed in our facility who really didn’t belong there, they were typically the better behaved kids who followed the rules, went to school, completed chores, and offered to help around the facility whenever possible. While staff attempted to provide as much praise and rewards as possible for their efforts, it becomes difficult to give the individualized attention these teens so desperately needed when 17 or 18 other girls in the house were acting out. The girls who were more problematic were constantly requiring attention, redirection, and crisis intervention, and it didn’t take long for the better behaved girls to become frustrated, as they should have been. “I’m doing everything I’m supposed to be doing, and yet I’m invisible.” I imagine they concluded. Eventually, they made themselves heard. Resorting to similar behaviors, we had several girls display about the house, sheepishly throwing objects at windows that never broke, spraying fire extinguishers, and threatening to kill themselves by jumping off the second story balcony, after which they would march to the balcony and hesitate, glancing over their shoulders to see if we were following. Naturally, whether or not we knew they weren’t serious, we were obligated by company policy to follow, and reinforced their attention-seeking behaviors. Once, however, when we became distracted with another girl threatening to kill herself, the one who had dashed off to the balcony realized we were not coming to rescue her, and returned, loudly displaying in the hallway, stomping her feet and cursing. Eventually behaviors escalated in severity, and the girls rarely returned to their sweet dispositions.

Though social problems in the group homes and treatment facilities largely contribute to exacerbating the issues these teens are faced with, it seems they are set up for failure right from the start by being placed in these facilities to begin with. It was mentioned in part one of this blog that compliance with the teen girls was difficult to come by. With the boys, it was not quite so hard. Given that these boys were placed in this facility as an alternative to the Hall, they understood that whatever problems they faced here, they were much worse there. With the threat of being replaced in the Hall looming, they were more motivated to try. As previously mentioned, the structure was tighter, interventions and support was more readily available in order to help these kids. In other words, they were placed in a laboratory.

Every moment of their day was planned out for them, from getting up in the morning to breakfast, school, group therapy, activity, showers, homework, dinner, more group, and sleep. Their roommates were carefully selected, they had emotional support and guidance from staff, and limited temptation from outside sources. They were removed from the environment that created so many of their issues to begin with: friends who were bad influences, families who were dysfunctional and damaging, freedom and free time to make bad decisions. What else could they do but succeed in such an intricately designed program? Many still struggled as they found other ways to get in trouble: fighting, gambling, refusing to attend school, being disrespectful to staff. But when you take into consideration the things they were placed there for, these offenses pale in comparison. They thrived in a strictly controlled environment.

After their time is served, however, they are returned to the defunct natural environments that bred them. They go back to their broken homes, back to their crime-riddled neighborhoods, back to the friends whose opinions mean so much and who always have access to drugs and booze, back to unlimited free will with little motivation to make the right choices in everyday life, and left without much aftercare. No one bothers to come out and check on them, no one bothers to take time out of their day to keep them in line. If they don’t go to school, no one really cares. If they don’t do their homework, they rarely have anyone to answer to; no one holds them accountable anymore. How long do you believe it takes them to revert to their previous lifestyle?

Such is the problem for adult convicts as well, and is a distinct answer to the question of rampant recidivism in prisons and juvenile halls. You cannot take an unruly chimp, teach him how to behave in a cage, then release him to the world and expect the same results you achieved in lockdown.

A better alternative, argued Richard Mendel in his report Less Hype, More Help: Reducing Juvenile Crime… was instead of removing the teens from their homes, to provide care within the natural environment. Offering therapeutic treatments in the home with the entire family, assigning a mentor to keep close tabs on the teen, and facilitating a collaborative effort between the multiple facets in their lives, such as family, teachers, and outreach programs, Mendel believed that the individual had a higher chance at success. The program’s therapeutic approaches, titled Multi-Systematic Therapy and Family Functional Therapy, addressed the issues at the root of the presenting problems, and guided the teen to make better independent choices in the current environment, instead of within a superficial one where the possibility to make their own choices was significantly reduced, thereby teaching them nothing. After longitudinal studies were conducted, not only did these programs prove to be more effective than treatment facilities and group homes, they were also significantly cheaper, costing anywhere between $2,000-5,000, whereas facilities and homes cost approximately $50,000 annually.

Granted, placement in this program is not appropriate for everyone, higher risk offenders that have been convicted on charges of violence, for instance, need alternative placement, but many of the offenders for drug use, minor theft, and behavioral issues such as truancy would benefit from it, rather than being placed in “criminal college”, where they will learn to be better convicts from more seasoned offenders, where their behaviors only get worse, and where emotionally, they’re as lost as they ever were.

So the question now is: when are we going to save them from themselves?

Troubled Teens & Jaded Juveniles: Failing Our Kids Part 1

Originally Published: 10/26/11: 
As I begin that perilous feat of pounding the pavement again in an unstable economy, I find myself reverting to positions where I hold the most experience: severely emotionally disturbed teens in foster care. Spending over two years working and volunteering with this troubled population, most of which were delinquents by one measure or another, I found the time to be often unpleasant, but invaluable. I was exposed to the dark world of child abuse and neglect, the typical underlying causes of behavioral problems and psychological disorders. I was frequently abused myself, be it verbally or physically, a punching bag for children who had no one else to lash out at. But, even in most difficult times, I found myself fighting to be the stability these children so desperately craved, the mother figure who disciplined and loved unconditionally, the parental figure who applauded good math grades and held numerous correctional meetings with principals and teachers, the mentor to guide them down the most beneficial path available to them, most of which were in short supply. Unfortunately, time and time again, experience proved there was little if any hope for lasting improvement in their lives, be it the group home, the treatment methods, or the environments they would inevitably be thrust back into once their time was served. This was a reality that threw me into a depression and I find myself asking if this is really where I need to go again.

Given the shortage of viable foster families, most mildly troubled teens are placed in group homes. These homes are evenly numbered in terms of severity of behavioral issues, going from 6 to 14, above which you find juvenile hall or psychiatric placement. Children are removed from biological families for various reasons: child abuse, neglect, criminal behaviors, or even voluntary placement when the parents have determined their behaviors are far too unmanageable for them.

Unfortunately, most group homes are in short supply as well, therefore more severe children are placed in lower levels that are not necessarily capable of providing the children the supervision or interventions required. Once I worked in a level 12 facility, typically reserved for teen girls suffering from depression, self-mutilation, anger management issues, or in recovery from drug abuse; however given the lack of adequate facilities, we were accepting intake patients suffering from suicidality (one girl was brought to us after attempting to hang herself in her basement with an electrical cord), bipolar disorder, aggression and assaultive behaviors (one client had recently been released from Juvenile Hall for stabbing a peer with a screwdriver), continuing drug use (a social worker dropped a client off at our facility still high after a three day bender on crystal meth), schizophrenia, mental retardation, and even autism. For the most part, we didn't know how to handle our clients; we were not properly trained and found ourselves struggling to do our jobs the best we could. It was frustrating, to say the least.

The behavioral interventions in place to manage these kids were largely ineffective. A hierarchical grading system providing four levels of achievement or failure, finding the rewards lackluster and the punishments unenforceable, the kids ignored our feeble attempts to discipline them. Level A, the highest level, promised rewards of larger weekly allowance ($20), more phone time, a later bed time, and the opportunity to take part in an outing reserved for high levels, usually a cheesy weekly trip to the mall or movies, once in a great while a reward of a night at the theater or an expensive theme park. Level B was largely the same, though slightly less allowance ($15). Level C was lower status, less allowance still ($10), restricted phone time, earlier bed time than higher levels, and participation in a weekend activity that was also usually quite pathetic, a trip to a skating rink, perhaps a few hours at the local arcade they frequent every month. Level D/C (Daily Contract), has a minimal allowance ($7), restricted phone time, earliest bed time, and losing the chance of any activity on the weekend, instead participating in group therapy taking responsibility for whatever action landed them on D/C status. Levels were determined collectively in group therapy sessions, whereby the individual's progress for the week was reviewed and their status voted upon by their peers.

While it seems fool-proof, the system is heavily laden with problems and flaws. First being the horrible reward system in place for high levels, most didn't care enough to work for activities they hated, there was no point in staying up late because the TV was broken, and though larger amounts of allowance were given, they were only permitted to have no more than $20 in their possession at any given time, therefore any more money was locked up out of reach. Lower statuses hardly cared for the punishments. Having hardly any privileges at all, there was little they could lose. Understanding limitations of our power, the girls realized we could not physically force them to bed, so most stayed up as late as they wanted, playing in their rooms with their friends, while staff stood in the doorway, doing the only thing they could: redirect them to bed until we grew tired enough to leave them alone. Finding that legally we could not restrict them from using the phone to call family, they typically requested to talk to "relatives", most of whom were probably friends and boyfriends. The state of California requires that children in foster care are given a minimum of $7 weekly for allowance. For those on D/C, usually for running away or not following the rules, $7 was more than enough for bus fare to any friend's house for the weekend, doing drugs, drinking, eating whatever they wanted, watching TV whenever they chose, only to return to the facility, remain on D/C level, and continue the tirade next weekend. Daily Contract also allowed the girls to complete a series of chores for access to any one privilege for the day: cleaning the house could mean time on the computer, going on an outing, or any one of the privileges afforded to high statuses. This usually meant momentary good behavior, which immediately returned to typical delinquent behaviors once the reward was given.

Additionally, there were a few aspects of the program that continually interfered with our interventions, one being day treatment classes. Every Tuesday and Thursday, the girls engaged in day treatment, which meant an off-site activity, usually to the mall or movies during the winter, to the local pool or beach during the summer. Though it was said to encourage appropriate behaviors within the outer community, not only was it ineffective (we were frequently banned from various venues for disruptive behaviors), but knowing that they would have the opportunity to engage in bi-weekly activities, motivation for additional activities was minuscule. Why work hard for a trip to a tar pit museum on the weekends when you know you're going to a nail salon to get a manicure for day treatment? Especially since Day Treatment was considered an integral part in their program, we were not permitted to pull the girls from it; it was a guaranteed activity, no matter how poor their behaviors might have been.

Likewise, state laws and restrictions interfered. California state law prohibits staff from taking clients' property from them without their permission. We soon found that this meant we could not confiscate desirable recreational items such as portable DVD players, radios, iPods, laptops, skateboards, etc. when a client was misbehaving. Though we frequently removed radios as they were a source of high motivation and clients would do damn near anything to retrieve them, we were instructed to replace them all. What parent could be successful in child-rearing if unable to take anything away from their child?

Given the problems that continuously presented themselves, we soon found the program was an expensive facade, and most of the administration was consumed with making money, not helping these teens. In the time I spent at one agency, a 43-bed facility, probably more than 150 girls rotated through the houses. Only one was successfully rehabilitated and reunited with her mother. One. The numbers don't lie, and yet hundreds of thousands of tax payer dollars are thrown into this black hole every year. The future for these girls is bleak and hazy, emotionally unstable and alone in the world, they are ticking time bombs waiting to self-destruct. And the plight for juvenile delinquents and society as a whole is no brighter...

The Anomalies of Normalcy

Originally Published: 7/2/11:

Normal. The word makes one cringe when they hear it. A word that should have every positive association attached to it carries a hoard of negative connotations when you realize it is a term that doesn't apply to you. A social definition of what is deemed acceptable behaviors and appearance in one's host culture, what is normal is rarely black and white; the boundaries are blurred and surrounded by a sea of gray. Its idea changes from person to person, family to family, to neighborhoods to states and so on; it is hard to know where you stand in the scheme of things and your placement is always determined by someone else, and is always changing.

There is often a movement somewhere in the world that sets out to magnify our differences. Highlighting how unique we are from one another, they call attention to wonderful qualities and talents that help us stand out, so we don't feel that dreaded monotonous sameness the Nazis once dreamed of. What these programs don't warn against is the risk of being too different. "Express yourself!" (but not too much), "Follow your dreams!" (except those dreams), "Love whomever you want!" (but not that person), "Be yourself!" (wait-not that self). And the people who dare to step out of the bounds of acceptable uniqueness are the individuals who are, in essence, excommunicated from society. Met with stares, frowns, abusive remarks, and even pure avoidance, those who go against the grain become isolated, save the small circle of friends with similar quirks who accept them without judgment.

In being a therapist, our business is Normalcy. Leave the people who are normal alone, make those who are abnormal become normal, with the help of societal standards and our handy dandy DSM IV TR (another socially determined collection of defined categories of normal). When a patient comes to my office, I am essentially charged with a Caesarian rule: thumbs up or thumbs down, sane or crazy, normal or abnormal. But how does one truly know what is normal? In one psychology class we were asked to develop a clear cut definition of normal, and few if any could compose an accurate representation of such. So who are we, above anyone else, to wield the power of labeling people who might just be different?

Working predominantly with a severely autistic population, I am exposed to the rare black and white that most of us can't see when it comes to determining "normal". Normal becomes survival in society, the ability to talk, the ability to communicate with others one's own thoughts, feelings, and needs without bursting into tantrums of frustrated screams and physical aggression, and most importantly, the ability to develop and maintain relationships with others, because we are, at our cores, a social specie. But once we gravitate to higher functioning autism, and even Aspergers, one is met with opposition to such labels of anomalies. Thought of as socially deficient, these individuals have found peace with their diagnoses and have learned to function in society without seeking or desiring a cure. They may struggle with interpersonal awkwardness, as we all do at times, but they are content in living their lives as they may, with or without judgment from others, and wish to be left with their oddities and idiosyncrasies.

The problem is, we all at one point or another want that normalcy. We want to fit in, we want to be like everyone else, we want to belong. In these times of desperation, we are given to sacrificing ourselves for that comfort of having a niche. But our uniqueness is what sets us apart, even if those idiosyncrasies are not always shining beacons for model citizens. Sometimes our idiosyncrasies are abnormal, and downright crazy, sometimes they annoy the hell out of the others around us, but what would the world be without them? Without van Gogh's inability to fit in, we would not know the pain-driven beauty of his creations. Without Emily Dickinsons' need to isolate herself from the world, we would not have her devastatingly breathtaking poetry.

While I can hardly compare my blogging and sporadic poetry to art, writing is my creation and my best way of communicating with the outside world when my mouth and my face can't say what I long to. I may be odd, but oddities create art, create beauty, and create change. Those who are different are the ones who make history, those who conform are the ones we forget. And yet, when they are living, the world is confounded by them, they challenge the balance of things and are usually scorned. Embrace them. The strange child of today can grow to be the quirky genius of tomorrow.

Children Who Kill

Originally Published: 4/19/11: 
Twelve years ago today, a small town in Colorado became temporarily notorious. Mention it's name out of context and many won't be able to place where Littleton is, let alone why it is infamous to begin with. But, on April 20th, 1999, no one could think of anywhere else after Eric Harris and Dylan Klebold glided onto the Columbine campus armed with semi-automatic guns and several home-made bombs that were strategically placed in the building. After just a few short hours, with both boys dead from self-inflicted wounds, they had succeeded in killing thirteen innocent people, and injuring twenty one others.

After this tragic incident, accusations were flying everywhere, everyone searching for something or someone to blame, and most people getting it wrong. From the goth culture to heavy metal music, from video games to psychotropic meds, the media hit each and every viable possibility and shoved it down the general public's throat, simultaneously demonizing the shooters and society as a whole. The one point of focus that probably carried the most merit faded into the background: school bullying. Social outcasts who were ridiculed every day, humiliated and hassled, labeled with homophobic slurs, they eventually reached their breaking points, as many in their positions do.

In reading the book Children Who Kill by Carol Anne Davis, I've come across many similar stories of seemingly sadistic cold-blooded murderers who, in a moment of rage or in simple remorseless apathy have killed innocent people. Some stories are unnerving, others, stomach-churning, but they all had similarities too prominent to ignore: child abuse, neglect, instability, social ostracization, and psychological illness. And much like the Columbine shooters, the media turned to other factors such as games, TV shows, movies, and just hanging with bad crowds as probable causes of the violence. In nearly every story, a blind eye was turned to the long term ill-effects that come with years of pain, suffering, and devastation these children experienced, typically inflicted by the very people who were meant to protect them.

Now over the past months of blogging, my own personal history has gradually been revealed as my blogs have taken a more intimate tone, and many of you are aware of several instances of abuse, various types from various perpetrators, school bullying, and my own resulting mood disorders. What has tapped into my being and struck a chord with me while reading about these kids is how easily I could have become one of them. With very similar backgrounds and long repertoires of emotionally and psychologically altering circumstances, what is that defining factor that sets one apart? What makes some of us killers and others productive members of society?

In Viktor Frankl's autobiography, Man's Search for Meaning, he discusses his own experiences with the continuing battle between Saints and Swine while serving time in a concentration camp during WW2. A prominent point Frankl made repeatedly in his book was the issue of freedom of choice. He argued that although events take place in our lives and we cannot always control what happens to us, what is in our control is how we respond to these events: we become saints, or we become swine. In his example, saints were defined as individuals who cared for fellow prisoners and looked out for one another, and the swine were individuals who adopted a more "every man for himself" approach to surviving the camps. In our lives, this can be more or less the individuals who go on to lead generally successful lives, have families and meaningful relationships, maintain employment and housing, and individuals who fall into more self-destructive and criminal behaviors and end up harming themselves or others.

I frequently utilized Frankl's theory in working with severely emotionally disturbed teens. Sadly, like the kids in Davis' book, most of them had seen the worst of life in the few years they had lived. Many survived neglect at the hands of their drug-abusing mothers, many suffered beneath the iron fist of alcoholic fathers who used them as punching bags. Some had been forced into early sexual awareness by perverted family members. All of these matters were events in their lives they couldn't control, so in a misguided effort to regain that control, they began engaging in their own destructive behaviors: truancy, theft, drug use, promiscuity, self-mutilation, even suicide attempts. In trying to redirect that sense of control into more productive actions, many of such teens can be molded into functioning healthy individuals, in spite of their dark pasts.

Unfortunately, for many of these kids who went on to commit these heinous crimes, intervention was too little too late, if it came at all. For some, any intervention may have proved useless, as the damage had been done and psychopathology had set in, rendering them sociopaths. However, for the most part, it seems that rehabilitation is more than possible, if we can find the missing link that sets us on the right path. Granted, many of the child killers were male and in the midst or on the brink of puberty. With the increased level of testosterone and the effect it has on aggression, it could be argued that hormones play a part. Other factors could be time and type of interventions, variations in abuse and abusers, genetics, etc. In short, I have no idea what makes some people killers and what makes some successful survivors. I don't know why I took the path I did and narrowly avoided becoming a statistic. I had the background, I had the resulting depression, I was a self-mutilator, I had deep-seated anger, a seething hatred for the people who hurt me and resentment and distrust of people in general. My intervention was therapy and medication, and eventually the depression, anger, and hate dissipated and I became a therapist to help others. Some are just not as lucky, I suppose.

Eric and Dylan were two of the unfortunates. Though not much has been written on their home life, I would imagine they were not stable situations with overly concerned and involved parents, as anyone could have seen this train wreck coming had they only paid attention. After Columbine, they were destroyed by the media as crazed psychotic killers who master-minded elaborate plans of attacks, plans which, if read with an impartial eye, come off more as the childish, nonsensical grandiose ideas of manic kids than highly intellectual criminals. Few even addressed what was probably a dark, lonely adolescence for two severely depressed young men. The same happened to Seung-Hu Cho of Virginia Tech, a long-disturbed child also destroyed by the media when "violent" short stories he had written were sensationalized as red flags. In reality, they were poorly written blips about angry high school students cursing their principal.

Criminals are not born, they're made. While some of us can be saved, many many more fall through the cracks, and soon make headlines. So before we allow the media to strip these poor kids of their humanity, let us not forget that at one point, these "cold-hearted murderers" were once someone's baby, and more than likely, that baby was not given much love.

A Therapist's Conundrum

Originally Published: 2/24/11:
As some of my more devout readers may know, I am a Marriage and Family Therapist Trainee (soon to be Intern with any luck from the Board of Behavioral Sciences once they get past their anal retentive stage). I began my journey to becoming a therapist back in 2003, but it didn't become apparent until 2007 that this was not going to be an easy profession for me, a perfectionist who seems to equate success with self-worth and a hard-nosed bitch who deep down inside cares more than she ever wishes to admit.

Working as a counselor with severely emotionally disturbed foster kids and juvenile delinquents for two years was never an easy job. At one job it was guaranteed you would be cursed out and met with attitude every single day; at another, bruises, cuts, concussions, and trips to the emergency room after various assaults from the kids were not in short supply. But, in spite of the frustrations, the abuse, and the resulting PTSD, the day I had to make the decision to leave these kids was one of the most difficult days of my life. The guilt of what I believed to be was giving up on these kids was overwhelming. Flashing back to my first day on the job at one facility, after being cussed out by one client, another came up and asked "Miss, are you going to quit?" Being cussed out was not a novelty and I wasn't phased, but I could see the genuine concern in her eyes. "No, of course not, I'm not quitting," I'd assured her. "Good," she said, "because staff here always quit, people always give up on us." The following three weeks after giving my resignation were murky with depression and self-condemnation. And as stories of my former clients continuing to fall and fail trickled back to me through the grape vine, I couldn't help but take a chunk of the responsibility for not being there to set them straight again. Their failure was my failure.

Now, as a therapist, I find myself in the same position, struggling with the question of removing myself from a case because various extraneous factors are impeding the progress of treatment. Coping with the resulting counter-transference is like standing on the shoreline battling the ocean, one wave conquered but another to come and then the promise of endless swells after that. I have been pummeled with question by confidence-eroding question: If I leave, am I giving up on my patient? If I can't help him, am I failing as a therapist? If I can't handle my counter-transference, have I failed as a professional? Walking into my supervisor's office last week and admitting that I am incapable of continuing on as things are was virtually degrading. Given that this was a known difficult case to begin with, with this confession came an admission of someone else's misplaced faith in me by putting me on it, and in spite of the chorus of supportive dictum, I carried the burden of failure on my shoulders.

Stepping outside the fog of my own clouded perception, I am well aware of the reality of the situation. Reality: there are factors beyond my control that have not only halted progress but have fostered a heart-breaking regression in this case. Reality: my patients are largely responsible for their own success, I am responsible for my conduct as a therapist. Reality: if, after three months of attempting to manage counter-transference, being successful with one issue before failing when being blind-sided by another, and if that counter-transference affects my therapeutic relationship with my patient, then as a professional, I am required ethically to remove myself from the case. Reality: the fact that I am angered and frustrated by the results of this case is a testament to my care for this patient and my desire to see him succeed. And with this final reality comes more implications.

Yesterday's psychology fervently warned about becoming too close to patients, caring too much, feeling too much, but I often wondered how effective one could be in dealing with the emotions of others when they cut themselves off. As a youngster in therapy, one recollection I have was sitting on the couch, recalling something painful and bursting into tears. My psychiatrist sat there opposite from me stone-faced, watching me cry like it was the most absurd thing I could have done. No movement was made to embrace me or lay a comforting hand on my shoulder, no soothing comment made to set me at ease, to reassure me. The ethical and legal issues that frighten therapists into cold professional conduct stayed her hand, leaving a broken nine year old to shatter, and I never felt more alone and ashamed of myself. I never wanted to be that, I could never manage a shot of Novocaine to the heart, to be dead from the chest up, and it seems to be the number one complaint I hear from friends and family who have sought treatment and ended up leaving, refusing to return to try someone new. The problem comes when that connection becomes too powerful (counter-transference), and the path the case follows becomes a personal issue (personal failure). The only medium I can manage to find is a balance between caring, recognizing when I care too much, and calling it off when I can't resolve the matter. Is this right? I'm not sure, but it's the only way I can, with a clear conscience, secure for myself the continuing passion to work in this field.

So, in knowing the reality of the situation, but feeling the opposite, the discrepancy lies in trying to align the thoughts with the feelings into a happy medium. But getting my head and my heart on the same page is easier said than done. It's a work in progress and this blog is acting partially as an example for other aspiring therapists to learn from my struggles, and partially as my own attempt to process this issue. I've not left the case yet, my supervisor has allowed for the rearrangement of treatment methodology to facilitate more success and lessen my frustration, and some colleagues on the same case are being incredibly supportive. I'm monitoring my counter-transference in the wake of these alterations, and hoping for some positive results. In the possibility that I have to walk away, I can only hope I can successfully navigate away from the destructive self-blame and carry on the lessons learned to the next patient. As my former supervisor once said "Don't take too much credit for your patient's success, and don't take too much blame for their failures".

To the Sound of Trumpets

Originally Published: 12/26/10
Nine years. For nine years we have been fighting this supposed war on terror in Afghanistan and Iraq. For nine years we have been losing our soldiers, losing our money, losing face to the rest of the world. For nine years we have been terrorizing the innocent people of these countries trying to find a multitude of rats in bunkers, mountains, and deserts. And after nine years of killing what is estimated to be hundreds of thousands of civilians, sometimes mistakenly, sometimes intentionally, the army is finally realizing that our soldiers are not well.

Today, Peter Chiarelli, a top army official, argued that soldiers need more time at home in between deployments in order to recuperate before being shipped back to the front lines. They usually get a year off for a year's deployment, with a minor break in between lasting about two weeks, almost like a typical job we have here at home. Of course, we don't spend the year killing and trying not to be killed. And if a year off hardly seems sufficient to piece together their shattered nerves, it's not, which is being proven time and time again.

The toll of this war is turning our weather-beaten soldiers into cold-hearted psychotic killing machines, as first evidenced by a 2007 video leaked by Wikileaks showing trigger happy soldiers celebrating the accidental killings of four civilians. Carrying cellphones and cameras that were somehow mistaken for AK-47s and grenades (yeah, I don't get it either), the soldiers opened fire amidst cheers and trash talking like they were playing a Wii game on their living room couches. They laughed as one body was mangled by a tank that ran over it, and opened fire on another group of civilians trying to rescue a survivor, riddling their van with bullets and hitting two small girls inside. The sudden realization of the children's presence yielded the icy response, "that's what happens when you bring kids into a warzone". Another incident is a highly publicized criminal proceeding where a number of soldiers killed innocent civilians and kept body parts as souvenirs, and a more recent trial has come to light after a soldier admitted to raping a 14 year old Iraqi girl and killing her and her family because he "didn't think of Iraqis as humans".

The outrage that these attacks have elicited from the world and from me is almost immeasurable, and it's so easy to point fingers, to curse and spit and damn them to Hell, but are we pointing the fingers at the right people? Thrust into an establishment that has only recently encouraged soldiers to seek mental health services (despite existing threats of dishonorable discharges and labels of weakness), fighting for a government that worries more about how many soldiers are killing others than about soldiers who kill themselves when they return home, and having the Us versus Them mentality hammered into their heads every waking moment of every day, it's amazing these men and women last as long as they do.

In Lt. Col. Dave Grossman's book, On Killing, he discusses the multiple psychological casualties of war which, from the civil war to the present, haven't changed much despite developing technologies and the abandonment of guerrilla and trench warfare. Fighting fatigue, many soldiers fall into confusional states of dissociation where they depersonalize from their environment and can suffer from manic-depressive episodes. A prominent syndrome of the state is that of Ganzer, where the soldier will become silly and make jokes, trying to ward off the horrors of war, but in a delusional state that is overwhelmingly morbid. One such soldier fighting in the Korean war had retrieved the severed arm of a North Korean soldier, using it as a puppetry prop. He carried it around waving it in other soldiers' faces, calling it Herbert, and even pretending to pick his nose with one of the fingers. Sadly, this psychotic behavior did not land him safely in a mental ward, but on a double shift of guard duty, and today, only when this behavior becomes deadly such as in killing civilians and keeping "souvenirs" does it warrant attention. The dissociative properties of the confusional state also account for the dehumanization of victims that makes it easier for soldiers to kill, whether it be their targeted enemy, or innocent camera toting civilians and adolescents.

Given the prolonged time periods of service, multiple deployments, watching strangers die, watching friends die, and a war that has actually gotten worse, it's no wonder these people are losing their minds. Many war vets throughout history have come home to PTSD, drug and alcohol abuse, destroyed personal lives and obliterated mental health. Nowadays, they develop these issues before leaving their barracks. Swank and Marchand (1946) found that after 60 days of continuous combat, 98% of soldiers became psychiatric casualties. The other 2% escaped the fate only because they were found to already be unstable with "aggressive psychopathic personalities" (did I really just do an APA citation in my freakin' blog? What have you done to me grad school?!). So with our soldiers serving upwards of 90 days of continuous combat and no sign of our government slowing this fight, we will no doubt have many more horror stories of murder, torture, and mind-numbing stomach-churning morbidity to come.

But it is important to keep in mind, however, that these soldiers were not sick to begin with. These are not deranged antisocial personalities who come into the army with the perverse desire to kill. Romanced by promises of honor and the idea of serving their country and saving another, the harsh reality of war hits hard, and, disillusioned, their better judgment and morals dissipate in favor of basic survival needs and paranoid delusions about who their enemies are and how to deal with them. War makes people crazy, then we give them a small vacation and ask them to come back and do it again. And again. Then possibly once more. So no, Mr. Chiarelli, they don't need more time off, they need this war to be over. They need to come home. They need aftercare, they need therapy.

Voltaire once wrote "it is forbidden to kill, and therefore all murderers are punished unless they kill in large numbers and to the sound of trumpets". Likewise it seems appropriate to write that all psychotics are locked away to protect society, unless they're zipped into fatigues, then they're given guns and asked to serve their country.