We don’t know what to do for Katrina! She keeps cutting herself, putting cords around her neck to hang herself, and recently she has begun using an eraser to create serious burns in her skin. She has given up running away and having sex with strangers, but she keeps up the unremitting self harm. Staff can work with her for hours, and she seems better, but an hour after they leave, she cuts and they feel the whole effort was useless. We are getting so exhausted and depleted. Please help!
Discussion with Katrina, her mother and her treatment team made clear how three facets of the effects of trauma interact to create dilemmas both for the child and the treatment team.
Katrina had a history, as so many of our children do, of repeated moves, changes of caretakers, and of serious abuse in each new home. Following her adoption at age seven she had many treatment episodes such as hospitalizations, emergency shelters, in home interventions and finally residential treatment.
This history had left Katrina with the following three characteristics (as well as others):
A deep sense of shame and self hatred, resulting from blaming herself for all the abuse, the moves, the symptoms and failures she had experienced: Her self hatred combined with a lack of a sense of self- who was she really? She has a tendency to take on the personality of whomever she is with. This lack of self and deep self revulsion results in her conviction that no one could possibly just like her. It also produces the conviction that she does not deserve anything good, or to have any fun, which results in sabotaging whenever something good does happen.
A lack of inner connection to others: for Katrina, when a person is not physically present it is as though they never existed. She cannot keep a representation of them in her mind to encourage her and help her, because she has not had the relationship stability in her life that would be necessary to develop that ability. So when a staff moves away from helping her it is although they disappear completely.
No self soothing skills: Katrina had not been taught how to manage life’s ups and downs. Her models had used drugs and violence to manage emotions. She has not been taught to recognize or name her own emotions, or what to do when she feels them. Through DBT Katrina is learning some of those skills, and she can name and describe them when she is calm. However, due to her over-active nervous system, when something goes wrong she becomes so over whelmed with emotions that her skills desert her.
Like all of us, Katrina needs connection, attention and support. However, both in her homes and in the many treatment programs she has experienced, it has been hard to engage adults by doing well. Early on Katrina learned that the easiest way to draw adult connection was through problems. Although her caretakers were absorbed in their own life pain, when Katrina was suicidal they had to pay attention to her. It is almost as thought she becomes addicted to having problems.
And this becomes harder and harder to change.
Start with Katrina’s conviction that no one would want to be with her just for herself.
Then, something happens, and Katrina becomes upset. Her need for help is intense and unbearable. Life feels hopeless and frightening, and she blames herself. So she does something to hurt or erase herself, which has the added benefit of bringing in the resources she needs.
In an adult’s calming presence, Katrina can some times gradually calm down. And when she does, what happens? The adult leaves. For Katrina, they disappear completely, never to return.
And Katrina does not know how to re-engage them in a positive way. She does not even have any idea this is possible.
So- she tumbles into another problem.
The intervention strategy that will help to change this is to give Katrina a lot of attention whenever she is doing well, and to be less emotional, less intense and less involved when she is doing self-destructive things. But this turns out to be quite difficult. One reason is that Katrina is rarely doing well. When ever she does start having fun or succeeding, she stops herself, because this is not her and she doesn’t deserve happiness. However, staff can still catch the moments in which she is more relaxed or more normal and engage with her then.
And this takes incredible stamina, planning and thoughtfulness of the staff, and demands much reinforcement and praise from those supporting the staff. Because if a child this needy is NOT calling your name, is doing well and enjoying life, who would want to approach her? Better to stay back and enjoy the momentary respite. And yet, this perpetuates the pattern- that she only gets attention and caring by having problems. Staff will have to work hard for quite a while before this pattern changes- but what a gift they will give Katrina! The gift is the repeated experience (more powerful than any words) that she is a normal girl who can be competent and can receive attention, caring and connection through achievement and every day life activities. This is what she needs to experience in order to move towards a life worth living.
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