An ongoing issue within our facility is: what exactly is the role of the clinical staff? Traditionally a heavily case management role, the nature of the clinical role’s purpose appears to be shifting. Clinicians must hold a graduate degree in a psychology or social work field and must be license eligible with the written obligation to pursue licensure while employed at the facility. The Department of Youth Services has recently directed a significant amount of resources and time into training staff in Dialectical Behavioral Therapy which is an intense but effective therapeutic approach. This would indicate the desired direction of the shift from purely case management to a more therapeutic one.
As with any major change, there is resistance. Direct care staff resent the implementation of a more therapeutic approach because they see it as a softened coddling treatment of youth who are being charged with crimes. In a sense, their resistance is an expected one as their long work history in the facility has socialized them to an approach firmly entrenched in intimidation and punishment. What I am constantly dismayed and surprised to encounter is the resistance of clinical staff to the increase of therapeutic focus. Coming from experience in outpatient and day treatment, I identify myself as a therapist and believe in the power of therapy (even brief intervention based) to bring positive change in the lives of clients. I am thrilled to be a part of the shifting role of clinicians in juvenile detention.
I am dismayed weekly to find myself in the minority of a palpable tension between the clinicians who desire a mainly case management role and those who value the therapeutic component. This tension is always present and occasionally mounts to a near cold war proportion. The two sides generally operate independently, politely ignoring the wide discrepancy in the nature of treatment individual clinicians provide. Occasionally, they collide and become mutually antagonistic. Case in point, if a resident working with his therapy oriented clinician is transferred to another unit without warning and the new unit clinician is primarily case management based, the therapeutic work and bond is disrupted. It is not the policy of case management oriented clinicians to allow termination sessions post transfer. Due to the case management orientation of the new clinician, therapy is abruptly discontinued. This heightens tension because the therapeutic perspective is that this abrupt cessation is not good for the kid while the case management perspective maintains that therapy should have never been initiated because of the risk of just this event.
Of course, neither party is right. Both perspectives are necessary as neither can solely fill the requirements of the job. The only viable and ethical solution is that an integration of the two must be demonstrated in each individual clinician. I continually raise this issue only to hear clinical administration answer back that like yin and yang, both sides are indispensable for balance. This answer is an active refusal to acknowledge the reality that presently, there is no balance. The current status is an extreme imbalance of 4:1, case management to therapeutic orientation. These are not conditions that are favorable to integration. The lack of administrative recognition, however, is a separate issue.
The relevance of the clinical question lies in two areas. The primary relevance is that as long as this tension goes unresolved, the kids will be further victimized by the unproductive behavior of adults. Secondarily, an ethics question arises, all clinicians are required to obtain licensure. Licensure hours are to accrue based on the amount of individual and group therapy you provide. If you are a case management oriented clinician, and you maintain that our role is not to provide therapy, how do you ethically justify claiming individual and group therapy hours while employed in this facility? How do you find that you have earned a license as a therapist when you admittedly do not provide therapy?
Although I will continue to pursue an administratively sanctioned resolution, at this time the only response I can control is my own. I am choosing to engage my residents in brief intervention therapy in the truest sense, acting as if any given time with them will be our last time together. In this way, I can feel that I’m doing some good and not setting them up to experience emotional or psychological harm.
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The Diagnostic Statistical Manual is currently undergoing revision for the fifth edition (see DSM V). The counseling community is expecting to see several major revision and additions in the disorders of childhood and adolescence arena. Personally, I have watched with curiosity the astronomic rise of the Bipolar Disorder diagnosis for children. In general, it appears commonly used as a way to describe any kid with volatile changes in mood without faithful regard to the defining terms of mania or depression. In my observation, it is most frequently used when a child exhibits an extreme reaction to any sort of stimuli or stressor. Classically, this is not Bipolar Disorder.
Many of the boys in our program are diagnosed with and treated for Bipolar Disorder, yet they continue to experience volatile shifts between sad, okay and angry despite their medication compliance. Similar behavioral issues appear to be happening nationally as psychologists working on the DSM V are now considering two new diagnoses which appear to better explain these behavioral patterns: Temper Dysregulation Disorder and Developmental Trauma Disorder. I recently attended a workshop taught by Dr. Martha Straus on the treatment of complex trauma where she described the criteria and implications of Developmental Trauma Disorder. DTD is a developmentally sensitive diagnosis which acknowledges that during childhood trauma can be indirect and non-violent. The experience of betrayal, neglect, or other non assaultive means of victimization can be significantly traumatizing to a child, equally so to that of direct victimization by violence or witnessing violence. Research is demonstrating that children exposed to these less recognized means of trauma can and do develop severe dysregulative patterns particularly evident when under stress (Straus, 2010). These dysregulative patterns: affective, somatic, behavioral, cognitive, relational and self-care difficulties are accompanied by dysfunctional regulatory behaviors such as aggression, cutting, avoidance and instability. A peek through the keyhole at out program on any given day would be a snapshot of at least most if not all of these descriptions playing out in real time as the boys seek to engage staff and peers in either a reenactment or avoidance of some of their most painful childhood experiences. It resonates with me that these young men, most of whom are treated with Bipolar Disorder but continue to exhibit symptoms, might have something else going on entirely.
In 2009, 70% of our admissions reported traumatic experiences. They share a history of serious self-regulation issues. They are explosively angry, some are extremely distrustful, others turn rage inward, cutting and injuring their own bodies. Often, these are the very issues that bring them into the court system. The framework provided by the DTD diagnosis makes sense of how these young men have grown into this way of interacting with the world and responding to stress. Currently, treatment usually includes a diagnosis of Oppositional Defiant Disorder, ADHD, or Bipolar Disorder often accompanied by PTSD. I have seen files of young men who were diagnosed with all four. Despite the heavy and sometimes long list of medications these young men take, they continue to be volatile. They continue to have problems in detainment and in the community. It has always been my understanding of Mood Disorders that the shifts in mood happen without apparent reason and totally out of one’s control. The shifts I am noticing happening with these kids are episodic and unnecessarily intense rage in response to specific stressors. Stressors that the kids are able to describe in part if not in whole.
Dr. Straus outlines an interesting approach to treatment of these young men based on theories of attachment. The trauma that children experience is interpersonal and profoundly impacts their perception of their selves in relation to the world. As a result, their manner of attaching to people, possessions or ideas can be problematic. They are hyper sensitive to feelings of betrayal, insult or rejection and they lack the means to soothe themselves. Her approach details the ways in which current ideas of parenting or teaching all children are based upon the idea that the child has experienced secure attachment when by definition, the traumatized boys of DYS have primarily experienced insecure attachment. From this perspective, our role as care providers for these children is to help them re learn how to attach in a healthy way because from this they can learn to trust and have faith in their ability to be safe in the world without their maladaptive regulatory patterns.
The DSM V has not yet been released and the Developmental Trauma diagnosis is by no means a sure thing at this time. The framework that both the diagnosis and proposed course of treatment provide is a novel and intuitively logical way to look that at the issues these young men are having despite medication and therapeutic intervention.
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Commitment is the New Black
A common expressed intent of human service organizations is to provide the best possible care in the least restrictive environment. The phrase “least restrictive environment” grew out of the de-institutionalization movement in the 20th century to reflect a change in attitude regarding the long term hospitalization of those with mental illnesses. Traditional long term psychiatric care was extremely expensive and the conditions were not always safe or humane for patients. The hospital setting also decreased a sense of autonomy in patients, encouraging learned helplessness and a subsequent inability to act as an agent of change in their own lives. For decades now, community and government organizations have struggled to maintain funding to support individuals with mental illnesses so that they may have as integrated a life as possible. As economic conditions worsen, these agencies are the first to feel budgets wither and in some cases die. I am not sure how to explain why these services are not seen as more essential but the reality is that despite overwhelming evidence as to why they are needed, they are among the first to be dismissed.
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Looking Forward
In 2008 and 2009, the Department of Youth Services suffered major budget cuts necessitating the decrease in the number of programs and staff in place to serve needs of the youth. Subsequently, the quality of the remaining programs has also been affected. DYS has responded to this crisis by redirecting the bulk of its resources into treatment for youth who have committed status which has meant a diversion of resources from the more prevention oriented services intended for detained youth.
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Waiting Rooms
The detention facility in which I work is becoming utilized more often than appropriate as a waiting room for youth who are mentally ill or compromised in some way that makes them at a high risk for problematic behavior in the community. The facility contains boys whose parents or the agencies charged to protect them cannot. The building is used to punish them rendering it to be a hardware secured time out room to provide a stimulus to motivate the boys to turn themselves around, by which everyone means to be a more compliant and less combative presence in society. It’s as if barred windows and razor wire act as magic wands that once brandished could transform even the wildest child into a model citizen. For the edification of society, this is neither true or appropriate.
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Jails or Asylums?
An August 10, 2009 article in The New York Times documented the increased use of the juvenile justice system as a means of containing mentally ill adolescents who have violent or psychotic symptoms. The article attributes this growing issue largely as a response to the obliteration of mental health program budgets nationwide. This is certainly a major factor although there is now the added stress of significant budgets cuts to social service agencies as well as cuts to the budget of the ever burdened juvenile justice system. Social services have been able to supplement the access to treatment for some affected youth and their families in the past; however the current economic climate has significantly undermined this source of aid. The result of the diminished funding is a desperate game of inter-agency “hot potato” to determine who will become fiscally responsible for youth. The object being to ensure that the youth remains in the care of the last agency to hold the file.
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“You are saying that all must seek the well-adjusted life in order to avoid neurotic and schizophrenic personalities. But on the other hand, I am sure that we all recognize that there are some things in our society, some things in our world, to which we should never be adjusted…We must never adjust ourselves to racial discrimination and racial segregation. We must never adjust ourselves to religious bigotry. We must never adjust ourselves to economic conditions that take necessities from the many to give luxuries to the few. We must never adjust ourselves to the madness of militarism and the self-defeating effects of physical violence“.
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Issues in Juvenile Justice and Mental Health 