Therapy Direction Meeting

E-mail I sent to Kitty's EMDR therapist, attachment therapist, skills trainer, and MHMR case manager:

We had a very tough EMDR session with Kitty on Friday (crying, screaming, cussing, threats - suicidal, homicidal, withdrawal of love, and running away…) that has made me want to rethink how we’re approaching therapy – at least for the Summer. It feels like everyone is telling Kitty that she’s basically “normal” with some issues and that if she can just control her behavior then she can be like other teens (even if this isn’t exactly what she’s being told, it’s what she’s hearing). This is causing a lot more meltdowns and issues on her part, because she is NOT a normal teen, and we usually cannot treat her as such (which makes her mad and triggers her abandonment issues – SHE feels that we’re treating her differently because she’s bad and believes that “bad” kids are unworthy and unlovable so she’ll be abandoned again). Plus, she is unable to actually control her behaviors all the time (which makes her feel like a failure and a bad person in addition to being terrified that it means she will be rejected).

At home, I work hard to keep her life as age appropriate (her emotional age vs her chronological age) as possible, because when we raise our expectations, Kitty tends to respond with an increase in meltdowns and stress. Actually I feel we have to provide even more extreme assistance with emotional regulation at home, to counterbalance the stresses and anxieties of her everyday life. At school and in public the expectations of all are of course MUCH higher and she is responding as best she can. She HAS learned a lot of self-control over the last year. The problem is that while Kitty does her best to control outbursts, the stress and anxiety are not actually being dealt with (merely internalized, ignored/ denied, and delayed), neither are we usually dealing with the reasons she’s having so much difficulty dealing with “’normal’ life and it’s stresses.”

When Bear went to {RTC} for residential treatment, he was a very angry, messed up kid. It took 6 months to get him on the right med combo to help him with his bipolar and other medical issues. Once he was on the right meds we were able to start making progress on his emotional issues. I won’t say that he’s made a complete turn around and I definitely won’t say he’s “healed” or “normal,” but we seem to have found the right combination of meds, supervision, and therapy to be moving in the right direction and allow him to emotionally mature as well.

Maybe because Kitty had farther to go, or maybe we just have higher aspirations for her (because she does seem capable of emotional attachment), but it really feels that Kitty is not progressing at anywhere near the same pace. While the two children have almost identical diagnoses, it is becoming increasingly evident that Kitty’s issues are not going to be resolved in the same way. Meds, supervision and support seem to have taken us as far as we can go. I have to wonder if there is more brain damage (FAS?) preventing her from going any farther.

The difference in Kitty’s chronological age vs. her emotional age is becoming more and more evident as she gets older and the gap gets wider. I believe she stuck around 7 or 8 years old. The problem is she perceives the others around her as getting to do what she wants to be able to do, and she’s externalized the reasons why she can’t have what the others do as because we are “mean” or “don’t love her” or think she’s “bad.” Possible solutions (like more restrictive school environment) feel like punishments to her. The younger children in the family (who are basically “neurotypical” and did not have the traumatic childhood) are rapidly passing Kitty up. It is traumatizing for her to see them getting to do things she knows she’s not capable of, but is jealous of nonetheless (little sister Bob will begin driving this Summer when she turns 15).

It feels like now that she’s out of school, that if we play it safe and keep just teaching her behavior management and calming techniques, then we’d be just applying bandages and all that is doing is delaying healing or any forward movement. Kitty is NOT a functioning member of this family or society in general and doesn’t seem to be moving in that direction. Plus, the family is so busy applying CPR to her that everyone else is not functioning. It seems like if we’re going to go through this torture anyway then we might as well be trying to achieve a goal, but I’m not even sure what goals are achievable at this point.

I’d like to sit down with the key members of Kitty’s team and decide what is she really capable of? At least try to get all of us heading in the same direction as no one seems to have the full picture. Sometimes it feels like she’s attached and working on the trauma, and other times it feels like I’ve just lowered my expectations so much that it seems like she’s making progress when she’s really not. Some see the totally damaged and draining kid with traits of Borderline Personality Disorder with a meltdown always simmering just below the surface waiting for any spark.. The school seems to be seeing a quiet teen that’s doing “fine” now that she’s not dealing with side effects from the med changes. What do you see?

Direction for therapy for the Summer?
· Helping Kitty see her capabilities, gain a realistic understanding of her diagnoses and face her limitations without blaming others.
· Do another psychological assessment to decide if she has FAS? the capability of functioning as an adult? Does she have borderline personality disorder? If she does have BPD, we know she isn’t capable at this point of handling the normal treatment (12 step program). So what are next steps?
· Should we “poke the bear” to restart progress? Ripping off the top layer and getting to the festering wound(s) and cleaning it out vs. keeping her calm all Summer.
· Going ahead with family therapy using the EMDR/trauma therapist who has worked with all members of the family, with Kitty and Bear in the knowledge that it’s probably going to help him more than her and will probably set her off (meaning she’ll most likely need residential treatment)
· Looking at her attachment therapy as a support (for making sure we don’t break/damage attachment too badly while we’re focusing on this other therapy). Ditto for skills training, trying to give her some coping techniques for dealing with this as well.
· Do we want to try to find a residential program that can take care of her (giving us respite) or possibly even help her? Do we need to decide if is she capable of living in a family?
· Should we be looking at more funding options for intense outpatient/ partial day hospitalization or similar programs.
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Mary