No words for her trauma

CASE STUDY
The name of the service user has been changed

Situation: Shona Simmons is a 13-year-old girl whose
mother has a dependency on class A drugs. Her father left when
Shona was five and hasn’t seen her since. However, his family has
remained in touch and Shona’s two uncles are often at the house.
They, too, have addiction problems and regularly invite their
associates into the house. With her mother unable to cope and the
drug lifestyle of the house, Shona was taken into care. However,
having sabotaged four foster care placements in a matter of weeks
through absconding, physical and verbal abuse and damage to
property, Shona was placed in a local residential unit specialising
in young people’s aggressive and challenging behaviours.

Problem: Shona, despite her chaotic lifestyle, had
been relatively stable in her education. However, she started
passing out and having convulsions at school. The doctor believed
that there wasn’t a physical reason for this and suggested that
some underlying mental health problem might be the cause. She was
referred to the child and adolescent mental health service. A
therapist working with her began to untangle some of Shona’s
emotional feelings and considered that these feelings were being
converted into physical outcomes. However, Shona would not talk
directly about these feelings because, it was assumed, she was
frightened and worried. Using creative writing therapies, it became
apparent that physical and sexual abuse had figured in the past,
and that she had been self-harming, unbeknown to anyone, for about
a year.

PRACTICE PANEL – Liverpool Children and Families
team
Steve Oliver – team manager adoption service ; Jill Thorburn – team
manager looked after children service ; Joyce Msiska – social
worker, family support service ; Vince Bartley – senior
practitioner ini Prescot Drive short term breaks unit ; Angela King
– family support co-ordinator

PANEL RESPONSES

Steve Oliver
The social worker should have explored the whereabouts of Shona’s
father – absent since his daughter was five – as one of the
principles of the Children Act 1989 is promoting family contact.
Although he might be unable to care for Shona he may be able to
play some role in her life. His absence from her life will have
affected Shona as she will have been old enough to remember him.

Shona’s life seems to have been chaotic and unstructured. Given her
dependency and lifestyle, her mother may not have been in a
position to protect her daughter. This placed Shona in a vulnerable
position and compromised her safety. Indeed, she is now disclosing
sexual and physical abuse.

Shona’s only stability appears to have been school. It is
imperative that social workers sustain this while considering her
placement. Shona’s psychosomatic physical symptoms in school may be
because she is trying to contain what she perceives as negative
behaviours. She is attempting to contain her physical and verbal
outbursts in school. The social worker should explore the reasons
why school has been such a stabilising factor, which might include
good relationships with teachers.

These are important factors in trying to develop suitable long-term
care plans for Shona. If she is going to succeed in making the
transition into adulthood she will need to be stabilised in the
residential unit but consideration needs to be given to finding
permanent, experienced foster carers who will be able to help her
feel safe and secure in a functioning family setting. A foster
placement will also be more likely to provide a setting where Shona
could form appropriate and secure attachments to her carers. She
will need to be fully consulted throughout this process as she is
likely to continue to rebel against any placement she has not been
in agreement with or emotionally ready for.

The social worker needs to ensure that school staff are involved in
Shona’s behaviour management plan and that they are aware of
actions they should take if Shona self-harms in school. They may
well provide pastoral support staff and a “safe place” for her to
go if she needs it.

Jill Thorburn
It is not surprising that Shona has broken down her
placements in a fostering setting. She has no experience of living
in a family which is not dysfunctional. She is angry and lashing
out. This may be symptomatic of the fact, she has not learned to
express her feelings or emotions verbally.

That she self-harms is again an expression of her frustration and
inability to articulate her emotions. Social workers and carers
should view her self-harming as her way of coping with her
experiences. It is likely she will continue to self-harm until she
finds different coping mechanisms and ways of self-expression.

In her care setting Shona should be encouraged to take
responsibility for self-harming. This can take the form of cleaning
her wounds and ensuring she has notified her carer of any incident.
She should not be made to feel her behaviour is wrong as this is
her only way of coping with what has happened to her.

Another factor which should be considered is that the major role
models in Shona’s life have also been self-harmers. From an early
age Shona will have seen people injecting class A drugs. It may be
possible to draw parallels in a child’s mind between withdrawing
blood in the process of taking intravenous drugs and doing so by
cutting. Both are ways of using self-harm to cope with life.

It may appear that Shona is unwilling to talk about her
experiences. It may well be that this is because either she is
trying to protect her mother or that she is too afraid to do so.
However, because she has begun to open up during the use of
creative therapies this is likely to suggest an inability to access
or express her emotions. This type of therapeutic intervention is
clearly working and should be continued. There should be an element
of the therapy being didactic in its nature so that Shona learns
new ways of self-expression and self-analysis.

Sometimes when very young children experience abuse and trauma
before they have developed language it is more difficult to explore
past trauma. The reason for this is that the child remembers the
experience in feelings rather than words. This may be why Shona is
exhibiting physical responses to her early trauma.

USER VIEW
Although this is clearly a serious situation, there are
aspects of Shona’s life that can be seen as slightly more positive.
To best support Shona, we should build on these positive aspects,
writes Mark Houston. 

Bearing in mind that Shona has recently had a chaotic and unstable
time, it is important that she has some continuity and so she
should continue living in the specialist unit. This provides a
secure environment, where not only can she feel safe, but staff can
monitor her non-intrusively. 

Having said that, it is equally important that she spends time out
of this facility, in order to not become institutionalised and too
reliant upon it.

The fact that a child and adolescent mental health services
therapist has been able to untangle some of Shona’s difficulties is
encouraging and suggests that, with the correct approach, it is
possible to further untangle her problems. The therapist needs to
continue to work with her, perhaps further exploring more creative
ways of expressing herself. 

It must be remembered, however, that this will  take time. Shona
needs to build trust with the therapist and, since her past
experiences are so painful, she may take time to be able to 
communicate what has happened and how it has affected her
emotions.

For example, constantly seeing the use of highly dangerous drugs
and the damaging effects, including physical and sexual abuse, must
have had a serious psychological impact on her. This is
particularly poignant given she is only 13. 

The fact that Shona is self-harming is concerning. This may be due
to severe frustration and low self-esteem and so I would suggest
that part of the solution be to boost her morale. 

Maintaining her involvement in school is essential. The fact that
this has been the most stable aspect in her life suggests that a
positive way forward would be for the school to continue to play a
major role in her future. As well as enabling her to keep up in
terms of educational progress, it will help to maintain Shona’s
social contact. Reduced social contact could lead to social
difficulties in the future. 

The school should help Shona engage in  extra-curricular
activities. Of course, extra human resources would be needed to
protect her from self-harming. This should be provided by the
school and the local children’s services department. She would also
benefit immensely from peer mentoring if this service is
available.  

Mark Houston is a care leaver