Installment #10
prism
So much for good omens.
I feel I have established good rapport with my class of the most troubled
and dangerous children at Arkmount Children's Psychiatric Center, and I
consider my first two days to have been relatively uneventful. But on
Wednesday morning I arrive at Little Ark to be told that Helma had been
taken to Nyack Hospital during the night. Helma, who had laughed so loudly
each time I reminded her that her Alternate School Program contract
stipulated she "not ingest non-FDA-approved substances," the very
bright girl who seems to understand that how she behaves---in Little Ark in
general, and here in Shangri La in particular---in the next few months
before she turns eighteen will determine whether she will be released to a
halfway house or locked up in Big Ark, emerged from the toilet the night
before to calmly announce to the cottage staff that she had just swallowed
a bottle of cleaning fluid. Taking her to Nyack Hospital to have her
stomach pumped was, of course, a forced move, but Helma has pulled this
kind of stunt several times in the past, and the staff in the Emergency
Room at Nyack was not amused. They are thoroughly tired of her. After this
latest episode of blatant self-abuse, I suspect it will be some time before
Helma is allowed to come up to class again. She is currently being kept on
the cottage in a locked room with an aide, officially "in
isolation," which means that no one but her therapist and the cottage
nurses can even speak to her. Isolation is the most punitive measure that
can be taken against patients in Little Ark.
I am both baffled and intrigued by Helma's behavior. Her clear appreciation
of her situation and her apparently sincere desire to act in her own best
interests is obviously not sufficient to prevent her from continuing to
commit---with good cheer, even---suicidal gestures. In a way she reminds me
of my son, who also seems unable to control his self-destructive impulses.
She also reminds me of Alan's mother. And she reminds me of myself, the way
I used to be. I can definitely relate, and I will make a note of this in my
prism journal when I have the time, and if I have energy left at the end of
the day to write anything.
The "star" of my show, the most difficult patient in my class for
me to handle, is turning out to be the child I would have considered the
least likely candidate two days before, the tow-headed, blue-eyed,
diminutive, homicidal Roy. Roy is not normally explosive and not nearly as
dangerous as the stocky Adam or the lithe, lightning-quick Lance. But
unlike Adam and Lance, Roy, behind his baby face and beneath his beguiling
smile, is unremittingly hostile and absurdly demanding of my attention. He
is a master of passive aggression. His favorite trick is to plop himself
down in my chair, or in one of the padded chairs in the room reserved for
the Therapy Aides. Roy, of course, knows that students must not sit in
these chairs, and the Boys Town Psycho-Educational Model dictates zero
tolerance for any aberrant behavior. Consequently, no matter what else I am
doing at the time, working with another student or otherwise engaging in
some activity that does not involve Roy, I must stop and turn my attention
to Roy, first demanding that Roy immediately remove himself from the chair.
Roy will simply remain seated and smile at me. Following the PEM protocol,
I award Roy one hundred negative points, and Roy is to take out his PEM
point sheet and record them. Roy will continue to sit and smile. More
negative points are awarded, and again Roy is directed to take out his
sheet and write them down. When a total of three hundred negative points
have been awarded and Roy has neither recorded them nor removed himself
from the chair, I have no choice but to call for the Crisis Intervention
Team. The CIT arrives and hauls Roy back to his cottage. Naturally, this is
what Roy wants, for as the only patient on the cottage during the day he
will receive the undivided attention of the cottage staff
Roy's PEM contract stipulates that he follow rules, and this kind of
behavior will prevent him from being returned to the hospital's regular
school program. But I have quickly come to the realization that Roy's
behavior is perfectly calculated, not the result of a sudden emotional
squall. He has performed the same act for the last three days---sitting in
my chair, refusing to comply with an order, not accepting negative points,
being taken back to his cottage. The problem with getting Roy to follow the
terms of his contract is that Roy does not want to get out of ASP. It is
turning out that the patient with the simplest contract, essentially
avoiding removal by the CIT for five days, is going to be the most
difficult to move back to the regular program.
Since it is my job to modify each patient's behavior to the point where he
or she can leave our isolated quarters, Roy views me as a problem, perhaps
even an enemy.
After being removed from class in the morning, Roy is allowed to return
after lunch. I stop him in the hallway and point to the array of cartoon
faces taped to the wall outside the classroom entrance, ask him which
figure best expresses how he feels at that moment. As he does each time we
go through this routine, he grins broadly and points to the
"angry" face. I ask him if he can tell me why he is angry, or who
he is angry at. Still grinning, Roy points to me. Slightly taken aback, I
ask him why he is angry with me, and he explains that it is because I have
told him he can leave the Alternate School Program.
When I think about it, Roy's attitude begins to make sense to me. Being
placed here in Shangri La means that he has few if any privileges in the
hospital, but he does not care; what he most craves is constant attention,
not privileges which he might be expected to enjoy independently, and here
he gets it. He has no friends in the hospital, and most of the other
children loathe him. In my class, even when he's being trundled back to his
cottage strapped to a stretcher, he's mostly being fussed over or tended to
by adults. I award the boy one hundred positive points for "expressing
his feelings," which he records on his sheet. Then I reassure him that
nobody will force him to leave my program until he feels he is ready. He
seems pleased.
Although I have assured Roy that he will not be forced to leave ASP against
his will, the boy, perhaps deeply mistrustful like all sexually abused
children, seems determined to insure that he stays where he is; his
aberrant, defiant behavior continues unabated. Day after day we go through
the same routine; he sits in my chair, refuses to move when told to do so,
refuses to accept negative points, gets taken away by the CIT. Then, just
when I have about become convinced that Roy is beyond reach, I begin to
notice some subtle changes in his modus operandi. In the past Roy has been
sent back to the cottage almost every day, usually fairly early in the
morning, and he has remained there throughout the day. He is still getting
taken away in the mornings on most days, but now he has begun returning
after lunch. After one incident, the cottage nurse calls me to explain that
Roy's outburst may have been caused by the fact that he was mistakenly not
given his usual post-breakfast medication.
On another occasion Roy asks me if he may voluntarily go back to his
cottage for extra medication because he is feeling "weak and
angry." It is the first time Roy has ever expressed a reason for his
behavior, the first time he has ever taken steps to pre-empt an outburst
before it occurred, and I am not only surprised and most pleased, but I am
touched. I award Roy one hundred points for expressing his feelings, and
ask a Therapy Aide to escort him back to the cottage.
I believe I have misjudged Roy, and his behavior may not be as cold and
calculated as it appears. When not calmed by heavy doses of medication his
mind boils with fear and anxiety. He is a boy who has had his rectum torn
too many times by adult penises, his mouth flooded with their semen, before
he was finally abandoned.
The boy continues to voluntarily remove himself from the classroom when he
is feeling particularly stressed, angry or anxious, sometimes into the
"bullpen" of the hallway to pace, other times walking back to his
cottage with an aide. I don't know if he will ever be able to string
together five full days of "following rules" without the CIT
having to be summoned, but I am now convinced that he is motivated to
change, and he is making some progress. He has opened up a window into
himself through which others can glimpse the torment that drives him.
I believe that Adam and Lance are also making progress. Their situations
are quite different from Roy's inasmuch as both boys are highly motivated
to leave the strict confinement of ASP, a placement they find highly
embarrassing. For both of these patients it is as much a problem of
psychopharmacology as behavior modification as their doctors struggle to
find the right combinations and dosages of drugs that will help them help
themselves to control their explosive behavior.
Lance, still shaky and full of rage, is ready to go off at any moment on
most mornings and in the early afternoons, but he seems to grow calmer as
the day progresses. He has still not opened up to his therapist as to his
motives for burning down his school, and he vehemently denies ever being
sexually molested by his stepfather or other family members - arson
considered to be symptomatic of such trauma. He has an important court date
approaching, at which time his future will be determined - whether he will
spend more time at Little Ark, with eventual transfer to another, less
confining institution, or be imprisoned in a Detention for Youth facility.
Adam's situation, like Helma's, is growing increasingly desperate. The
family that has expressed interest in adopting this fifteen-year-old is
still willing and waiting, but this could change. The parents have two
small children of their own, and the Little Ark psychiatrists' failure to
bring Adam's dangerously explosive behavior under control is making them
increasingly anxious. Adam, at his own request, is being given increasingly
larger doses of pyschotropic drugs, primarily Thorazine, but the larger
doses are not working; while his explosive rages have been contained, he
has become glassy-eyed and his demeanor zombie-like. He sleeps---or, to be
more precise, is unconscious---most of the time he is in class, and this is
not acceptable. The doctors plan to try a new combination of drugs, but it
will be some time before it can be determined how Adam will react to them.
