Splitting the Child: Marginalizing Medicine in Residential Treatment for Traumatized Youth

Background and Purpose: Ethnographic studies of psychotropic drugs illustrate that the effects of medications are contingent as much on specific bodies and drugs as they are on the institutional and ideological contexts in which drugs are administered. Such research often depicts biomedicine as an institutionally dominant mode of intervention and analysis, centering questions of whether and how professionals and patients take up or question biomedical ways of thinking about mental health.

This study was sited in a multi-disciplinary treatment setting in which medications are ubiquitous but medicine is marginalized. This paper explores how staff at a residential treatment center for youth in foster care attempt to communicate across professional boundaries about the effects and legitimate uses of psychotropic drugs. Specifically, it examines how psychotropic drugs come to be treated as both pragmatically indispensable and therapeutically peripheral.

Methods: 18 months of ethnographic fieldwork, interviews and archival research were conducted in administrative and practice settings to understand how professionals collaborate within and across specialties and pay-grades to regulate and monitor psychotropic treatment interventions for youth in foster care. This paper examines the practices of therapists, case managers, medical staff and residential counselors (n=50) at a center for youth (n=30) in state custody who have experienced multiple traumas and placement changes. Specific sources include psychiatric consultations, quarterly and monthly staffings, and weekly treatment team meetings, which were audio-recorded, transcribed and inductively analyzed. Archival sources, such as case files and professional training materials were also collected and coded. The researcher obtained IRB approvals as well as informed consent and assent from youth and professionals.

Results: Though virtually all youth in this setting are prescribed at least one medication, medical knowledge is explicitly treated as peripheral to the purportedly “real” treatment of skill-building through relationships. Staff at the on-site medical clinic—two nurses and a child and adolescent psychiatrist—are mindful of the role of medications in youths’ treatment, continually investigating their physical and behavioral effects on youth. However, treatment team staff—therapists, case managers, and residential counselors—focus on the effects of a treatment model called Collaborative Problem Solving, which asserts that social and emotional skills are built not through medications but through collaborative relationships. In turn, clinic staff approach youth as children whose bodies and minds (and, in turn, their behaviors) are significantly affected by medications, while treatment team staff treat youths’ thoughts, feelings and actions as primarily the product of their skills and relationships.

Conclusions and Implications: American child welfare systems are developing oversight programs that regulate psychotropic drugs in foster care. Though collaboration between the various caregivers and professionals in youths’ lives has been named as key to providing quality psychotropic treatments, there is limited research on what such collaboration looks like in practice. This paper concludes with a discussion of how professional divisions in multidisciplinary settings affect the kinds of treatment youth receive. Findings suggest that divisions between medical providers and other professionals reflect and reproduce a systemic prioritization of children’s minds over their bodies.