This is the second in a two-part special report on how courts and other institutions deal with traumatized children, especially Native American youth. You can read part one here.
FARGO — Fed up with a life of homelessness and alcoholic parents, Brandi Azure sought refuge in the foster care system as a 14 year old. It's a decision she believes saved her from disaster.
"Without the foster care, I think I'd be either dead or in prison," she said.
Brandi, who's now 26, can see the good that came from leaving her family. But in the months after entering the foster care system, which also took in her older sister, Brandi was consumed by regret because her family was angry over what she'd done.
Meanwhile, she was struggling with traumatic experiences from her past, notably witnessing her dad repeatedly stab her uncle when she was a young girl.
In a culmination of distress, 14-year-old Brandi tried to kill herself by slitting her wrists. From then on, most of her adolescence was spent in mental health facilities where, she said, she suffered new psychological wounds from staff restraining her and putting her in isolation rooms.
"To me in my head, it was they were harming me, not helping me," she said.
Brandi was a patient at a time before mental health facilities, juvenile courts, schools and other places that serve children had developed an understanding of childhood trauma and its effects. Consequently, the care she received was far from what today's professionals would consider trauma-informed.
Many institutions have made strides on this front, but experts say more can be done for traumatized kids, especially Native American youth like Brandi who, according to a 2014 Justice Department report, suffer post-traumatic stress at three times the national rate.
Isolation and restraint
Brandi was admitted to Prairie St. John's in Fargo and the St. Cloud Children's Home, but most of her mental health treatment she received at the now-closed Catholic Charities Intensive Treatment Unit (ITU) in Fergus Falls, Minn., where she lived for almost three years.
Awash in anger, Brandi would often lash out in the ITU. Multiple staff would respond by holding her down, one person on each of her limbs, she said.
Sometimes she felt like she couldn't breathe. Sometimes she ended up with bruises. "I mean, those holds can last up to 20 minutes, maybe longer," she said. "It sucked."
Afterward, she would be placed alone in a bare room. "They don't give you anything to cover up with. You're sitting there freezing," she said. "All you want is just someone to talk to, and say, 'Hey, I made a mistake.' "
Brandi said the holds and isolation left her with anxiety over being touched by people and being in empty rooms with closed doors. Now when she's held, she sometimes flashes back to memories of staff holding her down.
In the past decade, many mental health facilities have limited their use of holds and isolation to avoid creating more trauma for kids. Representatives of the facilities that treated Brandi said that these days, holds and isolation are only used as a last resort when patients are an imminent threat to themselves or others.
Instead of holds to quell aggressive outbursts, Prairie St. John's staff now use verbal de-escalation tactics to calm kids down, said therapist Emily Coler Hanson. And instead of isolation rooms, the facility has rooms with cushions, chalkboard paint, puzzles and other things to engage the senses, she said, adding that the rooms have windows and the doors stay open.
Catholic Charities of the Diocese of St. Cloud closed the Fergus Falls ITU in 2014, and the group still runs the St. Cloud Children's Home. Andrea Hendel, residential services director for Catholic Charities, said that using holds and isolation less often has produced better results in treatment.
Brandi said the ITU gave her structure and taught her things her family didn't. But she wishes the staff had known more about trauma.
"I just wish that somebody would have been able to understand me," she said.
While in the ITU, Brandi was accused of assaulting staff on four occasions. She doesn't remember doing it, but she believes it happened.
The four assaults were rolled into one case in Otter Tail County District Court. The judge told her he could send her to juvenile detention for what she'd done. But because she was already in a locked facility, he let her continue with treatment while on probation.
After appearing in court, Brandi's behavior improved, and she calmed down. She realized she was hurting people who were trying to help her, even though they weren't going about it the right way.
Given her outcome, Brandi said she thinks the judge did a good job recognizing what she needed. In general, she said, she believes judges should receive more training to help them understand traumatized youth.
It's a belief shared by the National Council of Juvenile and Family Court Judges, a nonprofit group in Nevada. "Courts need to understand that the majority of the population that come before them have probably experienced at least some sort of trauma," said Alicia Summers, the group's program director for research and evaluation.
Over the last few years, the council has done "trauma audits" at about 20 courts around the country, though none in Minnesota or North Dakota. During an audit, which costs about $15,000 to $20,000, council staff spend a couple of days meeting with court personnel and observing the court's policies, practices and environment.
What exactly a trauma-informed court looks like is not clear because researchers still need to gather more evidence, but the council can give courts broad-stroke recommendations on how to better serve people with traumatic stress, Summers said.
The council recognizes that most courts don't have the resources to make big changes to their systems. But there are some low-cost steps courts can take, such as training staff and giving parents more control over when they appear in court, Summers said.
"One of our main recommendations is often ensuring that victims have a safe place to wait separate from perpetrators of violence," she said.
Isaiah Pickens, of the National Center for Child Traumatic Stress in Los Angeles, said part of making courts more attuned to trauma is moving away from a solely punitive approach to juvenile delinquency cases. Though, Pickens said, this doesn't mean traumatized youth should be let off the hook. Such youth "probably need more structure and more boundaries, but they need support along with that," he said.
'With our ancestors'
Brandi left the foster care system at the age of 18. Just a year before, her mom had died. "I didn't have any guidance," she said. "I had nothing."
Adrift, Brandi went through a phase of drinking heavily and using drugs. In the past few years, she's been working to help herself, including going through drug treatment.
Brandi, who grew up in Fargo and still lives here, is a member of the Standing Rock Sioux Tribe. Just recently she began learning about native traditions and experiencing the overwhelming heat of a sweat lodge.
"When you go in to sweat, you're suffering," she said. "You're praying, and you're suffering right along with our ancestors."
Tami DeCoteau, a Bismarck psychologist who often works with native youth, said American Indians have traditional ways of dealing with trauma that she believes should be rediscovered. "Things like rhythm and movement and breathing restore the body's functioning and heal the faulty stress response system," she said.
In August, DeCoteau spoke at a field hearing hosted by U.S. Sen. Heidi Heitkamp, D-N.D., kicking off a statewide initiative to address trauma in Indian Country. "When doing work with native kids on the reservation, I see these kids fall through the cracks over and over," DeCoteau said in an interview. "What they might get is a punitive strategy where they get punished or have to serve detention. But what they don't get is the trauma-informed intervention."
In her practice, DeCoteau said, she encounters present-day trauma as well as the historical trauma of "people that for so long have been harmed and not properly cared for that they no longer know how to keep their own children safe."
Brandi said her mother, who struggled with addiction, wasn't there for her. She doesn't want that for her children. It's something that's been on her mind this year since she and her boyfriend learned they're expecting a baby.
She's due in February, and the news has given her cause to stay sober and look for work. "Because I want to give my child a life that I didn't have," she said.
A primer on childhood trauma
Trauma is a broad term that can include physical or sexual abuse, a serious car crash, a natural disaster, severe neglect, the death of a loved one or witnessing domestic violence. Native youth are often victims of multiple forms of trauma, and they're also faced with what's known as historical trauma, the cumulative emotional and psychological wounds inflicted across generations of native people.
A growing body of research shows that trauma can derail a child's normal brain development, increasing the chance of mental health problems like depression, anxiety, eating disorders and substance abuse. Some studies have tied childhood trauma to adult health and behavioral problems like cancer, emphysema, addiction and attempted suicide. There's even emerging research that suggests atrocities committed across a population, such as American Indians or Jews, caused stress that may have altered the expression of genes, negatively affecting the health of subsequent generations.