The Boy Who Was Raised as a Dog Page 2

  Sara never let her neighbor care for her children again, but the damage had been done. (The boy was prosecuted; he went to therapy, not jail.) Here we were, one year later. The daughter had serious problems, the mother had no resources, and I didn’t know squat about abused children.

  “Here. Let’s go color,” I said gently as I took her from my lap. She seemed upset. Had she displeased me? Would I get angry? She anxiously studied my face with her dark brown eyes, watching my movements, listening to my voice for some nonverbal cue to help her make sense of this interaction. My behavior didn’t fit with her internal catalog of previous experiences with men. She had only known men as sexual predators: no loving father, no supportive grandfather, no kind uncle or protective older brother had touched her life. The only adult males she’d met were her mother’s often inappropriate boyfriends and her own abuser. Experience had taught her that men wanted sex, either from her or her mother. So quite logically from her perspective, she assumed that’s what I wanted as well.

  What should I do? How do you change behaviors or beliefs, locked into place from years of experience, with one hour of therapy a week? None of my experience and training had prepared me for this little girl. I didn’t understand her. Did she interact with everyone as though they wanted sex from her, even women and girls? Was this the only way she knew how to make friends? Was her aggressive and impulsive behavior at school related to this? Did she think I was rejecting her—and how might that affect her?

  It was 1987. I was a fellow in Child and Adolescent Psychiatry at the University of Chicago, just starting the final two years of some of the best medical training in the country. I’d had almost a dozen years of postgraduate training. I was an MD, a PhD and had finished three years as a medical and general psychiatry resident. I ran a basic neuroscience research laboratory that studied the stress-response systems in the brain. I had learned all about brain cells and brain systems and their complex networks and chemistry. I had spent years trying to understand the human mind. And after all that time all I could think to do was this: I sat down with Tina at a small table set up in my office and handed her a set of crayons and a coloring book. She opened it up and paged through.

  “Can I color in this?” she asked softly, clearly unsure what to do in this strange situation. “Sure,” I told her.

  “Should I make her dress blue or red?” I asked Tina.

  “Red.”

  “OK.” She held up her colored page for my approval, “Very nice.” I said. She smiled. For the next forty minutes we sat on the floor, side by side, coloring quietly, reaching over to borrow crayons, showing our progress to each other and trying to get used to being in the same space with a stranger.

  When the session was over, I walked Tina back to the clinic waiting area. Her mother was holding a young infant and talking to her four-year-old son. Sara thanked me and we set up another appointment for next week. As they left I knew I needed to talk to a supervisor with more experience who could help me figure out how to help this little girl.

  Supervision in mental health training is a misleading term. When I was a medical intern learning to put in a central line, or run a code or draw blood, there were older, more experienced physicians present to instruct, scold, assist and teach me. I often received immediate—usually negative—feedback. And while it was true that we followed the model “watch one, do one, teach one,” a more senior, experienced clinician was always close by to help during any interactions with patients.

  Not so for psychiatry. As a trainee, when I was with a patient, or a patient and her family, I was almost always working alone. After meeting with the patient—sometimes multiple times—I discussed the case with my supervisor. During training a child psychiatry fellow will typically have several supervisors for clinical work. Often I would present the same child or issue to multiple supervisors to gather their different impressions and gain from their multiple, hopefully complementary, insights. It is an interesting process that has some remarkable strengths but also has some clear deficiencies, which I was about to discover.

  I presented Tina’s case to my first supervisor, Dr. Robert Stine1. He was young, serious, intellectual and in training to become a psychoanalyst. He maintained a full beard and wore what seemed like the exact same outfit every day: a black suit, a black tie, and a white shirt. He seemed a lot smarter than me. He used psychiatric jargon with ease: “the maternal introject,” “object relations,” “counter-transference,” “oral fixation.” And whenever he did, I’d look him in the eyes and try to look appropriately serious and thoughtful, nodding as if what he was saying was clearing things up for me: “Ah, yes. OK. Well, I’ll keep that in mind.” But really I was thinking, “What the hell is he talking about?”

  I gave a short but formal presentation, describing Tina’s symptoms, history, family and the complaints from her school, as well as detailing the key elements of my first visit with her. Dr. Stine took notes. When I finished he said, “Well, what do you think she has?”

  I had no clue. “I’m not sure,” I stalled. Medical training teaches a young physician to act much less ignorant than he or she really is. And I was ignorant. Dr. Stine sensed this and suggested we use the diagnostic guide for psychiatric disorders, the Diagnostic and Statistical Manual (DSM).

  At that point, it was the DSM III. Every ten years or so it is revised to include updates in research and new ideas about disorders. This process is guided by objective principles but is very susceptible to sociopolitical and other nonscientific processes. For example, homosexuality was once considered a “disorder” in the DSM and now it is not. But the main problem with the DSM—to this day—is that it is a catalog of disorders based on lists of symptoms. It is kind of like a computer manual written by a committee with no knowledge of the machine’s actual hardware or software, a manual that attempts to determine the cause of and cure for the computer’s problems by asking you to consider the sounds it makes. As I knew from my own research and training, the systems in that “machine”—in this case, the human brain—are very complex. As a result it seemed to me that the same “output” might be caused by any number of different problems within it. But the DSM doesn’t account for this.

  “So she is inattentive, a discipline problem, impulsive, noncompliant, defiant, oppositional and has problems with her peers. She meets diagnostic criteria for Attention Deficit Disorder and oppositional defiant disorder,” Dr. Stine prompted.

  “Yeah, I guess so.” I said. But it didn’t feel right to me. Tina was experiencing something more or something different than what was described by those diagnostic labels. I knew from my research on the brain that the systems involved in controlling and focusing our attention were especially complex. I also knew that there were many environmental and genetic factors that could influence them. Wasn’t labeling Tina “defiant” misleading, given that her “noncompliance” was likely a result of her victimization? What about the confusion that made her think that sexual behavior with adults and peers in public is normal? What about her speech and language delays? And if she did have Attention Deficit Disorder (ADD), might the sexual abuse be important in understanding how to treat someone like her?

  I didn’t raise these questions, though. I just looked at Dr. Stine and nodded as if I was absorbing what he was teaching me.

  “Go read up on psychopharmacology for ADD. We can talk more about this next week,” he advised.

  I left Dr. Stine feeling confused and disappointed. Is this what being a child psychiatrist was like? I had been trained as a general (adult) psychiatrist and was familiar with the limitations of supervision, and with the limitations of our diagnostic approach, but I was not at all familiar with the pervasive problems of the children I was seeing. They were socially marginalized, developmentally delayed, profoundly damaged and sent to our clinic so we could “fix” things that to me didn’t seem fixable with the tools we had at our disposal. How could a few hours a month and a prescription change Tina’s outlook and behav
ior? Did Dr. Stine really believe that Ritalin or some other ADD drug would solve this girl’s problems?

  Fortunately, I had another supervisor as well: a wise and wonderful man, a true giant in the field of psychiatry, Dr. Jarl Dyrud. Like me, he was from North Dakota, and we hit it off immediately. Like Dr. Stine, Dr. Dyrud was trained in the analytic method. Yet he also had years of real life experience trying to understand and help people. He had let that experience, not just Freud’s theories, mold his perspective.

  He listened carefully as I described Tina. When I finished, he smiled at me and said, “Did you enjoy coloring with her?”

  I thought for a minute and said, “Yeah. I did.”

  Dr. Dyrud said, “Very nice start. So tell me more.” I started to list Tina’s symptoms, the complaints the adults had about her behaviors.

  “No, no. Tell me about her. Not about her symptoms.”

  “What do you mean?”

  “Where does she live? What is her apartment like, when does she go to sleep, what does she do during the day? Tell me about her.”

  I admitted that I didn’t know any of that information. “Spend some time getting to know her—not her symptoms. Find out about her life,” he advised.

  For the next few sessions, Tina and I spent time coloring or playing simple games and talking about what she liked to do. When I ask children like Tina what they want to be when they grow up, they often respond with “If I grow up,” because they’ve seen so much real-life death and violence at home and in their neighborhoods that reaching adulthood seems uncertain. In our conversations sometimes Tina would tell me that she wanted to be a teacher, and other times she said she wanted to be a hairdresser, all with the perfectly ordinary, rapidly changing desires of a girl of her age. But as we discussed specifics of these various goals, it took some time before I was able to help her recognize that the future can be something you plan for, something you can predict and even change, rather than a series of unforeseen events that just happen to you.

  I also talked to her mother about her behavior in school and at home and found out more about her life. There was, of course, the daily routine of school. After school, unfortunately, there were often several hours between the time Tina and her younger brother came home and the time Sara got off from work. Sara had her children call her to check in, and there were neighbors nearby they could contact in an emergency, but she didn’t want to risk more caregiver abuse. So the children stayed home alone, usually watching TV. And sometimes, Sara admitted, because of what they’d both been through, there was sexualized play.

  Sara was far from a neglectful mother, but working to feed three young children often left her exhausted, overwhelmed and demoralized. Any parent would have been hard-pressed to cope with the emotional needs of these traumatized children. The family had little time to play or just be together. As in many financially strapped homes, there was always some pressing need, an economic or medical or emotional emergency that required immediate attention to avoid complete disaster, such as homelessness or job loss or overwhelming debt.

  A S MY WORK with Tina continued Sara always smiled when she first saw me. The hour that Tina had therapy was one time in her week when she didn’t have to do anything more than be with her other children. Tina would run down to my office while I took a moment to goof with her little brother (he was in therapy as well, but with someone else at a different time) and smile at the baby. When I was sure they were settled in with something to occupy them in the waiting area, I’d rejoin Tina, who would be sitting at her little chair waiting for me.

  “What should we do today?” she would ask, looking at the games, coloring books and toys she had pulled from my shelves and put on the table. I would pretend to think hard while she’d look at me with anticipation. My eyes would fix on a game on the table and say, “Mmm. How about let’s play Operation?” She would laugh, “Yes!” She guided our play. I slowly introduced new concepts, like waiting and thinking, before deciding what to do next. Occasionally she would spontaneously share some fact or some hope or some fear with me. I would ask questions to get some clarity. Then she would redirect the interaction back to play. And week by week, bit by bit, I got to know Tina.

  Later that fall, however, Tina was late to therapy for several weeks in a row. Because appointments were only an hour, this sometimes meant we would only have twenty minutes for our sessions. I made the mistake of mentioning this to Dr. Stine during an update on the case. He raised his eyebrows and stared at me. He seemed disappointed.

  “What do you think is going on here?”

  “I’m not sure. I think the mom seems pretty overwhelmed.”

  “You must interpret the resistance.”

  “Ah. OK.” What the hell is he talking about? Is he suggesting that Tina doesn’t want to come to therapy and is somehow forcing her mother to be late? “You mean Tina’s resistance or the mom’s?” I asked.

  “The mother left these children in harm’s way. She may be resentful that this child is getting your attention. She may want her to remain damaged,” he said.

  “Oh,” I responded, not sure what to think. I knew that analysts often interpreted lateness to therapy as a sign of “resistance” to change, but that was beginning to seem absurd, especially in this case. The idea left no room for genuine happenstance and seemed to go out of its way to blame people like Tina’s mom, who, as far as I could tell, did everything possible to get help for Tina. It was clearly difficult for her to get to the clinic. To get to the medical center, she had to take three different buses, which often ran late during the brutal Chicago winter; she had no childcare so she had to bring all her children; sometimes she had to borrow money for the bus fare. It seemed to me she was doing the best she could in an extremely difficult situation.

  Shortly thereafter, as I left the building one frozen night, I saw Tina and her family waiting for the bus home. They were standing in the dark and snow was slowly falling through the dim light of a nearby streetlight. Sara was holding the baby and Tina was sitting on the bench next to her brother under the heat lamp of the bus stop. The two siblings sat close to each other, holding hands and slowly rocking their legs back and forth. Their feet didn’t reach the ground and they kept time with each other, in sync. It was 6:45. Icy cold. They would not be home for another hour at least. I pulled my car over, out of sight, and watched them, hoping the bus would come quickly.

  I felt guilty watching them from my warm car. I thought I should give them a ride. But the field of psychiatry is very attentive to boundaries. There are supposed to be unbreachable walls between patient and doctor, strict borderlines that clearly define the relationship in lives that often otherwise lack such structure. The rule usually made sense to me, but like many therapeutic notions that had been developed in work with neurotic middle-class adults, it didn’t seem to fit here.

  Finally, the bus came. I felt relieved.

  The next week, I waited a long time after our session before going to my car. I tried to tell myself that I was doing paperwork, but really I didn’t want to see the family standing in the cold again. I couldn’t stop wondering about what could be wrong with the simple humane act of giving someone a ride home when it was cold out. Could it really interfere with the therapeutic process? I went back and forth, but my heart kept coming down on the side of kindness. A sincere, kind act, it seemed to me, could have more therapeutic impact than any artificial, emotionally regulated stance that so often characterizes “therapy.”

  It was full winter in Chicago now and bitterly, bitterly cold. I ultimately told myself that if I saw the family again, I’d give them a ride. It was the right thing to do. And one night in December as I left work and drove by the bus stop, there they were. I offered them a ride. Sara declined at first, saying she had to stop at the grocery store on her way. In for a penny in for a pound, I thought. I offered to drive them to the store. After some more hesitation, she agreed and they all piled into my Toyota Corolla.

  Miles away
from the medical center, Sara pointed to a corner store and I stopped there. Holding her sleeping baby, she looked at me, unsure whether to take all the children into the store with her.

  “Here. I’ll hold the baby. We’ll wait here,” I said decisively.

  She was in the store for about ten minutes. We listened to the radio. Tina sang along with the music. I was just praying the baby wouldn’t wake up. I slowly rocked her, mimicking the rhythm that Tina’s mother had used. Sara came out of the store with two heavy bags.

  “Take these back there and don’t touch anything,” she said to Tina, putting the bags on the back seat.

  When we arrived at her building, I watched as Sara struggled to get out of the car and walk through the unshoveled snow on the sidewalk, juggling the baby, her purse and a bag of groceries. Tina tried to carry the other bag of groceries, but it was too heavy for her and she slipped in the snow. I opened my door and got out, taking one bag from Tina and the other one from Sara.

  “No. We can manage,” she protested.

  “I know you can. But tonight I can help.” She looked at me, not sure how to deal with this. I sensed her trying to understand if this was kindness or something sinister. She seemed embarrassed. I felt embarrassed. But it still seemed right to help.

  We all walked up three flights of stairs to their apartment. Tina’s mother got out her keys and opened three locks all without disturbing her sleeping baby. How difficult this mother’s life was, I thought, all alone caring for three children, no money, only episodic and often tedious work, no extended family nearby. I stood at the threshold of the door with the bags in my arms, not wanting to intrude.