TINA WAS MY FIRST CHILD PATIENT, just seven years old when I met her. She sat in the waiting room of the University of Chicago child psychiatry clinic: tiny and fragile, huddled with her mother and siblings, unsure what to expect from her new doctor. As I led her to my office and shut the door, it was hard to tell which one of us was more nervous: the three-foot-tall African-American girl with meticulously neat braids or the six-foot-two white guy with the long mane of unruly curls. Tina sat on my couch for a minute, checking me out, looking me up and down. Then, she walked across the room, crawled into my lap and snuggled in.
I was touched. Gosh, what a nice thing to do. What a sweet child. Stupid me. She shifted slightly and moved her hand to my crotch and tried to open my zipper. I was no longer anxious. Now, I was sad. I took her hand, moved it from my thighs, and carefully lifted her off my lap.
The morning before I first met with Tina I read through her “chart”—one small sheet of paper with minimal information taken during a phone interview with our intake worker. Tina lived with her mother, Sara, and two younger siblings. Sara had called the child psychiatry clinic because her daughter’s school had insisted that she get her evaluated. Tina had been “aggressive and inappropriate” with her classmates. She’d exposed herself, attacked other children, used sexual language, and tried to get them to engage in sex play. She didn’t pay attention in class and often refused to follow directions.
The most relevant history the chart contained was that Tina had been abused for a two-year period that started when she was four and ended when she was six. The perpetrator was a sixteen-year- old boy, her babysitter’s son. He had molested both Tina and her younger brother, Michael, while their mother was at work. Tina’s mom was single. Poor, but no longer on public assistance, at the time Sara worked a minimum wage job at a convenience store to support her family. The only childcare she could afford was an informal arrangement with her next-door neighbor. That neighbor, unfortunately, often left the children with her son so she could run errands. And her son was sick. He tied the children up and raped them, sodomized them with foreign objects, and threatened to kill them if they told. Finally, his mother caught him and put a stop to the abuse.
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 the next week.
As they left I knew I needed to talk to a supervisor with more experience, one 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 Stine.
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 behavior? 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.
AS 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 I would 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.
“You can just put those on the table,” Sara said as she walked to the back of the one-room apartment to put the baby down on a mattress against the wall. In two steps I was at the kitchen table. I put the bags down and glanced around the room. There was one couch facing a color television and a small coffee table with a few cups and dirty dishes on it. On a small table with three unmatched chairs near the kitchenette, there was a loaf of Wonderbread and a jar of peanut butter. One double mattress sat on the floor, with blankets and pillows neatly folded at one end. Clothes and newspapers were scattered around. A picture of Martin Luther King Jr. hung on the wall, and next to it on either side were brightly colored school portraits of Tina and her brother. On another wall hung a picture of Sara and the baby, slightly crooked. The apartment was warm.
Sara stood and awkwardly said, “Thanks again for the ride,” and I assured her it had been no trouble. The moment was very uncomfortable. As I walked out the door and said, “See you all next week,” Tina waved. She and her toddler brother were putting the groceries away.
They were better behaved than many children I’d seen in much better circumstances; it seemed to me that they had to be.
The drive home took me through some of the poorest neighborhoods in Chicago. I felt guilty. Guilty about the luck, the opportunities, the resources, and the gifts I had been given, guilty about all of the times I had complained about working too much, or not getting credit for something I had done. I also felt I knew much more about Tina. She had grown up in a world so very different from mine. And somehow that had to be related to the problems that brought her to see me. I didn’t know exactly what it was, but I knew there was something important about how the world she grew up and lived in had shaped her emotional, behavioral, social, and physical health.
AFTERWARDS, OF COURSE, I WAS afraid to tell anyone what I’d done, that I’d driven a patient and her family home. Worse yet, that I had stopped at the store on the way and helped bring in some groceries. But part of me didn’t care. I knew I’d done the right thing. You just don’t let a young mother with two young children and a baby stand in the cold like that.
I waited two weeks and then, when I next met with Dr. Dyrud, I told him. “I saw them waiting for a bus and it was cold. So I gave them a ride home,” I said nervously, scanning his face for his reaction, just like Tina had done with me. He laughed as I slowly told him about the extent of my transgression.
When I’d finished, he clapped his hands together, saying,
“Great! We should do a home visit with all of our patients.” He smiled and sat back. “Tell me all about it.”
I was shocked. In an instant Dr. Dyrud’s smile and the delight on his face released me from two weeks of nagging guilt. When he asked what I’d learned I told him that one moment in that tiny apartment had told me more about the challenges facing Tina and her family than I could ever have learned from any on-site session or interview.
Later in that first year of my child psychiatry fellowship, Sara and her family moved to an apartment closer to the medical center, one twenty-minute bus ride away. The lateness ceased. No more “resistance.” We continued to meet once a week.
DR. DYRUD’S WISDOM AND MENTORSHIP continued to be liberating for me. Like other teachers, clinicians, and researchers who had inspired me, he encouraged exploration, curiosity, and reflection, but, most importantly, gave me the courage to challenge existing beliefs. Taking bits and pieces from each of my mentors, I began to develop a therapeutic approach that sought to explain emotional and behavioral problems as symptoms of dysfunction within the brain.
In 1987 child psychiatry had not yet embraced the neurosciences. In fact, the vast expansion of research on the brain and brain development that began in the 1980s and exploded in the 1990s (“the decade of the brain”) had yet to occur, let alone influence clinical practice. Instead, there was active opposition by many psychologists and psychiatrists to taking a biological perspective on human behavior. Such an approach was considered mechanistic and dehumanizing, as though reducing behavior to biological correlates automatically meant that everything was caused by genes, leaving no room for free will and creativity, and no way to consider environmental factors like poverty. Evolutionary ideas were seen as even worse, as backwards racist and sexist theories that rationalized the status quo and reduced human action to animal drives.
Since I was just starting out within child psychiatry, I didn’t yet trust my own capacity to think independently, to process and interpret accurately what I was seeing. How could my thoughts about this be right when none of the other established psychiatrists, the stars, my mentors, were talking about or teaching about these things? Fortunately, Dr. Dyrud and several of my other mentors encouraged my tendency to fold neuroscience into my clinical thinking about Tina and other patients. What was going on in Tina’s brain? What was different about her brain that made her more impulsive and inattentive than other girls her age? What had happened in her rapidly developing brain when she had suffered these abnormal, sexualized experiences as a toddler? Did the stress of poverty affect her? And why did she have speech and language delays? Dr. Dyrud used to point to his head as he said,
“The answer is in there somewhere.”
My introduction to neuroscience had started during my freshman year in college. My first college advisor, Dr. Seymour Levine, a world-famous neuroendocrinologist, had conducted pioneering work on the impact of stress during early life on the development of the brain, which had shaped all of my subsequent thinking. His work helped me see how early influences can literally leave imprints on the brain that last a lifetime.
Levine had done a series of experiments examining the development of important stress-related hormone systems in rats.
His group’s work demonstrated that the biology and function of these important systems could be altered dramatically by brief periods of stress during early life. Biology isn’t just genes playing out some unalterable script. It is sensitive to the world around it, as evolutionary theories predicted. In some of the experiments the duration of the stress was only minutes long, involving just a few moments of human handling of rat pups (baby rats), which is highly stressful for them. But this very brief stressful experience, at a key time in the development of the brain, resulted in alterations in stress hormone systems that lasted into adulthood.
From the moment I started my formal education in the field, then, I was aware of the transformative impact of early life experiences. This became a template against which I compared all subsequent concepts.
Frequently, while at the lab, my thoughts would turn to Tina and the other children with whom I was working. I would force myself to work the problem: What do I know? What information is missing? Can I see any connections between what was known and what was not known? Was seeing me making any difference in the lives of these children? As I thought about my patients, I also considered their symptoms: Why these particular problems in this particular child? What could help change them? Could their behavior be explained by anything that I and other scientists in my field were learning about how the brain works? For example, could studying the neurobiology of attachment—the connection between parent and child—help solve problems between a mother and her son? Could Freudian ideas like transference—where a patient projects his feelings about his parents into other relationships, particularly the one he has with his therapist—be explained by examining the function of the brain? There had to be some link, I thought. Just because we couldn’t describe it or yet understand it, there just had to be a correlation between what went on in the brain and every human phenomenon and symptom. After all, the human brain is the organ that mediates all emotion, thought, and behavior. In contrast to other specialized organs in the human body, such as the heart, lungs, and pancreas, the brain is responsible for thousands of complex functions. When you have a good idea, fall in love, fall down the stairs, gasp when walking up stairs, melt at the smile of your child, laugh at a joke, get hungry, and feel full—all of those experiences and all your responses to these experiences are mediated by your brain. So it followed that Tina’s struggles with speech and language, attention, impulsivity, and healthy relationships also had to involve her brain.
But what part of her brain? Could understanding this help me treat her more effectively? Which of Tina’s brain regions, neural networks, neurotransmitter systems were poorly regulated, underdeveloped, or disorganized, and how could this information help me with Tina’s therapy? To answer these questions I had to start with what I already knew.
THE BRAIN’S REMARKABLE FUNCTIONAL capabilities come from an equally remarkable set of structures. There are eighty-six billion neurons (brain cells), and for each neuron there are also equally important support cells, called glia. During development—from the first stirrings in the womb to early adulthood—all of these complicated cells (and there are many different types) must be organized into specialized networks. This results in countless intricately interconnected and highly specialized systems. These chains and webs of connected neurons create the varied architecture of the brain. For our purposes there are four major parts of the brain: the brainstem, the diencephalon, the limbic system, and the cortex.
The brain is organized from the inside out, like a house with increasingly complicated additions built on an old foundation. The lower and most central regions of the brainstem and the diencephalon are the simplest. They evolved first, and they develop first as a child grows. As you move upward and outward, things get increasingly more complex with the limbic system. The cortex is more intricate still, the crowning achievement of brain architecture. We share similar organization of our lowest brain regions with creatures as primitive as lizards, while the middle regions are similar to those found in mammals like cats and dogs.
The outer areas we share only with other primates, like monkeys and the great apes. The most uniquely human part of the brain is the frontal cortex, but even this shares 96 percent of its organization with that of a chimpanzee! Our four brain areas are organized in a hierarchical fashion: bottom to top, inside to outside. A good way to picture it is with a little stack of dollar bills—say five. Fold them in half, place them on your palm and make a hitchhiker’s fist with your thumb pointing out. Now, turn your fist in a “thumbs down” orientation. Your thumb represents the brainstem, the tip of your thumb being where the spinal cord merges into the brainstem; the fatty part of your thumb would be the diencephalon; the folded dollars inside your fist, covered by your fingers and hand, would be the limbic system; and your fingers and hand, which surround the bills, represent the cortex. When you look at the human brain, the limbic system is completely internal; you cannot see it from the outside, just like those dollar bills. Your little finger, which is now oriented to be the top and front, represents the frontal cortex.
While interconnected, each of these four main areas controls a separate set of functions. The brainstem, for example, mediates our core regulatory functions such as body temperature, heart rate, respiration, and blood pressure. The diencephalon and the limbic system handle emotional responses that guide our behavior, like fear, hatred, love, and joy. The very top part of the brain, the cortex, regulates the most complex and highly human functions such as speech and language, abstract thinking, planning, and deliberate decision making. All of them work in concert, like a symphony orchestra, so while there are individualized capacities, no one system is wholly responsible for the sound of the “music” you actually hear.
Tina’s symptoms suggested abnormalities in almost all of the parts of her brain. She had sleep and attention problems (brainstem), difficulties with fine motor control and coordination (diencephalon and cortex), clear social and relational delays and deficits (limbic and cortex), and speech and language problems (cortex).
This pervasive distribution of problems was a very important clue. My research—and the research of hundreds of others— indicated that all of Tina’s problems could be related to one key set of neural systems, the ones involved in helping humans cope with stress and threat. Coincidentally, those were exactly the systems I was studying in the lab.
These systems were “suspect” to me for two main reasons. The first was that myriad studies in humans and animals had documented the role these systems play in arousal, sleep, attention, appetite, mood, impulse regulation—basically all of the areas in which Tina had major problems. The second reason was that these important networks originate in the lower parts of the brain and send direct connections to all of the other areas of the brain. This architecture allows a unique role for these systems.
They are capable of integrating and orchestrating signals and information from all of our senses and throughout the brain. This capacity is necessary to effectively respond to threat: if, for example, a predator may be lurking, an animal needs to be able to respond just as quickly to his scent or sound as to actually seeing him.
Additionally, the stress response systems are among only a handful of neural systems in the brain that, if poorly regulated or abnormal, can cause dysfunction in all four of the main brain areas —just like what I was seeing with Tina. The basic neuroscience work I’d been doing for years had involved examining the details of how these systems worked. In the brain, neurons transmit messages from one cell to the next by using chemical messengers called neurotransmitters that are released at specialized neuron-to-neuron connections called synapses. These chemical messengers fit only into certain, correctly shaped receptors on the next neuron, in the same way that only the right key will fit into the lock on your front door.
Synaptic connections, at once astoundingly complex and yet elegantly simple, create chains of neuron-to-neuron-to-neuron networks that allow all of the many functions of the brain, including thought, feeling, motion, sensation, and perception. This also allows drugs to affect us, because most psychoactive medications work like copied keys, fitting into the locks meant to be opened by particular neurotransmitters and fooling the brain into opening or closing their doors.
I had done my doctoral research in neuropharmacology in the lab of Dr. David U’Prichard, who had trained with Dr. Solomon Snyder, a pioneering neuroscientist and psychiatrist. (Dr. Snyder’s group was famous for, among many other things, finding the receptor at which opiate drugs like heroin and morphine act.) When I worked with Dr. U’Prichard, I did research on the norepinephrine (also known as noradrenaline) and epinephrine (also known as adrenaline) systems. These neurotransmitters are involved in stress. The classic “fight or flight” response begins in a central clump of norepinephrine neurons known as the locus coeruleus (“blue spot,” named for its color). These neurons send signals to virtually every other important part of the brain and help it respond to stressful situations. Some of my work with Dr. U’Prichard involved two different strains of rats, which were animals of the same species that had some slight genetic differences. These rats looked and acted exactly the same in ordinary situations, but even the most moderate stress would cause one type to break down. Under calm conditions, these rats could learn mazes, but give them the tiniest stress, and they would unravel and forget everything. The other rats were unaffected. When we examined their brains, we found that early in the development of the stress-reactive rats, there was over-activity in their adrenaline and noradrenaline systems. This small change led to a great cascade of abnormalities in receptor number, sensitivity, and function across many brain areas, and ultimately altered their ability to respond properly to stress for a lifetime.
I had no evidence that Tina was genetically “oversensitive” to stress. I did know, however, that the threat and the painful sexual assaults Tina experienced had, no doubt, resulted in repetitive and intense activation of her threat-mediating stress response neural systems. I recalled Levine’s work that had shown that just a few minutes of stressful experience early in life could change a rat’s stress response forever. Tina’s abuse had gone on much longer— she’d been assaulted at least once a week for two years—and that had been compounded by the stress of living in a constant state of crisis with a family that was often on the economic edge. It occurred to me that if both genes and environment could produce similar dysfunctional symptoms, the effect of a stressful environment on a person already genetically sensitive to stress would probably be magnified.
And as I continued to work both with Tina and in the lab, I came to believe that in Tina’s case the repeated activation of her stress response systems from a trauma endured at a young age, when her brain was still developing, had probably caused a cascade of altered receptors, sensitivity, and dysfunction throughout her brain, similar to the one I observed in animal models. Consequently, I started to think Tina’s symptoms were the result of developmental trauma. Her attention and impulse problems might be due to a change in the organization of her stress response neural networks, a change that might have once helped her cope with her abuse, but was now causing her aggressive behavior and inattention to her class work in school.
It made sense: a person with an overactive stress system would pay close attention to the faces of people like teachers and classmates, where threat might lurk, but not to benign things like classroom lessons. A heightened awareness of potential threat might also make someone like Tina prone to fighting, as she would be looking everywhere for signs that someone might be about to attack her again, likely causing her to overreact to the smallest potential signals of aggression. This seemed a much more plausible explanation for Tina’s problems than assuming that her attention problems were coincidental and unrelated to the abuse.
I looked back through her chart and saw that upon her first visit to the clinic her heart rate had been 112 beats per minute. A normal heart rate for a girl of that age should have been below 100. An elevated heart rate can be an indication of a persistently activated stress response, which was more evidence for my idea that her problems were a direct result of her brain’s response to the abuse. If I had to give Tina a label now, it wouldn’t be ADD, but rather post-traumatic stress disorder, PTSD.
OVER THE THREE YEARS I worked with Tina, I was delighted and relieved by her apparent progress. There were no more reports of “inappropriate” behavior at school. She was doing her homework, going to class, and no longer fighting with other children. Her speech had improved; most of her problems had been related to the fact that she was so soft spoken that teachers and even her mother often couldn’t hear her well enough to understand her, let alone correct her pronunciation. As she learned to speak up and was spoken to more often, thereby receiving the repeated corrective feedback she needed, she caught up.
She had also rapidly become more attentive and less impulsive, so rapidly in fact that I didn’t even discuss medication with my supervisors after that initial conversation with Dr. Stine.
Tina guided our play during our sessions, but I used every opportunity to teach her lessons that would help her feel more confident out in the world and help her behave more appropriately and rationally. We initially learn impulse control and decision making from those around us, sometimes from explicit lessons, sometimes by example. Tina, however, lived in an environment where neither explicit nor implicit lessons were taught. Everyone around her just reacted to what happened to them, and so that’s what she did, too. Our meetings offered her the undivided attention she craved and our games taught her some of the lessons she had missed. For example, when I first began my work with Tina she hadn’t understood the concept of taking turns. She couldn’t wait to start things; she acted and reacted without thinking. In the simple games that we played, I modeled more appropriate behavior and repeatedly taught her to pause before doing the first thing that popped into her head. Based on her excellent progress in school, I truly believed I’d helped her.
UNFORTUNATELY, HOWEVER, TWO weeks before I left the clinic to start a new job, now ten-year-old Tina was caught performing fellatio on an older boy at school. What I’d taught her, it seemed, was not to change her behavior, but to better hide her sexualized activity and other problems from adults and to control her impulses in order to avoid getting in trouble. On the surface she could make others think she was behaving appropriately, but inside, she had not overcome her trauma.
I WAS DISAPPOINTED AND CONFUSED upon hearing this news. I had tried so hard, and she had really seemed to be getting better.
It was difficult to accept that what seemed to be a positive therapeutic effort had been so hollow. What had happened? Or more importantly, what didn’t happen in our work to help change her? I kept thinking about the effects Tina’s early childhood trauma and her unstable home life could have had on her brain. And soon I realized that I needed to expand my view of clinical mental health work. The answers to my failed, inefficient treatment for Tina—and to the big questions in child psychiatry—were in how the brain works, how the brain develops, how the brain makes sense of and organizes the world. Not in the brain as it has been caricatured as a rigid, genetically preset system that sometimes requires medication to adjust “imbalances,” but in the brain in all its complexity. Not in the brain as a seething complex of unconscious “resistance” and “defiance,” but in the brain as it evolved to respond to a complex social world. A brain, in short, that had genetic predispositions that were shaped by evolution to be exquisitely sensitive to the people who surrounded it.
Tina did learn to better regulate her stress system; her improved impulse control seemed to be good evidence of this. But Tina’s most troubling problems had to do with her distorted and unhealthy sexual behaviors. I realized that some of her symptoms could be fixed by changing her overreactive stress response, yet that would not erase her memory. I began to think that memory was what I needed to understand before I could do better.
So, what is memory, really? Most of us think about it in relation to names, faces, phone numbers, but it is much more than that. It is a basic property of biological systems. Memory is the capacity to carry forward in time some element of an experience. Even muscles have memory, as you can see by the changes in them that result from exercise. Most importantly, however, memory is what the brain does, how it composes us and allows our past to help determine our future. In no small part memory makes us who we are and in Tina’s case, her memories of sexual abuse were a large part of what stood in her way.
Tina’s precocious and oversexualized interactions with males clearly stemmed from her abuse. I began considering memory and how the brain creates “associations” when two patterns of neural activity occur simultaneously and repetitively. For example, if the neural activity caused by the visual image of a fire truck and that caused by the sound of a siren co-occur repetitively, these once- separate neural chains (visual and sound related-neural networks) will create new synaptic connections and become a single, interconnected network. Once this new set of connections between visual and auditory networks is created, merely stimulating one part of the network (for example, hearing the siren) can actually activate the visual part of the chain and the person will almost automatically visualize a fire truck.
This powerful property of association is a universal feature of the brain. It is through association that we weave all of our incoming sensory signals together—sound, sight, touch, scent—to create the whole person, place, thing, and action. Association allows and underlies both language and memory.
Our conscious memory is full of gaps, of course, which is actually a good thing. Our brains filter out the ordinary and expected, which is utterly necessary to allow us to function. When you drive, for example, you rely automatically on your previous experiences with cars and roads; if you had to focus on every aspect of what your senses are taking in, you’d be overwhelmed and would probably crash. As you learn anything, in fact, your brain is constantly checking current experience against stored templates—essentially memory—of previous similar situations and sensations, asking “Is this new?” and “Is this something I need to attend to?”
So as you move down the road, your brain’s motor vestibular system is telling you that you are in a certain position. But your brain is probably not making new memories about that. Your brain has stored in it previous sitting experiences in cars, and the pattern of neural activity associated with that doesn’t need to change.
There’s nothing new. You’ve been there, done that, it’s familiar.
This is also why you can drive over large stretches of familiar highways without remembering almost anything at all that you did during the drive.
This is important because all of that previously stored experience has laid down the neural networks, the memory “template,” that you now use to make sense out of any new incoming information. These templates are formed throughout the brain at many different levels, and because information comes in first to the lower, more primitive areas, many are not even accessible to conscious awareness. For example, young Tina almost certainly wasn’t aware of the template that guided her interactions with men, and shaped her behavior with me when we first met. Further, all of us have probably had the experience of physically jumping up before we even figured out what it was that startled us in the first place. This happens because our brain’s stress response systems carry information about potential threats and are primed to respond to them as quickly as possible, which often means before the cortex can consider what action to take. If, like Tina, we have had highly stressful experiences, reminders of those situations can be similarly powerful and provoke reactions that are similarly driven by unconscious processes.
What this also means is that early experiences will necessarily have a far greater impact than later ones. The brain tries to make sense of the world by looking for patterns. When it links coherent, consistently connected patterns together again, it tags them as “normal” or “expected” and stops paying conscious attention. So, for example, the very first time you were placed in a sitting position as an infant, you did pay attention to the novel sensations emanating from your buttocks. Your brain learned to sense the pressure associated with sitting normally, you began to sense how to balance your weight to sit upright via your motor vestibular system and, eventually, you learned to sit. Now, when you sit, unless it’s uncomfortable or the seat is unusually textured or shaped or you have some kind of balance disorder, you pay little attention to staying upright or the pressure the seat puts on your rear. When you are driving, it’s something you rarely attend to at all.
What you do scan the road for is novelty, things that are out of place, such as a truck barreling down the wrong side of the freeway. This is why we offload perceptions of things we consider normal: so that we can rapidly react to things that are aberrant and require immediate attention. Neural systems have evolved to be especially sensitive to novelty, since new experiences usually signal either danger or opportunity.
One of the most important characteristics of both memory, neural tissue, and of development, then, is that they all change with patterned, repetitive activity. So, the systems in your brain that get repeatedly activated will change, and the systems in your brain that don’t get activated won’t change. This “use-dependent” development is one of the most important properties of neural tissue. It seems like a simple concept, but it has enormous and wide-ranging implications.
And understanding this concept, I came to believe, was key to understanding children like Tina. She had developed a very unfortunate set of associations because she was sexually abused so early in life. Her first experiences with men and her teenage male abuser were what shaped her conception of what men are and how to act toward them; early experiences with those around us mold all of our worldviews. Because of the enormous amount of information the brain is confronted with daily, we must use these patterns to predict what the world is like. If early experiences are aberrant, these predictions may guide our behavior in dysfunctional ways. In Tina’s world, males larger than she was were frightening, demanding creatures who forced her or her mother into sex. The scent, sight, and sounds associated with them came together to compose a set of “memory templates” that she used to make sense of the world.
And so, when she came into my office that first time and was alone in the company of an adult male, it was perfectly natural for her to assume that sex was what I wanted as well. When she went to school and exposed herself or tried to engage in sex play with other children, she was modeling what she knew about how to behave. She didn’t consciously think about it. It was just a set of behaviors that were part of her toxic associations, her twisted template for sexuality.
Unfortunately, with only an hour a week of therapy, it was almost impossible to undo that set of associations. I could model the behavior of a different kind of adult male, I could show her that there were situations where sexual activity was inappropriate and help her learn to resist impulses, but I couldn’t, in such a small amount of time, replace the template that had been forged in the fresh tissue of her young brain, that had been burned in with patterned, repetitive early experience. I would need to integrate a lot more about how the human brain works, how the brain changes, and the systems that interact in this learning into my treatments before I could even begin to do better for patients like Tina, patients whose lives and memories had been marred in multiple ways by early trauma.
Commentary
Ten years is a long time in a child’s life—but a mere instant in the development of a discipline like child psychiatry or the neurosciences. During the decade since the first edition of this book was released, much progress has been made in these fields.
Yet systems—and the ideas within them that frame policies, practices, and programs—change far more slowly.
It is estimated, for example, that once a new concept or principle of practice is well established by research, it takes between twenty and thirty years for the “new” ideas to become standard practice.
And, as we all know, by that time there is often newer research that suggests modifications and improvements on this “innovation”— and it will take years before these become standard practice, too.
The bottom line is that the rate of discovery is faster than the rate at which an organization or system can adapt and incorporate these changes.
We see evidence of this “innovation gap” in all aspects of our life. An important example related to the main challenges that faced Tina and her family is in the early childhood area. For decades, there has been overwhelming economic and developmental research demonstrating the value of high-quality early childhood interventions for “at risk” young families like hers.
For every one dollar invested in high-quality early childhood programs like preschool and support for new parents, nine are returned in terms of improved academic performance, better employment, and reduced addiction, mental illness, and crime — yet we still do not provide high-quality, affordable preschool, paid family leave, and adequate support for vulnerable families. Sadly, if anything our public systems like child mental health, child welfare, juvenile justice, and education are slower to change than other organizations such as those in the corporate sector.
Over these last ten years, The ChildTrauma Academy has been working to close its “innovation gap” in several areas. One of the most important relates to the conceptualization of “therapy.” In the twenty-five years since I worked with Tina, my understanding of therapy and the therapeutic interaction has changed dramatically.
During our work, as we challenged ourselves to better understand these children, we kept asking: what is a meaningful therapeutic interaction? How long should that interaction be? Fifty minutes? Ten minutes? Two seconds? Does the “dosing schedule” of therapy—and the supposed therapeutic interactions—have to be once a week for fifty minutes? Could it be twice a week for thirty minutes or some other variant? What is an effective dose of therapy? Who provides that therapeutic experience? Only a “trained” professional? Or can a parent, coach, friend—or the client herself, in an inner process—provide a therapeutic moment? And how much time do you need between therapeutic interactions to optimize positive change? How do you “space” the therapeutic doses? Are there specific patterns that lead to more effective change—or is simple regularity enough? And are there specific environments or experiences that interfere with—or enhance—a therapeutic interaction? Over the last ten years our interest and understanding of these issues has matured. In the last paragraph of “Tina’s World,” we note that an hour a week of therapy was unable to “undo that set of associations,” which were related to her history of being abused. It is more accurate now to re-phrase that comment; therapy does not undo associations. Instead, it creates new associations which, over time, can become the new “default” or “template” for guiding responses to future experiences.
In Tina’s case, if she had been given enough time and opportunity to interact with healthy and attuned men and boys who provided sufficient positive or neutral interactions for a long enough time and in a clear enough pattern, she could have created new default associations about men—and male attributes. The associations created by her early history of sexual abuse would remain, although hopefully over time they would be much less “activated” and their intensity would fade.
The major challenge here is that we know so little about how to dose and schedule therapeutic experiences in order to create this therapeutic change. But study of the brain and how it changes may provide us some clues. These days, the buzzword in neuroscience is “neuroplasticity,” which refers to the capacity of neurons and their networks to be altered by experience.
There are some promising clues to the concept of therapeutic dosing in the study of how new synapses—those connections between neurons that link them into networks—are formed and altered to create or change memories. One of the most studied and most important areas of the neurosciences has to do with what is called Long-term Potentiation (LTP). Basically, this refers to the strengthening of synaptic connections, which occurs in response to a brief pattern of intense stimulation. The resulting cascade of cellular changes following this intense stimulation leads to enduring neuronal changes all the way to the chromosome, altering gene expression. It is widely believed that LTP is an important factor in learning and memory formation.
This has important implications for the dosing of therapy: it suggests that even really short experiences can have a big impact.
Indeed, long-term and enduring changes in neural networks can be created by an intense period of stimulation that lasts less than a minute. Synaptic splitting, which is one way these connections can change, can occur in mere seconds of intense stimulation—and if the intense experience is repeated four times within an hour, the change will be maintained long term.
Just as a traumatic experience can alter a life in an instant, so too can a therapeutic encounter. Unfortunately, in order for positive “doses” of interaction to lead to long-term change, much more repetition is needed. Consequently, the pattern and spacing required to ensure long-term maintenance of any therapeutic change is going to require a density of therapeutic interactions that our current mental health model of fifty minutes once a week cannot provide. For children like Tina to truly benefit from therapy, it needs to be embedded in a context of safe and positive interactions.
The good news is that anyone can help with this part of “therapy”—it merely requires being present in social settings and being, well, basically, kind. An attentive, attuned, and responsive person will help create opportunities for a traumatized child to control the dose and pattern of rewiring their trauma-related associations. For people who have been sexually abused, like Tina, just being acknowledged in a supportive, respectful, and non- threatening way aids healing. The more we can provide each other these moments of simple, human connection—even a brief nod or moment of eye contact—the more we’ll be able to help heal those who have suffered traumatic experience.
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