The Boy Who Was Raised as a Dog (29 page)

Ted agreed to try it and to continue seeing me for therapy.

He took the medication for four weeks, during which he had no further fainting episodes. But because the drug blocked the opioid response that allowed Ted to dissociate, he now became very anxious when he faced new or stressful experiences. This is a common problem with many drugs in psychiatry, and in general medicine. A drug may be excellent at eliminating a particular symptom, but does not treat the whole person and deal with the full complexity of his problem, and therefore it may exacerbate other symptoms. In fact, we found that parents and teachers often thought that naltrexone “made the child worse” because rather than “spacing out” in response to perceived stress, many children began to have hyper-arousal symptoms instead. These “fight-or-flight”
reactions appeared far more disruptive to adults because the children now appeared more active, more defiant and sometimes even aggressive. We could give clonidine to minimize the hyper-arousal, but without helping the child learn alternative coping skills, the medications had no enduring effects. We ultimately decided that while there were certain cases in which naltrexone could be helpful, it had to be used with great care.

Ted had problems that ran much deeper than occasional fainting. He had a dissociative disorder that had deeply affected his ability to deal with emotional and physical challenges. In order to help this young man, and not just “resolve” the medical issue that had brought him to us, we needed to help him learn how to cope with his stress. Thanks to the naltrexone, his brain was no longer automatically responding to minor stresses by shutting down the whole system, but now we needed to help his mind learn how to handle life stress in a healthier, more comfortable and more productive way.

As with Amber, it was not only Ted's sensitized stress system that had led to his problems, it was also the associations he'd made related to his abuse that were getting in his way. When Ted and I began to talk, I started to understand that his fainting was most often triggered by interactions with men and with the trappings of masculinity—cues that reminded him of his abuser, who had been an extremely macho military man. The fainting itself had been precipitated by his entry into late adolescence, a situation that exposed him to mature men far more often than before. Now, not only did he have contact with male teachers and coaches, but also he, along with his peers, was beginning to show signs of adult manhood. As a young boy he could avoid many of these triggers, but now they were everywhere.

In order to teach him to respond to these cues without overreacting and engaging a dissociative response once he was no longer taking the naltrexone, I needed to have him experience them in a safe setting. I decided to give him the shorter-acting opioid blocker, naloxone, at the beginning of his therapy session with me, expose him to male-related cues
and help him face them so that they would no longer be so powerfully stressful to him. By the end of our session, the naloxone would wear off, so that if he did experience cues later on, he could dissociate if he felt extremely threatened.

To maximize the effect, I had to act a lot more stereotypically masculine and macho than I usually do, which was a lot easier back then when I was a bit younger and in pretty good condition! On days I had therapy with Ted, I would tuck my shirt into my pants to emphasize the male characteristics of my waistline and roll up my sleeves to expose my forearm muscles. It seems silly (and sometimes it felt silly), but it allowed him to develop a healthy relationship with a male and get used to such cues. When he began to experience feelings and memories related to the abuse, I could calm him and reassure him that he was safe, and he could see for himself that he could handle things without having to shut down.

Ted was highly intelligent, and I explained the rationale for our treatment to him. He soon came up with his own ways of furthering the process. He got assigned to record statistics for the school basketball team, which would let him be around young men in situations where he would be safe and comfortable and could develop new associations to replace those that had previously prompted his symptoms. His fainting never returned and, while he continued to try to “fade into the background,” he became better at fully experiencing his own life.

I made progress with Amber, too. We met each week for the first ten months following her ER visit. Since she did not have regular fainting episodes and had some degree of control over her dissociative symptoms, I decided not to use naloxone or naltrexone. I looked forward to our sessions. Her intelligence, creativity and sense of humor allowed her to articulate her story in ways that gave me greater insight into other children who weren't able to be as clear about what they were going through. But she was also fragile, overly sensitive, dark and tired inside. It takes a great deal of energy to remain vigilant and “on guard” the way Amber was; it is exhausting to view the entire world as a potential threat. She didn't just fear physical threats, either. She tended to
twist positive comments from others into neutral remarks, neutral interactions into negative exchanges and any negative cues into catastrophic personal attacks.

“They hate me,” she would say. She was constantly perceiving slights where none were intended, which made the relationships she did have difficult and eliminated many others before they could start. As a result, much of our time was spent trying to get her to see these interactions as clearly as she could see so much else about her life. This part of our work was basically cognitive therapy, which is one of the most effective treatments for depression. Amber's abuse had produced a number of depressive symptoms, one of which was self-hatred. Often, people like Amber believe that others can “sense” that they are unworthy and “bad,” that they deserve to be hurt and rejected. They project their self-hate onto the world and become sensitized—indeed, hypersensitive—to any sign of rejection.

The key to recovery, then, is to get the patient to understand that her perceptions aren't necessarily reality, that the world might not be as dark as it seems. With Amber, it was slow work. I wanted to help her understand that not everyone was out to hurt her. There were people—teachers, peers, neighbors—who could be kind, supportive and positive. But she often shut out people to protect herself from the pain and terror Duane had brought to her in the past.

One day as she walked through my office door, she asked, “Did you know that the raven is the smartest bird?” She looked me in the eyes, almost challenging me. She plopped into a chair, putting her feet up on a little coffee table.

“No, I didn't know that. Why do you say that?” I shut the door to my office and sat down in my desk chair, swiveling it to face her.

“Corvus Corax.” She spoke the Latin species name for the common raven.

“You know Latin?”

“No. That is the official name of the raven.”

“You like ravens.”

“I am a raven.”

“You look like a girl.”

“Funny. You know what I mean.”

“Kind of.” She was quiet. I kept going. “You want to talk animals. Let's talk about the animal world.”

“OK.”

“Many animals have ways to send signals to other animals—their own species and their predators.” As I spoke she settled deeper in the chair. She grew quiet. I could see that I was getting close to pushing her to shut down. “Sometimes those signals say don't mess with me, I'll hurt you,” I continued, “A bear rises on both feet and huffs; dogs growl and bare their teeth, the rattlesnake rattles.” I paused and let the silence fill the room. I was trying to get her to understand how she gave off such powerful “leave me alone” signals. I knew she was often creating the self-fulfilling prophecy that “people don't like me.” She emitted negative signals—and elicited negative responses. Then, of course, those reactions further reinforced her perception that the world is full of people who didn't like her. She blinked and looked at me. She wasn't tuned out yet. “What does the raven do?” I asked. She smiled a little.

“The raven does this.” She sat forward, leaned toward me and pulled her long sleeved shirt up. I expected to see fresh cuts. But all I saw was a new tattoo, entirely in black ink. It was a raven sitting with spread wings. She held her arm out for me to study it a bit.

“Nice ink. Who did the work?” At least she knew by now that her dark clothes, piercings and new tattoo were sending signals.

“Bubba, down on Montrose.” She rolled her sleeve back down.

“So tattooing now. Does that have the same effect as cutting?”

“Not really. It didn't hurt that much though.”

“Are you cutting?”

“No. I'm trying to use those relaxation exercises. Sometimes they work OK.” I had taught her a form of self-hypnosis to use in situations when she felt the urge to cut. Hypnosis helps people access their own dissociative capacity in a controlled way. I wanted Amber to gain a
healthier control over when and to what degree she would use this powerful adaptive response.

I had taught her an induction technique that involved focusing on her breathing. After simply observing each breath she took for a moment or two, she would then take a number of deep, controlled breaths and count them down, from ten to one. With each inhalation she would imagine taking one step down a staircase. At the bottom of the staircase was a door, and when she opened that door she would be in her “safe” place, where no one could hurt her and where she was in total control. Once she had that technique down, we worked on helping her use it whenever she was distressed or overwhelmed, rather than cutting herself.

 

LITTLE BY LITTLE she would open up and then close back down. She'd discuss a bit of the hurt and shame that she carried around and then, when it got too painful, she'd withdraw again. I didn't push. I knew that her defenses were there for a reason and that, when she was ready, she'd tell me more. She kept getting more tattoos, most of them small, all of them black. There was a black rose. A black Gaelic knot. Another small raven. And still, she always dressed entirely in black.

In a later visit we talked more about how people are designed to read and respond to others. We talked about the signals we send.

“Did you know that the human brain has special neural systems that are designed to read and respond to the social cues from other people?” I held up a neuroscience journal I had been reading. I was trying, again, to get her to recognize the negative signals she was sending out to people, and that she might be misreading the social cues of others.

“Are you saying my social cue neurons are fucked up?” She had immediately jumped way past the point I was trying to make; her response itself precisely illustrated the problem I was trying to get her to address. I needed to back off a bit.

“Yikes. Where did that come from?”

“I know it's what you're thinking.”

“So now your powers extend to mind reading? Can you read everyone's thoughts or just mine?” She didn't see the humor in my comment. I decided that the safest way to move forward was to approach her at a cognitive, rather than emotional, level.

“When these special neurons in the brain fire, they are almost a reflection of similar neurons firing in the brain of someone you are interacting with. They're called mirror neurons, in fact. And they're a part of the systems that our brain has to help us connect with and communicate to others. Pretty cool, right?”

She was listening. I hoped that she was processing some of this, maybe thinking about what it might mean for her. I continued, “When a mother holds her newborn baby and smiles and coos, all of the primary sensory signals—the visual input from the mother's smile, the auditory input from the cooing, the olfactory signals from the scent of the mother and the tactile information from the warmth and pressure of the mother's touch—all get turned into patterns of neural activity that go up into the brain of the baby and actually stimulate the parts of the brain that match the parts of the brain that the mother uses to smile, coo, rock and so forth. The baby's brain is being shaped by the patterned, repetitive stimulation of the interactions from the mother!”

She was listening now. I could see that she was fully engaged, nodding her head. I said, “Pretty amazing. I love the brain.” I dropped the journal back on my desk and looked at her for a response.

“You are a strange dude.” She smiled. But I was pretty sure that she recognized that she had misinterpreted my comment, that I'd never said nor implied that her brain was “fucked up.” She was beginning to see how her perception could differ from reality and how her reactions to people might be based on a skewed vision of the world.

 

AND OVER TIME, Amber got better. Her resting heart rate was now above sixty beats per minute and was no longer frequently dipping dangerously low. She had not had any further spells of unconsciousness. All
reports from home and school suggested that she was doing well. She became more animated in our sessions. Now she talked about a small group of friends, all of them a bit marginalized, but overall healthy.

Then one day she came in, slouched down onto the chair and announced, “Well, we are moving again.” She tried to act nonchalant.

“When did you find this out?”

“Yesterday. Mom got a better job in Austin. So we're moving.” She stared into space, her eyes filling with tears.

“Do you know when you are going to move?”

“In a few weeks. Mom starts on the first of the month.”

“Well. Let's talk about this some.”

“Why?”

“Because I would guess that this feels pretty bad to you.”