SEVENTEEN-YEAR-OLD AMBER had been found unconscious in a high school bathroom. Her breathing was shallow, her heart rate sluggish, her blood pressure far too low. Unsurprisingly, her mother, Jill,* who had arrived at the emergency room after being called by the school, was distraught. I had just walked into the ER as well. I was the attending physician there that month and was reviewing the evaluation of a suicidal adolescent by one of the child psychiatry fellows.
As a group of doctors was trying to evaluate Amber, the girl’s heart had suddenly stopped. The medical team had quickly revived and stabilized the girl, but it had been terrifying for Jill to see. Despite the physicians’ best efforts, Amber was still unconscious and unarousable. Now Jill was hysterical. I was asked to help calm the mother so the other doctors could focus on her daughter’s problems. Toxicology screens, which would have found any drugs in Amber’s system, were negative, ruling out the most likely cause of teen unconsciousness in such a situation: an overdose. Jill could recall no previous health problems that might explain her state. Consequently, the doctors were thinking rare heart disease, or perhaps brain tumor or stroke.
I found Jill sitting by her daughter’s bedside, holding her hand and crying. A nurse was adjusting Amber’s IV. Jill looked at me, pleading with her eyes. I tried to reassure her that the hospital was excellent and that her daughter was receiving the best possible care. But when she asked me what kind of doctor I was and found out that I was a child psychiatrist, she became more, not less, upset.
“Are you here because she’s going to die?” she demanded.
“No,” I responded quickly, explaining that the rest of the team was busy trying to figure out exactly what was wrong with Amber. They knew that it would help Jill if she could talk with someone and I’d been assigned that role. She looked me in the eye and saw that I was telling the truth. She relaxed perceptibly and I thought, not for the first time, that simple honesty was vastly underrated and underused in medicine.
“Why won’t they tell me what is going on?” she asked. I explained that the other doctors probably weren’t withholding information, but that they most likely didn’t know themselves what was wrong with Amber. I told her I’d look at her chart myself to find out what I could.
I left the room, read the chart, and spoke with the resident and one of the other doctors. They described how Amber’s school had called EMS after a student had found the teen in the bathroom. Her vital signs had been stable; however, her heart rate was remarkably low: running between forty-eight and fifty-two beats per minute. A normal heart rate for a girl her age at rest is between seventy and ninety. The paramedics brought her to the hospital and the clinical team had been in the middle of their evaluation when her heart stopped. Then she had to be revived, in a scene now familiar from hundreds of episodes of medical dramas like “ER.”
By this time Amber had been in the emergency room for about four hours. During that period she’d been seen by neurology and a CAT scan had shown no brain abnormalities. Other neurological tests were equally normal. The cardiology service had also seen her and they could find no heart problem that would explain her symptoms. All of her blood work appeared normal and her toxicology screens were repeatedly negative. My suspicion had been correct: no one had told Jill what was going on because no one knew.
I went back into the room and told Jill what I had learned. And then, using a simple technique I had learned as a way of helping people relax before beginning hypnosis, I began to ask about Amber’s life, hoping to calm the mother while simultaneously finding some clue about whether something had gone wrong in the daughter’s past.
“Tell me about your daughter,” I said. Jill looked confused by this seemingly irrelevant question. “Where was she born?” I prompted. Jill started to think back, and then offered me the same stories she had probably happily told a hundred times since her daughter’s birth. Most people’s mood changes noticeably when they reminisce like this. As she talked about her daughter’s birth, Jill smiled for the first time in our conversation. Whenever Jill began to falter, I would re-prompt her, always sticking to topics that were likely to be neutral or positive, like Amber’s first day of school or the books she enjoyed as a small child.
I noticed, however, that she seemed to skip over long periods of time, and just by looking at her, I could also see that she’d had a difficult life herself. She looked ten years older than her actual age in her mid-thirties; her bleach-blonde hair was thin and her face haggard. Of course, no one looks especially good in a hospital room hovering over a seriously ill child, but Jill struck me as someone who had been through a great deal and had struggled hard to get where she was in her life. I could tell that she was leaving a lot out but, eventually, she filled in some of the blanks, admitting to a string of failed relationships and lousy jobs that had kept her and Amber moving around the country, rootless, for years. But now, at last, she had a good job as an administrative assistant and seemed committed to making Texas her home.
As Jill spoke, I also studied her daughter. Amber had dyed black hair. Triple piercings in one ear, double in the other. Then I noticed something that I immediately recognized might be important: her forearm had dozens of short shallow cuts on it. The cuts were perfectly parallel with an occasional crosscut. The location, the depth, and pattern were all characteristic of self-mutilation.
Trying to figure out if the cuts might be relevant to Amber’s medical problems, I asked Jill if anything had happened recently that might have upset Amber. The mom thought for a moment and then covered her mouth with her hands, as if to suppress a scream. It turned out that the night before, one of Jill’s former partners, Duane,* had phoned. Jill had broken up with Duane eight years back after discovering that he’d repeatedly raped her daughter, then age nine. The abuse had gone on for several years. Amber had answered the phone the night before she was hospitalized. Duane had suggested a visit before Jill got on the line and told him that neither she nor her daughter would have anything to do with him.
Many “cutters”—as I would soon find out Amber was—have a history of trauma. When they mutilate themselves, they can induce a dissociative state, similar to the adaptive response they’d had during the original trauma. Cutting can be soothing to them because it provides an escape from anxiety caused by revisiting traumatic memories or just the challenges of everyday life. In dissociative states, as we’ve discussed, people can become so disconnected from reality that they move into a dreamlike consciousness where nothing seems real and they feel little emotional or physical pain. These experiences are linked with the release of high levels of opioids, the brain’s natural heroin-like substances that kill pain and produce a calming sense of distance from one’s troubles. Research on rodents has shown that when these animals are totally restrained—a highly stressful experience for them—their brains flood with natural opioids, known as endorphins and enkephalins. People who suffer life-threatening experiences often describe a sense of “disconnection” and “unreality” and a numbness that is similar to what people feel when they take opioid drugs. Endorphins and enkephalins are an integral part of the brain’s stress response system, preparing the body to handle both physical and emotional pain.
It occurred to me that Amber’s physiological state as she lay in the ER was very much like that of someone who has overdosed on heroin, although, unlike most overdose victims, she was breathing on her own. Considering her self-mutilation and the unexpected contact with her abuser that she’d had the night before, I thought: Could this be an extreme dissociative response, which had essentially caused her brain to OD on its own opioids?
When I first broached this possibility, the ER docs thought it was absurd. Even I had to admit that it seemed far-fetched and that I had never heard of any similar cases. Still, I knew that the antidote to opioid overdoses, a drug called naloxone, is safe. In fact, it is so unlikely to prove harmful that some needle exchange programs provide it to people with addiction to reverse overdoses that they may witness. In our clinic we also use a similar, but longer acting, drug called naltrexone to help children who are prone to dissociative states modulate their reactions when they encounter trauma-related cues. After Amber continued to be unresponsive for a few more hours and more tests came back without offering any additional insight into her condition, her doctors decided to give naloxone a try.
And as with ordinary opioid overdoses, the results were rapid. Ninety seconds after receiving the injection, Amber blinked, came around and, within minutes, sat up and asked where she was. As I was soon to find out by learning more about her life, my theory that a dissociative reaction to traumatic memories had caused her symptoms was the most plausible explanation for both the loss of consciousness that brought her to the hospital as well as her response to the naloxone.
She was kept overnight in the hospital for observation. The next morning I went to see her. I found her awake and sitting in her bed. She was drawing and writing in a journal. I introduced myself, saying, “I met you yesterday but I’m sure you don’t remember. You were a little bit disoriented.”
“You don’t look like a doctor,” she said, looking me up and down, focusing on my T-shirt, jeans and sandals, not on my white coat. She seemed suspicious. But she also seemed confident and self-assured, and immediately went back to her drawing.
“Are you that shrink?” she asked, not looking up again. I tried to take a surreptitious glance at her work. The journal contained elaborate designs reminiscent of ancient calligraphy. There were serpent-like creatures around the edges of the corner of each page. She caught me watching her and slowly closed her journal. It was an interesting way to simultaneously conceal and reveal: as she shut the book, she turned it toward me so I could more easily see the pages as they were being obscured by the book’s cover. So she does want to talk, I thought.
“I had a chance to talk with your mom a little bit about you,” I said, “She loves you very much but she is worried. She thinks it would be helpful for you to talk with someone about what happened earlier in your life.” I paused, giving her a moment to digest what I had just said, and listened. “My mom likes you,” she replied, looking me straight in the eyes as she spoke. Then, she looked away for a moment as if she was thinking. Would I become another man her mother brought into her life who hurt her? I wondered if she distrusted all men, the way my first patient, Tina, had? Did some part of her brain loathe any man her mother liked? Should I have had one of our female clinicians work with her? Yet my instinct told me she would be OK with me. Ultimately, she would need, over time, to replace some of her bad associations with men, to experience an honest, predictable, safe and healthy relationship.
“Well, I think your mom likes that we were able to help you,” I said, trying to reframe the issue. “She told me what happened with Duane; that’s how I figured out what we should do to help you. And I think it would be really helpful for you to talk with somebody about all of that. It might help prevent something like yesterday from happening again.”
“What happened with him is over,” said Amber, emphatically.
I reached over to her hand, opened up her palm and exposed her forearm. I looked at the cuts and then looked at her and asked, “Are you sure?”
She pulled back, crossed her arms, and looked away from me.
I continued, “Listen, you don’t know me, you don’t know anything about me and you shouldn’t trust me until you get to know me. So I’m going to say a few things. After I leave, you will have a chance to think about whether or not you want to spend any time talking with me. Whatever you decide is final. You don’t have to agree to see me, it is your choice. You are in control.” I described our clinic’s work with traumatized children in simple terms, explaining how it might be of help to her and how we might be able to learn more from her to aid our work with other maltreated children as well.
I stopped for a moment and watched her. She looked at me, still unsure what to make of me. I wanted her to know that I did understand something of what she had experienced, so I continued.
“I know that when you feel anxious, you feel pulled to cut yourself. And that when you first put the razor to your skin and feel that first cut, you feel relief.” She looked at me as though I was revealing a deep secret. “I know that sometimes in school, you feel the tension build inside you and you can’t wait to get to the bathroom and cut yourself, even just a tiny bit. And I know that even on warm days, you will wear long-sleeved shirts to hide the scars.”
I stopped speaking. We looked at each other. I put my hand out to shake hands with her. She looked me over for a moment and then slowly put her hand out as well. We shook hands. I told her I’d be back to answer any questions and see if she wanted to make an appointment.
When I returned, Amber and her mom were waiting for me. “I think you’re ready to go home,” I said to the girl, adding, “So what about you coming in to see me next week?”
“Sure,” she responded and gave me an uncomfortable smile. “How did you know all that stuff?” She couldn’t resist asking.
“We can talk about that next week. Right now you get out of that stupid gown and go home and have a nice night with your mom.” I tried to keep the moment light. Trauma is best digested bit by bit. Both mother and daughter had had enough in the past two days.
WHEN AMBER STARTED THERAPY, I was surprised by how quickly she opened up to me. It is not unusual for several months to pass before a patient shares her intimate thoughts during a weekly psychotherapy session. It took only three or four weeks before Amber started to talk about having been abused by Duane.
“Don’t you want me to talk about being abused?” she asked one day.
“I figured that when you’re ready to talk about it you’ll bring it up,” I said.
“I don’t think about it very much. I don’t like to remember it.”
I asked her when she did think about it.
“Sometimes when I’m going to sleep,” she said, “But then I just go away.”
“Go away?”
I knew she was talking about dissociation but I wanted her to describe what happened. There was a change in her posture: she cocked her head and stared into space, her eyes fixed down and to the left. I knew she was running some painful images through her mind.
“When it first started to happen I was so scared,” she said in a quiet, almost child-like voice. “And it hurt. Sometimes I couldn’t breathe. I felt so helpless and so small and so weak. I didn’t want to tell my mom. I was so embarrassed and confused. So when it would happen, I would close my eyes and try to think about other things. Pretty soon, I was able to go to a safe place in my head.”
As she described it, she seemed to change. “Little by little, I made that place my special retreat. Whenever I thought about going there and being there, I felt safe. Nobody knew where it was. Nobody could come in there with me. Nobody could hurt me there.” She paused. She was now speaking in a low tone of voice, in a monotone, almost robotically. She was staring off into space as she spoke. She hardly blinked. We sat in silence for a moment and then she continued.
“I felt like I could fly when I was in that place. And I began to imagine that I was a bird, a raven. I tried being a beautiful bird, a bluebird or a robin but I couldn’t be beautiful there. I tried being a majestic bird, like an eagle or a hawk, but that didn’t work either. My mind kept making me something dark. Like a raven. But I was powerful. I could control other animals. I was wise and I was kind, but I was absolutely ruthless in hunting down and using my power to kill evil. To those creatures, the bad ones, I was the Black Death.”
She paused again. This time, she looked at me. Her words had been moving. I knew she’d never shared this with anyone and that she felt that some of the power of her fantasy to comfort her lay in its secret nature. It is critical to protect someone when they are vulnerable in moments like this.
“Are you still the Black Death?” I asked. She looked away for a moment and then back at me and started to cry. That was the real start of our work.
AS THE WEEKS WENT BY I LEARNED more and more about her. Amber’s story would ultimately teach me a great deal about the dissociative response to trauma and how to help those who suffer from it.
The sexual abuse that Amber had experienced was violent and terrifying, beginning when she was about seven years old. Her parents had split when she was two, and her mother found a new partner several years later and relied upon him to support the family. Duane would only molest her when he’d been drinking, which was about once every ten days or so. Then, for days afterwards, he would seem remorseful, showering her with gifts and praise, trying to make up for what he’d done. Since his drinking was unpredictable, Amber lived in a constant state of fear, always worrying about when it would happen next and about the pain and terror of the event itself. Her grades began to decline and she went from being a happy, outgoing child to being a withdrawn and anxious little girl.
She was too frightened to tell her mother what Duane was doing; he threatened her with even worse if she told. Feeling that the situation was inescapable, Amber did what she could to get control over it. She began to serve Duane drinks and behave provocatively, with the aim of getting the abuse over with. Knowing when it would happen allowed her to study and sleep through the night rather than worrying about when he’d come into her bedroom. In essence, she could schedule and isolate her terror so that it didn’t interfere with the rest of her life. Her grades improved again and, to those around her, she seemed to be back to herself. Although her behavior probably doubled the frequency of the molestation, the control she gained over the situation allowed her to manage her anxiety such that it minimized the effects that the abuse had on her daily life. Unfortunately, of course, this would later produce a whole new set of problems related to her guilt over her feelings of complicity in his actions but, at the time, it helped her cope with the trauma.
When she was actually being raped or sodomized, Amber dissociated, withdrawing into her Black Death/Raven fantasy world. She would be chased by evil creatures and demons, but she would always triumph over them, as in a role-playing video game. The fantasy was elaborate and detailed. In fact, it was so encompassing that she literally no longer felt what was actually happening to her body. She encapsulated the trauma in a way that allowed her to function and cope, although, of course, she still suffered its effects when she was exposed to cues that reminded her of what had gone on, such as Duane’s scent or the smell of certain drinks that he favored. Such cues would prompt a dissociative response that she could not control, in which she retreated to her “safe” world and did not respond to outside stimuli. The most extreme reaction was the one that had put her in the hospital the day after he called.
The abuse had continued for several years. Then, when Amber was around nine, her mother caught Duane in bed with the little girl, and immediately kicked him out. She didn’t blame Amber, as many mothers unfortunately do in such situations, but, other than calling the police, she didn’t seek help for her, either. Sadly, the district attorney didn’t pursue the case after the perpetrator moved out of state. And Jill had problems of her own to deal with: as a single mother with few skills, she now had to struggle to support herself and her daughter. She and Amber made many moves from state to state, seeking better employment opportunities. Jill eventually managed to go back to school and get a higher paying job, but the instability and the abuse had done its damage to Amber.
Amber continued to cope on her own, getting decent, but not spectacular, grades. Intelligent as she was, she almost certainly could have done better but, probably at least in part because of what had happened to her, she stayed a B-student and an underachiever. Though she was not the most popular girl in her class, she was not the least popular either. She hung out with a group of teens in the middle of the social spectrum who were “Goths,” dressed in black but not especially extreme in their behavior. They didn’t drink or take drugs, for example, but their interest in mysticism and alternative culture made them tolerant of those who did. A recent study of Goth youth culture, in fact, found that it tends to attract adolescents like Amber who have histories of self-harm. Interestingly, becoming a Goth didn’t increase self-harm: before these teens found a community that accepted their “dark” interests, in fact, they were more prone to cut or otherwise harm themselves.
In school, Amber discovered that pinching or deeply scratching her arms relieved some of her anxiety. And later, in private, she found that cutting her skin could produce a dissociative state, allowing her to escape what she experienced as an intolerable buildup of stress. “It’s like I have magical skin,” she told me, describing how cutting into it with a knife or razor prompted an incredible sense of relief and access to her “safe” place. Many teens, of course, find similar escape with drugs.
Though teen drug use is often seen as simple hedonism or rebellion, in fact, the teenagers who are most at risk for lasting drug problems are those like Amber, whose stress response systems have suffered an early and lasting blow. Research on addicts and alcoholics finds dramatically increased numbers of early traumatic events, as compared to those who have not suffered addictions. The most severe addicts’ histories—especially amongst women—are filled with childhood sexual abuse, loss of parents through divorce or death, witnessing severe violence, physical abuse and neglect and other trauma. Brain scans of those who’ve experienced trauma often reveal abnormalities in areas that also show changes during addiction. It may be that these changes make them more vulnerable to getting hooked.
While self-mutilation, too, is often seen as an act of rebellion or attention-seeking, in most cases it is probably better understood as an attempt at self-medication as well. Cutting releases brain opioids, which makes it especially attractive to those who have been previously traumatized and found relief in dissociation. Although anyone who cuts will experience some degree of opioid effect, the experience is far more likely to be perceived as pleasurable and attractive to those who have a sensitized dissociative response from previous trauma and are in emotional pain. The same is true of people who use drugs like heroin or OxyContin. Contrary to popular belief, most people who try these drugs do not find them overwhelmingly blissful. In fact, most people don’t like the numbing sensation they produce. But those who suffer the after-effects of severe stress and trauma are likely to find the substances soothing and comforting, not deadening.
Curiously, stimulant drugs like cocaine and amphetamine replicate the other common natural reaction to trauma: the hyperarousal response. Both drugs increase the release of the neurotransmitters dopamine and noradrenaline (also called norepinephrine). Both of those brain chemicals skyrocket during hyperarousal. Just as the dissociative experience bears a physiological and psychological resemblance to the opioid “high,” the stimulant high is physiologically and psychologically comparable to the hyperaroused state. In both stimulant “highs” and hyperarousal, the person experiences an elevated heart rate, heightened senses and a feeling of power and possibility. That feeling is needed to fuel fight or flight, but it also explains why stimulants increase paranoia and aggression. Brain changes related to hyperarousal may make some trauma victims more prone to stimulant addiction, while those related to dissociation may prefer opioids like heroin.
AS MY COLLEAGUES AND I BEGAN to recognize how trauma affects the brain and body, we began to look for pharmacological methods to treat some of its symptoms. We hoped that this might prevent the children we were able to reach at an early age from developing problems like drug addiction and self-mutilation later on. We knew, for example, that opioid-blocking drugs like naloxone and naltrexone might reasonably be tried to blunt sensitized dissociation. We had already studied clonidine as a way to reduce hyperarousal. Though Mama P. had, with some justification, been afraid that we might “drug up” the children she cared for if we used medications—or that we might decide that medications were all that was needed, and leave out love and affection—we found that the right medication can be helpful if used in the right context.
One of the first patients we tried naltrexone with was a sixteen-year-old boy named Ted. Like Amber, he had come to our attention because of his physical symptoms, not his psychological problems. Ted had what seemed to be unpredictable fainting episodes; sometimes at school, he would pass out. As in Amber’s case, medical tests revealed no discernable heart disorder, nor did he have a diagnosable neurological problem like epilepsy or a brain tumor that might cause such symptoms. Throwing up their hands and deciding that Ted was inducing unconsciousness in some kind of bizarre teenage attention-seeking gesture, the doctors who had ruled out these other problems called in psychiatry.
Ted was tall, rail-thin, and good-looking, but he carried himself as though he were depressed: slouching, moving with little confidence, seeming as though he wanted to disappear. He didn’t meet the criteria for depression, however. He didn’t report unhappiness, lack of energy, suicidal thoughts, social distress, sleeping problems, or any of the other classic symptoms of the disorder. His only apparent problem was that about twice a week, he would suddenly faint.
When I began to talk to him, though, I discovered that there was more. “I feel like a robot sometimes,” he told me, describing how he felt removed from the emotional aspects of his life, almost like he was watching a movie or going through the motions without fully experiencing what was happening around him. He felt detached, disconnected, numb: classic descriptions of dissociation. As I got to know him I began to find out what had prompted his brain to protect him from the world. Starting before elementary school, Ted had been a continual witness to domestic violence. His stepfather frequently beat his mother, and this was not just the occasional slap or push, but rather full-on assaults that left her bruised, scarred, and terrorized into complete submission. More than once, his mother had to be hospitalized. As Ted got older he began to try to protect his mother and found that he could redirect the man’s rage from her to him. As he put it, “I’d rather get a beating then watch my mother get beat up.” Although it didn’t happen immediately, it was seeing her child hurt that finally prompted Ted’s mom to end the relationship.
But by this point, Ted was ten years old. He’d lived most of his life with the daily threat or actual occurrence of serious violence. He’d become socially withdrawn and isolated. His teachers called him a “daydreamer,” noting that he often seemed to be “miles away” rather than paying attention to the class around him. However, he participated enough to get average, though not outstanding, grades. Even more so than Amber, he seemed to have discovered a way of fading into the background, recognizing that earning grades that were either too low or too high would bring him attention. He didn’t care if the attention for high grades was positive, since he found any attention stressful, even threatening. Ted seemed to have made up his mind that the best way to avoid any potential for further abuse was to be invisible, to disappear into the vast undifferentiated gray middle. And, until he began fainting in junior high school, that’s what he did.
I proposed a trial of naltrexone to see if it would stop the fainting episodes. As noted earlier, when people suffer extreme traumatic stress, their brains can become “sensitized” to future stressors, and it takes smaller and smaller amounts of stress to set the system off and prompt a full-blown stress response. As part of this stress response, especially when the stress is severe and appears inescapable, the brain releases opioids. By using a long-acting opioid blocker like naltrexone, I hoped to prevent these opioids from having an effect when they were released by his sensitized system, and thereby stop the fainting.
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 hyperarousal 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 hyperarousal, 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.”
“So who is reading minds now? You don’t know how I feel.”
“Mmmm. I believe I said that I would guess that this feels pretty bad. Is my guess wrong?” She pulled her legs up underneath her and dipped her head to prevent me from seeing her tears. A tear dripped onto her black pants. I reached over and handed her a tissue. She took it from my hand.
“I hate this,” she said quietly. I let silence fill the room. I pulled my chair closer to hers and put a hand on her shoulder, leaving it there for a few moments. We sat.
“What part do you hate the most?”
“All of it. New school, new kids, new freak in town. I hate starting over all the time.”
“That must be hard.” I didn’t want to invalidate her feelings by trying to put a positive spin on it. I knew that we would have time later to talk through some of the potential positive aspects of a new start. I just let her spill out her frustration and sadness. I listened.
The next week, she came in, announcing, “I can’t wait to get out of this town.” She had already flipped to the “who cares?” mode. It is easier to leave people places if you “don’t care” about them.
“So I guess all those tears last week were…?” She looked at me, angry. I held her gaze and allowed her to read my face, my expression, which told her that I was sad and concerned about her, and her anger melted. We started the hard work of helping her with this transition.
During those last few weeks she struggled with how to present herself to her new school. Was she ready to “start over?” Did she need to always project anger, darkness? Did she always have to wear black? She was beginning to think that she might be able to be softer, more open and more inviting to new relationships. Our discussions about the animal world and how the brain works had seeped into her understanding of herself.
“I can’t decide what to do. I don’t know if I should try to start over and be myself, or to protect myself. I don’t know what to do. I don’t know how to be.”
“When the time comes, you will make the right choice.”
“What do you mean?”
“If you make the choice it will be right. Just don’t let anyone else choose for you; don’t let your mom, or your friends, or me, or…” I paused and caught her eye, “the ghost of Duane make the choice for you.”
“How does Duane have anything to do with this?”
“I think that the darkness is not your own. I think those things that worked when you were being abused—the disengaging, the fantasizing, the darkness you projected to the world—were forced on you by Duane.”
“No. I made that world.”
“Remember when you told me that when you first retreated to that world you wanted to be a songbird? A bluebird or a robin. And it didn’t work?”
“Yeah.”
“Those beautiful, colorful songbirds were your first choice, Amber. Maybe they didn’t work then because they were too vulnerable; and you needed something more powerful, dark, menacing to protect you.”
“Yeah.”
“Maybe you don’t need that now, Amber. Maybe it would be ok to let the birds sing.”
“I don’t know.”
“Me neither. But when the time is right, you will know. And when the time is right you will make good choices.”
Before the move, I tried to encourage her and her mother to see a new therapist in Austin. I gave Jill a list of names and reassured her that I often worked with colleagues from a distance. I told her that I would remain available by phone or for occasional consultation visits to track Amber’s progress. But ideally, I hoped that she would find a primary therapist in Austin where she could continue the work we had started. Amber didn’t like that idea.
“I don’t need to see a shrink. I’m not crazy.”
“Have I been treating you like you are crazy?”
“No.” She was quiet. She knew her argument was ridiculous.
“Listen, it’s up to you. My opinion is that it would help you if you take the time to find the right person. Meet with these folks and you can see who you might feel comfortable talking with.”
“OK.” She looked at me knowing that I knew she wouldn’t really try.
“Well. Just make sure that whatever choice you make, it’s truly yours.”
And I reached my hand out to seal the deal. She shook my hand. “Sure thing, Doc.”
WE DID HEAR FROM AMBER’S MOTHER a few times in the first six months after they moved. She had taken her daughter to the first therapist on the list of referrals we’d provided, but Amber didn’t like the woman. They hadn’t gotten around to trying again. All too often when things seem OK, parents aren’t motivated to follow through with the expense and inconvenience of therapy. Since Amber was “doing great” her mom didn’t push it when Amber resisted finding a new therapist.
More than a year after Amber moved to Austin, I signed onto my email and saw a note from BlueRaven232. At first, I thought it was spam and almost deleted it. Then I saw the subject: “New Tattoo.” I read it:
Dear Doc:
Wanted you to be the first to know. I got a new tattoo; a bouquet of flowers—orange, red, purple and blue. Real girly girl. No black ink. Blue Raven
I wrote back.
Thanks for the note, sounds like a nice choice. Good work. One question: Sky Blue Raven?
Dr. P.
Later that day, she wrote back:
No. Navy Blue Raven. Hey, it’s a start, right?
I smiled as I typed back:
It’s a good start, Amber.
Every now and again, I get email from Blue Raven. She is now a young adult. She went to college and graduated in four years. Like all of us, she has had her ups and downs. But from what I can tell she is a healthy, productive and caring young woman. She works with young children now and can’t decide whether to go back to school to become a social worker, police officer or a teacher. I suspect, however, that she will make the right choice for her. And I know that because of what she’s been through and what she learned about how trauma can shape a child’s view of the world, in whatever capacity she works with children they will be very lucky to know her.