by Sam Kean
I’ve grown to like Carl: he has a lively intellect, a willingness to admit his flaws, and a desire to be good. Is he being sincere or manipulating me? Is Carl proof that psychopathy can be tamed—or proof that the traits are so deeply embedded that they can never be dislodged? I honestly don’t know.
At the San Marcos Treatment Center, Samantha is wearing her new yoga pants from Target, but they bring her little joy. In a few hours, her mother will leave for the airport and fly back to Idaho. Samantha munches on a slice of pizza and suggests movies to watch on Jen’s laptop. She seems sad, but less about Jen’s departure than about the resumption of the center’s tedious routine. Samantha snuggles with her mom while they watch The BFG, this eleven-year-old girl who can stab a teacher’s hand with a pencil at the slightest provocation.
Watching them in the darkened room, I contemplate for the hundredth time the arbitrary nature of good and evil. If Samantha’s brain is wired for callousness, if she fails to experience empathy or remorse because she lacks the neural equipment, can we say she is evil? “These kids can’t help it,” Adrian Raine says. “Kids don’t grow up wanting to be psychopaths or serial killers. They grow up wanting to become baseball players or great football stars. It’s not a choice.”
Yet, Raine says, even if we don’t label them evil, we must try to head off their evil acts. It’s a daily struggle, planting the seeds of emotions that usually come so naturally—empathy, caring, remorse—in the rocky soil of a callous brain. Samantha has lived for more than two years at San Marcos, where the staff has tried to shape her behavior with regular therapy and a program that, like Mendota’s, dispenses quick but limited punishment for bad behavior and offers prizes and privileges—candy, Pokémon cards, late nights on weekends—for good behavior.
Jen and Danny have spotted green shoots of empathy. Samantha has made a friend and recently comforted the girl after her social worker quit. They’ve detected traces of self-awareness and even remorse: Samantha knows that her thoughts about hurting people are wrong, and she tries to suppress them. But the cognitive training cannot always compete with the urge to strangle an annoying classmate, which she tried to do just the other day. “It builds up, and then I have to do it,” Samantha explains. “I can’t keep it away.”
It all feels exhausting, for Samantha and for everyone in her orbit. Later, I ask Jen whether Samantha has lovable qualities that make all this worthwhile. “It can’t be all nightmare, can it?” I ask. She hesitates. “Or can it?”
“It is not all nightmare,” Jen responds, eventually. “She’s cute, and she can be fun, and she can be enjoyable.” She’s great at board games, she has a wonderful imagination, and now, having been apart for two years, her siblings say they miss her. But Samantha’s mood and behavior can quickly turn. “The challenge with her is that her extreme is so extreme. You’re always waiting for the other shoe to drop.”
Danny says they’re praying for the triumph of self-interest over impulse. “Our hope is that she is able to have a cognitive understanding that ‘Even though my thinking is different, my behavior needs to walk down this path so that I can enjoy the good things that I want.’” Because she was diagnosed relatively early, they hope that Samantha’s young, still-developing brain can be rewired for some measure of cognitive morality. And having parents like Jen and Danny could make a difference; research suggests that warm and responsive parenting can help children become less callous as they get older.
On the flip side, the New York psychiatrist told them, the fact that her symptoms appeared so early, and so dramatically, may indicate that her callousness is so deeply ingrained that little can be done to ameliorate it.
Samantha’s parents try not to second-guess their decision to adopt her. But even Samantha has wondered whether they have regrets. “She said, ‘Why did you even want me?’” Jen recalls. “The real answer to that is: We didn’t know the depth of her challenges. We had no idea. I don’t know if this would be a different story if we were looking at this now. But what we tell her is: ‘You were ours.’”
Jen and Danny are planning to bring Samantha home this summer, a prospect the family views with some trepidation. They’re taking precautions, such as using alarms on Samantha’s bedroom door. The older children are larger and tougher than Samantha, but the family will have to keep vigil over the five-year-old and the seven-year-old. Still, they believe she’s ready, or, more accurately, that she’s progressed as far as she can at San Marcos. They want to bring her home, to give it another try.
Of course, even if Samantha can slip easily back into home life at eleven, what of the future? “Do I want that child to have a driver’s license?” Jen asks. To go on dates? She’s smart enough for college—but will she be able to negotiate that complex society without becoming a threat? Can she have a stable romantic relationship, much less fall in love and marry? She and Danny have had to redefine success for Samantha: simply keeping her out of prison.
And yet, they love Samantha. “She’s ours, and we want to raise our children together,” Jen says. Samantha has been in residential treatment programs for most of the past five years, nearly half her life. They can’t institutionalize her forever. She needs to learn to function in the world, sooner rather than later. “I do feel there’s hope,” Jen says. “The hard part is, it’s never going to go away. It’s high-stakes parenting. If it fails, it’s going to fail big.”
EVA HOLLAND
Exposure Therapy and the Fine Art of Scaring the Shit out of Yourself On Purpose
from Esquire
The panic grew with every move I made: gripping small handholds with suddenly sweaty palms, placing my soft rubber-soled climbing shoes onto small ledges and nubs in the granite face. My chest seized up; the fear gripping my lungs and my brain made me dizzy. I breathed loud and fast through my mouth. My brain screamed warnings at my body:
Stop! Go back!
Don’t do this!
This is dangerous!
You will fall.
It will hurt.
You will get hurt!
You! Are!
Not! Safe!
It was an early May evening at the Rock Gardens, a popular climbing crag in Whitehorse, the small capital city of the Yukon Territory, where I live. By attempting to climb a steep stone wall, I was deliberately terrorizing myself, creating a situation I knew would induce something similar to a panic attack. But if I could learn to be less afraid while harnessed up and clinging to a rock face, I had decided, I might learn to control my debilitating fear of heights more generally.
That night, I managed to force my way 6 or 7 feet up a 26-foot route before I begged my climbing partner, belaying me from below, to lower me down. As my feet touched the ground, I tried to control my panting and avoided looking anyone in the eye.
Acrophobia, or extreme fear of heights, is among the most common phobias in the world: One Dutch study found that it affects as many as 1 in 20 people. Even more people suffer from a non-phobic fear of heights—they don’t meet the bar to be technically diagnosed, but they share symptoms with true acrophobes like me. All told, as much as 28 percent of the general population may have some height-induced fear.
Plenty of people work around acrophobia, simply avoiding triggering situations. But seven and a half years ago, I moved to the Yukon, where many people spend their time hiking up steep mountains, climbing rock walls and frozen waterfalls, pinballing down mountain biking trails. My fear became a true liability—an obstacle between me and new friends, new hobbies, a new lifestyle. During my first full summer in Whitehorse, I panicked twice on hiking trails, curling up on the ground and refusing to move at all, or creeping along Gollum-like, on all fours, while everyone around me walked upright. It was intolerable. So last summer, I formulated a plan: I’d use the latest research to build myself a DIY cure—or, at the very least, a coping mechanism. I was going to master my fear by exposing myself to it, over and over again.
“Face your fears” is an old idea. Even its mod
ern, clinical variation—the idea that, as a 1998 paper in the Journal of Consulting and Clinical Psychology put it, “emotional engagement with traumatic memory is a necessary condition for successful processing of the event and resultant recovery”—dates back more than a century, to the work of Pierre Janet and Sigmund Freud. But its codified, therapeutic application is much more recent, and it has important implications not just for people with phobias, but for those dealing with all sorts of anxiety-based conditions, from obsessive-compulsive disorder to PTSD. Facing one’s fears, done correctly, could be a way forward for tens of millions of people whose anxieties control them.
I based my goals and methods of my DIY therapy program on the concept of “exposure therapy,” a concept that owes its existence largely to Israeli psychologist Edna Foa, now the director of the University of Pennsylvania’s Center for the Treatment and Study of Anxiety. As a postdoctoral fellow at Temple University in the early 1970s, Foa trained under Dr. Joseph Wolpe, the father of what was then known as systematic desensitization. Wolpe’s work involved exposing phobic or anxious patients to the sources of their fears, mostly using “imaginal” exposure—for instance, having an arachnophobic patient imagine a spider at a distance, and then imagine the spider slightly closer, and so on—combined with relaxation techniques.
Foa’s innovation was investigating whether a greater degree of “in vivo” exposure—exposure to the real fear stimulus, not just an imagined one—could improve on Wolpe’s promising results. Earlier researchers had assumed such direct exposure could be dangerous for patients with phobias and anxiety disorders, but the science on that front was changing. “I started to do studies of exposure in vivo, starting not with the highest level of fear but with moderate levels, and going faster, proceeding to higher and higher situations that evoke higher and higher anxiety,” Foa told me. The results, she said, were “excellent.”
Exposure therapy is basically an inversion of a well-known psychological technique known as classical conditioning. If you can teach an animal to expect pain from, say, a blinking red light by repeatedly combining the light’s appearance with an electrical shock until the animal reacts fearfully to the light alone, it makes sense that the twinning of stimulus and fear can be unraveled too. Show the animal the red light enough times without an accompanying shock, and eventually it will no longer fear the light—a process known as extinction. I was determined to extinguish my fear by proving to myself that I could climb a cliff.
If I was afraid of heights as a small child, I don’t remember it. I never climbed trees, and I was uncomfortable when my friends and I clambered up to sit on top of the monkey bars on the playground. But I was a timid kid in general—I once told my mom that I never ran as fast as I could in school races, for fear of losing control and falling—so all that was of a piece with my personality at that time.
In my first clear memory of feeling afraid of heights—not just afraid, but terrified—I am fifteen years old. It was the summer after ninth grade, and I’d signed up to spend a week sailing on an old-fashioned ship on Lake Ontario with a dozen other teens. I loved everything about life on board that ship: sleeping in my narrow metal bunk below deck; waking in the middle of the night to stand watch, peering out at the endless darkness; lounging on sunny afternoons in the net that hung below the carved bow. On deck, we wore harnesses around our chests, fitted with a short rope ending in a heavy metal clip. In very rough weather, or if we were climbing the mast to adjust the sails, we were meant to clip ourselves in, just in case.
The problem came the first time I tried to climb the mast—to “go aloft,” in sailing terminology. I got partway up, moving my clip as I went, fighting panic with each step on the ladder-like holds. Then I froze. I couldn’t stop staring at the wooden deck swaying below me, couldn’t stop picturing my body splattering against it, my bones shattering, my blood running into the lake.
The ship’s “officers”—our camp counselors—managed to coax me down, and I never went aloft again. Everyone was kind to me about my failure, but there was no point in coming back the following year. A sailor who can’t adjust the sails in a pinch isn’t much use.
After that, my fear went dormant again for nearly a decade. It resurfaced after grad school, while I was backpacking with friends in Europe. I’d developed a fascination with the art and architecture of old churches, and we hit cathedral after cathedral across the southern half of the continent. We visited a few cupolas, and I gritted my teeth going up and down the narrow stone stairways. But I didn’t truly panic until Florence.
I’d made it to the top of the legendary Duomo and was breathing deeply, trying to stay calm and enjoy myself as I looked out over the city’s terracotta rooftops. The famous steep red dome of the cathedral curved away below me, and as I glanced down at it, suddenly all I could think about was how it would feel to tumble over the flimsy metal railing in front of me, to slide down over those red tiles toward the drop-off. I couldn’t breathe.
The viewing platform was crowded with tourists. I pushed through them to the wall and slid down with my back against it, put my head between my knees to block out the view, and hyperventilated through my tears. My friends found me there, eventually talked me to my feet, and held my hands while we inched back down the twisting staircase to safety and solid ground. We didn’t visit any more cathedral towers after that.
In the years since that humiliating incident, I’ve tried to figure out why I react to heights—specifically exposed heights; I’m generally fine in enclosed spaces, like elevators and airplanes—the way I do. Phobias can often derive from traumatic experiences, or even observations of others’ traumatic experiences, early in life. But it turns out that the acrophobia is different. If I’m anything like the subjects of recent research, I have measurably sub-par control over my body’s movement through space, as well as an overdependence on visual cues—which are distorted by heights—to manage my movement through the world. In other words, I am afraid of falling from heights because I am more likely than other people to fall from heights.
For a 2014 paper in the Journal of Vestibular Research, a team of German scientists studied the eye and head movements of people who are afraid of heights, plus a control group, as they looked over a balcony. They found that their fearful subjects tended to restrict their gazes, locking their heads in place and fixing their eyes on the horizon rather than looking down or around at their surroundings. That description will ring true to anyone who’s ever felt afraid of heights, or tried to counsel someone who is: Don’t look down. Whatever you do, don’t look down.
So, ironically, I fix my gaze to the horizon as a defense mechanism against my fear, but because that fear is rooted in my over-reliance on visual cues, restricting my range of vision can only make things worse. It’s a cycle: My brain knows that my body is bad at navigating heights, so it sends out fear signals as a warning. My body shuts down in response, which only increases the likelihood that I will actually harm my klutzy self. And thus a once-rational response to a reasonable concern feeds on itself, growing and spreading to the point where I can hardly stand on a sturdy stepladder.
A few weeks after that first outing in May, I was back at the Rock Gardens. I’d been making sporadic attempts to face my fears for years, but now I intended to be more systematic about my efforts, and to document them as I went.
The route I was attempting was a beginner’s climb, laughably easy for most people with any experience. And it came with a cheat option: a detour of a few feet to the right, into a wide crack between two rock faces, made it even simpler. But to get to the crack and the easiest way up, I had to make one slightly tricky move. I would have to step forward with my left foot, balance the toe of my shoe on a small nub, shift all my weight briefly to that left toe, then swing my right foot over and across to the next proper ledge—all without any handholds for balance.
My climbing partner stood below me, holding the other end of the rope that secured me to the bolted metal anchors at t
he top of the climb. If I fell, she would pull down on the rope, stopping me before I’d plummeted more than a foot or two. Climbing on top rope, as it’s known, involves almost no real risk. But my lungs constricted anyway, and I fought to squelch my dizziness and panic. From the ground, my friends encouraged me: Trust your shoes, trust your feet. This will be fine. You can do this.
Finally, I took a deep breath, stepped forward, shifted my weight from one foot to the next, and made it across. I fumbled above my head for handholds to steady myself, then grinned and tried to breathe. For a moment while I was in motion, I had felt weightless, in control. Unafraid. Now the fear came seeping back as I continued climbing, scrambling through the loose dirt that had collected on the ledges and lumps of rock in the crack. I finished the climb, but raggedly, fending off panic the whole way. It was a good start, but as my belayer lowered me back down to the ground, I knew I had a long way to go.
We don’t know exactly what happens in the brain during the extinction process. As Foa puts it, “is it that you erase the connections” between stimulus and fear, “or that you replace them with a new structure?” Her hypothesis is that exposure therapy trains the brain to create a second, competing structure alongside the traumatic one. The new structure, she explained, “does not have the fear, and does not have the perception that the world is entirely dangerous and that oneself is entirely incompetent.”
That was why my panicked success in the Rock Gardens that day was really no success at all. I had climbed the wall, sure, but I had failed to convince my brain to build a new structure. Repeatedly terrorizing myself wouldn’t solve my fear; it wasn’t enough to scramble through with wild eyes and a pounding heart. I had to learn to stay calm.