by Bruce Perry
Humans are social animals, highly susceptible to emotional contagion. Training, logic and intelligence are often no match for the power of group-think. Early humans who couldn’t quickly pick up on and follow the emotional cues of others would not have been able to survive. Following such cues is a key to social success, and being unable to perceive them is a serious handicap, as we saw in Connor’s case. But the “side effect” of this legacy can lead us to witch hunts like the one in Gilmer, Texas.
chapter 8
The Raven
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 reprompt 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 t
hat 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 addicts 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 k
ind, 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.