The best talk I have ever heard. She presented her investigative reporting about a boy named Enrique who fought incredible odds to find his mother in the United States. He traveled through five countries, as a twelve-year old, in search of his mother. As Ms. Nazario says, storytelling is the best way to help people understand, and indeed, she told an amazing story. What was gripping and sad about her tale was that she mirrored his journey, herself, so that she could convey the determination and the tenacity that these children, these young people, who cross multiple borders in search of a parent. Her emphasis on wanting to tell Enrique’s story, mirrors my daily attempt to understand my patient’s story. It is through understanding the narrative, the tale, that we connect as human beings, and we reach out to each other. If we do not take the time to understand the story, then we miss out on understanding the common humanity. I cried and cried as she illustrated the danger that Enrique faced, day after day, and yet he persevered, and yet she persevered in parallel. Sonia first told her own immigrant story, and then told Enrique’s story, and at the end she tied them together, as if they were one tale, as if there were more commonalities than differences. She was right. The deeper you dig, the more the differences drift apart. Rarely, am I that moved by one speaker. Sonia Nazario did that for me.
“Toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment, well into the adult years.”
Parents may facilitate development, but more likely they need to “get out-of-the-way,” as I like to say. Getting out-of-the-way means protecting kids from what is now labeled as “toxic stress”. Children are biologically programmed to develop and mature, and with a basic environment of positive affirmations, good attachments, and provisions for food, sleep, friends, and education, most children and grow and flourish and reach their biological potential. However, in the face of tension, violence, or deprivation, then the child must go into what I call “brain freeze” and this stunts the development of the brain, in terms of understanding and knowing how to please oneself. Psychotherapy steps into to deal with toxic stress, but this requires many hours of trying to understand what happened in the preverbal period, where most memories are implicit and not explicit, Uncovering the trauma, so the adult can return to the developmental train where they learn to love themselves is a lengthy process, involving struggle and psychological pain.
Emily, fifty-six, youngest of eight children, always felt like she was a “burden” and consequently, never experienced love from her mom. As a result, Emily spends her time feeling angry, at little things and big things. She is angry with her husband, her children, her friends and her co-workers. She collects all of their misdeeds and she stew over them, simmering with ill feelings day in and day out. By Emily’s account, all of these people in her life are trying to make her feel better. I suggest an alternative viewpoint that Emily is really angry at her mom, for depriving her of a loving environment, and now that anger is transferred on to the meaningful people in her life. “It is a struggle for me to see that,” she says, as she cries. “The struggle is a good one,” I say, highlighting that understanding projection is a struggle, and it is hard to see when a feeling is being displaced. “The struggle implies that you are trying to see another point of view, and in that angst, there will be growth and understanding. Emily’s toxic stress hit her pretty hard, such that the only way she can handle a feeling is to throw it out to someone else and then feel victimized by that feeling, rather than owning that feeling and then trying to metabolize it. The toxin is the neglect. The anti-toxin is her awareness of it.
The healer needs to be healed. That is what I took away from this sweet, touching, and yet painfully unrealistic film in which abused teenagers are housed until a more permanent, sometimes less desirable placement is found. We, the audience, feel the pain of both the staff and the “inmates,” so to speak, feel as they try to heal each other. There is a deep sense of humanity in this film, as the victimization of childhood is shown in full color. As the audience, I imagine the collective group, wants to scream out and remind these unseen parents that no child asks to be born. The responsibility on these parents is clear, and yet, the helplessness to make people take good care of their children is also clear. As the movie unfolds, as with life, the victim becomes the victimizer, as the pain is shared in so many directions. The line between self-harm and aggression towards other is blurred. In a way, it does not matter. There is just a lot of pain. There is the agony of abandonment, physical and sexual abuse, and most of all, the absence of a nurturing figure. How can these abused teenagers break out of their past and not live in a world guided by emotional vulnerability? What kind of people are drawn to work in these residential care settings? Is the answer to the former, the latter? The movie makes us think that. I felt sad, really sad, experiencing this movie as the hours and days have gone by. Emotional pain begets more emotional pain. It is so hard to break out of that universe.
“A number of factors has exacerbated the foster bed shortage. For one, the county lacks an accurate, real-time database of foster home vacancies. The system, updated just once a month, lists the licensed capacity of a home but not the number of beds a foster parent now is willing to fill.”
This LA Times article, detailing the lack of foster homes available in LA County, hurts me deeply, as I ponder the implications. In particular, technology today has made tracking systems ubiquitous. We can track birds, flowers, stocks, and weather, but knowing the number of available foster beds, seems beyond our capacity. This, to me, seems like evidence of LA County’s priorities, of which our children, are not included. The system is large, but keeps failing. Yes, we do not hear about the successes, so perhaps I am being too harsh. Yet, taken together with my previous post, https://shirahvollmermd.wordpress.com/2011/12/01/shame-foster-kids-given-psychiatric-drugs-at-higher-rates/, the data mounts to suggest that LA County prioritizes other County services, at the expense of the welfare of our children. Perhaps political dollars do not float towards foster care, since these children, even when they grow up, do not present a major voting force. Advocacy is needed, as so many of these children will have mental health needs which will overwhelm the healthcare system. The more we can do to mitigate the trauma these children have already experienced, the more we can help to have a stronger society. Instead, we layer trauma over trauma for these children, leading to over-medication, and a life path which is dark and destructive. Children who require foster care deserve better. They are victims of being brought into a world which betrays them. Then, our County warehouses them, furthering their feeling of abandonment, making an understandable feeling of deep hopelessness. How can such an affluent city let these children down? I am ashamed.
Kids raised, with the almost universal assumption, that parents want to promote the mental health of their child, are left to feeling alone as they struggle with the inability to please their parents. Kids, some more than others, need to feel that they are making their parents proud, often suffer, when this goal is simply unobtainable. This “little t” trauma, as some call it, cause these kids to suffer from depression and anxiety, giving them a psychiatric diagnosis, which often, further disappoints their parents, thereby promoting the disappointment that they already feel. This downward spiral requires these children to develop the self-confidence, where their well-being is no longer tied to the pleasure in their parent’s eye. This separation is often the work of long-term psychotherapy, leaving many therapists with the upward battle of promoting boundaries, while at the same time, understanding how attachment to a disappointed parent can feel safer than no attachments at all. Psychopharmacology can be helpful, but the majority of the work, lies in creating a bridge for the patient to mentally leave their plea for parental acceptance, so that they can learn to please themselves and people they choose to care about. Some families can be cherry picked, and some people need to understand that those ‘families’ will stimulate positive growth and fulfillment. Elisa, twenty, comes to mind. She is the product of a single parent. Her mother, Jasmine, had a “quickie” and wanted to keep her. Jasmine, frustrated with her life, always made Elisa feel like she wished she was not born, or so Elisa relates to me. Elisa, trying to make Jasmine happy, has been frustrated at her inability to do that. Elisa is doing well in college, has a nice boyfriend, but she still feels that Jasmine is disappointed. Their relationship is strained and so Elisa avoids interacting with Jasmine. Jasmine does not initiate contact with Elisa. Elisa gets depressed and engages in self-injurious behaviors. She feels like she will never be happy with herself. This dynamic where her struggle with her relationship with Jasmine, appears now, to be the central theme of her depressed mood, is the core of our work. Elisa needs to develop the self-esteem, where her mood is not a reflection of Jasmine’s mood. This involves a movement away from the centrality of this relationship, while at the same time, understanding that Elisa and Jasmine’s connection has been intensely important to both of them for two solid decades. This is the work of therapy. This takes time and patience. There is simply no quick fix. Once again, the theme of my rants continue. Time and sophistication are essential to helping Elisa.
Shirah Vollmer MD 