In the Academy Award winning film, Precious, the main character’s transformation comes about largely through her ability to tell the story of her trauma, specifically in the form of writing. In this endeavor she is encouraged by a loving teacher. In the book History Beyond Trauma, two French psychoanalysts argue that symptoms their patients exhibit represent the horrors of war that are not spoken of, sometimes for generations. The patient is relieved of his symptoms when the stories of trauma are finally told, usually in the setting of the relationship between patient and analyst.
These works brought to mind a referral I recently received in my pediatric practice to prescribe medication for a seven year old child. The details have been changed to protect privacy. The psychological testing report read, “Given these findings relative to attention and working memory, it would be prudent for _____’s parents to share these testing results with their pediatrician regarding a medication trial aimed at mitigating his difficulties with self-regulation and attentional control."
Two years earlier I had seen Sam’s parents, Rebecca and John, for a consultation. Rebecca was feeling overwhelmed. Sam would get over-stimulated in groups of people. He was becoming increasingly oppositional. They had adopted Sam after taking him in as a foster child when he was three. Prior to this, he had lived with his mother, who was an actively drinking alcoholic. She had physically and emotionally abused him, saying frequently that she wished she’d never had him. His father was in prison and had never been involved in his life.
Rebecca and John wanted some advice about what to do to manage Sam’s challenging behavior. I began at that visit to introduce the idea that early trauma can have a significant effect on children’s behavior. My thinking was guided by important research by Miriam Steele. She and her colleagues studied children who had all suffered serious adversity, including neglect and both physical and sexual abuse. What was it, she and her colleagues wanted to know, that led to a positive relationship between an adoptive parent and child?
They found that one key factor was the adoptive parent’s ability to think about the child’s behavior as related to their life story. When parents did think about the meaning of their child’s behavior in relation to this story, they were more likely to describe joy and pleasure in the relationship. This is where I wanted to bring Rebecca and John.
While I did offer some of the advice they were looking for, I also recommended that they engage in therapy for the whole family. I acknowledged that raising a child with a history like Sam’s could be extraordinarily difficult. Even with all the love, safety and security they were giving him, teaching him how to trust and to regulate his feelings, things children usually learn in the first years of life, would be a big challenge for all of them.
They did not come for a follow up visit, and did not follow through on my recommendation. Why they did not I am not sure. I do know that there is a severe shortage of quality mental health care in our community. I also learned that Rebecca was suffering from significant depression. Thinking about what happened to Sam in his early life, and facing the enormity of the task of raising a traumatized child might have been too much for her.
I did not hear from the family until I received the report suggesting I prescribe medication. Stimulant medication will likely be of help to Sam in the short term. Many children who have been traumatized feel much calmer on medication. It may even help them to learn. The problem comes when medication is used instead of, rather than in addition to therapy. Alleviating symptoms with medication often decreases motivation to do this difficult but important work.
Precious, in the context of a caring relationship with her teacher, was able to tell of her experience. The patients with history of war trauma similarly have this chance in the relationship with their therapist. Medicating Sam will be a Bandaid. It may fix his problematic behavior in school. But underneath will be an open wound that will only begin to heal when he has the opportunity not only to tell his story, but to have his story heard.