WAITING, HIDING, SEEKING
Initiating psychotherapy with disorganized and agitated children is psychologically disruptive and regressive for the therapist. Often, only my belief that, over time, psychotherapy is helpful, sustains me through the confusing and intense beginnings with these children. This essay describes my anticipation and experience of the second session with a five-year-old boy, Brady. Recently placed in residential treatment after a series of failed foster placements and three psychiatric hospitalizations, he is a towhead whose thick glasses magnify bright blue eyes. He was removed from his parents, reported drug addicts, because of extreme neglect when he was three.
In our first session, Brady separated easily from his caretaker by letting go of her hand and immediately clasping mine. He did not seem to understand what was happening, accepting the change without notable concern. Brady was a listless boy with red cheeks and a runny nose; he did not feel well, and was in unfamiliar surroundings with yet another stranger. Too wary to explore my face, the room or the toy cupboard, he cautiously and quickly accepted the offer of a lollipop. Then he pulled his feet up on the seat of his chair and covered his chest and face with his knees. He occasionally peered out, intently seeming to look at the space around me as he absently worked on the candy. He responded to some of my inquiries, but his language was a jumble of mostly unintelligible sounds.
By the end of the session I am taxed by the cautiously maintained distance, and despairing about how much energy it will take to work with this boy who has experienced such disruption in relationships with adults. In the three days between our first and second session I found myself wondering how our work will go, and then the day and hour comes… Now I’m waiting for Brady to return. My gut is tightening in dread. Why do I think this is a good idea? The beginning is so difficult, each time I have to re-learn how to balance the regression necessary to engage the treatment process with maintaining a therapeutic stance, and also observe how the process is unfolding. It is uncomfortable and difficult to manage the ambiguity of being in these places of reality and unreality simultaneously.
I rearrange some books on the shelf, flick away specks of dust and wonder if this will be the case where I will not know what to do, go blank, lose myself in the disorganization. Do I have the energy and patience to wade through the beginning with another chaotic child? Can my rational mind tolerate the experience of this boy long enough to begin to develop a therapeutic relationship? All the while, I watch the clock, and wait for the buzzer to sound. Once it rings there is no more time to ponder my motivation for beginning and for waiting. It will take all my energy to tolerate and manage the frantic assault of feelings, and of not knowing how this hour, this case, this life will turn out. The buzzer, from high on the wall, nagging and bleating, tears me away from comfort into active not knowing.
He’s waiting too. Brady is in my waiting room, and when I open the door I see his little frame tightly braced in the depth of an overstuffed chair. The tension I observe in the way he holds his body is matched by my own; we share the dread of beginning. Anxiously scanning the room, he looks past me rather than at me. I break the ice, respond to the stress in the room, and say, “Hello, Brady.” He does not acknowledge the greeting. I wonder if he remembers where he is and who I am. I begin to think about how his chaotic life experiences affect this moment just as he catapults out of his seat, grabs my hand, and without a glance or word to the caretaker who brought him, pulls me through the door mumbling something I do not understand.
The power of his energy surprises me, I feel like I am being pulled by a force that neither of us have control over, and that is intensifying into a swirling morass of emotion. I want to relieve my discomfort by telling him to slow down and speak more quietly, but I do not follow my impulse, because he is too upset to hear me or to respond to my structure. But more significantly, I have come to understand that a therapeutic relationship grows out of this initial chaos, tolerating the agitation facilitates its development. My initial thought, to set a limit, is more likely to spark a power struggle, and I want to find a different sort of connection.
We continue down the hall, and up the stairs toward a second longer corridor leading to my office. He avoids eye contact as he moves as fast as his five-year-old legs will carry him. I provide ballast, and slow us down to a rapid walk. He pulls away from me, and as he shoots ahead he begins to speak in a pressured staccato voice with a chant-like cadence:
I no longer battle to keep my head above the rush and intensity of his words and physical energy. I vibrate with the realization that he is calling me Pete. The relief that he knows me and can speak intelligibly is quickly replaced with a surge of my own anger. I do not like being called Pete, nobody calls me Pete, is he trying to get under my skin? I think about correcting him, setting him straight. But even in the pitch of the moment I am surprised by my outrage and know my reaction does not fit the situation. I table the idea to correct him. Besides, he leaves no opening for my words, to say anything means speaking even louder than he talks.
I re-focus on his intensity. The pressure in his voice and movement make me aware that he can only barely tolerate being with me. He is not soothed by my presence or by my words. I intensify his agitation, and by inserting my words run the risk of setting off a shouting match. This, I think to myself, is not good. My mind flashes to the image of an “ideal” child therapist: an ideal child therapist does not give in to his own anger and fear, certainly not in a public hallway preceding the second session with a terrified five year old. I will hold the feelings until I understand more. Taking a deep breath I collect my thoughts, even if I can’t calm him I can calm myself, just as Brady begins another word explosion:
Erupting words, he darts straight toward and enters my office. He heads directly to the desk and yanks open the candy drawer, while asking where the candy is in his staccato chant. This happens so quickly and with such emotional intensity that I do not stop to think that he remembers exactly where my office is, and that he also remembers there is something there that he wants from me. Brady stops talking and grabs candy with both hands. Finally in my own space, I feel less vulnerable and recognize feeling held hostage by him in the hallway. Now I want to assert my therapeutic presence, not just my reactive presence. No longer waiting, I interrupt his frantic rummaging to say with calm authority: “Brady! Brady! You can have three candies, Brady.” FIVE-SUCKA-PETE FIVE-SUCKA-HUH-PETE FIVE-SUCKA “You can have three today.”
WHAD-DIS-PETE I-LIKE-RED-PETE-WHAD-DIS “Lemon.”
OOOOH. I LIKE LEMON PETE, he says more slowly. The wait is over. The tension is diminished, and there is an interaction between us without the earlier tenuous frenzy. In the calm, I can relax a bit, and think about how this moment came into being. In my office, with the door safely shut, I feel more in my element, less anxious and ineffectual. I am less critical and more certain of my therapeutic ability; it is easier to allow myself to go the emotional places where Brady takes me. Perhaps Brady senses my settling into greater certainty and comfort, and responds with the lessening of his own tension. We feel less cut off from one another, and I begin to feel more confidence in our ability to grow into a treatment relationship. In the moment he is relieved that there is something here for him, and I am relieved that I am capable of offering something to him.
As I observe and think, little Brady jumps into my big chair and rips the wrapper off his first lollipop. He jams it into his mouth, and bites and chews. He is facing me, but still not looking at me. He devours the candy, shards of it flying out of his open mouth onto the seat of the chair and into the carpet. As he quickly gnaws through the hard candy I look at his face for
Waiting, Hiding, Seeking Peter Shaft, M.S.W.
signs of enjoyment or pleasure. None. I think, “He does not trust. He is afraid that if he does not eat quickly enough I will take the candy away from him, and eat it myself.” Because we have experienced a moment of calm togetherness, I am more settled and can develop ideas about his experience. I decide to identify the fear of betrayal I observe in the way he eats and say, “Brady, you are eating your candy with a worried look on your face.” There is no verbal response, but he immediately plants his boot on the white wall, swivels the chair and faces away from me.
For the third time I consciously curb my impulse to angrily set a limit on behavior that annoys me. First my name, then bits of sticky candy flying around the room, and now a snow boot to my wall. My reaction is so strong I nearly miss the possibility that he feels assaulted by my words. I work to regain my capacity to observe, in order to forge the beginning of this relationship. If I lose my way of thinking, I no longer have access to my ideas about his experience. Quieting myself, I absorb and contain the surge of feelings we both radiate, and have another idea. Although I can not see Brady, I do feel his anxious energy and I know about his multiple losses. Turning away from me may be an invitation to find him. In my experience, children who have been abandoned often use a game to deal with their concerns about being valuable enough to be found. I try again, starting the hide-and-seek game by saying: “Where is Brady? Brady, I thought you were here with me. Where are you, Brady?”
PETE-PETE-HOME-PETE “Home? I’m disappointed. I thought you were here with me. This is our time together.” With this Brady swings the chair around and faces me. He smiles broadly, directly at me for the first time, then he turns the chair back around so I can not see him.
PETE-CALL-AGArN-PETE No longer waiting, we are engaged and connected. We repeat the game over, over, and over again. I am relieved to find something to do together that does not make him too anxious or me too angry. The repetition of the game quickly bores me, but Brady responds with the same gusto and glee each time he revolves the chair to surprise me with his presence, so I continue to respond in the over-determined way parents respond to their toddlers in hiding games. I tolerate my boredom because I believe in this sequence we are working on a piece of Brady’s development which has been disrupted. This boy, who has experienced the disappearance of so many caretaking adults, is learning in the repetition of the play that he can go away and come back, that he can begin to understand that I will be there when he returns. And by responding in an over-determined way, I believe I break through his agitation sufficiently for him to recognize that he has made an impact on me.
The session is over, and we say quiet good-byes. I am comfortable in my knowledge that we will meet again. I also believe that Brady has a dawning internal recognition that he can depend on there being another time too, that he might be found again.
I find Brady by tolerating the disorganization he brings to the session. I allow him to express his jumbled feelings, but I work to avoid joining him in succumbing to fear, rage, and powerlessness. I engage, but attempt to maintain enough distance to observe and develop an understanding of his agitation. Scattered brief moments of “calm meeting” occur in the midst of the chaos. These moments provide opportunity for a therapeutic alliance to develop. Another factor that aids the alliance is that by managing to tolerate simultaneous organization-disorganization, I begin to formulate my therapeutic response. For example, setting too firm limits at the beginning of our contact is likely to lead to power struggles. By tolerating some agitation, I improve the chance of moments of “calm meeting” which can lead to therapeutic alliance. With Brady, I use this understanding to respond in an informed way rather than with my initial reactive impulse to set limits. By tolerating the agitation and using the evolving moments of conflict-free interaction, I have an essential tool in working with this disorganized traumatized boy.
Candy is an important factor in the beginning of Brady’s treatment. It is something I have that he wants. In addition to its obvious meaning, I believe candy represents a deeper wish for connecting psychologically, no matter how fleeting or deeply buried. This too signals a hope for something more in the relationship, and gives me energy to continue to tolerate the agitation while waiting for windows of calm. The candy is a vehicle I use to develop a real connection between us; it opens the door to hide and seek, and to interactions which allow positive engagement between us.
Waiting, Hiding, Seeking Peter Shaft, M.S.W.
In my experience, psychotherapy with traumatized disorganized children can be successful if I am able to tolerate and work with the child’s presenting behavior rather than attempting to limit and control it. Enduring the intensity of the emotions, and meeting the child in his or her experience, enables the therapeutic relationship to evolve. I have learned that a well-formulated dynamic understanding of the process in the heat of the moment of engagement is nearly impossible. The most important task of the therapist in the opening phase of treatment with traumatized disorganized children is to begin to learn how to provide a safe expectable environment, how to be curious, and how to begin to assist the child to recognize their affective experience. Then, the experience of brief moments of positive contact becomes possible and a significant therapeutic development for both the child and the therapist. These fleeting, golden moments are what I later reflect on to begin to formulate a dynamic understanding of the child, and of the work we are just beginning.