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Go ahead and be angry.
You do well to be angry—but don’t use your anger as fuel for revenge.
And don’t stay angry.
Don’t go to bed angry.
Don’t give the Devil
that kind of foothold in your life.

—Ephesians 4:26-27

Cynthia, our charge nUrse, stuck her head into my office. “Dr. Burns, your evaluation is here. Remember Allison from the state hospital? Dr. Gaskin called and requested a case review. Are you ready? Should I bring her in?”

Suffe the little children to com unto me for as such is the kingdom of heaven. Matthew 19:14

A young girl who was on the children’s unit at the state psychiatric hospital was coming to be interviewed. Her inpatient doctors wanted to discharge her to White Pines, but she was doing so poorly that there was little hope she would be ready for transfer. Our job was to meet her, give her a tour of the facility, and assess our ability to keep her safe at a lower level of care. Looking up from her chart and sighing, I wondered what trauma could create such behaviors in a small girl. What had she seen in her short life, and what more could I learn after spending two hours interviewing her?

I asked Cynthia, “How can I impact this young girl’s life when so many doctors and providers have failed?”

She had no answer, so I got ready to meet Allison, to listen in a new way. I hoped her treatment plan could be altered, and she could decrease the behaviors that got her kicked out of school and foster homes. Her psychiatric record read:

Allison is a 9-year-old white female who has a long history of neglect, physical and sexual abuse. Symptoms included verbal aggression, mood lability, sleep disturbance with sleep walking, poor hygiene, fighting with siblings, sexual acting out, and self-injurious behaviors, including picking sores and biting her tongue until it bleeds. Her previous diagnoses include bipolar disorder, Attention- deficit disorder, and oppositional defiant disorder.

Where is post-traumatic stress disorder, chronic type? I typed her clinical summary:

Allison was seen with her biological father—who recently gained custodial care—and his girlfriend. Her father reported severe neglect in the maternal home from zero to two years of age. Allison was frequently found wandering the streets at night. She was removed at the age of two on grounds of neglect. Allison’s older sister, four at the time of the children’s removal, was the primary caretaker in the family.

All the children were exposed to alcohol in utero. And in the home, they were exposed to adult sexual activity. At a young age, they played a game called “dragon or diaper,” where the mother’s father “peed on them and they had to sip it off.” The social service worker noted this seemed to be a reference to oral sex. When Allison was examined, there were bruises and red marks in the diaper area. Allison had multiple imaginary friends who “play games with her and keep her company late at night.

It is not unusual for aggressive children to act out only when challenged. A good child psychiatrist is a team member and operates like a tenacious detective, scouring medical records for clues and extracting information about a patient’s function— often never seeing the maladaptive behaviors, because even aggressive, hyperaroused children can behave normally under controlled situations.

Mental status exam reveals a clean, white female in no apparent distress. Eye contact is good. Speech is of regular rate and rhythm. Thoughts are goal directed. Content centers around missing her mom, but liking it at her dad’s house. No auditory or visual hallucinations. No suicidal or homicidal ideation. No thought insertion, broadcasting, or withdrawal. Mood is euthymic. Affect is appropriate. She endorses thoughts of wishing she had never been born. No attempts at suicide. Cognition is intact. She demonstrates abstract thinking. Judgment is fair. Insight is fair. Her response to three wishes is, “Live in New Orleans, live with my grandma, live with my grandpa who is dead, and that’s my three wishes.”

And what were my three wishes? I wished Allison had not been abused by her mother’s father and her mother’s boyfriends. I wished I’d never heard a perpetrator say, “I do it because it’s the only time I feel anything. I’m numb except when having sex with children. I know it’s wrong. Every time, when it’s over, I swear, never again. But then I find myself circling back, hovering, watching, waiting until its bath time. I live only for the next connection.

I can’t remember what my third wish was that day, but I’m certain it had to do with God.

Allison was already receiving the maximum level of care at the state psychiatric hospital. As a consultant reviewing her behavioral plan and recommending medication changes, I hoped her aggression would decrease so she could shower without a fight. But what if showers led to sexual molestation for her like they did for so many children? The soap a lubricant for sex, occurring in the bathtub while her older sister watched and waited, knowing she was next. Who was I to speak to her about cleanliness and going to school smelly when she knew what happens when little girls step into the tub? And how could we put that in a treatment plan?

My mind tumbled. What could I do but increase her Depakote, a mood stabilizer, or decrease it and wean her off so we could observe her without medication, and then perhaps start Lithium, another medicine with mood-stabilizing properties?

This little girl cleared the teacher’s desk in anger, breaking a favorite coffee mug. She grabbed the crotch of her friend; she didn’t know how to play hopscotch, but she knew sex games well. Her individualized treatment plan already included intensive services, individual therapy, cognitive behavioral therapy, and family therapy. What could I possibly add? I reviewed psychoeducational material about bipolar disorder and post-traumatic stress disorder, and we discussed the symptoms of chronic trauma, including dissociation. I attempted to explain the phenomenon of flashbacks—that Allison might not remember her aggression or sexual acting out.

“It’s harder for her to take responsibility if she cannot remember,” I told her father, counseling patience.

But where were the providers and individualized treatment plans nine and a half years ago when she was born? Born into an addicted, aggressively sexualized family that molested her, forgot to feed her, or lock the front door at night after they passed out, she needed our help then.

Documenting findings and chairing team meetings felt ineffective. Each patient was medicated in hopes of giving them a life without aggression, but I felt trepidation. I wanted them in school where they could learn, but I knew that anger and aggression were their defenses. And so I persisted—writing prescriptions, signing off on treatment plans, and supervising therapists, hoping some good was being created, that healing was occurring.

After six years at White Pines, I was suffering physically and mentally. There was a ringing and fullness in my right ear that irritated me. Rushing through the work day, I rarely had time to eat, and would come home ravenous, grabbing snacks from the pantry to assuage my hunger as I put supper on the table. My knee hurt and buckled when I climbed stairs. Allergies plagued me. Those frigid, sub-zero days when my nose hairs froze and my head pounded from the barometric pressure were exceptionally painful. Bitterness and anger grew as every case revealed maltreatment. I blamed God for Allison’s life, and called to him for some meaning in her abuse.

I did not hear an answer. Neither did she.

“Hey, God, listen up. Let’s start over. Change creation. Let’s counsel Eve about the day the snake came. Let’s caution her not to fall for his cunning argument. Let her read a psychiatric evaluation of a six-year-old who was sexually groomed in infancy, tell her about the hundreds of victims that one single perpetrator violates in a lifetime. Please, Lord, tell her before she takes a bite of the apple.”

Focusing so much on darkness, I lost sight of the light, lost my faith and joy. Convinced I had to create a trauma- sensitive milieu, then a trauma-sensitive world so abuse could be abolished, I persevered. It was too much to ask, but I couldn’t give up, afraid that if I stopped working, things would get worse, that more children would suffer and no one would care. I knew God existed before and outside of time, and that he could fix this, but I didn’t believe he would.

God continued loving me during my oppositional outrage. He urged me to see a wider story and asked for a cease fire, but I turned from his goodness. Confused, I felt I couldn’t love him and continue listening to my patients, too.

Thus my own secondary post-traumatic stress symptoms were born in this environment of distrust and exhaustion. Some days, I was so distraught over a patient’s story or an administrative decision that I was barely present for my own family. This was not the part-time career I had envisioned when I drew a pie chart and chose child psychiatry over OB-GYN.

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