Words&Dirt

Summary:

Bruce D. Perry and Maia Szalavitz’s The Boy Who Was Raised as a Dog is a harrowing yet hopeful examination of childhood trauma and its consequences. Presented as a series of real-life clinical narratives backed by scientific research, Perry and Szalavitz tell the story of how Perry learned to care for some of the least fortunate and most mistreated people in our society––a process that eventually produced the Neurosequential Model of Therapeutics (NMT). The clinical cases describe victims of abuse (sexual and physical), neglect, religious brainwashing, and other forms of developmental and attachment disruption. Perry and Szalavitz provide an inside view of the intense challenges that these individuals and their caregivers must face, along with the neurological and psychological frameworks that allowed Perry to help them begin healing. The book also explores systemic causes and reasons for the perpetuation and mishandling of childhood trauma, and proposes some general directions for societal improvement. 

Key Concepts and Notes:

• Much of the scientific content was review/synthesis of information I’ve learned from other books and my graduate program in counseling psychology, but some aspects of the neuroscience and NMT theory were new to me. It was really the clinical narratives that drew me in and kept me engaged; these stories are so valuable for clinicians who want to learn about how these problems manifest and play out in treatment.
• This probably goes without saying, but if you have a hard time facing the facts of how child abuse occurs in the modern world, you might want to stay away from this book. It’s really upsetting and ugly, despite Perry and Szalavitz efforts to focus on the positive as well as the negative. I would definitely recommend it to anyone interested in the subject matter, but it’s not an easy or light read by any means.
• The most important and dominant theme throughout the book is that relationships are the single most important factor in a child’s life. “The more healthy relationships a child has,” Perry and Szalavitz write, “the more likely he will be to recover from trauma and thrive. Relationships are the agents of change and the most powerful therapy is human love” (258). This might sound cheesy but it’s actually true, as documented in this book and so many other sources. In the therapeutic relationship and also in families and communities, we are learning more and more that social connection is a kind of co-regulatory “master dial” that can reduce human suffering and increase flourishing––or vice versa.
• I pulled a lot of useful lessons from this book that will serve as rules of thumb in my clinical practice. Here are the highlights:

1. All kids need a stable, safe, loving, and predictable life structure that is controlled and adapted to their needs by caring adults. Getting some version of this structure in place––or strengthening an existing structure––is the best thing to help a traumatized child.
2. While the old adage that “kids are resilient” is true, it’s also true that kids are acutely sensitive to developmental disruption. Neuroplasticity cuts both ways. Children can “bounce back” from challenging and traumatic experiences, but they need a lot of support to do so effectively. Also, the sad reality is that some traumas leave a child so damaged that they will never fully recover; the rest of their lives will be spent coping and managing the problems created during a time when they had absolutely no power or ability to choose a different path.
3. Trauma can cause certain sequences of a child’s neurobiological development to slow or stop altogether, even as other sequences proceed as normal. The result is that their cognition and behavior may change radically depending on context, and may not be congruent with our expectations for someone of their chronological age. Helping such children requires being able to identify which “part” of them is current expressing itself and meeting it with an age-appropriate response. In some cases, doing so can help restart the brain’s natural development process and promote recovery. As far as I can tell, this is the core principle of NMT.
4. Oftentimes, diagnoses of Oppositional Defiant Disorder, Attention-Deficit Hyperactivity Disorder, and/or Conduct Disorder ought to be reconsidered in favor of a diagnosis of Posttraumatic Stress Disorder resulting from childhood adversity/trauma. Especially in cases of severe dysfunction and/or violent behavior, taking the time to acquire a full clinical history is essential for understanding the developmental narrative in which oppositionality, inattention, hyperactivity, or misconduct are arising.
5. Rushing a traumatized child into treatment––especially talk therapy that expects them to verbally explore their trauma––is generally not a good idea. Some kids are ready to talk about trauma right away, and that’s fine. But many need time to think, to feel, and to learn to trust adults again in a therapeutic setting. Playing games, making art, or allowing children to nonverbally reenact things that happened to them at their own pace is usually the best approach. Allowing the child to be in control of how they “dose” their explorations of traumatic experiences is essential for restoring their sense of safety, predictability, and capacity for self-regulation.
6. A key aspect of healthy neurobiological development is the linking of social engagement––including touch, language, and body language––with the brain’s capacity to reward itself, producing the internal experience of pleasure. If socializing and pleasure are not adequately associated in early life, a child is much more likely to experience social disconnection and/or exhibit antisocial behaviors later in life.

• The chapter called “Healing Communities,” which is second to last in the 2017 edition but was the final chapter in the first edition, contains impressive summaries of collective problems that make it harder to protect and nurture young people in modern America. Given that this book was originally published almost twenty years ago, Perry and Szalavitz were ahead of curve in understanding the negative impacts of bureaucratic dysfunction in social work and education, technological distraction, family structure breakdown, poverty, discrimination, safetyism, poor sleep hygiene, and a justice system that focuses more on punishment than rehabilitation. They rightly point out that even the best therapies and treatments we can offer won’t fix these problems without complementary systemic change.
• Overall, this was an excellent book that helped me wrap my head around a difficult topic.

Favorite Quotes:

Surprisingly, it is often when wandering through the emotional carnage left by the worst of humankind that we find the best of humanity as well.

Ultimately, what determines how children survive trauma, physically, emotionally, or psychologically, is whether the people around them––particularly the adults they should be able to trust and rely upon––stand by them with love, support, and encouragement. Fire can warm or consume, water can quench or drown, wind can caress or cut. And so it is with human relationships: we can both create and destroy, nurture and terrorize, traumatize and heal each other. (xxvii-xxviii)

Throughout history, while some humans have been our best friends and kept us safe, others have been our worst enemies. The major predators of human beings are other human beings. Our stress response systems, therefore, are closely interconnected with the systems that read and respond to human social cues. As a result we are very sensitive to expressions, gestures, and the moods of others. As we shall see, we interpret threat and learn to handle stress by watching those around us. We even have special cells in our brains that fire, not when we move or express emotions, but when we see others do so. Human social life is built on this ability to “reflect” each other and respond to those reflections, with both positive and negative results. For example, if you are feeling great and go to work where your supervisor is in a vile mood, soon you will probably feel lousy, too. If a teacher becomes angry or frustrated, the children in her classroom may begin to misbehave, reflecting the powerful emotion being expressed by the teacher. To calm a frightened child, you must first calm yourself.

Recognizing the power of relationships and relational cues is essential to effective therapeutic work and, indeed, to effective parenting, caregiving, teaching, and just about any other human endeavor. (71)

The price of love is the agony of loss, from infancy onward. The attachment between a baby and his first primary caregivers is not trivial: the love a baby feels for his caregivers is every bit as profound as the deepest romantic connection. Indeed, it is the template memory of this primary attachment that will allow the baby to have healthy intimate relationships as an adult. (98)

Those of us who work with troubled children have to guard constantly against our preconceptions about a situation; one person’s “troubled teen” may be another person’s “victim of sexual abuse,” and the label given to the child often determines how he is treated. A child seen as “bad” will be treated differently from one viewed as “mad,” and both will have their behavior seen in a very different light depending on whether the clinician sees a “victim” or a “perpetrator.” Further, depending upon one’s point of view, the exact same behavior can be framed as “running away” or “seeking help” and the perspective will profoundly affect decisions about what to do for and two the child. (234)

The more healthy relationships a child has, the more likely he will be to recover from trauma and thrive. Relationships are the agents of change and the most powerful therapy is human love. (258)

Trauma and our responses to it cannot be understood outside the context of human relationships. Whether people have survived an earthquake or have been repeatedly sexually abused, what matters most is how those experiences affect their relationships––to their loved ones, to themselves, and to the world. The most traumatic aspects of all disasters involve the shattering of human connections. And this is especially true for children. Being harmed by the people who are supposed to love you, being abandoned by them, being robbed of the one-on-one relationships that allow you to feel safe and valued and to become humane––these are profoundly destructive experiences. Because humans are inescapably social beings, the worst catastrophes that can befall us inevitably involve relational loss.

As a result, recovery from trauma and neglect is also all about relationships––rebuilding trust, regaining confidence, returning to a sense of security and reconnecting to love. Of course, medications can help relieve symptoms and talking to a therapist can be incredibly useful. But healing and recovery are impossible––even with the best medications and therapy in the world––without lasting, caring connections to others. Indeed, at heart it is the relationship with the therapist, not primarily his or her methods or words of wisdom, that allows therapy to work. All the children who ultimately thrived following our treatment did so because of a strong social network that surrounded and supported them. (259-60)

Relational health measures are more predictive of outcomes than adverse developmental experiences are. In other words, having a strong social network with many, high quality relational interactions over time predicts good mental health and other positive outcomes better than traumatic experiences predict poor prospects. Relational connectedness buffers current distress and helps heal past trauma.

That’s not to say that developmental adversity doesn’t do serious harm––it certainly can. But strong relational health can help protect children from lasting damage connected to these experiences and is essential to their resilience. Consequently, if you want to predict someone’s mental health and functioning based on their childhood experiences, looking at positive social factors will actually tell you more than focusing exclusively on trauma. If there is trauma, good social supports can actually counteract the harm that has occurred. (328-9)

Rating: 9/10