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bryan and mia were discharged yesterday...he used to call me dr
bob.
it became mr. bob after awhile then just bob. as i watched them leave
with their foster mom an image popped into my mind - the image of a
strapping young lad and of a confident young woman - the image of their
future, made of many tomorrows, the story of which has yet to be
written...they were smiling in that image and one could sense how at ease
they were and how it felt to think that i had been a part of their
world...for a time...for all time...
watching them leave the unit my emotions were running high with a
mixture of sadness and joy - love and loss - i managed to escape
temporarily using my usual devices of bursts of goofy activity and verbal
circumstantiality... ( ? a higher level defense mechanism for Vaillant's
list although humor does come across as more doctorly then goofiness
does). bryan, now almost 6 years old, had spent the last 20 minutes
horsing around with me in the hallway, gleefully pushing me down then
helping me up. mia was being her usual coy and seductive self, already
full of feminine mystique at age 3 and 1/2...hiding her face in her hands
every time i looked over at her delighting in her cat and mouse game...
played on her terms...of course.
i remember bryan's first day on the unit 12 months ago...he was
tense, anxious, defiant and mistrusting. he was clutching a stuffed
animal with both arms crossed and responded to all interventions by saying
"i don't wanna talk". he had been admitted the previous evening by one of
the child psychiatrists and responded to all questions in that manner. he
refused to play. dr. bob, 3 months into his residency in general
psychiatry , made a few feeble attempts to establish a relationship with
this 4 year old boy who was determined not to let anyone get too close ...
it was not difficult to understand why...bryan and his sister had been
physically and emotionally abused by both parents, their basic needs for
food, shelter, clothing and nurturing had been neglected and following the
murder of their 3 month old brother ( baby adam ) by their father they had
became wards of the state and had been placed in a foster home, together
fortunately.
"i don't wanna talk"...the words kept resonating inside my head like
the lingering echo of a muted trumpet in an empty concert hall on a cold
winter night...dr bob was nervous, under the watchful eye of an
experienced psych nurse who had seen how dr W had tried and failed to
connect with bryan last night...dr W who had done an internship with anna
freud and had once skipped a lecture on a new model of child development
by some guy she hadn't heard of before...his name was piaget. "i don't
wanna talk"... it was turning into a power struggle between the two of
us...to fight or struggle implies that there be a winner and a loser, yet
if a stalemate occurs both lose in a way...so in order to find a way for
both to "win", dr bob "regressed". (this could be aptly reframed however
as letting out one's inner child or relaxing one's superego or simply
being spontaneous ).
dr bob crossed his arms, frowned as best he could and looked bryan
square in the eye and said "i don't wanna talk". it didn't take too long
for it to become a game and he started to giggle as he peered at me from
his safe vantage point behind the nurse's skirt. he then went into his
room with me and talked about his stuffed animal. over the next few weeks
he would talk of safe topics and when threatened would shift back to "i
don't wanna talk".his inability to keep a straight face when teased was a
source of mutual amusement. bryan needed to be "in charge"...and by
playing variations of the game of "follow the leader" the relationship was
able to grow.
the transition from inpatient to partial hospitalization went
well and
shortly thereafter dr bob was assigned to a different training site. dr W
asked me to stay on the case as a co-therapist and needless to say the
offer was readily accepted. from then on, dr bob's only patient on the
unit was bryan, who proudly made sure all the other kids noticed how
special he thought that was. in the cafeteria, he distinctly disliked it
when i interacted with the other kids, which invariably happened.
in play bryan was initially bossy and aggressive...at times it
seemed
more like search and destroy, the battle ground being dr bob's body. it
was easier for him to engage affectively by this means than directly, or
so i supposed. i became quite adept at dodging kicks, swipes, droplets of
saliva and various flying objects propelled by a giggling little kid with
endless energy who loved teasing dr bob...(my mom always said i'd get it
some day). amongst my most clever interpretations were: "ouch"..."are
you trying to hurt me" and "who is going to clean up this mess"... with
time, bryan began to respond with empathy to dr bob as a person...a person
with genuine feelings expressed within the context of a relationship based
on stable and secure ground affectively...indeed bryan had tested it time
and time again.
play became less aggressive and more focused. on the unit his
behavior was less oppositional. he continued to have problems when in
group settings and had a low tolerance for frustration when not in control
of the situation. because of violent sibling rivalry at home his sister
mia was admitted to the partial hospitalization program. age 3 and
already taking 22.5 mg of ritalin daily. dr W asked me to participate in
mia's care. so one friday, bryan saw me come in and horror of horrors...he
had to share dr bob...and to make it worse, he had to share with his most
hated rival - mia. he pouted, regressed, acted out and became more
aggressive in play yet with the ability to directly express his feelings
about not wanting mia to spend time with me. in joint sessions he had
violent altercations with her, then would play the victim role to the max
when she retaliated and hit him back. mia was jealous of the relationship
bryan had with me and became quite seductive to get dr bob's attention,
she would coyly feign indifference when she felt slighted or neglected.
she loved to hide herself and to be pursued, as if to say "am i really
wanted here...".
in play mia hid her face in her hands, she would crawl under tables,
hide behind doors, would scurry behind nurses and staff members always
peering with a mischievous gleam in her eye. mia had no trouble
expressing her feelings..."that makes me mad"....and she was frequently
mad. she would love to cling to female staff members and to my knowledge
she never willingly participated in any group activities, preferring to
isolate herself, perhaps her way of hiding out waiting for someone to find
her and be with her, yet terrified of it at the same time...once bryan
figured out that mia was no threat to his relationship with dr bob he
started to willingly share with her and to be protective of her. he would
gallantly offer her the first session with dr bob and would tolerate
separate lunchtime visits from which he was excluded, that is as long as
he got plenty of reassurances that he would be seen as well..."when are
you gonna see me mr bob...see me today okay?...are you gonna see me today
mr bob?.."
little by little bryan began to speak of mia in more positive terms
and the violence between them grew less. he got to know almost everyone
in the hospital by their first name and would constantly be calling out
cheerful greetings and giving and receiving hugs galore. his play
reflected these changes in that the affection was always readily apparent,
albeit with a rough and tumble/ contact sport type predominance! he
accepted limits easily and was markedly less bossy. he began to request
discharge, not to break off the relationship, but because he knew that
hospitals are for sick people and he didn't think he needed it any more.
when dr N, who had taken over for dr W as the attending and who likes to
tease, told him yesterday that it had been decided that was going to stay
in the hospital until the third grade he grinned knowing that this was the
day he would be discharged...
he spent 20 minutes or so playing with dr bob in the hallway before
leaving with his foster mom and mia, who was hiding herself like usual. i
feel fortunate to have been a part of the lives of these children and
there is no doubt in my mind about wanting to learn more about how to help
children and their families through a therapeutic relationship.
my main interests lie in the area of developmental issues - from
preconception fantasies and expectations and early parent/child bonding
during pregnancy to adult development, parenting/grand parenting issues,
the whole spectrum of social, cultural, spiritual factors interwoven
intimately in the process. my native american roots have sparked an
interest in multi cultural psychiatry and chemical dependency issues. i
enjoy working with families and groups and would like to continue to learn
in those areas.
although primarily interested in psychodynamic, metaphorical and
interpersonal theoretical frameworks, i value the contributions
cognitive-behavioral and psychopharmaceutical approaches provide. i am
truly looking forward to working and learning as part of a multi
disciplinary team and having a blast doing it...in fact, i'm counting on
it!
Robert Shubinski, MD
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Last Modified 3/March/2002
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