By Richard Zuckerberg, Ph.D.
Brooklyn, NY
On the morning of Sept. 13, 2001 I received a consultation request from the Pediatrics Department of the hospital where I am a psychologist. I called the inpatient unit and spoke with Dr. Gray who told me that an 11 yr. old boy was admitted to pediatrics from the ER on the night of Sept. 11, after being brought to the hospital's ER by his grandmother. He told me that the boy presented with the following symptoms: he had a choking sensation in his throat, he was not able to talk, he indicated by gesture that he had chest pains, and responded to questions only by writing his responses. His written responses were simple, his spelling was poor, and his penmanship looked poor as well. In addition, his right leg had a tremor, and both his arms were experienced as "heavy" by the boy and he appeared to have problems lifting his arms in front of him. He had a difficult time breathing as well, and the grandmother reported to the ER staff that he had chronic asthma. Based on what they saw, the ER physicians suspected that he might have had a seizure, or some other neurological problem. The boy was worked up neurologically, was given a CT scan of the head, an EEG, and an MRI. Over the next two days all findings were found to be negative.
In terms of events of that day, the grandmother told the ER staff that the boy's morning was essentially normal, but that he, like his classmates, was absorbed by the disaster at the World Trade Center, and late in the afternoon, he had returned home and watched replays of the disaster on TV. In addition, she reported that at around 7:30 pm he got into a fight with another boy, and it was actually during this fight that he began to experience these symptoms and was taken to the ER.
Before going in to see the boy, I reviewed his medical chart and found a sheet inside the chart with his writing of his answers to questions that were asked of him while he was seen in the ER that night. The writing was fragmented, poorly constructed, expressing incomplete ideas, and quite suggestive of the possibility of an organic insult.
After reviewing the chart and the history, I spoke briefly with the nurse on the unit, and she told me that she had just been with Donny, and that she had suggested to him that it might be helpful to write down some of his feelings about the WTC. She said he decided to write a letter to the President. She also informed me that all of the symptoms he had presented with in the ER two nights before had disappeared, but the doctors still didn't know what had caused his symptoms. When I went in to see Donny he was sitting up in his bed, with an IV in his right arm, and he appeared alert and calm. He was a good looking, African American child, well built, who was socially responsive and quite forthcoming when I introduced myself. As I sat down on a chair next to his bed I saw the letter on another chair, and asked him about it. I asked if he wouldn't mind if I read it. Immediately, I was struck by the difference between the structure of his written responses to questions in the ER and the letter to the president. The overall quality of the ER notations was poor: characterized by tremulous line quality, fragmented grammar, incomplete expression of ideas, and increasing loss of control as the writing progressed in each sentence. All of this clearly suggested the presence of some underlying organic impairment. By contrast, his letter to the president was much more integrated and age appropriate in terms of style, content, and overall structure. In addition, the improvement in quality from one to the other occurred in less than two days, and suggested that whatever had happened, or the effects of it, was of short duration.
Donny and I talked about the letter, and I underscored to him that I could see that he was obviously very shaken by this experience, and I asked him if he remembered anything about how he was when he came to the ER. He did, and he described to me pretty much what the doctors had indicated in their notes. I asked him how he had felt about that happening to him and he said he was scared, and he didn't know why it happened. I asked him about what he was doing the day this happened to him, or if it ever happened to him before. He said it didn't, and then began to tell me about watching the replay of the WTC on TV, and also about the fight he had with the boy. I mentioned that in the letter he said he was scared and I asked him if he had any other feelings then or now. He said, "I felt bad and guilty - that I could have been there to help the people - I felt I did something - I could have helped the people or something." I was struck by his statement that he felt guilty, as I had immediately projected into his remark that he wanted to be there to simply help the people that were part of the rescue effort. I didn't see how the expression of "guilty" fit in to this. So, I asked him about that, and he said to me, "I also was mad - like I was blaming myself for it." I said, "tell me how that is, how is it that you could blame yourself." He said, "Like if I had some powers or something, and I told the people before it happened or got into the plane or been on the phone when the people made the emergency calls."
For some reason I felt I wanted to go back to his presenting symptoms, of how he felt when he saw what had happened at the WTC, and how these physical symptoms seemed to appear shortly afterwards. He remembered that he began to feel bad after the fight with the boy saying, "I couldn't breathe - my chest was tight, very tight, and I couldn't get enough air through my lungs - I was stiff and out of it - my arm was in this place ( held both his arms slightly out in front of him) like somebody had to pull it down - I was angry with myself, like I could have done something to help. I was not talking - like somebody was holding me down and choking me - it felt like I was in a dream - that I was trying to defend the people - to stop the terrorists - that I was on the plane." I said, "You mean when you had all these things happening to you, it felt like you were in this daydream, imagining it ?" "Yes", he said, "That I was on the plane, it felt real - I was trying to stop them and they were choking me, and holding me down - I couldn't breathe, I was very scared." "And, what happened to you next ?", I asked. "Then I took control of the plane, and landed it in a nearby airport. It was like I made a miracle and the people were happy and safe and thanking me and stuff, that I did it."
His reconstruction of what amounts to a dissociative experience suggests that the appearance and development of the symptoms began to emerge and merge, as part of his experience of both being in this fight with this boy and having been witness to the events of the WTC disaster. I was taken by Donny's fantasy of rescue which had this preventive aspect to it, the wish that he could do something to stop it, his failure to do anything, and his subsequent fantasies of undoing something bad that had happened - the super power fantasy. He seemed to be trying to turn an experience of being overwhelmed into one in which he was in control. I shared with him my thoughts about this, and as I did, I saw his face had a little smile and the sense of urgency and pride and satisfaction of preventing this from happening. There was a pause, and I began to reflect on other questions I could ask, things that I wanted to know more about him.
I was still curious about the feelings of guilt, the wish to prevent the bad thing from happening with super powers, and the anger at himself. I remembered that he had been brought in by his grandmother, and that the nurse told me he was soon to be visited by his grandmother. I wondered where his mother and father was in all of this and so I then asked him how his mother felt about this and where she was at the time. He looked at me sullenly and said, "She's here." I said, "here, you mean in the hospital ?". And, he said, "Yes, up there, on the 10th floor." I paused longer than I should have because the 10th floor is one of the floors which is part of the nursing home which is adjacent to the hospital, and I realized that his mother must be a resident there. I said, "you mean your mother is in the nursing home?" "Yes", he said. I asked what was wrong with her and how long she had been there. He told me, "she has Multiple Sclerosis." "And, how long has she been here?", I asked. "For a few years."
I expressed my sympathy for her and him, and said that it must have been really rough on him, to see his mother get sick, and to be separated from her, and I asked him about what he remembers about her getting sick and how she is now. "I always think about when she got sick," he said. "What do you think about Donny?", I asked. "I think that I wish I could go in to her body, and stop it - like take my life instead of hers." I was stunned and asked him what other thoughts he had. He said, "I'm angry with myself, that I couldn't go into her body and stop it from happening."
I felt so bad for this little boy who had been carrying around these awesome feelings of sadness, of watching his mother get sick, the loss of his being mothered, the wish that he could have done something to prevent this from happening to her, for his sake and hers, the guilt about not being able to save her and the anger at himself for this failure of power to influence the happening of bad events. The similarity between the events of the day, his fantasy and daydream of preventive heroism for the people on the planes and his mother, the fight with the boy in reality and the struggle with the terrorists in fantasy, became increasingly apparent to both of us. I drew the parallel for him in words, and he seemed to take this in as we just sat together and held these thoughts between us silently.
Then I asked him what he remembered when his mother got sick. He told me now, not unexpectedly, that she began to have problems in lifting up her legs, speaking, and using her hands. I said, "Donny, you know that sounds a lot like what happened to you on Tuesday night when you came to the hospital." He nodded in agreement.
I saw these symptoms now not so much as simply an acute stress reaction, but as perhaps more of what I think of as the symptoms of a conversion disorder. That is, the witnessing of the WTC, the fight with the boy, and the subsequent appearance of symptoms were not so much a simple stress reaction, but more that his witnessing the unpredictable assault against these innocent people and the collapse of these buildings, and the subsequent fight with the boy, triggered, reawakened, and revealed the earlier trauma of his mother's sudden collapse, and his feelings of helplessness. It became clear to me that this complex psychic- bodily reaction was not merely the nonverbal expression and reaction to a current event, but that his old trauma was suddenly reawakened in the context of the present happenings which provided a useful and structurally parallel metaphor for its expression.
Now, I felt that I wanted to rescue him myself, to prevent something bad from happening to him, but I also was interested in just what this all meant to him. In all of this, was he identifying in some way with his mother?, was this some sort of punishment for not being able to enact his wishes to come to his mother's rescue and overpower the hidden disease like the mysterious terrorists who killed other innocents?, was this the expression that he himself was getting MS, and these were the symptoms of the disease?, or was this some expression of a union with his mother who clearly has been lost to him in many ways over the past five years?
I remembered back to his letter to the president, to the part about "if you need help in the secret service, give me a call." We talked a little about this, and I told him that there were ways that people could help other people in their lives, that wishing to help was the first step, and then doing something to help is another step. He said, "I know - maybe I'll grow up and be a life saver - I could help people like in the World Trade Center, or help to make new medicines."
We talked a little more about this, and I told him what a wonderful wish this was, and how sensitive and caring a boy he was. But I also wanted to know more about how he felt about himself in relation to his mother and her illness. I asked him if he ever worried that he could get sick like his mother. He said, "I worry every day that I could get sick. I remember when my mom said that her legs hurt, and she was tired. I get this feeling every day that I could get it one day."
And, then he paused and looked me straight in the eyes, and said, "Can I ask you a question?" "Of course," I said. "What does it come from?" At that moment I had no answer for him, so I told him I really didn't know, but that I would ask Dr. Gray and Dr. Chang, and I would let him know what I found out. In the meantime I asked him what he imagined it comes from. He said, "I think maybe it comes from working a lot - like my mom - she worked very hard." I told him that I was pretty certain that it did not come from hard work, but that I would talk with him further after I found out more.
After doing some research with Drs. Gray and Chang, I met again with Donny and Dr. Gray. We were able to tell him that MS is not a hereditary disease, and I explained what this meant, and that it is not a childhood disorder either. He was clearly relieved about this. I told him that I thought that it would be a good idea if he and I talked more about some of these feelings he had for a long time about his mother, and some of his wishes for himself in the future, and he agreed that it felt good to talk about this, and would like to talk with me more.
This was a compelling experience for me personally, and a fascinating case for psychological inquiry and differential diagnosis. It brought up many aspects of what psychological inquiry means, how we proceed with an inquiry, and the personal and cultural subtext in which inquiry takes place. For example, for the two days after the WTC disaster I, like my colleagues, had been thinking about the immediate and long term effects of this catastrophe on the minds and souls of all of us who had witnessed these events. In fact, during the days following this event, I became part of a team of mental health professionals at the inner city hospital in which I work, who quickly pulled together training seminars for our ER and social work staff, and we were on call to provide counseling for those in need. Because of my obvious immersion in the expectable reactions to an event of this magnitude, I was alert to the symptoms and treatment interventions for people presenting with symptoms of acute stress disorder, and, after time, with post traumatic stress disorder. I must say, that I was less sensitive to the potential development of what in this case is probably what I would consider the development of a conversion disorder triggered by a confluence of current and historical events in this boy's life.
This experience was an education for me, and hopefully will serve as a guide and a reminder to other professionals who may be called in to evaluate and treat children, adolescents, and adults with various symptoms and patterns of symptoms triggered by disastrous events of this kind. During our staff development programs for crisis intervention we all agreed that that the first principle of help we needed to emphasize to others was to listen, listen, and listen. And, this, of course, is a reminder to all who require help or may be thrust into the role of helpers themselves; loved ones of the victims and all those significant others who want to help and be of help.
From the clinician's perspective, the value of really listening to what we are told and what we see is multidimensional. First, from a clinical perspective, it will prevent us in not jumping to diagnostic conclusions or treatment interventions that may have some truth but are limiting. In the wake of this kind of disaster it is only natural to apply a diagnostic formulation without further consideration of a particular persons unique presentation of self. Secondly, and relatedly, we must always be alert to and interested in the very personal histories of our patients, and our inquiries must follow from this interest. In so doing, we will be able to truly understand that events of this kind are always experienced in unique and personal ways, and will always occur within the context of an individual's historical conflicts and personality. As such, continuous empathic understanding provides possibilities for the the treatment not only of reactions to a current trauma, but also an understanding and treatment of pre-existing conflicts, which may include links to earlier traumas as well.
Finally, this case underscores some of the enduring principles of a psychoanalytic vision of the human condition, the human psyche, and the nature of clinical intervention. One of these principles is that we all reenact our idiosyncratic histories in the current events of our lives. Second, we assume that in this tendency to re-enact there is a press to especially "live out" "incomplete experiences," and this incompleteness is, to me, one way of defining what it means for something to be unconscious. In particular, I think it is within the structural dynamic of what we call trauma that the press for completing the incomplete process of mourning is particularly relevant. Third, that our unconscious is "receptive" to or "primed" for experiences which may provide opportunities for some kind of completion of the incomplete, or some kind of closure. Fourth, that this openness to closure may actually have an active agentic aspect to it, in that the unconscious "searches" for those opportunities to allow for expression of the incomplete experience. Reality events always have the potential to trigger and and therefore to actualize what is latent, repressed, dissociated, or incomplete. And, finally that the role of the therapist is to "be there" as part of this opportunity, and that our function can be as both translators of the hidden and disguised verbal and nonverbal messages seeking to be understood and as the human medium into which this incomplete experience can be delivered, lived out, and finally brought to further completion and closure.
And, on a more personal note, in retrospect it became clearer to me that my immersion in Donny's experience occasioned through the disaster of the World Trade Center echoed the sudden and bewildering death of my own father in early childhood. In some essential way my empathic being there for Donny was mirrored by his being there for me. In this link of his unconscious with mine, we found, discovered, and completed a being there with each other that had been missing and incomplete for both of us.
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