Chapter 2: For Your Own Good

I found Perry's explanations of the "use-dependence" function of our brains and his arguments against children being wholly "resilient" to trauma quite helpful. The way he explained that young children are often more deeply affected by persistent and intense traumatic experiences than are adults because they are relatively powerless and vulnerable reframed the “resiliency” argument nicely for readers. Even though CPS, the court, and Sandy’s guardian-at-litem did not have this information about trauma’s impact on the brain at the time, I was deeply shocked at their hope for Sandy to testify against the man who raped and murdered her mother and slit her throat. No one appeared to have this young girl’s psychological or physical health in mind, nor did they consider the devastating impact that testifying in front of her attacker would have on her in both the short- and long-term. I was relieved that Perry decided to take her case and once again was thoroughly impressed with how he established a strong alliance with her by allowing her to guide their play and her own treatment and how he advocated for her within multiple systems.

It was surprising that Perry had chosen to prescribe Clonidine to the boys at the residential treatment facility, especially after his decision to not medicate Tina after his supervisor's suggestion in the first chapter. While it seemed that this medication was helpful for these young patients who were exhibiting symptoms of PTSD, I wondered about the impact that the long-term and possibly unsupervised use of this medication would have on these boys’ developing brains. I thought about our brief discussion in class about the use of medication with children. While Perry seemed to have thoroughly contemplated the potential consequences of Clonidine, I wondered about the quality of therapeutic care/follow-up at this RTC and whether the staff working with these patients were using trauma-informed practices and interventions to supplement the use of this medication. While this medication seemed to “level the playing field” for these young residents to benefit from any treatment that was being provided, I wish Perry had given us more information about any of the long-term therapeutic outcomes for these patients.

Even though I was skeptical of this decision, Perry’s discussion of the absence of differential diagnoses for these young patients is a timely one, even decades later. Children and adolescents are often still diagnosed with ODD, ADHD, and conduct disorder based on their behavior in school settings, with peers, and at home, without consideration of other external dimensions that may help explain their behaviors and responses to stimuli (i.e. violence at home, essential needs for shelter, sleep, food, care, or consistency not being met, exposure to traumatic events, etc.). Clinicians and doctors who work directly with children may still be hesitant to include PTSD in their differential diagnosis list possibly due to the stigmatizing nature of this diagnosis and the complexity that comes with treating and managing PTSD symptoms (although a diagnosis of ADHD or ODD can be just as stigmatizing and can follow a child throughout their young life). While I think a paradigm shift is occurring around the importance of identifying the symptoms of PTSD and providing trauma-informed care, this shift may take longer than Perry initially expected.

Chapter 1: Tina's World

Reading Chapter 1 of The Boy Who was Raised as a Dog was a validating and refreshing experience. I think I had some minor concerns about the book being inaccessible or overly clinical. I instead found Perry’s discussion of his early supervisory experiences, uncertainty about the diagnostic processes characteristic of the time, internal conflict over how to approach Tina and develop a treatment plan, and his desire to create a therapeutic environment that would provide Tina with an emotionally and psychologically safe space honest and written with great humility. Perry was easy to relate to as an emerging professional, and I repeatedly thought about my own experiences as a first-field intern with CIS in a middle school setting. My initial experiences in this setting were filled with uncertainty and doubt in my capabilities as a growing social work clinician, as well as concern about the traumas many of my students faced on a daily basis, how I could facilitate emotionally safe and enriching interactions with students, and how I could most effectively approach supervision to improve the care I was providing and the relationships I was attempting to establish. Ultimately, I resonated with Perry’s struggles and found his perseverance and focus in Tina’s case inspiring. This chapter also offered a great foundation for the rest of the book with its accessible explanations of the impact of traumatic experiences on the brain and the neurological symptoms of trauma.

Perry offered a strong commentary on the importance of sociocultural and economic factors and their impact on treatment and the client. Having a glimpse into “Tina’s World” helped me better understand the challenges she had been facing as a young child living in poverty and hearing about a young professional navigating potential boundary issues and treating Tina with cultural sensitivity resonated with me. Sharing his first encounter with an impromptu home visit was such an important start to the book. The way in which he worried about having driven Tina’s family home one night after a session painted a picture of the real anxiety that comes with navigating boundaries in unique and complex therapist-client situations, and Perry handled it well. I found myself thinking about my own internal conflict around therapeutic boundaries and only having 45 minutes a week with each of the students on my caseload at the middle school. I constantly questioned whether I was doing enough for them or was having an impact as an intern. While I was able to reframe this after several months working at the school, this conflict arose from witnessing some of the disheartening and difficult issues so many of my students were dealing with on a daily basis and really wanting to provide them with as many positive interactions with a trusted adult as possible and a place of emotional safety and understanding.

I thought about Maslow’s Hierarchy as Perry described Tina’s daily experiences with living in impoverished conditions and the sexual abuse she experienced at the hands of her caregiver’s son. Although Tina’s mother worked hard to provide Tina and her younger siblings with shelter, care, and love, Tina’s basic “physiological” and “safety” needs had been compromised by her early traumatic experiences (Maslow, 1958). I appreciated Perry’s work to meet these in the therapeutic milieu by allowing Tina to guide their play and direct her own therapy, modeling patience, and demonstrating unconditional positive regard and true empathy for Tina. Perry’s compassion for Tina was clear, and this chapter gave me additional insight into how I might improve my own approach to trauma work with youth.

Maslow, A. H. (1958). A Dynamic Theory of Human Motivation. In C. L. Stacey, M. DeMartino, C.L., Stacey, M. (Eds.), Understanding human motivation (pp. 26-47). Cleveland, OH: Howard Allen Publishers.