David W. Reid, MD

One gray February morning, I received a distraught phone call from a harried inner-city hospital administrator: “Dr Reid, if we can’t find a child psychiatrist in the next 48 hours, we will need to close down our unit due to lack of accreditation. Can you help us?”

I had not done inpatient psychiatry for a decade and was very busy in my outpatient private practice. I almost declined, but it occurred to me that if I held the job for five months, I could then entice a graduating child psychiatrist in need of a starting salary to our practice (Clinical Associates of Tidewater).

The next morning, after a quick tour and hurried deliberations, I agreed to work as the attending psychiatrist on the 12-bed unit for children and adolescents. In my negotiations, I insisted I be allowed to eat breakfast with the kids every morning and then lead a 45-minute group psychotherapy session with them and the staff. I reasoned that the fastest way to understand and begin to guide the milieu was to regularly share a meal with all involved.

Most of the children and teenagers were victims of physical abuse, sexual abuse, neglect, abandonment, violence, and chaos. I marveled at their emotional resilience. Many were depressed and angry at society and themselves; some sought to numb themselves with drugs and alcohol. Talking about their problems, especially with adults listening in, seemed ludicrous to them. So, after a few frustrating weeks, I decided to make an “intervention.”

The previous Christmas, my son Jon had given me a huge, fuzzy brown teddy bear that cradled a smaller teddy bear in his arms. He had heard me tell about the cherished stuffed bear of my youth I called Teddy. I took his present into the group session and told them the following story:

This bear’s name is Rocko. When he was very young and barely able to survive on his own, hunters shot and killed both his mother and father. Rocko escaped and somehow managed to live through the first cold winter all by himself. He grew to maturity and met a very attractive female bear. They mated and had a little cub, named Beara. But soon tragedy struck again. The hunters returned and killed Beara’s mom. Rocko managed to escape with his son and is courageously trying to raise his son in spite of the hardships in his life.

I proposed that at the end of each group, the kids and staff nominate the kid who had tried the hardest in group that day. Everybody would vote, although not for themselves. Whoever won had the honor of keeping Rocko and Beara until the next meeting. Most of the children quickly accepted the mythology of Rocko and Beara and competed to win them for a day. This competition allowed them to open up more and helped them create alliances among themselves in order to be nominated. Everyone on the unit participated in embellishing the story of Rocko and Beara’s lives. The kids hugged and loved Rocko and dressed him in their clothes. Sometimes, an especially angry kid would physically abuse Rocko. More than once, he needed to be returned home for emergency repair surgery. Invariably, the attacker had been abused earlier in his or her young life.

Rocko’s story was like theirs-tragedy, survival, despair, resilience, family loyalty, and hope. I wanted him to portray the idea that a man can be strong and nurturing. I also wanted to convey that make-believe and playfulness are possible and helpful even in the midst of distress, loss, and turmoil. I give credit to Donald Winncott (the English pediatrician and psychoanalyst) for showing us the value of play as a metaphor to use in therapy with children. Many of the kids, even the teenagers, expressed considerable affection and protectiveness towards Rocko and Beara and got angry with those who mistreated them.

“Bruce,” an angry, out-of-control 16-year-old, illustrates how Rocko’s transformative power worked. The police escorted Bruce to our hospital. His father called them when Bruce became enraged and combative. At the emergency department, where the police first took him, he threatened to “punch out the doctor’s lights” if he was touched. The hospital staff obtained a temporary detaining order so that Bruce could be involuntarily placed on our unit.

As soon as the police took off his handcuffs, Bruce began threatening the staff and other patients. With a show of force by four male staff, he agreed to go to the seclusion room, cursing and threatening as he went, fists clenched. Before I went in to interview him, I asked a burly childcare worker to wait outside and help me if he attacked. Frankly, I was afraid of Bruce. His right hand was swollen from punching the walls in eruptions of anger. He looked like a taut spring ready to go off if anyone irritated him. Seething with rage, he refused to talk with me. I told him every enraged person has reasons for his anger and invited him to tell me about his life, but he remained silent, his back turned.

In his days on the unit, Bruce’s story gradually unfolded. He was the youngest in a large family. The father rarely worked and often verbally and physically abused his wife and the boys. As they grew older, each son in turn put a stop to his beatings by fighting the father. A year ago, Bruce had confronted his father in a struggle for dominance. Then, after his parents separated, Bruce lived with his mother, but she soon demanded that he go live with his father. His mother refused to come to a single family session. After Bruce moved in with his father, he also began to use and sell drugs. He provoked fights wherever he went, taking on a fearless, ferocious identity even though he was only 5’4” tall and 135 lbs. His brothers had smeared toothpaste on him while he slept, which had triggered his rage.

In group sessions, he snarled and scoffed at the idea of talking about his feelings. Mostly, he remained sullenly silent. But slowly, he started taking a leadership role, often to protect some of the younger boys on the unit. As he realized he was safe and did not need to fight to protect himself, he grew less defensive. He began to tell some of his traumatic experiences-the mockery and beatings by his older brothers and school bullies.

During one session, he was nominated for the hardest worker, and won! He acted nonchalant as he took Rocko and Beara to his room, but I could sense he was softening and allowing our care to soak in. Later that day, his father came for a visit. Bruce proudly showed him Rocko and explained how he had won him for the day.

Sarcastically, the father said, “Oh how nice, you won a teddy bear!” The father showed distain for everything, including his son.

As soon as he was “no longer out of control,” his HMO insurance company began a drumbeat for us to discharge Bruce. We resisted for as long as possible. In his final group session, Bruce told each kid, one by one, he would miss them, and why. He then apologized for his meanness the day before to the charge nurse, and tearing up, he said that he would miss her the most.

Then a six-year-old boy jumped out of his seat, ran over to Bruce, threw his arms around his neck and said, “Thank you for being my friend. I really mean it.”

Bruce began to cry. When he tried to hide it, I said, “Bruce, don’t hold it back. It’s okay to cry. If you keep it up, you’ll turn into a real human being.”

Bruce continued to cry for about an hour after the meeting. Clearly, he experienced a sense of being appreciated, understood, and respected-and longed for more. Bruce won Rocko that day with no contest and proudly carried him around the unit until his moment of discharge. In doing so, he was embracing Rocko and the value of caring, hope, and the struggle to overcome loss.

When we did not recruit a child psychiatrist in July, I could not bring myself to leave the unit and risk it being shut down. I continued working there for another year until we finally found someone to take over the position.

Bruce and my time with the unit staff taught me to never give up trying to help the most difficult and damaged patients. Showing kindness, respect, and caring often touches the heart of the most troubled patients we try to help. Creating a safe caring environment comes from strong leaders who are free to share their tender feelings.

Dr Reid is a child psychiatrist in private practice in Virginia Beach, VA.

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Rocko’s story was like theirs-tragedy, survival, despair, resilience, family loyalty, and hope.