Elena was four years old when I first saw her. She was physically and sexually abused by one of her mother’s boyfriends, and her mother said she did not believe her. When Elena began to act out with others, the authorities became involved. Her mother belittled her often, and did it in front of others. The current boyfriend cursed at her, called her names, and would go into alcoholic rages that were unpredictable. He had been physically abusive, but when he began to sexually abuse her Elena became even more frightened all the time. She remained at home for several years while services were provided to the mother and the boyfriend moved out, but there were other boyfriends and she was often left alone in the house, without food or support of any kind. Elena had therapy, but the result was minimal as her mother was uncooperative. When Elena would cry or tell her mother she was afraid of the dark and afraid to be in her room, her mother would laugh and make fun of her.
Having Elena placed in a better foster home did not seem like it would happen, and the mother engaged in services just enough to not have her parental rights terminated. Meanwhile, Elena was a very difficult child. She had different therapists she liked and who tried to help her, but nothing seemed to really have an impact. When I evaluated her at this age, she was able to cry and say she wished she had a mother. Her mother would schedule visits; Elena would get dressed and be transported to the child welfare agency, and the mother would invariably fail to show up. Over and over and over again she got her hopes up, only to be disappointed and humiliated, because others witnessed her repeated rejections. She tried to refuse going to these visits that rarely happened, but being a young child, she had no choice. Her caseworkers felt badly, but said the mother would attend a few therapy sessions once in a while, seem to be invested, and then disappear once more, and the law was such that she had to be totally uninvolved for a certain length of time before parental rights could be terminated. Elena learned that what she wanted and how she felt did not matter. When she did see her mother, her mother and male friend would speak in front of Elena as if she were an adult, and Elena learned that she was not worthy of respect. She was still able to cry and grieve and say that, no matter what she did, she got yelled at and punished and made fun of, and was able to discuss her sadness.
I was last asked to re-evaluate Elena when she was eight years old. This time she did not run up and hug me and did not act happy to see me—with good reason, really, as she figured out that these evaluations were not changing her life, even though from the beginning I tried. She acted very grown up and formal. Her foster parents said that she became very nice and well-behaved. I brought out crayons, and she put all of them in color groups, laying them neatly on the table. When one rolled a little bit, she put it back. She did this for a very long time, but was unable to draw anything; asked why, she said she did not draw well. I had a portable dollhouse I offered her. She took all the characters out of the house, laid them down in a row, and said everyone was sleeping. She refused candy she was offered, saying it could make crumbs and was dirty. On the intelligence testing she would not guess but would only answer easy items she was certain of. At her break to use the bathroom, she took a long time. When I went to look for her she was washing her hands repeatedly.
I spent a couple hours with her, told her it was nice to see her again, that I was so sorry her life had been so hard and so unfair. She smiled and said it was all ok, that she was safe now. She confided to me that she would arrange her knick knacks on her bureau a certain way at bedtime, and that no one could hurt her or surprise her because of this; if she forgot to do this, she would get hurt. She told me her foster mother, who knew she liked to know things ahead of time, would never tell her when they were going shopping or out to eat and would tell her at the last minute. The foster mother would then tell her she looked dirty, had messy hair, and was not dressed well enough to go out. She said none of this mattered anymore because she had her secret. She knew she would be criticized, knew she was ugly, stupid, bad, and bossy, but knew she could go through the motions of everything and still be safe. She now had friends and expressed empathy for some other children she knew.
Elena had, with only one ritual, a mild form of OCD that I call PCS (perfectionism, control issues, shame) in my book. She was not dominated by rituals but was in severe emotional pain. This did not have to happen. More grief, anxiety and painful experiences interacting with the world awaited her, as her issues would get in the way. What is sad is that her emotional issues were probably the highest adaptation any little child could have had under the circumstances. She had stopped acting out sexually, cared about others (she chose to share some of her secrets with me), and was a very decent person. She did not go crazy or become violent or cruel. It is appalling to me that this excruciating outcome is the best that could happen—an outcome only a strong person can manage, and it is still so very painful.