Case Study: Dylan

A few years ago, Shelly called me about her three-year-old son Dylan. His teacher called to say that he had become violent toward her and other children. Dylan's father Chet had been diagnosed with an aggressive form of cancer a year earlier, and was close to death. Shelly had watched with sorrow as her husband grew sicker and pushed Dylan away. At first she had thought Chet’s declining physical condition had something to do with his harsh dismissal of Dylan, but she now knew it was Chet’s way of dealing with leaving his family behind. Chet told Shelly, ‘‘It will be easier for Dylan if he learns not to love me.” Shelly was silent for a while before quietly adding, "That just broke my heart." She went on to tell me that over the last few months Dylan seemed to be regressing. He was wetting his bed, having frequent nightmares, and bouts of inconsolable crying. "We haven't told him what’s happening to his dad," she continued, "but he knows that something is terribly wrong." We ended our first conversation by making an appointment for the following week.

At the time of our appointment, I entered the playroom to find Dylan crouching behind a chair. I observed him as he watched his mother fill out forms with my co-therapist. From time to time, he would pop up from his hiding place, shoot at his mother with an imaginary gun, and dip down again behind the chair. After introducing myself to Shelly and talking with her for a few minutes, I sat on the floor next to two chests of toys. Thinking of Dylan and what toys he might like to play with, I began rummaging through the chests. As Shelly left for the observation room, Dylan stared at me intently from behind his chair. If he caught me looking back at him, he would huddle down, and hide his eyes.

After a few unsuccessful attempts to engage him by asking questions or inviting him to play, I decided to play on my own. I wondered if, perhaps, he was showing me how it felt to be rejected and have to play alone. I tried to remember all those times in my life when I had felt rejected. If I could get into that state of mind, it might help me to connect with Dylan. He watched closely as I pulled out a toy, played with it for a while, and replaced it with another. I finally came upon a wooden train set. Putting together a few pieces of track, I began to slowly push the train forward while doing my best steam engine sound. "Choo, Choo, Choo, Choo..." As I approached the end of the track, instead of getting the next piece out of the toy chest, I said, "Choo, Choo, Choo. Oh no, I'm running out of track! What am I going to do? Choo, Choo, Choo."

Dylan darted from his hiding place, ran to the toy chest, picked out a piece of track, attached it to the existing track, and shot back behind his chair. "Whooo, that was a close one!" I said as I continued to move the train forward. "Choo, Choo, Choo..." Halfway through the new length of track, I repeated, "Oh no!" Dylan popped out of his hiding place to repeat his heroics. This time, he smacked me on the back as he ran by. 

We repeated this scenario a few more times. Dylan's smack gradually evolved into longer and longer touches as he passed. He no longer retreated behind the chair, but would stand near the train waiting to add the next piece of the track. Then, as if maintaining "electricity" with home base in a game of tag, he kept one hand on my shoulder as he reached out with the other to grab new track. Finally, he planted himself in my lap and added track from there. He slowly began to giggle and squeal with delight. We spent the last half of the session like that, Dylan sitting in my lap, looking at the tracks he had set up, telling me stories of the other kids at preschool, talking about his favorite toys, and, to my surprise, explaining to me what was happening at home.

Because working with young children involves symbolic play and the imagination of both therapist and child, you can never be certain of exactly what may happen in therapy. Dylan seemed angry at his mother for what I imagine was her failure to protect him from the pain and confusion he was experiencing. Through his initial actions with me, Dylan posed many questions: Am I important to you? Am I needed? Am I wanted? Am I safe? Will I survive? For a child his age, and perhaps all of us, these questions are one and the same. 

By playing by myself, I gave Dylan an opportunity to evaluate me in this strange and new situation. Allowing him to save the train gave Dylan the chance to demonstrate his competence and value. He found he could smack me without retaliation and then move closer, testing my safety and acceptance of him. Our play became a dance of bonding, trust building, and attachment. When he finally felt safe, he wanted sustained physical and verbal contact. He showed me what he had lost and what he needed from his father. Despite his regressive behaviors, or maybe because of them, Dylan had become very receptive to an open heart. 

However, Dylan’s struggle was only one element of the breakdown in his family. Besides connecting with Dylan, I wanted to help Chet say goodbye to his wife and son. I also suspected that Dylan and Shelly would need some help adjusting to their future life without Chet. Shelly was encouraged by the connection I was able to forge with Dylan and was eager to have me talk with Chet. This would be a challenge. Not only was Chet unable to leave his bed, but he wanted no part of sympathetic relatives, well-meaning rabbis, or, most especially, a touchy-feely therapist. Still, Shelly and I set up a time for me to visit with Chet, knowing that he would probably refuse to speak with me. 

As I walked into his room, Chet did everything but pull the covers up over his face to avoid me. He shot a glare or two in my direction and remained silent. I felt like I was once again with Dylan in the playroom, only this time there were no toy trains to help us bond. Certain that Chet had already heard all the clichés, platitudes, and comforting remarks from others, I was careful to avoid my impulse to say them. After sitting quietly for a few minutes, I began telling him about my sessions with Dylan and how fond I had become of him. I also told him what I thought was going on in his son's heart and what Dylan needed from him.

Chet began crying softly, but his sadness quickly changed to anger. He was angry at death, at his friends, his wife, his doctors, and at God. He even admitted being angry at Dylan for his youth, health, and the time that lay ahead of him. He stared at the paper cup in his hand, slowly crushing it, the water running out through his fingers and onto the blanket. "I know it's no one's fault, just bad luck, I'm just so pissed off!" Inexplicably, I reacted to his anger with sadness. I felt my eyes grow moist. Seeing my tears, Chet, too, began to cry again. I thought of my own death and of Dylan having to say goodbye to his father for the last time. We cried together for a while and, then, as we sat in the growing darkness, Chet began to speak. He told me about meeting his wife, their courtship and marriage, and his experience of Dylan's birth.

In the few sessions I had with Chet before his death, I discovered that it was his anger that kept him silent. I gave him opportunities to be angry, but he soon realized that what he really needed to do was to say goodbye to his family, his friends, and to Dylan. From that point forward, he would muster up some of his failing energy each day - to play with Dylan, to reminisce with his wife, and to talk about their future without him. If a tragic young death can be considered good, such was Chet's. 

My social brain was in overdrive while working with Dylan and Chet. I watched their movements, facial expressions, and gaze, and listened to the tone and cadence of their voices. I was the wooden body of the cello and they were the strings as I resonated with their feelings and emotions, both expressed and held within. I imagined how I would feel in each of their situations in order to help me establish an empathic attunement with them. With both of them, I blended observations, ideas, and my own emotions to try and discern what was in their hearts. Memories of my own childhood emerged, helping me to interact with Dylan at his level of development and understanding. My paternal instincts also led me to want to comfort and soothe Dylan's distress - I felt my body relax as he felt increasingly safe with me. In an entirely different way, being with Chet required me to face my own mortality and the cruelty of fate. Together, we shared the fundamental human experience of inhabiting an incomprehensible and sometimes frightening universe.

This is an excerpt from Dr. Cozolino’s book The Neuroscience of Human Relationships.