The Case of Robert Matteo
To learn more about the texture of desperate adoptive situations, I watched tapes of several therapy sessions that Leichtman had held in 1988 with Robert Matteo, a personable, dark-haired boy of twelve, and of the reunion that Leichtman had engineered between Robert and his birth mother. (The names of this family have been changed.) I also saw tapes of two sessions that Leichtman had with the birth mother alone, to prepare and debrief her.
Robert, now the oldest in a family of three adopted children and occasional foster children, had joined the Matteos at age three and a half. Connie Matteo, forty-five, is an early-childhood teacher; Frank Matteo, forty-four is a machinist. Robert had been relinquished by his birth mother (I'll call her Thelma) six months earlier, and had then lived in a foster home. He had been a failure-to-thrive baby and had been hospitalized twice in the first four months of his life, for ear infections and severe dehydration. At three he could say very few words, and, Frank says, "when he first came to the foster home, he didn't know how to hug or kiss; he went to the bathroom like an animal, on all fours; and he would eat until he choked."
The Matteos worried about whether Robert was retarded, but tests showed a normal intelligence, and he had made great progress in the foster home, They were particularly taken by his curiosity and his response to nature, and, Connie says, "we knew he had to have been a survivor to get where he was, because he hadn't been given much attention at all before the foster home."
For four years Robert did well, and the Matteos next adopted a daughter. They were also serving as emergency foster parents for the New Hampshire Welfare Department, and when Robert was seven, they received two very difficult children who proved too much for the family and had to be returned. From then on Robert - worried, perhaps, that he, too, might be sent away - grew increasingly difficult, provoking his teacher and other children at school Neither behavior modification nor play therapy kept the problems from getting worse over the next few years. Then, when Robert was ten, Connie Matteo's brother died of cancer. Connie had nursed him for many months before that, and now she went into a deep depression, ultimately requiring eight weeks of hospitalization. Leichtman says, "As his mom became increasingly involved with her brother or incapacitated, Robert was seriously affected. These kids have templates established from early experience. You can see how this would key into the template of his earlier neglect and loss."
Robert, too, began to be depressed, tried to run away, and finally said he had nothing to live for. The Matteos, who were active in adoptive parents' groups, had heard Leichtman speak several times, and they called him straightaway. In therapy Leichtman learned how deeply haunted Robert was by thoughts of Thelma and the belief that she had kept his younger brother. Robert had some attention-deficit-disorder symptoms, and Leichtman also diagnosed seasonal affective disorder, in which mood disturbance occurs in the winter months. Robert was medicated for depression. "We had gone through just about every intervention we could possibly use," Leichtman says. They tried techniques that help with attachment problems, such as putting the child on temporary "boarder status" or "in a bubble," regimes in which the child follows the rules of the house but is not expected to participate fully in the family's emotional life.
"One Sunday morning we woke up at six-thiry to the sound of an engine," Connie remembers. "I looked out the window and I could see the taillights on the Blazer going on and off. I yelled to Frank, 'Somebody's trying to steal my car!' So Frank jumped out of bed and ran outside to look. The engine was going, and we couldn't see who was in the car." "It's raining," Frank says. "There I am in my underwear, soaking wet, and I'm ready to put my fist through the windshield: who the hell was trying to steal my car?" At that point the car door opened and Robert emerged. "I said, 'Just get in the house and get out of my way, because I'm ready to kill,'" Frank says.
That is when Leichtman decided to track down Thelma. The social worker had to seek court permission first. Surprisingly, Robert's birth mother was in the phone book.
By the time of the reunion "Robert had been at a standstill, physically, socially, and educationally for a good two years," Connie says. "Dr. Leichtman said, 'There's no way this boy can go on with his life till he meets the birth mother and takes care of these issues that are consuming him.' We agreed. We said maybe it's a drastic step, but something has to be done to help this kid carry on."
At the first taped session Leichtman asked Robert how long and how often he thought of Thelma, and Robert said about an hour a day for the past four years. Leichtman told Robert that thoughts of his birth mother had gotten him "stuck in mud," and they discussed the problem.
HL: We know when things have been going really well for you with your adoptive parents, what always happens after a period of time?
Robert: I start to act up and stuff...I get mad at my sister...I just take it out on them.,..just like punishing them, doing things that hurt them...
HL: and when you start punishing them, what do you think inside?
Robert: I don't want to get like too close...'cause I kind of like my biological mother.
HL: So if you really throw your cards in with your adoptive parents,a and you allow yourself to love your adoptive parents, where you don't hold any more cards back, you say, 'Here are all my cards I love you,' What happens to Thelma?
Robert: She gets left out...I sort of get mad...'cause I didn't like save a spot, I guess.
HL (very gently): and when you feel you haven't saved a spot for her, what do you do?
Robert (vigerously): Get a spot!
HL (with enjoyment): You get a spot, don't you? And how do you get your spot?
Robert: By acting up, so my adoptive parents don't like me.
[HL asks what Robert does once he has gotten the spot back by beating up on his adoptive parents.]
Robert: Then be good again.
HL: And what happens to that spot?
Robert: It goes gonzo!
Robert was stating a theme that Leichtman finds pervasive in his conversations with traumatized adopted children: conflicting loyalties. "This is very different from testing," he says. "Kids test all the time, but it's not the same as the attachment-detachment process, when they act out these loyalty conflicts. I have another interesting boy whose mother was actually dead, and he had to protect the bonding to a dead person."
As Leichtman remembers Robert's fantasy of Thelma, "She had this lovely house with a Pepsi machine at one end and a Coca-Cola machine at the other and a soft-ice-cream machine in the middle, with a hundred-yard football field as her back yard. He would have this all to himself, with the birth mother giving him a constant supply of quarters."
Robert and Leichtman reviewed the questions Robert would ask Thelma the next day: How do you feel on my birthday? Would you take me back again? And, as Leichtman put it, the question "that makes your head go boingggg" - Why did you send me away and not my brother? Leichtman told Robert that he had just learned what no one knew before: That ultimately Thelma gave up all her children. They talked about Robert's sadness, and Leichtman told Robert that the next day they would have a wonderful opportunity to set the record straight, to understand things they hadn't understood for ten years. "No matter what happens," Leichtman said, "you can't make a mistake."
Leichtman also prepared Thelma, trying to impress on her the need to help Robert get on with his life. (Thelma had also met the Matteos.) She was an obese woman in her late thirties with dyed red hair; she looked frightened and sad, and her feet were fidgety. Leichtman was clearly Robert's advocate, although he was pleasant to Thelma. He eyes glistened as he told her what to expect and said, once again, that "we can't make any mistakes"; Thelma, tearful, mouthed the proper phrases about loving Robert and wanting him to be happy.
For the meeting, at Thelma's house, Thelma had spruced up with a bright yellow blouse and hair ribbon. Conversation began with Robert's telling Thelma about his life, his interest in soccer and animals: Robert and his sister each had a kitten. "You like cats, huh?" Thelma said. "I just had two little kittens, but I gave them to the lady next door, because they're playful and scratch up my furniture and stuff." After this ironic bit of small talk, they moved toward meatier subjects, such as Robert's conflicting loyalties and why Thelma had relinquished Robert. Thelma claimed that Robert's stepfather drank and beat her up. She was afraid Robert would get hurt, and even her mother "hit kids with belts." The only solution was to call the welfare office and hand Robert over. Thelma had four other children, all living with her ex-husbands or their wives, because "I was depressed and on medicine, and it was really hard to handle them and raise them." Robert asked his questions, they agreed to remain in contact, and they exchanged presents: he gave her a Wediko sweatshirt, and she gave him a baseball glove, a gym bag, a birthday card, and the can of Pepsi sitting on the table as he left ,which Robert said he would keep forever.
When Robert and Leichtman left Thelma's house, they went to Burger King for lunch. Then Robert vomited and had diarrhea in the car, and went back to Wediko and slept in Leichtman's cabin for many hours.
Shortly afterward, Leichtman went to see Thelma. His main purpose was to make a tape for Robert of "the things you most want him to know about and remember." I saw the tape of this visit. As they discussed the reunion, Leichtman said, "He holds on to this love for you with such ferociousness, almost to the exclusion of other things, like his schooling, his parents. And our goal is to see if we can make a big picture for him, keeping his love for you in place, that allows him to love his family and progress in school."
Thelma talked about her hope that Robert would lead a nice clean life, and admitted to wishing she could relive her own differently. Leichtman started to question her with increasing toughness and irritation, mainly to have things spelled out for Robert, and perhaps also because therapists can't resist doing therapy. Thelma, it turns out, had been drinking a taking drugs a couple of years earlier, and had stolen $2,000 for her current husband, whom she now intended to divorce for another man. "I get all these men who drink," she said, and who hit her "while they're drinking and while they're not drinking....it's like they're all alike." She was not at all insightful, and very passive. Leichtman established that Thelma's life was too unstable to accommodate Robert's returning, and ended with the hope that this reunion would boost her spirits. (On subsequent visits Leichtman learned that Thelma had married her latest violent boyfriend. When he saw her last, she was out of work, living in a tenement redolent of urine, and deploring the way she always got involved with the wrong people.)
Meanwhile, Robert, back at Wediko, was deeply depressed, he lost all interest in soccer and swimming and spent his time lying in bed and provoking his cabin mates. His manner on the first tape was utterly flat, and he claimed boredom, tossing off the reunion, in Leichtman's phrase, "as spare change." Leichtman went after him for disengaging, finally saying, "I have a hunch that if you really allowed your self to think it through, you'd be so disappointed you wouldn't know what to do." As they began to watch the tape of the reunion, Robert looked increasingly tearful.
A year before the reunion, when Robert had been at his lowest ebb, Leichtman had used a controversial technique know variously as "rage therapy," "implosion," and "emotional flooding." A leading proponent of this technique is Foster Cline, of Evergreen Consultants in Human Behavior, in Evergreen, Colorado, a physician who specializes in treating severely disturbed children with attachment problems. Cline has written extensively on the theoretical basis for this technique; objections to it come from some psychodynamic therapists who say it's too confrontation all controlling, and some behaviorists who also note that it's unproved by acceptably structured clinical trials with control groups. In essence, Cline's version of this therapy involves holding the child and provoking him verbally and on occasion physically until he lets out the huge reserve of repressed rage that has governed his behavior (or paralyzed him). After the child achieves a catharsis, the therapist shows affection. Leichtman says that similar techniques have been used in Europe for bereaved patients who are unable to grieve. The process - which may last for several hours- suggests the way a plumber uses a snake to clean out a stopped - up sink.
In general Leichtman finds this technique of limited value and desirable only as a last resort in desperate times. "It's something you take out of your armamentarium when the child is absolutely frozen. It's very hard, very confronting, very taxing, not only on the child but on the clinician. We'd done a major emotional flooding a year before the reunion, with the Matteos watching. Robert was able to release his anger, but, as is often the case, the relief was momentary. It lasts about a month, and the anger reaccumulates. You always have to suture this affective experience with the child's behavior."
I watched the tape of Robert Matteo's second implosion, a week or so after the reunion, when Leichtman and the Matteos felt the boy had completely shut down. It was harrowing. Robert looked very small, wedged in between Leichtman and Tom Hays, who were trying, in a Pinteresque manner, to get him roiled up, confronting him with his behavior and his evasiveness about the reunion. Robert answered most questions with a shrug and "I don't know," and Leichtman suggested that Robert, who now confessed to thinking about Thelma "half the day," wanted to go back and take care of her. Robert agreed that he could remind her to take her medicine and go to work and could "counsel her" if her boyfriend got violent. Through all this Robert was fiddling with his T-shirt, twisting it up around his neck and chewing on it.
Leichtman - whose manner with kids is normally empathetic and humorous - did a brutal imitation of Thelma and her drunken boyfriend, reminding Robert of the impracticality of a twelve-year-old boys's parenting a weak, whining, dissipated woman ("a big, overgrown baby," as Leichtman put it) and of Thelma's ill treatment of Robert during his infancy.
Robert did not achieve catharsis in this session. Two more sessions released some feelings, but "Robert really never let go with us," Leichtman says, "and we decided we would bring the procedure to a halt." aA this point, however, the boy was functioning again: they had achieved a sort of emotional jump start. What proved much more effective was the videotape of the reunion. "The procedure we established," Leichtman says, "was that every time Robert got angry out of context, he and his parents would sit there and watch the video. They watched it six to ten times a month for eight months. Implosion always needs a follow-up."
Frank Matteo says,"While he was watching, I could talk to him about it. Every time Robert would watch the tape, he would find out something different that he'd missed. One time he said to me, 'You know, Dad, she lied to me a lot.'"
Robert - whose periods of successful functioning have been progressively longer - and Leichtman wound up their talk therapy a year after the reunion. In the fall and winter Robert receives imipramine to help him sleep and two hours of light therapy daily to treat the seasonal affective disorder, he's had a successful stay at an ordinary summer camp. When I met Robert, he showed a realistic perspective on Thelma and a slightly spooky precocity about psychological problems - "the way cancer patients have all this medical knowledge," Leichtman says. The Matteos do feel that his adolescent rebelliousness is stormier than most kids'. But Leichtman believes that Robert, although he'll need touchup therapy throughout his life, will be able to hold a job, marry, have children, and not perpetuate the cycle of abuse and neglect from which he suffered in Thelma's care. "These kids are capable of functional, adaptive, purposeful lives in which they can make contributions to society," he says. "Our goal is that they will never do to their children what was done to them."
Although a child's temperament and constitution affect the way trauma will be played out, Leichtman says, many patents who adopt traumatized children are essentially turning their homes into a therapeutic milieu. Rearing these children requires a set of skills beyond those normally expected of parents, and parents should not expect their affect tion to be returned in the normal way. The children's multiple problems require a complicated, long term treatment plan; Robert and Harold, for example, have received medication, many years of individual outpatient psychotherapy, family-systems therapy, and residential treatment. The parents risk emotional and financial disaster; marriages sometimes break up, and in addition to paying for services not funded by insurance from the government, parents lose considerable work time. Children whose parents are at work may need supervision to a fairly advanced age, and destructive children will incur expenses that are probably relatively minor but are surely demoralizing.
"There's still a lot of denial about the effects of early trauma, and consequently a lot of blaming the adoptive parents,' says Lauren Frey, the post-adoptive-services coordinator at Project Impact. "We typically try to look at adoption as a exit service for kids. You get adopted, and 'See you later.' We don't want to pay for the ordeals after this, because we believe adoption is going to cure you. We need more of a view that adoption is one intervention in he life of a child, the first of many that will have to take place."
Most states offer some subsidies for the adoption of special-needs children, subsidies that are partly reimbursed by the federal government. In general, adoption subsidies don't exceed foster-care payments, and tend to be less. Richard Barth and Marianne Berry report in Adoption Disruption that the average adoption subsidy in California in 1986 was $3,264 a year.
Frey explains the subsidies in Massachusetts: "The amount is different for every child. The state adoption subsidy administrator uses a formula to determine eligibility and to define the child's special needs. It's tougher to get an adoption subsidy for children with emotional behavioral needs, because their requirements are not as concrete as developmentally disabled kids'." Subsidies may or may not include Medicaid coverage, which in any case pays for only a limited amount of outpatient therapy. Parents might or might nor be reimbursed for work time lost while participating in their children;s therapy.
Leichtman takes Medicaid in his clinical practice, and is one of the few experts on adoption problems to do so. "A psychiatric hospital would have to take Medicaid," Frey says. "But it's become much more difficult to get Medicaid beds for children unless the state Department of Mental Health gets involved; this means taking the child to a pre-screening crisis-intake session at the DMH." However, a child sometimes has an emergency need for psychiatric hospitalization, and families under heavy stress may have to decide on a Friday night, when state offices ha e closed for the weekend, on courses of action that may cost thousand of dollars. As for private health insurance, six weeks of diagnostic observation at a psychiatric hospital used up one Wediko boy's lifetime Blue Cross Blue Shield mental-health benefits. David Brodzinsky, of Rutgers, has treated families whose insurance did not cover fees of $30,0000 to $100,000 a year for residential treatment. Though they maintained contact with the child, the families were obliged to sever their legal relationship, thus making their child once again a ward of the state.
Fees for a residential treatment center like Wediko might be split between the Department of Social Services and the Education Department (several Wediko families pointed out that this is an incentive for schools to play down a child's problem,s).
Finally, Frey says, "You need to apply for an adoption subsidy prior to legally adopting your child. We've advocated successfully for families when the child's needs changed, but it depend on the budget and good will of the administrator."
Massachusetts is not unique in sealing all records once an adoption is made final. What this means is that parents who haven't had (or taken) the opportunity to read the case fully will not, without a court procedure, be able to find out many details about the genetic history of any condition the child may develop later.
Sealed or incomplete records have resulted in lawsuits in several states, in which adoptive parents, claiming that information about previous abuse or ill health of their children was not disclosed to them, have sought post-adoptive services, monetary damages, or termination. Neil Cogan, a professor of constitutional law at Southern methodist university, in Dallas, began one case in federal court by asserting, on behalf of several adopted children, a violation of due process. When this suit lost, he and the parents initiated tort and contract-violation suits, which are still pending, at the same time, he was able to help draft a state law requiring full disclosure of all information that would not identify the parents and providing for post-adoptive services (a $6 million appropriation over two years, covering support groups, parenting programs, therapeutic testing and counseling, respite care, and residential treatment), which the Texas legislature passed. To receive post-adoptive services in Texas, however, children have to have been wards of that state.