Adam Lanza and Preventive Mental Health Care

In keeping with my wish for continued meaningful dialogue in the wake of last week’s horrific events, I would like to expand upon what I mean by "preventive mental health care." I am referring to relationship-based care that focuses on young children and families. All of the best science of our time, at the interface of neuroscience, genetics and developmental psychology, tells us that by supporting parents and young children together we will have the best chance to promote both physical and emotional health.

This is not to say that when there are problems it is a parents "fault," nor certainly, as many parents fear, that a young child who is struggling is at risk for becoming a mass murderer. But the brain grows in relationships, and supporting relationships supports healthy brain growth. 

Early reporting suggests that Adam Lanza struggled with severe social anxiety from a young age. This is a description, not a DSM diagnosis.  His mother apparently had some kind of conflict with his school and ended up home schooling him (early reports that his mother worked at the school where the shooting occurred, that I refer to in my previous post, turned out to be incorrect.) 

I wonder if our best chance at preventing this horrific event would have been to carefully listen to these parents, including the father, when Adam was a young child, to understand their experience and find meaningful help for the whole family.

The  piece I Am Adam Lanza's Mother originally published in the Blue Review, that has now gone viral, offers a striking up-close view of how parents suffer in the face of a troubled young child. It offers evidence for the need for intensive help for parent and child together.  Simply labelling the child with a psychiatric disorder and prescribing medication is grossly inadequate care. 

Current standards of care in psychiatry, including both the focus on DSM diagnostic category, in psychiatrist and author Daniel Carlat’s words the “what” rather than the “why,” as well as over-reliance on psychiatric medication, is more narrow than my definition. Preventive mental health care consists of careful listening and support of parent-child relationships. 

On NPR this week there was a comment made that other countries with better gun control laws do not have these kind of events. But what if the important difference is that we are seriously behind in supporting young children and families with such things as parental leave for newborn care?

I wonder if there is some insight to be gained from the venom directed against me in some of the comments on my last post. I see similar venomous in comments on similar posts.They seem to represent an underlying rage (at least among those who comment on blogs) as well as the loss of the capacity to listen to each other.  Assumptions are made about me that are completely unfounded and could easily be dispelled by simply reading my bio and or most recent blog post.

We are as a society traumatized by this event, and by the continued horror of watching the funerals of these young children. To find a way to take meaningful action in the wake of this trauma, we all need to calm down and take a collective deep breath. Perhaps the opening point of meaningful dialogue would be an effort on all sides to take the time to listen to each other.

Gun control and preventive mental health care to honor the lost children of Newtown

For the families who lost children, their world as they knew it has effectively ended. Yet somehow the sun rises again and the next day is here. For the rest of us grieving along with these families, the only way to move forward is to take what President Obama called "meaningful action." I interpret this to be action that is radical and significant enough that it will somehow give meaning to this unimaginable loss.

The first and most obvious front is gun control. Without access to guns, apparently the same rifles used by troops in Afghanistan and Iraq, one individual could not have done this degree of harm. The politics of gun control is not my area of expertise, but certainly the politicians must now be motivated to, as Obama said, "put aside differences" and honor these children with dramatic changes to gun control laws.

The second front is preventive mental health care. This event is the result of a deeply disturbed individual with access to guns. My inbox this morning was full of emails from mental health colleagues referring to pieces they had written for other massacres such as Virginia Tech. I hope that this unspeakable horror will be  the one that will finally lead to real change in access to preventive mental health care.

One of these colleagues wrote of how these events are often perpetrated by young adults who have not been "acting out," but rather have been quietly bullied for years and seriously neglected at home. Their symptoms may be more subtle. Yet it is difficult to imagine that there were not people in this family's life who did not recognize that this boy/young man was mentally ill.

The emerging information speaks to  a deeply troubled relationship between the shooter and his mother as being at the root of the event. Apparently he first shot his mother and then went to the school to deliberately kill the children at the school where she worked. I wonder, was the hurt he experienced in his relationship with her magnified by his witnessing of the care she gave her young charges at her job?  Of course I don't know, and this is only theory as I struggle to make sense of something that doesn't make sense.

As I said to my editor when she asked for our thoughts on this event, the trauma is perhaps too fresh for an in-depth discussion of theory and policy change. However, I am hopeful that the coming weeks and months will be filled with meaningfully dialogue of how we as a society can honor the dead children, both through gun control and improved access to quality preventive mental health care.

Where is the media coverage of the DSM V vote?

Last Sunday I awoke to a news story in our local paper, The Berkshire Eagle, about the vote by the American Psychiatric Association the previous day approving massive revisions for DSMV, the newest version of the Diagnostic and Statistical Manual of Mental Disorders. The article stated:

Board members were tight lipped about the update, but its impact will be huge, affecting millions of children and adults worldwide (italics mine.)

Figuring that this would be big news, I asked my husband if we could delay our morning hike while I wrote a blog post about it. I was sure there would be an active public discussion on the subject.

But I was wrong. Mainstream media had virtually nothing on the story. There was not one word about the DSM vote in the New York Times.  The Boston Globe similarly did not cover the story. There was a brief mention on NPR's Morning Edition on Monday. Boston.com  had my piece as well as an article about Asperger's being dropped from the new version.

There was news on the blogs. Most striking was from Allen Frances, MD, professor of psychiatry at Duke University, who was chair of the DSM IV task force. On his Huffington Post blog he wrote:

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM-5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public -- be skeptical and don't follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. 

While he defends his colleagues against accusations that they have been influenced by big pharma, he  writes that:

The APA's deep dependence on the publishing profits generated by the DSM-5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM-5 public trust and DSM-5 as a best seller... The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only -- so that DSM-5 publishing profits can fill the big hole in APA's projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM-5 preparation.

When MGH psychiatrist Joseph Biederman was found guilty of violating conflict of interest rules in accepting large amounts of money from the pharmaceutical industry, the news was announced on July 2nd 2011, a Saturday of a holiday weekend. A number of bloggers suggested that this timing was deliberate: an effort to bury the story.

Some may suggest that the weekend DSMV vote and lack of media coverage is related to the power of the APA and big pharma to squash controversy. For the sake of children, families and adults who struggle with mental illness, I hope that there is a more benign explanation.

A relational view of DSM V: a care-rationing document?

Because DSM V the newest version of the Diagnostic and Statistical manual, sometimes referred to as the "bible of psychiatry" set to come out in May 2013, makes no mention of relationships, the relational perspective is that it is a flawed instrument. The whole discussion about what categories should and should not be included is off the mark. Nonetheless, as it currently dictates who will and who will not receive treatment, it is a force to be reckoned with.

Psychiatrist Daniel Carlat, in his book Unhinged: The Trouble with Psychiatry writes:

The tradition of psychological curiosity has been dying a gradual death, and the DSM is part cause, part consequence of this transformation of our profession. These days psychiatrists are less interested in ‘why’ and more interested in ‘what’.

In an excellent NYT piece on the subject, Not Diseases, but Categories of Suffering, the author states:

And as any psychiatrist involved in the making of the D.S.M. will freely tell you, the disorders listed in the book are not “real diseases,” at least not like measles or hepatitis. Instead, they are useful constructs that capture the ways that people commonly suffer.

He goes on to say that the problem with DSM is that it has been taken “too seriously.” This is reflected by the fact that even though these diagnoses are artificial constructs, they dictate who does and who does not receive treatment. In other words, if you meet diagnostic criteria you are suffering enough to get help. If not, you’re on your own.

Consider the new diagnostic category, voted on Saturday to be included in the new version: Disruptive Mood Dysregulation disorder. The boy I describe in the following story(details as always have been changed to protect privacy) may or may not meet the criteria for this label. Either way, he and his family are in trouble. Even asking the question of diagnostic category diverts us from the task of helping them.

Four-year-old David's mother, Alice, described him as "explosive." She told of a typical scene- a request to get ready for bed was met with a firm "no," and soon mother and child were head to head in battle. An hour later, David was kicking and screaming on the floor and Alice was crying, horrified with herself for having threatened to hit him. Similar scenes occured several times a day.

Rather than launching right in to "what to do" I took some time to listen to Alice's story while David played on the floor. Many things emerged, but most striking was the fact that the family had moved three times in the past year after David's father, Ron, lost his business, leaving the family in financial ruin. Ron had been severely depressed, but according to Alice, they were settled now and he had a good job. When I commented that it sounded like a very stressful year, she immediately responded with,"Yes, but we didn't let it affect David."

From my position, this clearly seemed impossible. Such an experience is inevitably stressful for a four-year-old child. But for some reason, Alice, who was an intelligent woman, did not see it. Perhaps she felt so much guilt, or even shame, about what had happened to her family that she could not let herself recognize this truth.

I saw my task at that moment as helping Alice to understand David's experience, to recognize that his increasingly frequent battles for control were likely in part due to feeling things were out of control for whole past year. But I needed help Alice recognize this without increasing her guilt and shame. It was a difficult and sensitive procedure.

When I saw them two weeks later, the explosive episodes had significantly decreased. Alice told me that his behavior no longer seemed so bewildering to her. Rather than getting angry, she listened to him, yet set more firm limits. She was delighted with the results and felt proud of her ability to regain a sense of joy and stability in her relationship with her son.

The research coming from the field of infant mental health offers a way to make sense of this change. It gives us a completely different model from DSM for both understanding and treatment.  Ed Tronick, a leading researcher in developmental psychology who is perhaps best known for developing the still face paradigm,  has described mutual regulation model.

The MRM(mutual regulation model) stipulates that caregivers/mothers and infants/children are linked subsystems of a dyadic system and each component, infant and caregiver/mother, regulate disorganization and its costs by a bidirectional process of behavioral signaling and receiving.

The still face paradigm, in which a mother interacts face to face with her infant as she usually would, then for a two minute period presents a completely still face, followed by a reunion episode of resumed face to face interaction, in Dr. Tronick's words "demonstrates the costliness of an experimental disruption of the mutual regulatory process...as it serves as a model for the stress inherent in normal interactions."

In other words, it is impossible to understand the behavior of a child without looking at the behavior in the context of this mutually regulating or dysregulating relationship.

Another leading researcher in the field, Arietta Slade, has written extensively about what is referred to as parental reflective functioning. This is also described as "holding a child's mind in mind."It  refers to a parent's capacity to reflect on the meaning of her child's behavior. Slade, along with other researchers, has shown how enhancing a parent's capacity for reflective functioning is associated with many positive outcomes for a child's emotional development, including flexibility, cognitive resourcefulness and the ability to manage complex social situation.

When things go well in my office, supporting a parent's efforts to reflect upon the meaning of her child's behavior, as I did with David, is simply the point of entry. Once the child feels understood, he becomes calm. Evidence indicates that this change is on a neurobiological basis, occurring at the level of the structures of the brain that produce stress hormones. 

When a child is calm, a parent begins to feel better about herself. In fact, often a child's out of control behavior itself produces a feeling of shame in a parent. When parent and child are more in control, this sense of shame decreases. In turn, when a parent feels less shame, and less stress, she can think more clearly. She is better able to reflect on the meaning of her child's behavior. In turn a child feels even more calm and in control. This is what is meant by mutual regulation.

Any parent-child pair who is suffering in this way deserves to get help.

DSM V might have some role if it is used simply as a way to guide thinking. One of its original aims was to offer a structure for clinicians to recognize similarities and differences among their patients and to talk to one another about them. (The DC 0-3,  a similar document, includes a relationship classification and offers a much more comprehensive model for understanding emotional problems.)

But that is not how it is used. It is essentially a document that rations care.  The issue of the elimination of the diagnosis of Asperger's is a complex one and beyond the scope of this post. However, the frequently made objection that people who have this diagnosis will no longer be eligible for help, supports this way of understanding the DSM. 

If DSM, then, is a care-rationing document, the solution is not to spend years refining the categories. The solution is to improve access to care.