Is There a Role for Literature in "Evidence-Based" Medicine?

A recent article cast a long shadow over the highly touted concept of "evidenced-based" medicine, when a professor of ethics delineated multiple transgressions in research in the University of Minnesota's department of psychiatry. In another example, a colleague who questioned the way the data has been manipulated in favor of the popular "Triple P" parenting program, upon publishing a large study that did not support these findings, experienced professional repercussions. Complex relationships between the academic world and the pharmaceutical industry are well recognized. 

Certainly there exists a wealth of high-quality research that is not subject to this kind of corruption, and has an important role to play. But a hefty dose of caution is called for. Where else might we look for evidence to guide our practice of medicine? 

In my behavioral pediatrics practice, when we have time, we inevitably find that behind every "behavior problem" there is a story that makes sense of, or gives meaning to, the problem. In my forthcoming book (Da Capo, Spring 2016) about the need to protect space and time for listening in order to promote growth, healing and resilience, I offer these stories as a form of evidence. 

Literature, another form of storytelling, can offer a kind of evidence. In my book, I refer to one of most famous quotes from To Kill A Mockingbird, when Atticus tell his daughter Scout, "You never really understand a person until you consider things from his point of view, until you climb in his skin and walk around in it."  I now understand this as a description of an essential of human characteristic, namely the ability to reflect on the meaning of another person's behavior.  The enduring power of Harper Lee's book speaks to the significance of listening, of taking time to put ourselves in another person's skin.

In a section of my book titled “Listening for Loss,” I expanding upon the way loss, as in the case of infertility, pregnancy loss, loss of a child, and even loss in a previous generation, particularly when it has been unacknowledged and unmourned, can exert significant effects on subsequent relationships. I describe how the specter of unbearable loss is an inevitable, if usually unspoken, part of becoming a parent.

I recently discovered a beautiful, if exquisitely painful, expression of this idea in Hanya Yanagihara’s novel, A Little Life.

You have never known fear until you have a child, and maybe that is what tricks us into thinking it is more magnificent, because the fear itself is more magnificent. Every day, your first thought is not “I love him" but “How is he?” The world, overnight, rearranges itself into an obstacle course of terrors. I would hold him in my arms and wait to cross the street and would think how absurd it was that my child, that any child, could expect to survive this life. It seemed as improbable as the survival of one of those late-spring butterflies-you know, those little white ones-I sometimes saw wobbling through the air, always just millimeters away from smacking itself against a windshield.

I suspect this passage will resonate with many, if not most parents, to varying degrees, in large part according to their own life experience with loss. For me this is evidence that loss is part of parenting, and when things go wrong, when children have "problem behavior" we must protect space and time to listen for loss.

One young woman for many years had been treated for ADHD for her distracted and impulsive behavior. Only when she experienced a significant decline in his mental health did the story come to light that she had a brother who was stillborn about a year before her birth. Her mother had suffered prolonged severe depression in the face of this loss, which was never acknowledged or spoken about.

Perhaps we need a healthy combination of all three. High quality research, together with stories, both from our patients and from literature,  can help guide us to "best practice" of medicine.

How Does Infant Mental Health Inform Psychoanalysis?

Distancing from interpretation, when the analyst explains back to the patient the meaning of her words as he understands them, was a common theme at three recent psychoanalytic presentations. At one, a leading psychoanalyst explained how rather than interpret a patient's words, he seeks "clarification." A second spoke of how he too steers away from interpretation, aiming instead to "get out of the way" and let the patient come to his own understanding, to,  echoing the words of D.W. Winnicott, become himself.  A third similarly tried to distance him from this classical analytic concept, describing instead an attention to the "field of characters" that inhabit the patients thoughts. 

As I sat in the audience of these lectures, I found myself trying to retro-fit what I had learned in the past few years of immersion in infant mental health -or what I prefer to describe as the developmental science of early childhood- to the classical psychoanalytic theory I was exposed to as a scholar with the Berkshire Psychoanalytic Institute. 

When a recent talk I gave about my infant mental health informed treatment of a 2-year-old boy prompted a psychoanalyst colleague to ask, "what about the unconscious?" it all came together in a kind of "aha" moment. 

Psychoanalysis, originally called the "talking cure" is sometimes described as an effort to make the unconscious conscious. The idea that we have feelings that are out of awareness but yet influence our current relationships and behavior is so integral to our understanding of ourselves that it is hard to imagine that we did not always think this way. Yet the "unconscious" was in fact Freud's revolutionary discovery. 

In infancy and early childhood we have the original experience of connecting feelings with thoughts and words.  The analytic relationship thus in a sense seeks to recreate that original experience.  That is not to say that the analyst is the "better parent." Rather, by offering similar kind of holding environment, the analyst helps the patient to discover, or re-discover, that capacity. We can become calm, creative, flexible and develop healthy relationships- or as Freud said "to work and to love" -when we are able to think about and give words to our feelings. 

The mother (or primary caregiver) originally fulfills this function by containing the infant's experience, not only with words but also with her body, her voice, her presence.  In toddlerhood the actual words take on more significance. As a mother labels her child’s feelings with words, the child develops the capacity to think about and give words to feelings.

However, when the mother is not able to hold the child in this way, feelings remain unconnected to thoughts or words. They remain unlabeled and confused. Or one could say, they remain unconscious.

There are many reasons why a mother has trouble with this holding, containing, meaning-making function. She may be depressed. She may have experienced loss- as in infertility and pregnancy loss- and/or in her own childhood.  A baby may be particularly dysregulated, making this containing function particularly challenging. As a mother feels inadequate to the task, she may then slide in to depression, especially in the context of the severe sleep deprivation that accompanies a dysregulated baby.

When I treat a parent-child pair, I have the opportunity to support- in real time- this capacity to give words and thoughts to feelings, make meaning of experience, or, as I describe in my first book, to hold a child in mind. The transformative effects, for both parent and child, are often dramatic. 

In order to support a mother’s efforts to think about her baby’s mind, it is not necessary to analyze her, a process that may be helpful but can take a long time. As soon as a mother feels recognized and understood, she begins to be more present with her baby.  The baby becomes better regulated, in turn improving a mother's sense of self-esteem and decreasing feelings of shame. These changes, in turn, positively affect the mother’s ability to hold her baby in mind, further facilitating the baby's capacity for emotional regulation and development of a healthy sense of self. This process is described by Ed Tronick as the mutual regulation model.

Without this kind of holding, this kind of giving voice to feelings, a young child will have only a bodily awareness of stress without being able to connect thoughts and words to the experience. When there are no words connected to feelings, the experience continues to exert influence, living both in the unconscious mind and in the body. As such it maintains a grip on an individual's behavior and relationships. 

The analytic process then, in making the unconscious conscious, in a sense recreates this early experience of being held, recognized and understood in such a way as to connect feelings with thoughts and words. Rather than being hijacked by these feelings that are out of awareness, an analytic patient develops the ability to pause, to think about a feeling rather than unconsciously act it out.  

As I listen to these senior analysts wrestle with the question of how to capture the therapeutic effects of the psychoanalytic process, I see how the discipline infant mental health, where the work is done in real time with infants and parents, adds an important dimension to this exploration.

For Mothers and Babies: Big Weeks Ahead at Boston's State House

Recently the Massachusetts House of Representatives did a very good thing.  As described in a Globe editorial, they reinstated funding for a program that supports new mothers struggling with perinatal emotional complications.

At Southern Jamaica Plain Health Center (SJPHC), when a new mother reveals that she is overwhelmed and struggling in the care of her newborn, thanks to the special legislative commission on Postpartum Depression chaired by Representative Ellen Story, help is available on the spot. SJPHC is one of four sites chosen for this pilot program focused on perinatal emotional wellness and postpartum depression prevention. 

By placing perinatal support services within existing healthcare facilities, this program lowers barriers and increases access to care.  By bringing services to where women already are-- with a prenatal provider and/or a pediatrician—the program provides critical support to diverse and underserved populations, including many people who have no other access to healthcare.  

Clinicians meet with all new families at their first pediatric visit, often as early as 4 days postpartum. This is a period of uncertainty, and most new parents have many questions about sleep, feeding, caring for their baby, and managing the adjustment to parenthood.  

Divya Kumar, a doula and lactation consultation, describes how she can listen to new moms for extended periods. As she explains, “I can sit with a mom and say, ‘OK, I'm going to help you figure all of this out.  And if I don't have all of the answers, I'm going to connect you with someone who can help you get them.’ ”

It is not simply about screening for PPD and referring the mother for treatment. Divya and her team can hold the baby and mother together over time, seeing how the baby feeds, when the baby fusses, supporting a mother’s efforts to be present and calm in a way that soothes her baby. The program offers fertile ground for growing a healthy relationship.

Now another important program for mothers and babies, MCPAP for Moms, is on the chopping block.

In a new moms group, where mothers feel supported and listened to, extraordinary thing happen. As a consultant to groups at William James College Freedman Center, I have had the privilege of witnessing this powerful transformation again and again. On the first of eight weeks, when moms sense the safety of the group, they share experiences not only about the lack of sleep and ability to take a shower, but also fears, anxieties, self-doubt, sadness and even depression. By the last group meeting, these mothers, many of whom have developed powerful bonds with each other, interact with their babies, whose unique little personalities have emerged, with confidence and joy. 

In our culture today, where extended family may be far away, where spouses often return to work long hours almost immediately, mothers may be very much alone in the task of caring for a new baby. Mother-baby groups have a critical role to play in filling that void.

MCPAP for Moms, in collaboration with MotherWoman, an organization that offers a network of groups as well as training for group leaders, seeks to make these groups available to mothers all across the state.

This program, too, has its roots in the postpartum depression commission. While at first the focus of the commission was to implement statewide screening for postpartum depression, it quickly became clear that such a step was meaningless without first having resources in place to help mothers identified by the screening.

MCPAP for Moms works in collaboration with William James College INTERFACE Referral Service. When a new mother feels alone, scared and overwhelmed, a three-month- or even a three-week-wait is unacceptable. She needs help today. This program not only helps to locate a support group, but also will connect a mother with a mental health clinician who has experience treating mothers who are struggling with perinatal emotional complications. MCPAP for moms also offers toolkits, as well as immediate phone consultation, for a range of clinicians- including pediatricians, obstetricians, psychiatrists and family practitioners- who are in a position to identify and treat these vulnerable mothers and babies. 

Sadly, the $500,000 needed for MCPAP for Moms to be implemented throughout the state was not even included in the budget.

Budget amendments are due this week, and the floor debate will occur the week after. Let’s hope our legislators, and then Governor Baker, will do the right thing- reinstate the funding for MCPAP for Moms and approve the funding for the pilot programs.  When we as a community support new mothers, we promote healthy development of the next generation, and so the future of our country.