Recent calls for screening for a range of mental
health problems point
to an important recognition of the need to identify and address emotional
suffering. Such screening offers an opportunity to decrease the stigma and
shame that often accompany emotional pain.
A
powerful new documentary The Dark Side of the Full Moon calls attention to
the under-recognition and under-treatment of postpartum depression. In one
scene, a mother refers to resistance from doctors who lack
resources to address positive screens as "ridiculous." She is
correct, if the alternative to screening is to look the other way in the face
of women who are suffering.
But she is highlighting a real dilemma.
For the value of screening lies in being able to listen to, and offer healing
for, the diverse range of struggles of individuals and families that fall
under the umbrella of postpartum depression, or other DSM defined mental
illness.
Recently a colleague spoke of her distress at
the lack of care available in her clinic where large numbers of women struggled
terribly in the early weeks and months of motherhood. “At least a doctor gets them started on a medication, but it’s a long wait for an appointment with a
therapist.”
Decades of longitudinal research in developmental psychology offer evidence that
when people who are important to us listen for the meaning of behavior rather
than responding to the behavior itself, we develop the capacity for empathy,
flexible thinking, emotional regulation and resilience.
Connectedness regulates our physiology and protects against the harmful effects of stress. Charles Darwin, in a work less well known but equally significant to the Origin of Species, addresses the evolution of the capacity to express emotion. He identifies the highly intricate system of facial muscles, and similarly complex systems of muscle modulating tone and rhythm, or prosody, of voice that exist only in humans. These biologically based capacities indicate that emotional engagement is central to our evolutionary success.
This week the US Preventive Services Task Force (USPSTF) called for universal screening of depression in teens. A recent New York Times article addressed the controversy surrounding screening for autism. This summer the USPSTF made a similar call for screening for depression in pregnant and postpartum women.
Screening is an essential first step in alleviating emotional suffering. However, universal screening for mental health disorders, in the absence of opportunity to listen to the full complexity of the experience of a child and family, may lead to massive increases in prescribing of psychiatric medication. Medication may have an important role to play, and may at times be lifesaving. However, as I argue in my forthcoming book, prescribing of medication in the absence of protected space and time for listening may actually interfere in development.
This is an excellent discussion of an extremely important clinical concept: the healing power of connecting to someone whom we trust.
ReplyDeleteI wish you hadn't blown by the objection that there aren't resources to address positive screens with a facile comment that 'an hour of listening' can make a huge difference.
I have a question: what hour of clinical activity should be replaced by the hour of listening?
Peter Elias, MD
(http://petereliasmd.com)
Hi Peter
ReplyDeleteThanks for your comment. I agree that the concern about screening without adequate resources for treatment is a huge problem. Placing a value both cultural and monetary on time spent listening is critical. I'm not sure what you mean by your question. I don't think of it as a replacement but rather as a valuing and prioritizing. In my forthcoming book I deliniate in detail both the healing power of listening and the forces in our culture that work against listening, including the lack of adequate reimbursment in the primary care setting for time spent listening.
My question is based that, at least in my clinical universe, time is a finite quantity. If I spend an hour listening to a patient because of a positive screen for depression (or for any other reason), it means that two or three other patients do not get seen. I do not have any extra hours in the closet to use. Every single additional activity, from the shortest(one extra click on a form in the EHR) to the longest (my institution making me spend 4 hours learning ICD10 coding) comes at the expense of some other activity.
DeleteThe way this plays out in my real world is typified by what happened this afternoon. I saw a patient with a significant new social crisis during his 20 minute BP follow-up visit. We spent 50 minutes today and will spend 30-45 minutes again before the end of the week. Today that meant that several patients waited an extra half hour and a patient later in the week will have his appointment rescheduled for 4-6 weeks down the road.
My comment was because I thought (think) you gave pretty short shrift to the time pressure and ***chronically*** unmet and unmeetable needs in primary care. We already do only 1/2 to 2/3 of what the literature says is shown by evidence to be appropriate and effective - because we do not have time.
Thank you for this clarification. I completely agree that the shortage of time in the primary care setting is in many ways the essence of the problem, as you clearly articulate with this example. Your criticism that I gave the issue short shrift in this piece is valid. My aim in my writing in general, though not specifically in this piece, is to call attention not only to the value of listening in healing but also the way the lack of protected time and space can be harmful. This is particularly true in the case of children whose development is unfolding. So I am not saying that you should "take away" from other activites on any given day, but that we need to think about changing the whole system to re-prioritize listening.
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