The doctor as drug

Psychoanalyst Michael Balint said: “If you ask questions, you get answers, nothing else.” In his work with primary care doctors in post World War II London, where many patients had symptoms related to complex psychological trauma, he supported efforts to use the “doctor as drug,” encouraging these physicians to be fully present to listen to their patients rather than asking questions guided by a need to make a diagnosis.

I thought about this idea of the "doctor as drug" when reading two recent articles in the New York Times on the same day. The first, A Dry Pipeline For Psychiatric Drugs, bemoaned the lack of development of new psychiatric drugs. 

This is news that I would cheer for, if only our system of health care allowed for doctors to use themselves as the drug. What is needed is value of time and space for listening. In such an environment the doctor, (or I should say clinician, as today the caregiver is often someone other than an MD) can let the story emerge rather than being guided by a need to make a diagnosis, which is now more often than not followed by prescribing of psychiatric medication. 

For example, a recent study identified an alarming rise in prescribing of atypical antipsychotics to young children. 

Data from the inspector general's five-state probe indicate that 482 children 3 and under were prescribed antipsychotics during the period in question, including 107 children 2 and under. Six were under a year old, including one listed as a month old. The records don't indicate the diagnoses involved.

The very availability of such powerful drugs, that can quickly suppress symptoms, may actually act in direct opposition to careful listening and meaningful change.

The second article , A Powerful Tool in the Doctor's Toolkit, addresses the issue of placebo effect. It refers to the work of Dr. Ted Kaptchuk, director of the center for placebo studies at Harvard:

Dr. Kaptchuk thinks of placebo effects as just one of the many things in the toolkit of medicine. It would never be a substitute for appropriate medical care, but it is something that can enhance medical care greatly. Wise doctors and nurses already do this. They’ve found, usually just by personal experience, that their “everything else” — respect, attention, comfort, empathy, touch — often does the lion’s share of medical care, no deception required. Sometimes the prescription is just the afterthought.

Under the influence of Big Pharma and the health insurance industry this issue has gotten turned on its head. The pill has become known as the treatment, and the relationship- the respectful, careful listening- has become the "everything else." Balint and Kaptchuk wisely recognize that it is actually the other way around.

Should pediatrics and child psychiatry marry for the sake of the children?

There is an interesting exchange of letters in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry between a prominent pediatrician and two psychiatrists regarding an article that recently appeared entitled "Is There a Child Psychiatrist in the House?" The pediatrician, William Carey, argues that pediatricians are well trained to manage such things as colic, sleep disturbances, toilet training and temper tantrums, perhaps more so than child psychiatrists. The authors of the original article reply that they are puzzled that Carey sees anything in the original article that threatens the role of the primary care clinician, and agree wholeheartedly with the proposed marriage.  Carey quotes a prominent British pediatrician, probably Winnicott, saying "many years ago" that "pediatrics and psychiatry have been living together long enough and its time we got married, if only for the sake of the children."

Here I would like to point out that Winnicott, a pediatrician turned psychoanalyst, practiced in a time before the explosion of psychiatric medications, and when psychoanalytic thought heavily influenced the practice of psychiatry. If that were still the case, I would agree with this marriage. However, in our current climate of mental health care, where the 15 minute "med check" is the most common type of visit, I think both fields would do well not to marry each other, but rather to marry the growing field of infant parent mental health.

I trained in both general and developmental and behavioral pediatrics, and work in a department of child psychiatry.  I know that for the most part neither discipline is exposed to the explosion of research and knowledge coming out of this new discipline, at the interface of neuroscience, genetics and developmental psychology. This knowledge has great bearing on preventive mental health care.

Here is a case in point. Prior to my own education in this new field, that came in part from my studies as a scholar with the Berkshire Psychoanalytic Institute and in part from a superb post-graduate training in infant parent mental health at U Mass Boston, I would not have known how to work effectively with mother-baby pairs in the setting of maternal mental illness.

Three-month-old Jenna sleeps peacefully in her mother’s lap. The cards seem stacked against her. Cara at 17 is struggling to finish high school. She has been diagnosed in the past with depression and anxiety, but currently is receiving no treatment. Her primary care doctor, who referred her to me, has been prescribing an anti-anxiety medication as a temporizing measure. Cara has been playing phone tag for over a month with the therapist at the community mental health center, whom she needs to see in order to get an appointment with a psychiatrist.

Cara is scheduled as my patient in my behavioral pediatric practice. I put anxiety as the diagnosis on the billing form. But in truth the aim of my work with this mother-infant pair is to protect her daughter’s developing brain from the well-documented ill effects of maternal mental illness on child development.

Cara talks in a rambling manner about a range of subjects- her older sister at 20 pregnant with her second child, but neglectful of the first, her father who abandoned the family when she was two. She is particularly focused on her difficult relationship with Jenna’s father, Ed. She tells of his drug use, his neediness and his difficulty accepting his role as father.

An infant’s brain makes as many as 1.8 million neural connections per second. The way in which these connections are formed is highly influenced by human relationships. As Cara responds to Jenna’s face and voice, is attuned with her rhythms and needs, both physical and emotional, she is literally growing her brain.

Important research has shown that when a mother can think about her baby’s mind and attribute meaning to his behavior, she helps him to develop a secure sense of himself and of his relationship with her. This security helps him to regulate himself in the face of difficult emotions. As he grows older he will have the capacity to think clearly and flexibly and manage himself in a complex social environment.

When I work with mother-baby pairs like Cara and Jenna, I focus on one simple thing. I listen to these mothers with the aim of helping them to reflect on their baby’s experience of the world and the meaning of their behavior. It never ceases to amaze me that with this singular focus, meaningful communication happens even in what appears to be chaotic and dismal circumstances.

As I listen to Cara’s rambling story, I know I need to help her start thinking about how all of this affects her relationship with Jenna. I use a technique I learned from leading researcher and clinician Peter Fonagy to help a person who is stuck in this kind of non-reflective thinking. I hold up my two hands. “Wait," I say. “I want you to help me understand how you think these problems with Ed connect with your relationship with Jenna.”

She pauses for a moment and then begins to cry. “When Jenna is so needy of me, it makes me think she’s just like her father, and I get so mad. Then I feel terrible for getting angry at her.” It’s a remarkable insight. But she isn’t done. She looks down at Jenna. “See how relaxed she is when I am calm. But when I get upset, she starts to cry.” Then she tells me of a time when she felt about to lose control, but somehow had managed to make Jenna laugh. “We were having a conversation,” she says joyfully, “even though she doesn’t say any words!”

After a year of visits like this every one to two months, despite having grown up in a quite chaotic environment, Jenna is a bright, curious well-regulated toddler. The research from infant-parent mental health clearly supports devoting this kind of time and attention early on to parent-child relationships as a model of preventive mental health care.

However, in order for a marriage between the two disciplines and infant-parent mental health to be successful, both need to divorce the current climate of health care where, under the influence of a powerful health insurance industry, there is no time for listening.

Potty training advice: take time to tell the story

Yesterday I had the pleasure of doing 22 radio interviews in 4 hours as part of a PR tour for a new potty training book Potty Palooza: A step-by-step guide to using the potty.  I did not write the book, which is a fun but quite quirky board book designed to introduce children to the process. Rather, after writing a blog last year entitled The Poop Wars, I was approached by the publisher to write the short   parent guide that comes as an insert in the back of the book.

As I explained to my interviewers, it is not a "how to" guide but rather a set of "guiding principles." For just as in the case of sleep , the path to successful  toilet training is to know the family story. This became very clear in one interview about halfway through the morning.

The five guiding principles, that I repeated in some form in response to the radio hosts' questions are: trust yourself and your child, look for signs of readiness, relax, have fun, and pay attention when your child resists.

This particular interviewer was the mom of a three-year-old. As it was a public radio interview, rules of confidentiality that I follow strictly in my practice do not apply. The bulk of the ten minute conversation was taken up by her telling me about her frustration with her son saying "no" to repeated requests to poop on the potty. As she was not in fact a patient, and the purpose of the conversation was to talk about the book, I repeated the "advice" from the parent guide. I explained that each child-parent pair is unique, and it is important  to tailor the process not only to each individual child, but also to the family circumstances under which toilet training is occurring.

With about two minutes to go, she mentioned that she was pregnant with twins. After giving me about 30 seconds to address the possible relevance of this fact, she switched to the topic of her husband, who rather than helping model for their son, locks the door to the bathroom to protect his private time. The other radio host, a man, wisely interjected with, "when the twins come there will be no private time." Now we were getting somewhere. Seconds later came, "Thank you for joining us on our program."

The whole process felt emblematic of the trouble with our culture of advice and quick fixes. If there is an exclusive focus on "what to do" about "problem behavior" there is no time to reflect on the nuances and complexities of relationships. These relationships, and the family stories they are part of, are inevitably inextricably linked to the "problem." In telling the full story, "what do do" usually becomes clear.

For the mom of this three-year-old, that might mean backing off on the toilet training until after the babies are born. It might mean that some more explaining about where babies come from is indicated (a three-year-old might very well confuse the babies in the tummy with poop and hold on to the poop in an effort to be like mom.) There might be some work that needs to be done in the marriage in terms of shared responsibility for parenting.

Of course I am part of our culture, and I'm the one who wrote the 1,000 word guide to toilet training. And I do think that some "advice" can be helpful.  But above all, parents know their child best, and should trust their judgment. When things get derailed, and families are stuck, taking the time to tell the story and make sense of the problem can be very useful.

Sleep and childhood behavior problems: a complex relationship

A study published in the July/August issue of the Journal of Developmental and Behavioral Pediatrics showing a connection between hours of sleep and childhood behavior problems has received a lot of media attention. Children who slept less than 9.4 hours of sleep had more impulsivity, anger, tantrums and annoying behavior. The obvious conclusion-more sleep, better behavior. If only it were that simple.

If one takes the time to look closely, one will discover that what is correctly described as an "association" in the original article is in fact two interlinked phenomena that have a common underlying cause. Sleep problems are behavior problems. To know the cause, one must know the family story.

Sleep is a developmental phenomenon. In infancy a child learns what is commonly called "sleep associations." The breast, a pacifier, a lovey or even a parent's hair may be what a child associates with falling asleep. Frequent night wakings, expected by parents in the early weeks and months, can become a problem if that sleep association requires a parents' physical presence. As the months wear on parents become severely sleep deprived, and often find that this pattern is not so easy to change. In toddlerhood as a child in a normal healthy way begins to assert his independence, he may resist bedtime in the way he says "no" to many things. Further complicating the picture is the fact that sleep represents a major separation. A child who handles the first day of preschool with grace may suddenly refuse to go to bed, or begin waking during the night.

Given the complexity of this process, there are many ways it can get derailed. If parents do not agree about teaching a child to sleep independently, a child in the bed can cause significant marital discord.  When  parents struggle with depression, and this includes both fathers and mothers, they will have aggravation of symptoms, which often includes irritability. in the setting of sleep deprivation. When a parent is quick to lash out at a child, he may become anxious. Sometimes this anxiety leads to "acting out" in the form of oppositional behavior. It seems illogical, but a two-year-old doesn't know how to say "I need you to be with me and I feel sad when you are angry." He may simply see that when he is "difficult" his parents are more engaged with him. Separation anxiety is common in these situations, and sleep is a major separation.  Bedtime refusal and frequent night wakings are common in this setting. This leads to a vicious cycle as both parent and child become increasingly irritable.

These are some examples, and there are as many different stories as there are families. By the time parents come to see me at the Early Childhood Social Emotional Health Program with behavior problems, which in my experience always include sleep problems, they may be hard pressed to describe moments of joy with their children.

I feel for the parent who reads an article with the title More Sleep Might Help Tots' Tantrums, with its recommendation to have a child get more sleep to improve behavior, and is unable to change the situation because the underlying cause is not addressed. This is where our culture of advice and quick fixes can lead parents to be overwhelmed by feelings of inadequacy and guilt.

The key to treating these complex problems is to give parents space and time to tell the full story. When parents themselves feel heard and understood, they are in a better position to be curious about the meaning of their child's behavior.

This study is important because it calls attention to the need to address sleep in the setting of behavior problems. However, when a child and family are struggling, simple recommendations have a child get more sleep are not only not helpful, but may make parents feel worse. A downward spiral of sleep deprivation and behavior problems will likely persist.

If a family and clinician has the time, then it is possible to make sense of the situation and take steps to set the whole family on a better path; to bring joy back in to relationships.  The younger the child, the easier this is to do.

How to grow a baby's brain

The Grow America Stronger Campaign was created to organize support for funding for investment in early childhood. This month the theme is early brain development. In support of these efforts I am publishing a short segment from my book Keeping Your Child in Mind that elaborates on how relationships grow the brain. It is a companion piece to my previous post that speaks to the need to support and value parents. Today's Rally 4 Babies, with featured guests Secretary of Health and Human Services Kathleen Sebelius, Secretary of Education Arne Duncan, and actress Jennifer Garner, will address the need for social policy supporting early learning.

A very brief discussion of the structures of the brain responsible for regulating emotions will, I hope, serve to demonstrate how parents can promote their child’s brain development in a healthy way… Research at the interface of neuroscience and infant development is offering great insights into how the exchange of looks between mother and baby actually grows the brain. Researchers have learned a great deal about infant development from a combination of detailed video observations of mothers and infants interacting and MRI studies of the brain in action. These imaging studies can actually see which parts of the brain are responsible for what behaviors. This research has shown that healthy wiring of a baby’s brain depends on attuned responses of caregivers. These responses can consist not only of words, but also looks, touch, sound of voice, and facial expressions.

A part of the brain called the medial prefrontal cortex (MPC) is primarily responsible for emotional regulation. When a person has a well-developed MPC, he experiences a sense of emotional balance. He can feel things strongly without being thrown into a state of chaos. The MPC controls and regulates the amygdala, a tiny, almond-shaped structure that is significantly more developed in the right brain and is responsible for processing such strong emotions as terror. Trauma researcher Bessel van der Kolk refers to this area as the “smoke alarm of the brain.” This structure, via another part of the brain called the hypothalamus, connects with the glands responsible for re- leasing stress hormones such as adrenaline and cortisol. These hormones give us the physical sensations of stress. 

The development of the amygdala begins in the third trimester of pregnancy; it is fully formed at birth. Development of the MPC begins in the second month of life and continues well into a person’s twenties. By virtue of its location, the MPC literally hugs the amygdala. It serves to regulate and control the smoke alarm and in turn the powerful “fight or flight response.”

A third important part of the brain responsible for emotional regulation is the insula. The insula, another primarily right brain structure, connects with the visceral organs of the body, including the heart and intestines, as well as the skin. When experiencing empathy for another person, one often has a number of physical sensations, such as a tightening in the chest and tingling in the skin. These physical experiences of empathy, literally feeling what another person is feeling, are mediated by the insula. Mirror neurons, a special set of neurons first discovered in the early 1990s, are also thought to be important in the experience of empathy. They activate when a person is either doing something or watching another person doing something. They seem to code for not only the action, but also the goal or intention of the action. Thus they may play an important role in interpretation of the meaning of another person’s behavior. The insula, and perhaps the mirror neurons as well, play a critical role in attunement and the sense of being understood by another person.

When these connections are not well developed, intense emotions are not well regulated. In the face of fear, for example, a person may be flooded with stress hormones. However, with a well-developed MPC, she will experience the feeling, but her hormonal response will be turned down so that she is not overwhelmed. If, on the other hand, she does not have a well- developed MPC, the amygdala will go off unrestrained, and she will be flooded with fear that she cannot manage. In the face of overwhelming distress, she cannot make use of the parts of her brain responsible for rational thinking. She may become completely overwhelmed and be unable to function. In fact, the amygdala is overactive in post-traumatic stress disorder (PTSD) and all anxiety disorders. 

When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping to wire it for a secure sense of self. The MPC has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that tells her, not with words but with feelings, “I understand you,” the baby begins to recognize herself, both physically and psychologically. This mutual gaze, in which the baby is literally and figuratively “seen,” actually encourages the development of the MPC and with it her sense of self. As her brain matures in this kind of secure, loving relationship, it becomes wired in a way that will serve her well for the rest of her life. She will be able to think clearly and to regulate feelings in the face of stressful experiences.

Obama Rallies for Babies to Grow America Stronger

President Obama is investing in our future by investing in early brain and child development.  The July 8th event, Rally4Babies, sponsored by Zero to Three, was organized to call attention to the importance of this investment. Obama's "Preschool for All" proposal in its entirety can be seen on the Grow America Stronger website that describes the research behind the Early Childhood Initiative. It includes a link to sign a petition in support.

I was very pleased to learn that while the main focus of the proposal is on preschool, it includes a good deal of funding for programs for infants and very young children. For example, the voluntary home visiting program allocates $15 billion over 10 years to expand home visiting services for families with very young children. The proposal speaks of "evidence-based home visiting programs [that] demonstrate improved maternal and child health in the early years, long-lasting positive impact on parental skills, and enhanced children's cognitive, language, and social-emotional development and school readiness." The Nurse-Family Partnership is one such evidence-based program.

In my book Keeping Your Child in Mind, essentially an argument for his proposal, I outline all of the contemporary research and knowledge at the interface of developmental psychology, neuroscience and genetics supporting this investment in early childhood (although I examine the issue from the perspective of health care, rather than education.) This excerpt offers an explanation for the success of home visiting programs.

John Bowlby, describing the essential role of attachment relationships in survival, spoke of a child’s need for what he called a “secure base” from which to explore the world and grow into a separate person. He also recognized the need for a mother to have a secure base of her own in order to provide this security for her child:

I have referred to the ordinary sensitive mother who is attuned to her child’s actions and signals, who responds to them more or less appropriately, and who is able to monitor the effects her behavior has on her child and to modify it accordingly. . . . This is where a parent, especially the mother who usually bears the brunt of parenting during the early months or years, needs all the help she can get—not in looking after her baby, which is her job, but in all the household chores. . . . In addition to practical help, a congenial female companion is likely to provide the new mother with emotional support or, in my terminology, to provide for her the kind of secure base we all need in conditions of stress and without which it is difficult to relax.

In some cultures an extended family can fill this role. A supportive grandmother can be very important. If a new mother holds in her mind a warm, loving relationship with her own mother, even if the grandmother is not nearby or is deceased, this relationship can provide the secure base she needs when she becomes a mother.

It is not uncommon in our culture for a mother to raise her children without benefit of her own secure base (and most do not have help with household chores!!). Families are fragmented by geography and/or divorce. A spouse may be relied upon both to be the breadwinner and sole emotional support, which can put significant strain on a marriage. Many new mothers I see describe highly troubled relationships with their own mothers, full of grief and loss.

A home visiting program provides such a secure base to at-risk families. In our society today, where many live in poverty and families are fragmented, many mothers are raising children without a secure base of her own.

When a parent herself has experienced abuse, providing such a secure base is especially difficult. The home visiting programs share much in common with Selma Fraiberg's original infant mental health program, described in this excerpt.

This way of thinking about and working with children and families is well described in a relatively new field known as “infant mental health.” The field grew out of the work of Selma Fraiberg, a child psychoanalyst who, in her groundbreaking 1974 article “Ghosts in the Nursery,” described the Infant Mental Health Program. A staff of experienced psychologists and social workers went into the homes of mothers who had been abused. By forming a close connection in a supportive and understanding way while these mothers were interacting with their children in their own homes, the staff were able to significantly improve the parenting capacities of these traumatized mothers. The most important part of this intervention turned out to be the relationship between the therapist and the mother. It was different from therapy with the mother. The aim of the intervention was to help the mother connect with her child in a meaningful way.

This intervention, and others modeled on Fraiberg's approach, actually serves to wire healthy brains, as described in this excerpt (stay tuned for more on this subject in my next post):

Contemporary research in neuroscience reveals that a child’s brain develops in relation to other people, not simply on its own. When parents are attuned to their child’s emotional experiences, new connections are formed that control the way that child regulates her experience. These relationships actually wire the brain. This is particularly true in the first year, when the volume of the brain doubles, but relationships can continue to shape the structure of the brain well into adulthood. 

Quality preschool is for all is a good thing. But equally, if not more important, is finding a way to provide a secure base for all new parents, with the aim of supporting their efforts to provide such a secure base for their children.  Currently the United States lags significantly behind many countries in the value we place on parents and young children (A lovely alternative example is Finland, where every expectant mother receives a box of baby goods-a baby box- from the Finnish state social services agency.) Fortunately, not only does Obama recognize this fact, but he also understands that remedying the situation is essential for the future of our country.

The made-up reality of psychiatry's new DSM 5

A member of the American Psychoanalytic Association posted the following on an internal email list, and I am reproducing it with permission. It captures the kind of circular reasoning behind the current paradigm of psychiatry as represented by DSM 5. As in "we define the disease by these symptoms, therefore if you have these symptoms, you have the disease."

The following two questions were published in a recent (June 8) issue of Psychiatric News and also distributed by APA in an email message, apparently as part of a PR quiz program to popularize the DSM-5.  However, I'm posting them here to convey an idea of what many of us feel has gone wrong in American Psychiatry in the last decades.  Each of these clinical vignettes describes a patient with some kind of mental disorder.  Each vignette ends with a quiz question. Fair enough.

However, I have changed to UPPER CASE some words in the two questions to which I'd like to call your attention.  Note in both cases, the question is phrased in such a way that the task is to decide which of the listed DSM-5 entities CAUSED the patient's symptoms and clinical "picture" described in the vignette.  However, the real task is to try to guess which set of symptoms listed in the DSM-5 most closely matches the patient's symptoms.

Framing the questions as they are indicates a mind set that these DSM-5 "disorders" are "real" things which are somehow present in the patient (like a bacteria) and which then CAUSE the patient's symptoms.  In actual fact, because there are no such entities other than in the DSM-5's attempt to classify the myriad variations of human mental disorders into convenient slots, the actual meaning of psychiatric diagnoses in the current state of our knowledge is being turned on its head in the minds of contemporary (biologically based) psychiatric thinking. As you know, in the DSM-5 all "disorders" supposedly reflect an "underlying psychobiological dysfunction" which then leads to the conclusion that all one has to do is to discern the biological mechanism underlying the disorder, find the right pill, and voila!  Cured! What a great doctor!  What a great specialty!!

He then quotes the two quiz cases.

 A 65-year-old woman reports being housebound despite feeling physically healthy. She reports falling while shopping several years ago; although she sustained no injuries, the situation was so distressing to her that she becomes extremely nervous when she has to leave her house unaccompanied. She has no children and few friends. She is very distressed by the fact that she has few opportunities to venture outside her home. Which of the following disorders BEST ACCOUNTS FOR her disability?

a) specific phobia*situational subtype

b) social anxiety disorder

c) posttraumatic stress disorder

d) agoraphobia

e) adjustment disorder

 A 35-year-old man is in danger of losing his job; the job requires frequent long-range traveling, and for the past year he has avoided flying. Two years prior, he traveled on a particularly turbulent flight, and although he was not in any real danger, he was convinced that the pilot minimized the risk and that the plane almost crashed. He flew again one month later, and although he experienced a smooth flight, the anticipation of turbulence was so distressing that he experienced a panic attack during the flight. He has not flown since. Which of the following disorders IS THE MOST LIKELY CAUSE of his anxiety?

a) agoraphobia

b) acute stress disorder

c) specific phobia*situational type

d) social anxiety disorder

e) panic disorder

He references a commentary in the very same issue of Psychiatry News entitled New Evidence Said to Challenge Psychiatry's Basic Paradigms that calls attention to the lost state of the discipline.

Psychiatry is at a crossroads, according to Patrick Bracken, M.D., Ph.D., clinical director of the West Cork Mental Health Service in Ireland, at APA’s annual meeting in San Francisco in May.

“Accumulating evidence challenges the current paradigm underlying psychiatric thinking and practice,” said Bracken. The problem lies deeper than just “too many drugs....”

Psychiatry is not like cardiology, he said. The mind is not simply another organ of the body, but encompasses relationships, values, and meaning.

Clearly a new paradigm is needed.