A Thanksgiving Tale of Loss, Love, and the Joy of Reconnection

(I have been fully absorbed in the editing of my soon-to-be released book The Silenced Child so have had less time for my blog. I hope readers will enjoy this little vignette exemplifying the power of relationships)

This Thanksgiving, while discussing great works of toddler literature such as Big Red Barn with the parents of my 2-year-old cousin, I was pleased to discover I still could recite many of the words from memory.  "Has he read Owl Babies?" I asked. When they said no, but that he loved owls, I offered to read it to him.  I immediately located the book on the shelf of my now 21-year-old daughter's bedroom among the classic board book with which I will never part.

He settled into his mother's lap, nestled against her 5-month pregnant belly. The noise of the adult chatter around us faded to the background as the three of us became fully absorbed in both the telling and listening to the story. Owl Babies, by Martin Waddell, is a classic tale of attachment, loss, and love.  Sister Sarah, brother Percy, and baby brother Bill are living happily in a tree with their owl mother. When one night they wake up to find her gone, they together find ways to manage their growing anxiety. "I think she's gone out hunting," practical Sarah suggests. To each stage of escalating worry, together with efforts to make sense of the situation, Bill repeats his refrain, "I want my mommy!"

The feelings of the story, and the memory of reading it to my own kids many years ago came back with intensity. I watched my little cousin, fully absorbed in rapt attention in the plight of the baby owls. While keeping the three of us together in the present moment of the drama by slowly and carefully reading every word, I looked both at his face and that of his mother. When Sarah suggests that all three siblings sit on one branch together, I thought simultaneously of my cousin's new sibling on the way, and how my now adult children support each other. When on the final page the mother returns with her reassuring "WHAT'S ALL THE FUSS?" I felt a flood of relief and joy along with my young audience.

While Sarah and Percy bravely deny that they had ever really been worried, Bill simply declares, "I love my mommy!" Both grown-ups had tears in our eyes, though I did not have the excuse my little cousin's mother offered of being "too pregnant for this." "May I read it again?" she asked. "Of course," I replied, and left them together to join the adult company.

Does the DSM System Perpetuate the Stigma of Mental Illness?

In a recent conversation with a group of pediatrician colleagues, we bemoaned the lack of access to good therapy for our child patients and their families. One wisely observed that until we integrate mental health care into primary care , we will continue to have this problem. He went on to point out how the direct result of this lack of access to care is prescribing of medication to children without offering opportunity for listening and understanding. I agreed wholeheartedly, calling attention, as I do in my forthcoming book, to the way vast income disparity for professionals who offer this kind of listening has a big role to play in perpetuating this shortage of quality care.

But he went on to say that, as part of the solution, we should view DSM defined mental disorders as medical problems that are no different from any other medical problems.

Here I identified a paradox. On the one hand, we are calling for time and space for listening, for healing through human relationships that good therapy can offer. But the DSM 5 gives the illusion that mental health problems are, in the words of Andrew Solomon in his book The Noonday Demon, "single-effect illnesses." None of the named DSM disorders are known specific biological processes, but rather represent collections of "symptoms" or behaviors that tend to go together. 

I would argue that under the influence of the health insurance and pharmaceutical industries, DSM 5 is part of the problem, rather than the solution.   The DSM 5 can have the opposite effect of what we are calling for, because a single effect illness can be treated with a drug alone. By emphasizing the value of listening in healing, we are calling for recognition of the intricate interplay of biology and environment, and the complex relationship among brain, mind, feelings, and behavior. 

When we invoke the DSM 5 in this way, it is with well-meaning effort both to de-stigmatize mental illness and to obtain parity, or equal pay, for mental health care. But we may inadvertently be getting in our own way with this approach. When we compare, for example, depression and diabetes, we may in fact devalue the complexity of human experience. Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. Unlike the brain, the pancreas has no corresponding mind with thoughts and feelings. The pancreas does not love. It does not grieve, nor does it produce great literature.

A recent study identifying the important role of psychotherapy in treatment of schizophrenia, one that received great media attention, seemed to give an infusion of life to the notion that listening is healing. However, as psychoanalyst Todd Essig points out in his Forbes article on the subject, the stigma of talk therapy is prominent both in the media coverage and in the study itself. He writes:

Therefore, it was a big media surprise that people who suffer a psychotic illness benefit from the support and hope that comes from a therapeutic relationship with a knowledgeable, non-judgmental and empathic other. What’s tragic is we needed to spend millions of dollars on an NIMH study to re-discover this. It should have remained clinical common sense.

Before we look to the DSM, and rush to equate of “mental illness” with “physical illness” we as a culture must first and foremost return to a recognition of the healing power of human connection. We need to value -both culturally and monetarily- time spent listening. If this step does not come first, we may be sabotaging our own efforts.

In another conversation with a colleague who is a family practitioner, she spoke of the need for this kind of listening for all of her patients, including those who present with what is thought to be a purely “physical” illness. Underlying these symptoms is often complex emotional pain that can only be healed when we offer time to hear the full story.

Maybe what is called for is the mirror image of what my pediatrician colleague expressed. Perhaps rather than equating mental illness with physical illness, we need to recognize that all suffering has some emotional basis, and that relationships are central to all healing.

The DSM system may have some role to play. It offers clinicians opportunity to communicate, to know that they are talking about similar sets of behaviors. But in our current system of health care, without renewed value placed on listening, using it to equate physical and mental illness may serve only to stigmatize our humanity. 

Can Mental Health Care be Freed From the Medical Model of Disease?

I recently ran in to a colleague, an experienced psychotherapist, who marveled at my ability to "get out from under the medical model of disease." I have been fortunate to work with colleagues in the growing field of infant mental health who come from a range of disciplines. They bring model of strength and resilience, rather than a disease model, to treatment of emotional and behavioral problems of early childhood. 

Younger psychiatrists trained in the age of biological psychiatry have grown up in a professional family with a language of disorders. This language has likely shaped the way they think. It is embedded in their brains in a way similar to the language we grow up with in our homes. As such it may not be easy to change.  But the abundance of evidence at the interface of developmental psychology, neuroscience and genetics suggests that the path to healing lies in listening for the meaning of behavior, not in simply naming disorders and eliminating symptoms. The biological model of disease reifies the DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnoses, when in fact they simply are descriptions of behaviors, or "symptoms," that tend to go together. 

This point was brought home for me when I taught a class on early childhood mental health to a group of child psychiatry fellows at a well-respected Boston teaching hospital. I was presenting the work of child psychiatrist Bruce Perry.  His neurosequential model of therapeutics (NMT,) that guides treatment based on an understanding of brain development, grew out of his frustration treating children with trauma histories according to the medical model. He recognized this approach was failing.   After presenting his alternative model in detail, I described a case of a 7-year-old boy with a complex history of early developmental trauma who was impulsive and getting in to dangerous situations.  I turned to the group of fellows and asked how they might treat this family. The first response was, "I would see if he met diagnostic criteria for depression and consider an SSRI." 

In another example,  I had a conversation with a young psychiatrist about our work with mothers who are struggling in the postpartum period. We agreed that there is a broad range of factors contributing to these struggles. There is the cultural context, with many mothers experiencing social isolation and unrealistic expectations of rapid return to pre-pregnancy functioning. The transition to parenthood under normal circumstances involves massive biological and psychological shifts. Relationships between partners are dramatically altered, and when both partners struggle alone, the sense of social isolation is magnified. And then there is the baby, a new person with unique qualities that may make this transition more challenging, for whom parents are now completely responsible.  I suggested that we think of the term "postpartum depression (PPD)" as an umbrella term that encompasses all of these factors. I wondered if the biological model of disease, that placed the problem squarely in the mother, might be limiting our approach. She replied, "but any good therapist would look at all these things when treating PPD." 

This way of thinking is exactly the problem I was trying to point out. When we speak of postpartum depression as a complication of pregnancy "just like diabetes" we reify the "disorder."  We need to listen for the full complexity of a new mother's experience before we label her with a psychiatric disorder. If, for example, the baby was premature and has difficulty with feeding, we can find meaning in the mother's struggles that lead us to treat the mother and baby together. Or if the father is feeling depressed and abandoned, the treatment might be a father-baby group. Or a mother who is in a new neighborhood with little social support and a spouse who works long hours might need a mother-baby group and an opportunity to go to the gym. I wonder if we really needed to label  a mother with a "disease" in order to engage this kind of support. 

A third example of this reification comes from a child psychiatrist in a blog post about the new DSM 5 diagnosis "Avoidant/Restrictive Food Intake disorder."  He wondered if this represented a "real problem" or over-pathologizing a normal behavior. There is a third option not mentioned anywhere in his article. Eating is a relationship-based behavior with often complex meaning. In my forthcoming book I have numerous cases of picky eaters whose behavior was a communication of distress related not only to sensory issues but also to troubled family dynamics that were only uncovered with space and time for listening. 

In our current system of health care, diagnostic categories are necessary for insurance to cover treatment. In all of these circumstances I describe above, treatment is definitely needed. It is important not to fall in to the trap that if it is not a "disorder," it is "normal" and therefore families don't need help. I use the generic "adjustment reaction" to avoid this trap and still work within the system. When it comes to working with young children and families, this "disease" vs. "normal" is an inaccurate and potentially dangerous dichotomy.

I am hopeful that the explosion of knowledge of the developmental science of early childhood is making its way in to mainstream mental health care. This is in part due to the Adverse Childhood Experience study that shows the long-term impact on both physical and mental health of early childhood experiences.  I hope it will be possible for all mental health professionals to learn a new language, not of diagnosing disease and eliminating symptoms, but of listening with the aim of promoting growth, healing, and resilience.

Screening for Mental Health Disorders: A Double Edged Sword?

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.”

 In a primary care practice, for a teenage who screens positive for depression, medication may similarly be the only option. 

 When a person feels alone and overwhelmed, whether a socially isolated sleep-deprived mom with a fussy baby, a parent at a loss in the face of an out-of-control preschooler who disrupts the whole family, or a teen struggling to make sense of a new explosion of feelings that accompany this stage of separation and identify formation, an hour of listening, particularly with someone with whom we have a longstanding trusting relationship, can have great healing power. 

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.

These recommendations for screening can be understood as a well-intentioned effort to bring attention to the troubled state of mental health care in our society.  But as we move forward to address the vast scope of problems that we will uncover, we need to think very carefully. The value of listening cannot be underestimated.

Autism, Anxiety, or Neither: A Tale of Two Boys

The subject of autism is so highly fraught, a well-respected child development researcher told me,  that she might need to be the only one in her field to never address the issue. A recent study showing that the likelihood of a child receiving a diagnosis depends on the center conducting the evaluation highlights the complexity of the problem.  For his PhD thesis, Phech Colatat at MIT Sloan School of Business Management reviewed records from three clinics established specifically for autism spectrum diagnosis.   At two centers the rate was around 35% while at a third the rate was 65%. The MIT news release about the study states: 

Those rates persisted over time, even when Colatat filtered for race, environmental factors, and parents’ education. 

But then comes what may be the most interesting finding: 

"...when doctors moved from one clinic to another, their rates of diagnosis immediately changed to match that of the clinic as a whole."

Colatat, based on extensive interviews and observations within the clinics, develops a theory for this phenomenon: imprinting. The article continues:

He conducted dozens of interviews with the clinicians to get a sense of how they had learned to diagnose autism. What he heard was the same few names again and again. At one clinic, a consultant from a nearby university had served as an intellectual mentor to the staff. She had impressed upon them how subtle the signs of autism can be, and as a result, they tended to give out the diagnosis more readily. At another, the clinic’s first director instilled the belief that autism can look like a lot of other conditions, which caused staff to be more conservative. These charismatic individuals made an impression that lasted.

Most striking about this study is the subjective nature of the diagnostic process. Once the purpose of the evaluation is to answer the question, "Does he or does he not have autism?" the possibility of exploration of the complexity of a child's experience is already limited. 

Referring to a recent trend to reframe the symptoms of autism as anxiety disorder, one pediatrician colleague described a kind of "aha" moment, saying excitedly, "Now I see that many of those kids diagnosed with autism really have anxiety disorder!" But both diagnostic labels may be similarly limiting. 

For both Charlie and Max, family outings often dissolved into screaming meltdowns. Both developed rituals of lining up toys, and could recite whole segments of Disney movie dialogue as they insisted on seeing the same film over and over again. Getting wet in a lake, hearing fireworks at a fair, being in a crowd, even of close family members, precipitated scenes of disaster. Teachers at their preschool had raised the question of autism.

Charlie's mother, Elena, had struggled her whole life with anxiety. His father Peter came from a family where discipline was strict, often shaming. He became overwhelmed with rage both at his wife, whom he blamed for his sensitive son's behavior, and at Charlie. Elena felt she had to protect Charlie from his father. Peter clearly favored Charlie's older brother, who he described as "laid back" and "easygoing." This tense family dynamic persisted for years as Charlie's challenging behaviors steadily escalated. Finally at the age of 8 he was referred to a center for autism and received a diagnosis. He entered the special education system as his behavior problems worsened.

Max's family took another route. They got a lot of support for themselves, from family members and from his mother Angela's own therapist, to make sense of Max's "quirks." They worked hard to help him manage what he experienced as onslaught of sensory stimulation. Angela, too, struggled with anxiety and sensory sensitivities, as did multiple family members. But her husband Mark, unlike Peter, came from a warm and loving family. Max's parents found a balance of limit setting and accommodation to his unique qualities. He discovered a love for both drumming and dance and excelled in both. By the time he was in high school, while his quirky behavior persisted, he recognized his challenges and found ways to manage them. He had a number of close friends and excelled academically. 

The need to find something "wrong" with a child may preclude meaningful help. Both these boys, and their families, needed time and space to be heard and understood. Our current system of DSM diagnosis, without this protected space time and space to listen, may bypass this search for understanding.

At the end of the article on Colotat’s research, the author raises the question of how we “get at the truth.” The term"autism" covers such a wide range of experience as to include both adults who advocate for themselves and individuals who cannot communicate at all. There is no “truth” for the diagnosis of autism, or for that matter any other DSM based  "mental disorder," all of which are based on subjective assessment of behavior or "symptoms."

The truth lies in our humanity, in the complex interplay between biology and environment. It lies in the stories we tell and the meaning we make of our experience. The search for the truth lies in protecting space and time to listen to those stories, in all their richness and complexity.