The Wisdom of the Ordinary Devoted Mother

 As both a pediatrician and psychoanalyst, D.W. Winnicott had a unique view of human development. In his pediatric practice, he was immersed in the lives of developing infants and parents. (As the mother was usually the primary caregiver at the time he was practicing, he writes primarily of the mother-baby relationship.) In his psychoanalytic practice where his patients, in his words "regressed to dependence," he had a kind of mothering experience with an adult person who could communicate with both body and verbal language. 

In preparation for teaching a course on early childhood mental health at William James College starting in January, I have had the pleasure of reconnecting with the profound wisdom of his writings. While Winnicott wrote extensively for both a general and a professional audience, I discovered, on careful re-reading of his essay for a general audience entitled "The Ordinary Devoted Mother" that it contains a vast wealth of ideas. In fact, if I had to assign only one paper for the entire course, this could be it. 

He begins in his delightfully humble way by saying that he had no wish to tell mothers what to do because, " To start with, I didn't know." Like his American counterpart Benjamin Spock, he acknowledges the mother as the expert with respect to her child.

Identifying how his approach is sometimes misinterpreted as blaming mothers, he calls attention to an inherent conflict. He writes:

"But is it not natural that if this thing called devotion is really important, then its absence or relative failure in this area should have consequences that are untoward?"

Later in the essay he returns to the problem of blame, but first points out that this ordinary devotion is contingent on the mother herself being cared for. 

“I think that by the time the baby is ripe for birth the mother, if properly cared for herself by her man or the welfare state or both, is ready for an experience in which she knows extremely well what are the baby's needs."

Had he been writing today he would likely call attention the profound implication of our failure to support for mothers in the postpartum period, as represented by the absence of government sponsored paid parental leave. We are uniquely lacking in a culture of postpartum care, as I describe in detail in a previous post.

Next Winnicott introduces another central concept of his, referred to in other works as "the holding environment." He identifies the profound nature of the care a mother offers:

"You will understand I am not simply referring to her being able to know whether the baby is hungry or not, and all that sort of thing; I am referring to innumerable subtle things, things that only my friend the poet could put into words. For my part, I am contented with the word hold, and to extend its meaning to cover all that a mother is and does at this time."

He then goes on to speak of what in his other writings he refers to as the "good-enough mother." He describes how a mother in a healthy way fails to adapt completely to her baby's needs, in parallel with his growing ability to manage frustration. 

"In time the baby begins to need the mother to fail to adapt-this failure being also a graduated process that cannot be learned from books. It would be irksome for a human child to go on experiencing omnipotence when the apparatus has arrived which can cope with frustration and relative environmental failures. There is much satisfaction to be got from anger that does not go over into despair."

This concept has been supported in the research of developmental psychologist Ed Tronick who has shown that these very disruptions, along with their subsequent repair, give a developing child a positive sense of himself. 

Winnicott then returns to the idea of blame, wisely pointing out its close connection to the concept of guilt, an experience that comes naturally with the role of parent.

  

"Here I must go back to the idea of blame. It is necessary for us to be able to look at human growth and development, with all its complexities that are internal or personal to the child, and we must be able to say: here the ordinary devoted mother factor failed, without blaming anyone. For my part I have no interest in apportioning blame. Mothers and fathers blame themselves, but that is another matter, and indeed they blame themselves for almost anything."

He sticks with his conviction that we cannot shy away from calling attention to the importance of the mother-child relationship for fear of being accused of blaming parents.

"But I have one special reason why I feel we must be able to apportion etiological significance (not blame), and that is that in no other way can we recognize the positive value of the ordinary devoted mother factor- the vital necessity for every baby that someone should facilitate the earliest stages of the process of psychological growth, or psychosomatic growth, or shall I say the growth of the most immature and absolutely dependent human personality."

Contemporary research at the intersection of developmental psychology, neuroscience and genetics is revealing more every day of how early experience gets into the body and brain, and how disruptions in early relationships can lead to long-term problems of both physical and emotional health. Winnicott anticipates this knowledge when he writes:

"Psycho-somatic existence is an achievement, and although its basis is an inherited growth tendency, it cannot become a fact without the active participation of a human being who is holding and handling the baby. A breakdown in this area has to do with all the difficulties affecting bodily health which actually stem from uncertainty in personality structure. You will see the breakdown of these very early growth processes takes us immediately to the kind of symptomatology which we find in mental hospitals belongs initially to infant care."

He concludes with the following observation, which can serve as a kind of call to action for our  society to nurture and protect these earliest relationships. 

"It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations of mental health. A great deal of course is done at later stages, but it is when the beginning is good that all that is done at later stages can take effect."

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 Experiencestudy 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.