Mental illness and motherhood: lessons from Miriam Carey

We do not have medical records or diagnoses. The news is filled with speculation. What we do know is that Miriam Carey’s one-year-old daughter lost her mother, and that because the incident occurred in Washington D. C. in front of the White House, it is shining a spotlight on the subject of mental health and motherhood. And the message should be simple. Diagnoses don't matter. As part of our nation's health care system (another complex and fraught subject this week!) we must provide a safety net for mothers who are struggling emotionally in the weeks and months following the transition to motherhood.

Recently in my role as director of Newton-Wellesley Hospital’s Early Childhood Social Emotional Health program I have had the privilege of participating in a mother-baby group on a regular basis. During the 90 minute session, as these moms share feelings about such things as sleep deprivation, navigating new territory with a spouse, and going back to work, the babies cycle through sleep, alert interaction,  fussy periods, crying and feeding. These mothers, all of them doing this for the first time, intuitively guide their infants through multiple transitions while simultaneously engaging in meaningful conversation.

But it doesn’t always go well. Almost every session, there is a mother-baby pair who struggles. A baby may scream inconsolably, and his mother may leave, overwhelmed by helplessness and shame despite the reassurances from the other moms and group leaders.  A mother may break down in tears as she describes the way her own family is not supportive, and how alone she feels. The contrast between the easy attentiveness of the rest of the group, and the pain these mother-baby pairs are experiencing is striking. We expect motherhood to be a time of falling in love; a time of joy and bliss.  When it is not, the suffering can be profound.

There is nothing quite like the aloneness of mental health struggles in the setting of motherhood. I recall being startled by the story of  one mother in my behavioral pediatrics practice who had struggled with severe postpartum depression. She told me that she had experience relief when her father died when her daughter was about a year old. It was not that she didn’t love her father. But in sharing the grief with her mother and siblings, she no longer felt so terribly alone.

The Massachusetts Postpartum Depression Commission, led by Representative Ellen Story,  in collaboration with such organizations as MotherWoman and the Massachusetts Child Psychiatry Access Project, is working hard to provide a safety net for every mother-baby pair who is struggling in this way.

Through a combination of screening, support groups and a network of clinicians who are experienced in working with mothers and babies in the setting of perinatal emotional complications, the aim is to be able to identify and treat every one of these pairs.

This type of effort is also occurring on national level, through such organizations as the National Coalition of Maternal Mental Health. Perhaps the attention on the issue, due to the fact that an incident involving a car chase occurred on Capitol Hill, will give some meaning to Miriam Carey’s daughter’s loss.

Can we stem the rising tide of serious psychiatric illness in college?

Last week I "launched" my oldest off to college. As anticipated, it was an intense emotional experience full of joy, sadness, and many things in between. (I have to tip my hat to fellow Globe writer Beverly Beckham for her piece I was the sun, the kids were my planets that was very helpful. However, I might have written that my child was the sun, a burst of light in our household, and the experience of leaving her is like being temporarily knocked out of orbit as our family re-orients to life without her.)

The same week I received in the mail, in exchange for filling out a questionnaire about a study on diversion -use of ADHD medications by individuals for whom it was not prescribed- this pretty laminated poster of all the drugs currently available for treatment of ADHD.

Statistics indicate that serious mental health problems in the college community are growing at rapid rates. Some optimistically speculate that this is because of decreased stigma for getting care. But I wonder at the paradox of the parallel increase in availability of new psychiatric drugs- I counted 22 different formulations for ADHD medications on that poster- and the rise of serious mental health problems. Could it be that the drugs themselves are responsible for this increase? If the drugs were effective in childhood, shouldn't we see a significant decline in serious mental illness in college?

How would this work? Starting at a young age, rather than learning to manage stress in the context of supportive relationships, the symptoms are medicated away. The brain is actually wired in relationships, and in the absence of this kind of co-regulation of emotion, the areas of the brain responsible for emotional regulation do not develop properly. All forms of mental illness, including depression, anxiety and attention problems are essentially problems of emotional regulation. Then as the challenges of life increase in complexity, the medications often increase in strength and complexity. Children learn to be defined by their medication and are further estranged from a core sense of self. Add to that unknown side effects on the developing brain, and it is no wonder that there is a significant increase in serious mental illness by the time a child gets to college.

But what about that issue of decreased stigma? That also is likely true. At a superb talk given by a psychology professor at our child's orientation, we learned about the school's  "invisible safety net." It is made up of an elaborate interconnected system of students, faculty and mental health professionals to monitor the emotional well-being of the students. It is all about relationships and connection.

The very existence of this net reduces the stigma of emotional struggles. The fact that the school goes to the trouble to train such an elaborate system of care (sophomore advisors- or "SA's" the front line of this system, must apply in January of their freshman year, and they get several weeks of training prior to the start of the school year), conveys to both students and parents that it is normal and expected that people will struggle and need help.

I believe there is something to be learned from this "invisible safety net" model. If we as a country were to implement a model of preventive mental health care, we would have in place a net made up of primary care clinicians, early childhood educators, childcare workers, mental health care professionals, as well as others who come in contact with young children and families. There would be open and expected lines of communication. (At this college, if a parent calls with a concern about their child, within the hour there is a person making face-to-face contact with that student, even if it is just inviting them out for a slice of pizza- and that person is trained to recognize when it is necessary to call in a higher level of intervention.)

If such a net were there from infancy-including a system for identification and treatment of perinatal mental health problems- through adolescence, then maybe kids wouldn't need all those pretty little pills to take to college.

NYT on mental illness, talk therapy, drugs: what about children?

Last week there was an invitation to dialogue in the New York Times on this subject.  In today's Times there is a fascinating array of responses, but none addresses the issue as it relates to children, for whom there has been an exponential rise in prescribing of psychiatric medication in the last decade. Here is the letter I sent in.

We live in a culture of advice and quick fixes. Increasingly, understanding of human experience is reduced to lists of symptoms, diagnosis and medication. There is less curiosity, less careful listening to one another.

Talk therapy, which perhaps should be called “listening therapy,” offers space and time to create a meaningful narrative, including an opportunity to experience feelings of grief and loss.

This is particularly important in work with children. When symptoms are medicated away, the opportunity to tell stories that give meaning to behavior may be lost. Research has shown that a child’s knowledge of family narrative, both the ups and downs, is highly correlated with self- esteem, resilience and mental health. Giving a parents an opportunity to tell their story to a nonjudgmental listener, to integrate their own narrative,  is critical to treatment of childhood “behavior problems.”

I am not advocating for talk therapy for children. Rather, in order to help children who are struggling with a range of "behavior problems," it is essential to listen to their parents, to give them an opportunity to reflect on the meaning of behavior. The behavior is a symptom, perhaps even an adaptive response, to the underlying problem. There is extensive evidence, that I describe in my book Keeping Your Child in Mind, that when parents reflect on the meaning of behavior in this way, they have the opportunity to promote healthy development at the level of gene expression and structure and biochemistry of the brain.

In my practice, where I see children under the age of five, parents typically present with concerns like, "he never listens" or "she is defiant." But as we take the time to think about how the problem developed, meaningful shifts in understanding occur. For example, parents may recognize the way a child's behavior pushes their buttons because of their own history of abuse. Or serious marital conflict, that often has zeroed in on the child's behavior, comes to the fore.  Or the impact of an easygoing sibling may be recognized. Tantrums and meltdowns at birthday parties may be understood in the context of a child's longstanding difficulty with processing sensory input.

Creating this narrative, this story that makes sense of the problem, may only be the beginning of the treatment. Intensive work with parent and child together, to address the way the child's behavior provokes the parent, is often indicated. Marital counselling, or even working with a couple who are not together, to help them work together to support their child may be necessary. Quality occupational therapy can be invaluable to help a child to feel calm in his body. Parents may benefit from things such as yoga to help them to calm their own reactions.

Here is where the trouble really starts. Quality clinicians who offer these services are in short supply. Insurance is often a huge obstacle. But, creating perhaps an even bigger obstacle, is the cultural norm of the "quick fix" approach of medicating symptoms, even in children as young as 5.  Not only must parents overcome these obstacles of finding a provider, making the time, allocating funds, as well as doing the important but often challenging emotional work of addressing these issues. They must go against pressure from teachers, relatives, friends and  health care providers.

I will continue to offer parents space and time to be heard, to create meaningful narrative, because I am confident that telling stories, and working through the feelings of grief and loss that often accompany them, is the path to meaningful connection and healthy emotional development.  It causes me great heartache when these efforts are thwarted by a system that works in opposition to this approach.